Aging Clin Exp Res (2014) 26:269–278 DOI 10.1007/s40520-014-0230-2
ORIGINAL ARTICLE
A multidimensional assessment of physical performance for older Japanese people with community-based long-term care needs Miji Kim • Kiyoji Tanaka
Received: 6 March 2013 / Accepted: 10 October 2013 / Published online: 14 May 2014 Ó Springer International Publishing Switzerland 2014
Abstract Background and aims A multidimensional assessment representing overall lower- and upper-extremity performance is necessary to identify functional decline among older adults. The aim of this study was to develop and validate a physical performance scale (PPS) using both cross-sectional and observational approaches in older adults with and without community-based long-term care (LTC) needs in Japan. Methods A total of 416 community-living adults aged 75 years and over. The 7 items of the PPS include a range of physiological challenges, such as assessment of upperextremity strength, lower-extremity strength, balance, and walking ability. Concurrent validity [correlating the PPS with self-reported functional status in activities of daily living (ADLs), instrumental ADLs, and Physical Function subscale of the Medical Outcomes Study 36-Item ShortForm Health Survey (SF-36PF)] and discriminative validity were assessed. Sensitivity to changes was evaluated with a 12-week exercise program. Results Total PPS score was significantly correlated with self-reported functional status such as ADLs, instrumental ADLs (IADLs), and SF-36PF (r = 0.53–0.62) and M. Kim (&) Research Team for Promoting Independence of the Elderly, Tokyo Metropolitan Institute of Gerontology, 35-2 Sakae-cho, Itabashi-ku, Tokyo 173-0015, Japan e-mail: [email protected] M. Kim The Center on Aging and Health, Johns Hopkins University, Baltimore, USA K. Tanaka Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
demonstrated no floor effect and minimal ceiling effect (8.7 %). The total PPS score showed large areas under the curve (AUC = 0.89; 95 % confidence interval, 0.86–0.92) with regard to discrimination between individuals with and without LTC needs. In observational analysis, total PPS score demonstrated small meaningful change in high-risk individuals requiring care (effect size 0.34). Conclusions The PPS may be a useful tool for identifying functional status decline and improvement in older adults requiring community-based LTC. Keywords Physical performance Long-term care Geriatric assessment Older adults
Introduction Around the world, communities face extraordinary growth in the number of older adults who will require some longterm care (LTC) services. The Japanese government initiated the public LTC insurance system in April 2000 in response to the increasing number of older adults that require care [1]. LTC insurance covers 2 types of services: community-based services include services provided to those with LTC needs living in the community (e.g., home help, day care, day rehabilitation, short-stay personal care, or medical and home modifications) and institutional services (e.g., nursing homes, group homes, and respite care).In April 2006, the LTC insurance system was changed and new preventive benefits were introduced. LTC insurance facilitates use of community-based services by individuals certified as requiring long-term care, thus aiming to prevent the decline of functional status by allowing elderly people to live independently in the community for as long as possible and by expanding community-based care [2].
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Decline in functional status [e.g., functional limitation, instrumental activities of daily living (IADLs), and activities of daily living (ADLs)] is a common feature of aging and has important outcomes in terms of necessitating medical and long-term care [3, 4]. Objective performancebased measures provide more information about individuals’ functional status and offer the ability to assess change over a continuous scale in a wider range of abilities as compared to categorical changes assessed by self-report measures [5, 6]. Physical performance is a critical component of the assessment of older adults, and performance measures including summary scores and single items have proven useful in the prediction of adverse health outcomes [7–11]. The short physical performance battery (SPPB), composed of 3 objective tests that measure lower-extremity function, has been widely used since its validation in large epidemiological studies of relatively healthy older adults [7]. However, an initial screen for disability should take into account both upper- and lower-extremity function. For instance, testing for upper-extremity grip strength is considered an important component in the causal pathway for the development of functional limitations, frailty, and disability [9, 12]. Balance ability is an important risk for falls and is affected by the progressive loss of sensorimotor function with increasing age [13]. The ability to maintain both static and dynamic balance is a key predictor of falls and indicator of function in older adults [14, 15]. Brief clinical assessments often focus on the tandem stance component of SPPB. However, the addition of the one-leg stance to the tandem stance tests is more sensitive and appropriate for the screening of functional decline [16, 17]. Furthermore, increasing the complexity of administering and interpreting multiple tests in a clinical setting has been associated with an increased ability to predict the risk of developing adverse health outcomes [11]. An appropriate and standardized multidimensional measurement that includes grip strength, several balance tests, and mobility performance may help to identify at-risk individuals, preferentially at early stages of functional decline, and establish preventive strategies derived from different functional domains. To select tailored preventive programs in the Japanese LTC insurance system, individuals at risk for subsequent disability are identified by a basic functional status questionnaire. To our knowledge, no previous studies have conducted a validation of a multidimensional assessment of physical performance among older adults with communitybased LTC needs in the context of a public LTC insurance system. The aim of our study was to develop and validate a multidimensional assessment of physical function, which we term as the physical performance scale (PPS).Our goals were to (a) determine the correlation of the PPS with self-
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reported functional status (ADLs, IADLs, and SF-36 PF), (b) compare the capacity of the PPS with the SPPB and SF36 PF to discriminate between individuals with and without LTC needs, and (c) analyze whether the PPS was sensitive to change within communities of older adults at high risk of requiring community-based LTC.
Methods Study sample Participants were enrolled on a voluntary basis in response to a series of informative lectures at senior centers, leisure centers, and community-based day care service centers and recruited from the towns of Ibaraki and Fukushima, Japan, between October 2008 and June 2009. This study was conducted in accordance with the guidelines proposed in the Declaration of Helsinki, and the study protocol was reviewed and approved by the ethics committee of the University of Tsukuba, Japan. We enrolled 367 participants with a mean age of 83.3 ± 4.3 years (range 75–101 years) in the cross-sectional study, including 148 individuals with LTC needs and 219 individuals without LTC needs according to the Japanese LTC insurance system, referred to as ‘‘Kaigo-Hoken’’ [2]. LTC needs were determined by the local government through a predetermined process. To receive LTC services, an older adult or his/her caregiver contacts the municipal government to have their care needs officially certified. A trained local government official visits the home to evaluate nursing care needs using a 74-item questionnaire on current mental and physical condition, and the primary decision is reached by a computer-based evaluation of various criteria. The secondary decision is made within 30 days of application by a Care Needs Certification Board based on results of the primary decision, the home-visit report, and the family doctor’s written opinion. A government computer program classifies each applicant into care-need levels. Care Needs Certification Boards are composed of physicians, nurses, and welfare specialists in health and social services appointed by the mayor. Finally, LTC needs are provided through homeand community-based or institutional services. LTC needs are re-evaluated every 6 months, and LTC recipients may request changes to the care plan and, if dissatisfied, change the manager and/or provider. The participants in this study included individuals with and without LTC needs living in their homes. The observational analyses were collected as part of a care prevention program and included 49 participants with mean age of 80.4 ± 3.5 years (range 75–92 years) who represented a sample of the elderly community at high risk
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of requiring care based on medical examinations [2]. Individuals identified as high risk included those who required additional support or care, had become less active, and were candidates for preventive care services provided by the community support project [1]. The exercise intervention comprised a comprehensive program of 12 weekly 90-min group physical exercise (actual exercise duration approximately 45 min) and a daily home-based exercise routine based on physical function. The low-intensity program included exercises to improve balance, mobility, ADL, and recreational activities. The balance and mobility exercises consisted of activities such as standing in various postures, walking with various challenges such as obstacles, sit-to-stand movements, and rapid knee raises while standing. In this study, all assessments were conducted in community-based settings (e.g., senior centers, leisure centers, community general support centers, and facility-based day care service centers).The participants had to meet the following inclusion criteria for the cross-sectional and observational studies: (a) aged 75 years or older, (b) able to walk with or without a walking device, (c) ability to understand the instructions of the performance tests and questionnaires, and (d) no history of any neurological disease (e.g., stroke or Parkinson’s disease) with residual impairment. Measures Development of the physical performance scale Performance criteria for functional status categories differ [11, 18, 19], possibly because of differences in physical characteristics, culture, and lifestyle, especially between older adults from Western and Eastern countries [20, 21]. Therefore, the reference criteria for cutoff values should be established for each population being assessed. We began the process of establishing content validity with a comprehensive review of the published literature, which allowed us to establish a conceptual and theoretical framework for measures and individual test items. The 7 items of the physical performance scale were selected, in part, to include a spectrum of physiological demands, including upper-extremity strength, lower-extremity strength (5 chair sit-to-stand and alternating step), ability to balance (tandem stance, one-legged stance, and tandem walk), and ability to walk. We used 5 chair sit-to-stand and alternating step tests as proxy indicators of lower-extremity strength. The 7 items in the PPS scale are presented in the Appendix. Gender-specific levels of grip strength, 5 chair sit-to-stand, static balance, and gait speed tests were scored using a 0- to 4-point scale. The alternating step and tandem
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walk tests were scored using a 0- to 2-point scale, for a total of 20 possible points on the PPS. In this study, each item used revised scoring criteria for the identification of hierarchical physical function based on a reference population of older Japanese adults assessed in our previous study [19, 22–24]. The PPS takes approximately 15–20 min to administer, which for each test included 2 trials after a simple demonstration of how to complete each item. The average score of 2 trials for each test was used in the analysis. Grip strength was measured using a dynamometer (GRIP-D, T.K.K 5401, Takei Scientific Inc. Co., Ltd., Japan) with participants in a standing position with arms hanging naturally at their sides [23]. The chair sit-tostand test measured the time required to stand up and sit down 5 times as quickly as possible from a straightbacked armchair. The participants were asked to complete 5 repetitive chair stands after first demonstrating the ability to rise once from the chair with arms folded across their chests. If they were unable to perform without using their arms, the participants were asked to complete the task, while using their arms (holding the armrest) [7]. The alternating step test involved weight shifting, which measured lateral stability. Participants were asked to step alternately 8 times with each leg onto a raised platform (19-cm high) [19]. The static balance test consisted of 4 tests of increasing difficulty, with eyes open and in a standing position; each participant underwent a series of tests including the performance of a side-by-side stand, a semi-tandem stand, a tandem stand, and a one-legged stand on an increasingly narrower base of support [25]. The tandem walk measured dynamic balance and was assessed using the timed forward tandem walk test over a 3-m course 5 cm in width. In addition, the number of mistakes was recorded. A composite measure was calculated by summing the times and number of mistakes [19]. For the usual gait speed test, participants were instructed to stand still with their feet just touching a starting line marked with tape. When they received the examiner’s command to start, they walked at their normal pace along a 5-m course until a few steps past the finish line. Participants were allowed to use canes or walkers [26]. Short physical performance battery The SPPB consists of 3 standing balance measures (tandem, semi-tandem, and side-by-side stands), 5 continuous chair stands, and gait speed. Each test was scored from 0 to 4 based on the normative scores obtained from the Established Population for Epidemiologic Studies of the Elderly. The scores were summed for a total score ranging from 0 to 12 [7].
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Measures of physical function Functional status was evaluated by IADLs and ADLs based on the Barthel Index. Functional status was reported by both participants and their proxies. The elements of physical function affecting health status were evaluated using the Physical Function subscale of the Medical Outcomes Study 36-item Short-Form (SF-36) and Health Survey (SF36 PF). Health-related information Participants were interviewed to obtain information on age, gender, living conditions, and body mass index (BMI, kg/ m2). The number of chronic comorbid conditions was recorded, including hypertension, diabetes mellitus, kidney disease, heart disease, breathing difficulties, osteoporosis, cerebrovascular accident, back problems, dyslipidemia, and arthritis. The participants were also asked to rate their current health status (poor, fair, very good or excellent). Statistical analysis Validity was evaluated using 3 approaches. First, we evaluated these measures by bivariate correlations between the total PPS scores and self-reported functional status (ADLs, IADLs, and SF-36 PF) using Spearman correlation coefficients. The Shapiro–Wilk W test assessed the normality of the distribution. Second, we assessed the differences in the proportions and means of the physical performance tests, PPS, and SPPB scores between the LTC needs group and the non-LTC needs group using the v2 and Mann–Whitney U tests. Third, the discriminative validity of the total PPS scores was determined using the area under the curve (AUC) and its 95 % confidence interval (CI) from receiver operating characteristic (ROC) curve analysis. AUC from 0.7 to 0.8 was classified as ‘‘acceptable’’ and from 0.8 to 0.9 as ‘‘excellent’’ discrimination. Areas under the ROC curves of the total PPS score, SPPB score, and SF-36 PF were compared using the DeLong method implemented in SigmaPlot software version 12.0. Sensitivity and specificity between SPPB score and PPS score were compared using the McNemar’s test. The optimal cutoff values with the greatest sum of sensitivity and specificity for correctly identifying LTC and non-LTC participants were determined using the Youden index. The observational study was designed to examine whether the PPS was sensitive to changes within communities of older adults. To analyze the changes within the study group after intervention, the Wilcoxon signed-rank test was used. An effect size over the intervention period for changes in PPS and SPPB scores was calculated for each group using the following equation: effect
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size = (meanPost - meanPre)/SDPre. Effect sizes of 0.2, 0.5, and 0.8 represent small, moderate and large effects, respectively [27]. Statistical analyses were performed using IBM SPSS Statistics 20 and SAS, V.9.2. All P values were 2 tailed, with values \0.05 considered statistically significant.
Results A total of 416 community-living adults aged 75 years and over were included in this study. Table 1 shows the demographic characteristics of participants in the crosssectional and observational studies. Table 2 shows the correlations between the PPS and SPPB scores and selfperceived physical function. Total PPS scores were significantly correlated with ADLs, IADLs, and SF-36 PF (range, r = 0.53–0.62). Total PPS scores and subscale scores were significantly correlated with SPPB scores (range, r = 0.47–0.88). Table 3 shows the proportions and means of the physical performance tests, PPS scores, and SPPB scores for these 2 groups. For all physical performance tests, individuals with LTC needs had lower performance scores than those without LTC needs (P \ 0.001). A greater proportion of those with LTC needs were unable to perform the PPS subtests as compared with those without LTC needs (one-legged stance test, 25.8 vs. 6.8 %; tandem stance test, 23.6 vs. 0.9 %; tandem walk test, 55.4 vs. 7.8 %; alternating step test, 62.2 vs. 3.7 %; Table 1 Characteristics of the analytical sample Characteristics
Cross-sectional analytical sample (n = 387)
Observational analytical sample (n = 49)
Age (years)
83.3 ± 4.3
80.4 ± 3.5
Women
248 (67.6)
41 (83.6)
Body mass index (kg/m2)
23.9 ± 3.6
24.9 ± 3.4
Living alone
54 (14.7)
8 (16.3)
Number of chronic medical conditions
1.5 ± 1.4
1.7 ± 1.4
Fair/poor self-perceived health
79 (21.5)
12 (24.4)
Activities of daily living* Instrumental activities of daily living à
Physical function
97.1 ± 10.4
96.5 ± 6.5
100 (90–100)a
100 (95–100)a
6.0 ± 2.3
7.2 ± 1
a
7 (5–8)
7 (7–8)a
61.5 ± 25.3
61.3 ± 20.2
Values are mean ± SD or n (%) of participants * The Barthel Index à a
The Lawton IADL scale 36-Item Short-Form, Physical Function Subscale Median (interquartile range)
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Table 2 Correlation between PPS, SPPB, and SF-36PF
Age Total PPS score
Age
Total PPS score
Upper-extremity strength
Lower-extremity strength
Ability to balance
Ability to walk
SPPB score
1.00
-0.31à
-0.22à
-0.28à
-0.24à
-0.29à
-0.30à
à
à
à
à
à
1.00
Upper-extremity strength
0.69 1.00
a
Lower-extremity strength
0.88
à
0.45 1.00
b
Ability to balance
0.85
à
0.46
à
0.66 1.00
Ability to walk
0.82
à
0.43
à
0.73
à
0.60
1.00
SPPB score
ADLs
0.88
à
0.47
à
0.86
à
0.74
à
0.79
1.00
ADLs
IADLs
SF-36PF
-0.24à
-0.27à
-0.15
à
à
0.53à
à
0.27à
à
0.50à
à
0.47à
à
0.48à
à
0.49à
à
0.70
0.54à
1.00
0.52à
0.55
à
0.29
à
0.56
à
0.48
à
0.48
à
0.53 1.00
IADLs SF-36PF
0.62 0.33 0.62 0.52 0.54 0.59
1.00
PPS physical performance scale, SPPB short physical performance battery, ADL activities of daily living, IADL instrumental activities of daily living, SF36PF 36-Item Short-Form physical function subscale a
5 chair sit-to-stand and alternating step
b
Tandem stance, one-legged stance, and tandem walk
Spearman rank correlation.
P \ 0.01,
à
P \ 0.001
and 5 chair sit-to-stand test, 6.8 vs. 0 %). The mean ± SD of total PPS scores for those with and without LTC needs was 9.9 ± 4.2 and 16.5 ± 3.0, respectively. Figure 1 shows the distribution of total PPS scores in the 2 groups (range 2–20).The figure shows that total PPS scores were highly skewed toward the low end of the range, with approximately 59 % of individuals with LTC needs scoring 10 or less. In comparison, 5.0 % of individuals without LTC needs scored 10 or less. AUC values are shown in Fig. 2. Total PPS score demonstrated large areas under the ROC curve with regard to discrimination between participants with and without LTC needs (AUC = 0.89; 95 %CI 0.86–0.92). While the AUC for total PPS score demonstrated a significantly greater ability to discriminate between those with and without LTC needs (P \ 0.01) as compared with the SPPB score (AUC = 0.81; 95 %CI 0.77–0.86)and SF-36 PF (AUC = 0.76; 95 % 0.70–0.80),the AUC for SPPB and SF-36 PF was not significantly different (P [ 0.05). The AUC of the age-adjusted multivariate regression model was 0.882 using the total PPS score, compared with 0.785 for the SPPB score (data not shown). The cut-off values for distinguishing between individuals with and without LTC needs and the sensitivity and specificity values for the total PPS and SPPB scores are listed in Table 4. The optimal cut-off value for the total PPS score was 14 for identifying LTC needs (with sensitivity of 80 % and specificity of 84 %);the optimal cut-off value for the SPPB score was 11 for identifying LTC needs (with sensitivity of 76 % and specificity of 78 %).The specificity of total PPS score was significantly higher than SPPB score (P \ 0.01).
The sensitivity was not significantly different between the two scales (P = 0.189) (data not shown). Table 5 shows the change in total PPS and subscale scores after a 12-week exercise intervention. Following the exercise intervention, the mean total PPS score (effect size 0.34) SPPB score (effect size 0.25), and all subscale scores (effect sizes 0.23–0.33) improved significantly (P \ 0.05), except for upper-extremity strength score (P = 0.687) and SF-36 PF (P = 0.557).
Discussion The aim of our study was to develop and validate a multidimensional assessment of physical performance among older adults with community-based long-term care needs in a public LTC insurance system. The PPS demonstrated concurrent validity with respect to self-reported functional status in the form of ADLs, IADLs, and SF-36PF. In the AUC analysis, total PPS score demonstrated a greater discriminative validity as compared to the SPPB score and SF-36PF. Moreover, the PPS showed sensitivity to change through implementation of an exercise intervention. These findings suggest that the PPS may be a useful tool for identifying functional status decline and improvement in individuals requiring community-based LTC. Physical performance measures have gained acceptance for functional status evaluation in older adults. In particular, summary scores have been created that can assess performance along a broad spectrum of functioning [7, 8, 28, 29]. The Physical Performance Test (PPT), a measure
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Table 3 Description statistics of the physical performance tests, PPS, and SPPB Without LTC needs (n = 219)
With LTC needs (n = 148)
Age (years)
82.3 ± 3.2
84.7 ± 5.2
Women
134 (61.2)
114 (77.0)
P \ 0.001
Grip strength (kg) Men
30.9 ± 6.2
23.4 ± 5.6
Women
20.6 ± 4.6
16.1 ± 4.1
17.6 ± 17.9
8.2 ± 11.2
Unable to complete Tandem stance (s) Unable to complete Tandem walka Unable to complete Alternating step (s) Unable to complete 5 chair sit-to-stand (s) Able to perform with use of arms Unable to complete Usual gait speed (m/s) Use of canes or walkers
15 (6.8)
38 (25.8)
22.3 ± 9.6
15.8 ± 10.6
2 (0.9)
35 (23.6)
15.9 ± 6.5
19.2 ± 6.4
17 (7.8)
82 (55.4)
6.1 ± 2.6
7.4 ± 2.4
8 (3.7)
92 (62.2)
9.9 ± 3.9 2 (0.9)
13.5 ± 4.6 26 (17.6)
0 (0)
10 (6.8)
1.0
0.8
1.08 ± 0.30
0.69 ± 0.30
6 (5.5)
22 (14.9)
Physical performance scale Total score (range 0–20)
16.5 ± 3.0
9.9 ± 4.2
Upper-extremity strength (range 0–4) Lower-extremity strength (range 0–6)b
2.9 ± 1.1
1.9 ± 1.0
5.3 ± 1.1
2.9 ± 1.8
Ability to balance (range 0–6)c
5.0 ± 1.1
2.9 ± 1.7
Ability to walk (range 0–4) SPPB score (range 0–12)
3.3 ± 0.9
2.2 ± 1.0
10.8 ± 2.0
7.3 ± 3.5
0.6
0.4
Total PPS score (AUC=0.89; 95%CI: 0.86-0.92) SPPB score (AUC=0.81; 95%CI: 0.77-0.86) SF-36PF (AUC=0.76; 95%CI: 0.70-0.80)
0.2
0.0 0.0
0.2
0.4
0.6
0.8
1.0
1 - Specificity
Values are mean ± SD or n (%) of participants. All performance measures demonstrated significant differences between groups (P \ 0.001). P values were based on the v2 and Mann–Whitney U tests PPS physical performance scale, SPPB short physical performance battery a
Composite measure was calculated by summing the time and the number of mistakes
b
5 chair sit-to-stand and alternating step
c
Tandem stance, one-legged stance, and tandem walk
of activities including ADLs and IADLs (e.g., writing a sentence, simulated eating, simulated dressing, and picking up a penny), was highly correlated (r = 0.50–0.80) with functional status assessments (i.e., modified Rosow–Breslau, ADLs, IADLs) in a sample of 183 elderly outpatients with mean age of 79.0 years [28]. Sherman and Reuben [30] reported that the PPT (r = 0.37–0.46) and SPPB
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Fig. 1 Distribution of the total PPS score in individuals with LTC needs and those without LTC needs. PPS physical performance scale, LTC long-term care
Sensitivity
One-legged stance (s)
Fig. 2 The receiver operator curve (ROC) of the total PPS score, SPPB score, and SF 36 PF. PPS physical performance scale, SPPB short physical performance battery, SF-36PF 36-Item Short-Form Physical Function Subscale
(r = 0.42–0.48) were well correlated with ADLs, IADLs, and SF-36PF among 363 community-dwelling elderly adults with mean age of 75.9 years. Our study is consistent with previous reports in the moderate correlations observed between total PPS score and self-reported functional status based on ADLs (r = 0.55), IADLs (r = 0.62), and SF-36 PF (r = 0.53). Floor and ceiling effects are considered to be present when more than 15 % of respondents achieve the lowest or highest possible score, respectively [31]. A previous study reported that the continuous scale physical functional performance test (CS-PFP), consisting of a battery of 15 everyday tasks, showed no floor effect for LTC facility residents or ceiling effect for community dwellers [29].
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Table 4 Sensitivity and specificity of PPS and SPPB for identifying LTC needs
Physical performance scale Total score
SPPB score
Cutoff value
Sensitivity (%)
Specificity (%)
Sum of sensitivity and specificity
12
67
93
160
13
71
88
159
14
80
84
165
15
85
76
161
16
88
68
156
17 7
91 41
59 95
150 136
8
46
90
140
9
55
85
141
10
66
80
147
11
76
78
153
12
86
60
146
PPS physical performance scale, SPPB short physical performance battery
Table 5 The PPS, SPPB, and SF-36PF at baseline and at 12 weeks (n = 49) Baseline
12 weeks
P value
Effect size
14.3 ± 3.5
15.5 ± 3.7
0.001
0.34
Upper-extremity strength (range 0–4)
2.5 ± 1.2
2.6 ± 1.1
0.686
0.08
Lower-extremity strength (range 0–6)a
4.6 ± 1.3
4.9 ± 1.2
0.033
0.23
Ability to balance (range 0–6)b
4.5 ± 1.2
4.9 ± 1.3
0.016
0.33
Ability to walk (range 0–4)
2.8 ± 0.9
3.1 ± 0.9
0.004
0.33
SPPB score (range 0–12)
9.6 ± 2.4
10.2 ± 2.5
0.015
0.25
SF-36PF
61.3 ± 20.2
63.9 ± 19.0
0.709
0.18
Physical performance scale Total score (range 0–20)
Values are mean ± SD. P values were based on the Wilcoxon signedrank test PPS physical performance scale, SPPB short physical performance battery, SF-36PF 36-item Short-Form physical function subscale a
5 chair sit-to-stand and alternating step
b
Tandem stance, one-legged stance, and tandem walk
However, this battery requires measurements of 15 activities of daily living and takes approximately 45 min to administer to community-dwelling older adults and
60–75 min to LTC facility residents. Thus, CS-PFP may be limited in community and home settings. Total PPS score demonstrated no floor effect and minimal ceiling effect (8.7 %) in our study subjects. By contrast, SPPB score demonstrated a substantial ceiling effect (41.1 %), with 59.8 % of maximum scores recorded in individuals without LTC needs (data not shown). Guralnik et al. [8] reported that among 1,122 community-dwelling men and women aged 71 or older, 10.6 %of participants had the highest possible SPPB score of 12. This difference in distribution may arise from marked differences in performance criteria for the functional status categories [11, 18, 19] arising from differences in physical characteristics, culture, and lifestyle [20, 21].Therefore, the scaling of the PPS from a reference population of older Japanese adults can provide basic physical information about those at the very lowest functional levels. Total PPS score in our study demonstrated a higher level of AUC discrimination between individuals with and without LTC needs than SPPB score or SF-36 PF. The difference in AUCs between the PPS and SPPB was 13 %, with a small overlap between the 95 % CIs of total PPS score (lower 95 % CI, 0.86) and SPPB score (upper 95 % CI, 0.86). To our knowledge, no comparative studies have determined the discriminative capacity of a summary performance score for care requirements established by the LTC insurance system. However, a previous study found that a summary performance score incorporating walking speed, one-leg standing, and grip strength was more useful for older people (over 75 years) than younger people (aged 65–74 years) in predicting the onset of functional dependence, suggesting that at advanced age, physical performance becomes more critical for maintaining an independent life than at younger ages and stressing the importance of functional evaluation in a clinical setting even at advanced ages. In our study, the PPS included grip strength and complex tests of lower-extremity performance. The simple test for upper-extremity performance, handgrip strength, is a useful marker of frailty and an important predictor of disability in community-dwelling older adults [9, 12]. Taekema et al. [32] reported that lower handgrip strength predicted an accelerated decline in ADL disability and cognition, and thus contributes to increasing dependency in old age. Therefore, measuring handgrip strength can be useful to identify those ‘‘oldest old’’ patients at risk for future decline in clinical geriatric practice. In 7,250 community-dwelling non-disabled French women aged 75 years or older, after adjustment for multiple potential confounding factors, poor SPPB and lower handgrip strength were independent predictors of mortality [33].Moreover, grip strength is a good indicator of overall nursing home transfer,
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fracture, and functional change (e.g., decline in ADLs per 100 days) in older adult residents in residential care and assisted living facilities [34]. Tandem stance is 1 of 3 positions comprising the SPPB balance scale [7] and is also included in the Berg Balance Scale [35] and the Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT)-4 scale [25]. Rossiter-Fornff et al. [25] reported that the FICSIT-4 scale with the addition of the one-legged stance to the FICSIT battery of stance tests (parallel, semi-tandem, and tandem) is useful to discriminate balance over a wide range of health status levels. While SPPB is a composite measure of static balance, chair stand, and gait speed, the PPS includes upper-extremity strength and a comprehensive range of tests of sufficiently varying difficulty (e.g., dynamic balance, alternating step) to predict changes in physical abilities along the entire spectrum of functioning [36].Therefore, the PPS is more likely than the SPPB alone to discriminate a high risk of functional dependence in individuals requiring community-based long-term care within a public LTC insurance system. To identify the risk of functional decline and necessity for LTC in older adults, criterion reference points can be used in clinical practice (12, 14). Our study found that the optimal cut-off value for the total PPS score was 14, and the PPS had the highest sensitivity (80 %) and specificity (84 %) in identifying LTC needs. Thus, this cut-off point may be used in other settings due to its high sensitivity and specificity. The optimal cut-off value for the SPPB with the highest sensitivity (76 %) and specificity (78 %) in identifying LTC needs was 11. In previous studies, an SPPB score of 9 was associated with progressively higher risk of disability [8]. Again, this difference may be due to differences in physical characteristics, culture, and lifestyle. Like vital signs such as body weight or blood pressure, physical performance measures may offer a powerful mechanism to understand the healthcare needs of older adults [37]. Despite its short term, our observational study demonstrated that the PPS could detect meaningful small changes in older adults at high risk of requiring care based on the LTC insurance system. The mean total PPS score, SPPB, and most subscale scores improved significantly (effect size, 0.23–0.34). These results are similar to those obtained in a previous systematic review [38]. The upper-extremity strength test was the only subscale not significantly changed by physical exercise. In a previous study, the upperextremity strength test also failed to detect such changes [39], although the handgrip strength test for upper-
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extremity function is a highly useful marker of frailty and important predictor of disability. Further research may provide a better understanding of the importance of handgrip strength as a physical performance screening tool and the appropriateness of handgrip strength as a sensitive measure for intervention studies. Taken together, the PPS provides more information about physical abilities relative to the SPPB and appears clinically useful as a comprehensive assessment tool in communities of older adults at high risk of requiring care based on the LTC insurance system. The present study has several limitations. First, our use of the PPS among older community-dwelling volunteers in a primary care setting may not be applicable to populations in nursing homes, hospitals, and other institutions. Second, our findings were based on crosssectional data, which did not allow us to evaluate the predictive capacity of various functions considered in the study, and which may have limited the generalizability of the results. Finally, the observational study, which examined sensitivity to change, did not include a control group. Further research is needed to confirm the capacity of the PPS to detect changes in randomized controlled trials and cohort studies. In conclusion, the PPS demonstrated concurrent validity with self-reported functional status reflected by ADLs, IADLs, and SF-36PF. Although the PPS is slightly more timeconsuming than the SPPB inmost clinical settings, the PPS has the capacity to discriminate between groups and is sensitive to functional changes. These findings suggest that the PPS may be a useful tool for identifying functional status decline and recovery in older adults. Thus, the PPS may help to guide the implementation of interventions that have been effective in clinical trials in LTC settings in Japanese communities aged 75 years and older. Investigators and clinicians are encouraged to consider using this measure to examine outcomes in clinical settings and for clinical trials that examine the overall functional impact of interventions. Acknowledgments We are very grateful to the subjects for their enthusiastic participation during measurements. The study was supported by the Japan Society for the Promotion of Science (Grant-inAid for Scientific Research (A) # 19200047). Conflict of interest
Appendix See Table 6.
None.
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Table 6 Test items and scoring categories for the physical performance scale Components of physical performance
Test items
Upper-extremity strength
Grip strength
Lower-extremity strength
Scoring categories
5 chair sit-to-stand
Men
Women
4
C33 kg
C22 kg
3
28–32.9 kg
18–21.9 kg
2
24–27.9 kg
16–17.9 kg
1
\24 kg
\16 kg
0
Unable to grip
Unable to grip
4
B10.0 s
3
10.1–12.5 s
2
[12.5 s (able to do 5 chair stands without use of arms)
1
Able to do 5 chair stands with use of arms Unable to stand
0 Alternating step
Ability to balance
Ability to walk
2
B8.5 s
1
[8.5 s
0
Unable to step C10 and C30 s
One-legged stance and full tandem stance
4
Full tandem stance
3
C15 s
Full tandem stance and semi-tandem stance
2
C10 s
Full tandem stance and semi-tandem stance and side-by-side stance
1
\10 and C10 and C10 s
Side-by-side stance
0
\10 s or unable to complete
Tandem walk
2
B18.5
1 0
[18.5 Unable to complete
4
C1.0 m/s
3
0.80–0.99 m/s
Usual gait speed
Total score
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ORIGINAL ARTICLE
A multidimensional assessment of physical performance for older Japanese people with community-based long-term care needs Miji Kim • Kiyoji Tanaka
Received: 6 March 2013 / Accepted: 10 October 2013 / Published online: 14 May 2014 Ó Springer International Publishing Switzerland 2014
Abstract Background and aims A multidimensional assessment representing overall lower- and upper-extremity performance is necessary to identify functional decline among older adults. The aim of this study was to develop and validate a physical performance scale (PPS) using both cross-sectional and observational approaches in older adults with and without community-based long-term care (LTC) needs in Japan. Methods A total of 416 community-living adults aged 75 years and over. The 7 items of the PPS include a range of physiological challenges, such as assessment of upperextremity strength, lower-extremity strength, balance, and walking ability. Concurrent validity [correlating the PPS with self-reported functional status in activities of daily living (ADLs), instrumental ADLs, and Physical Function subscale of the Medical Outcomes Study 36-Item ShortForm Health Survey (SF-36PF)] and discriminative validity were assessed. Sensitivity to changes was evaluated with a 12-week exercise program. Results Total PPS score was significantly correlated with self-reported functional status such as ADLs, instrumental ADLs (IADLs), and SF-36PF (r = 0.53–0.62) and M. Kim (&) Research Team for Promoting Independence of the Elderly, Tokyo Metropolitan Institute of Gerontology, 35-2 Sakae-cho, Itabashi-ku, Tokyo 173-0015, Japan e-mail: [email protected] M. Kim The Center on Aging and Health, Johns Hopkins University, Baltimore, USA K. Tanaka Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
demonstrated no floor effect and minimal ceiling effect (8.7 %). The total PPS score showed large areas under the curve (AUC = 0.89; 95 % confidence interval, 0.86–0.92) with regard to discrimination between individuals with and without LTC needs. In observational analysis, total PPS score demonstrated small meaningful change in high-risk individuals requiring care (effect size 0.34). Conclusions The PPS may be a useful tool for identifying functional status decline and improvement in older adults requiring community-based LTC. Keywords Physical performance Long-term care Geriatric assessment Older adults
Introduction Around the world, communities face extraordinary growth in the number of older adults who will require some longterm care (LTC) services. The Japanese government initiated the public LTC insurance system in April 2000 in response to the increasing number of older adults that require care [1]. LTC insurance covers 2 types of services: community-based services include services provided to those with LTC needs living in the community (e.g., home help, day care, day rehabilitation, short-stay personal care, or medical and home modifications) and institutional services (e.g., nursing homes, group homes, and respite care).In April 2006, the LTC insurance system was changed and new preventive benefits were introduced. LTC insurance facilitates use of community-based services by individuals certified as requiring long-term care, thus aiming to prevent the decline of functional status by allowing elderly people to live independently in the community for as long as possible and by expanding community-based care [2].
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Decline in functional status [e.g., functional limitation, instrumental activities of daily living (IADLs), and activities of daily living (ADLs)] is a common feature of aging and has important outcomes in terms of necessitating medical and long-term care [3, 4]. Objective performancebased measures provide more information about individuals’ functional status and offer the ability to assess change over a continuous scale in a wider range of abilities as compared to categorical changes assessed by self-report measures [5, 6]. Physical performance is a critical component of the assessment of older adults, and performance measures including summary scores and single items have proven useful in the prediction of adverse health outcomes [7–11]. The short physical performance battery (SPPB), composed of 3 objective tests that measure lower-extremity function, has been widely used since its validation in large epidemiological studies of relatively healthy older adults [7]. However, an initial screen for disability should take into account both upper- and lower-extremity function. For instance, testing for upper-extremity grip strength is considered an important component in the causal pathway for the development of functional limitations, frailty, and disability [9, 12]. Balance ability is an important risk for falls and is affected by the progressive loss of sensorimotor function with increasing age [13]. The ability to maintain both static and dynamic balance is a key predictor of falls and indicator of function in older adults [14, 15]. Brief clinical assessments often focus on the tandem stance component of SPPB. However, the addition of the one-leg stance to the tandem stance tests is more sensitive and appropriate for the screening of functional decline [16, 17]. Furthermore, increasing the complexity of administering and interpreting multiple tests in a clinical setting has been associated with an increased ability to predict the risk of developing adverse health outcomes [11]. An appropriate and standardized multidimensional measurement that includes grip strength, several balance tests, and mobility performance may help to identify at-risk individuals, preferentially at early stages of functional decline, and establish preventive strategies derived from different functional domains. To select tailored preventive programs in the Japanese LTC insurance system, individuals at risk for subsequent disability are identified by a basic functional status questionnaire. To our knowledge, no previous studies have conducted a validation of a multidimensional assessment of physical performance among older adults with communitybased LTC needs in the context of a public LTC insurance system. The aim of our study was to develop and validate a multidimensional assessment of physical function, which we term as the physical performance scale (PPS).Our goals were to (a) determine the correlation of the PPS with self-
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reported functional status (ADLs, IADLs, and SF-36 PF), (b) compare the capacity of the PPS with the SPPB and SF36 PF to discriminate between individuals with and without LTC needs, and (c) analyze whether the PPS was sensitive to change within communities of older adults at high risk of requiring community-based LTC.
Methods Study sample Participants were enrolled on a voluntary basis in response to a series of informative lectures at senior centers, leisure centers, and community-based day care service centers and recruited from the towns of Ibaraki and Fukushima, Japan, between October 2008 and June 2009. This study was conducted in accordance with the guidelines proposed in the Declaration of Helsinki, and the study protocol was reviewed and approved by the ethics committee of the University of Tsukuba, Japan. We enrolled 367 participants with a mean age of 83.3 ± 4.3 years (range 75–101 years) in the cross-sectional study, including 148 individuals with LTC needs and 219 individuals without LTC needs according to the Japanese LTC insurance system, referred to as ‘‘Kaigo-Hoken’’ [2]. LTC needs were determined by the local government through a predetermined process. To receive LTC services, an older adult or his/her caregiver contacts the municipal government to have their care needs officially certified. A trained local government official visits the home to evaluate nursing care needs using a 74-item questionnaire on current mental and physical condition, and the primary decision is reached by a computer-based evaluation of various criteria. The secondary decision is made within 30 days of application by a Care Needs Certification Board based on results of the primary decision, the home-visit report, and the family doctor’s written opinion. A government computer program classifies each applicant into care-need levels. Care Needs Certification Boards are composed of physicians, nurses, and welfare specialists in health and social services appointed by the mayor. Finally, LTC needs are provided through homeand community-based or institutional services. LTC needs are re-evaluated every 6 months, and LTC recipients may request changes to the care plan and, if dissatisfied, change the manager and/or provider. The participants in this study included individuals with and without LTC needs living in their homes. The observational analyses were collected as part of a care prevention program and included 49 participants with mean age of 80.4 ± 3.5 years (range 75–92 years) who represented a sample of the elderly community at high risk
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of requiring care based on medical examinations [2]. Individuals identified as high risk included those who required additional support or care, had become less active, and were candidates for preventive care services provided by the community support project [1]. The exercise intervention comprised a comprehensive program of 12 weekly 90-min group physical exercise (actual exercise duration approximately 45 min) and a daily home-based exercise routine based on physical function. The low-intensity program included exercises to improve balance, mobility, ADL, and recreational activities. The balance and mobility exercises consisted of activities such as standing in various postures, walking with various challenges such as obstacles, sit-to-stand movements, and rapid knee raises while standing. In this study, all assessments were conducted in community-based settings (e.g., senior centers, leisure centers, community general support centers, and facility-based day care service centers).The participants had to meet the following inclusion criteria for the cross-sectional and observational studies: (a) aged 75 years or older, (b) able to walk with or without a walking device, (c) ability to understand the instructions of the performance tests and questionnaires, and (d) no history of any neurological disease (e.g., stroke or Parkinson’s disease) with residual impairment. Measures Development of the physical performance scale Performance criteria for functional status categories differ [11, 18, 19], possibly because of differences in physical characteristics, culture, and lifestyle, especially between older adults from Western and Eastern countries [20, 21]. Therefore, the reference criteria for cutoff values should be established for each population being assessed. We began the process of establishing content validity with a comprehensive review of the published literature, which allowed us to establish a conceptual and theoretical framework for measures and individual test items. The 7 items of the physical performance scale were selected, in part, to include a spectrum of physiological demands, including upper-extremity strength, lower-extremity strength (5 chair sit-to-stand and alternating step), ability to balance (tandem stance, one-legged stance, and tandem walk), and ability to walk. We used 5 chair sit-to-stand and alternating step tests as proxy indicators of lower-extremity strength. The 7 items in the PPS scale are presented in the Appendix. Gender-specific levels of grip strength, 5 chair sit-to-stand, static balance, and gait speed tests were scored using a 0- to 4-point scale. The alternating step and tandem
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walk tests were scored using a 0- to 2-point scale, for a total of 20 possible points on the PPS. In this study, each item used revised scoring criteria for the identification of hierarchical physical function based on a reference population of older Japanese adults assessed in our previous study [19, 22–24]. The PPS takes approximately 15–20 min to administer, which for each test included 2 trials after a simple demonstration of how to complete each item. The average score of 2 trials for each test was used in the analysis. Grip strength was measured using a dynamometer (GRIP-D, T.K.K 5401, Takei Scientific Inc. Co., Ltd., Japan) with participants in a standing position with arms hanging naturally at their sides [23]. The chair sit-tostand test measured the time required to stand up and sit down 5 times as quickly as possible from a straightbacked armchair. The participants were asked to complete 5 repetitive chair stands after first demonstrating the ability to rise once from the chair with arms folded across their chests. If they were unable to perform without using their arms, the participants were asked to complete the task, while using their arms (holding the armrest) [7]. The alternating step test involved weight shifting, which measured lateral stability. Participants were asked to step alternately 8 times with each leg onto a raised platform (19-cm high) [19]. The static balance test consisted of 4 tests of increasing difficulty, with eyes open and in a standing position; each participant underwent a series of tests including the performance of a side-by-side stand, a semi-tandem stand, a tandem stand, and a one-legged stand on an increasingly narrower base of support [25]. The tandem walk measured dynamic balance and was assessed using the timed forward tandem walk test over a 3-m course 5 cm in width. In addition, the number of mistakes was recorded. A composite measure was calculated by summing the times and number of mistakes [19]. For the usual gait speed test, participants were instructed to stand still with their feet just touching a starting line marked with tape. When they received the examiner’s command to start, they walked at their normal pace along a 5-m course until a few steps past the finish line. Participants were allowed to use canes or walkers [26]. Short physical performance battery The SPPB consists of 3 standing balance measures (tandem, semi-tandem, and side-by-side stands), 5 continuous chair stands, and gait speed. Each test was scored from 0 to 4 based on the normative scores obtained from the Established Population for Epidemiologic Studies of the Elderly. The scores were summed for a total score ranging from 0 to 12 [7].
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Measures of physical function Functional status was evaluated by IADLs and ADLs based on the Barthel Index. Functional status was reported by both participants and their proxies. The elements of physical function affecting health status were evaluated using the Physical Function subscale of the Medical Outcomes Study 36-item Short-Form (SF-36) and Health Survey (SF36 PF). Health-related information Participants were interviewed to obtain information on age, gender, living conditions, and body mass index (BMI, kg/ m2). The number of chronic comorbid conditions was recorded, including hypertension, diabetes mellitus, kidney disease, heart disease, breathing difficulties, osteoporosis, cerebrovascular accident, back problems, dyslipidemia, and arthritis. The participants were also asked to rate their current health status (poor, fair, very good or excellent). Statistical analysis Validity was evaluated using 3 approaches. First, we evaluated these measures by bivariate correlations between the total PPS scores and self-reported functional status (ADLs, IADLs, and SF-36 PF) using Spearman correlation coefficients. The Shapiro–Wilk W test assessed the normality of the distribution. Second, we assessed the differences in the proportions and means of the physical performance tests, PPS, and SPPB scores between the LTC needs group and the non-LTC needs group using the v2 and Mann–Whitney U tests. Third, the discriminative validity of the total PPS scores was determined using the area under the curve (AUC) and its 95 % confidence interval (CI) from receiver operating characteristic (ROC) curve analysis. AUC from 0.7 to 0.8 was classified as ‘‘acceptable’’ and from 0.8 to 0.9 as ‘‘excellent’’ discrimination. Areas under the ROC curves of the total PPS score, SPPB score, and SF-36 PF were compared using the DeLong method implemented in SigmaPlot software version 12.0. Sensitivity and specificity between SPPB score and PPS score were compared using the McNemar’s test. The optimal cutoff values with the greatest sum of sensitivity and specificity for correctly identifying LTC and non-LTC participants were determined using the Youden index. The observational study was designed to examine whether the PPS was sensitive to changes within communities of older adults. To analyze the changes within the study group after intervention, the Wilcoxon signed-rank test was used. An effect size over the intervention period for changes in PPS and SPPB scores was calculated for each group using the following equation: effect
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size = (meanPost - meanPre)/SDPre. Effect sizes of 0.2, 0.5, and 0.8 represent small, moderate and large effects, respectively [27]. Statistical analyses were performed using IBM SPSS Statistics 20 and SAS, V.9.2. All P values were 2 tailed, with values \0.05 considered statistically significant.
Results A total of 416 community-living adults aged 75 years and over were included in this study. Table 1 shows the demographic characteristics of participants in the crosssectional and observational studies. Table 2 shows the correlations between the PPS and SPPB scores and selfperceived physical function. Total PPS scores were significantly correlated with ADLs, IADLs, and SF-36 PF (range, r = 0.53–0.62). Total PPS scores and subscale scores were significantly correlated with SPPB scores (range, r = 0.47–0.88). Table 3 shows the proportions and means of the physical performance tests, PPS scores, and SPPB scores for these 2 groups. For all physical performance tests, individuals with LTC needs had lower performance scores than those without LTC needs (P \ 0.001). A greater proportion of those with LTC needs were unable to perform the PPS subtests as compared with those without LTC needs (one-legged stance test, 25.8 vs. 6.8 %; tandem stance test, 23.6 vs. 0.9 %; tandem walk test, 55.4 vs. 7.8 %; alternating step test, 62.2 vs. 3.7 %; Table 1 Characteristics of the analytical sample Characteristics
Cross-sectional analytical sample (n = 387)
Observational analytical sample (n = 49)
Age (years)
83.3 ± 4.3
80.4 ± 3.5
Women
248 (67.6)
41 (83.6)
Body mass index (kg/m2)
23.9 ± 3.6
24.9 ± 3.4
Living alone
54 (14.7)
8 (16.3)
Number of chronic medical conditions
1.5 ± 1.4
1.7 ± 1.4
Fair/poor self-perceived health
79 (21.5)
12 (24.4)
Activities of daily living* Instrumental activities of daily living à
Physical function
97.1 ± 10.4
96.5 ± 6.5
100 (90–100)a
100 (95–100)a
6.0 ± 2.3
7.2 ± 1
a
7 (5–8)
7 (7–8)a
61.5 ± 25.3
61.3 ± 20.2
Values are mean ± SD or n (%) of participants * The Barthel Index à a
The Lawton IADL scale 36-Item Short-Form, Physical Function Subscale Median (interquartile range)
Aging Clin Exp Res (2014) 26:269–278
273
Table 2 Correlation between PPS, SPPB, and SF-36PF
Age Total PPS score
Age
Total PPS score
Upper-extremity strength
Lower-extremity strength
Ability to balance
Ability to walk
SPPB score
1.00
-0.31à
-0.22à
-0.28à
-0.24à
-0.29à
-0.30à
à
à
à
à
à
1.00
Upper-extremity strength
0.69 1.00
a
Lower-extremity strength
0.88
à
0.45 1.00
b
Ability to balance
0.85
à
0.46
à
0.66 1.00
Ability to walk
0.82
à
0.43
à
0.73
à
0.60
1.00
SPPB score
ADLs
0.88
à
0.47
à
0.86
à
0.74
à
0.79
1.00
ADLs
IADLs
SF-36PF
-0.24à
-0.27à
-0.15
à
à
0.53à
à
0.27à
à
0.50à
à
0.47à
à
0.48à
à
0.49à
à
0.70
0.54à
1.00
0.52à
0.55
à
0.29
à
0.56
à
0.48
à
0.48
à
0.53 1.00
IADLs SF-36PF
0.62 0.33 0.62 0.52 0.54 0.59
1.00
PPS physical performance scale, SPPB short physical performance battery, ADL activities of daily living, IADL instrumental activities of daily living, SF36PF 36-Item Short-Form physical function subscale a
5 chair sit-to-stand and alternating step
b
Tandem stance, one-legged stance, and tandem walk
Spearman rank correlation.
P \ 0.01,
à
P \ 0.001
and 5 chair sit-to-stand test, 6.8 vs. 0 %). The mean ± SD of total PPS scores for those with and without LTC needs was 9.9 ± 4.2 and 16.5 ± 3.0, respectively. Figure 1 shows the distribution of total PPS scores in the 2 groups (range 2–20).The figure shows that total PPS scores were highly skewed toward the low end of the range, with approximately 59 % of individuals with LTC needs scoring 10 or less. In comparison, 5.0 % of individuals without LTC needs scored 10 or less. AUC values are shown in Fig. 2. Total PPS score demonstrated large areas under the ROC curve with regard to discrimination between participants with and without LTC needs (AUC = 0.89; 95 %CI 0.86–0.92). While the AUC for total PPS score demonstrated a significantly greater ability to discriminate between those with and without LTC needs (P \ 0.01) as compared with the SPPB score (AUC = 0.81; 95 %CI 0.77–0.86)and SF-36 PF (AUC = 0.76; 95 % 0.70–0.80),the AUC for SPPB and SF-36 PF was not significantly different (P [ 0.05). The AUC of the age-adjusted multivariate regression model was 0.882 using the total PPS score, compared with 0.785 for the SPPB score (data not shown). The cut-off values for distinguishing between individuals with and without LTC needs and the sensitivity and specificity values for the total PPS and SPPB scores are listed in Table 4. The optimal cut-off value for the total PPS score was 14 for identifying LTC needs (with sensitivity of 80 % and specificity of 84 %);the optimal cut-off value for the SPPB score was 11 for identifying LTC needs (with sensitivity of 76 % and specificity of 78 %).The specificity of total PPS score was significantly higher than SPPB score (P \ 0.01).
The sensitivity was not significantly different between the two scales (P = 0.189) (data not shown). Table 5 shows the change in total PPS and subscale scores after a 12-week exercise intervention. Following the exercise intervention, the mean total PPS score (effect size 0.34) SPPB score (effect size 0.25), and all subscale scores (effect sizes 0.23–0.33) improved significantly (P \ 0.05), except for upper-extremity strength score (P = 0.687) and SF-36 PF (P = 0.557).
Discussion The aim of our study was to develop and validate a multidimensional assessment of physical performance among older adults with community-based long-term care needs in a public LTC insurance system. The PPS demonstrated concurrent validity with respect to self-reported functional status in the form of ADLs, IADLs, and SF-36PF. In the AUC analysis, total PPS score demonstrated a greater discriminative validity as compared to the SPPB score and SF-36PF. Moreover, the PPS showed sensitivity to change through implementation of an exercise intervention. These findings suggest that the PPS may be a useful tool for identifying functional status decline and improvement in individuals requiring community-based LTC. Physical performance measures have gained acceptance for functional status evaluation in older adults. In particular, summary scores have been created that can assess performance along a broad spectrum of functioning [7, 8, 28, 29]. The Physical Performance Test (PPT), a measure
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274
Aging Clin Exp Res (2014) 26:269–278
Table 3 Description statistics of the physical performance tests, PPS, and SPPB Without LTC needs (n = 219)
With LTC needs (n = 148)
Age (years)
82.3 ± 3.2
84.7 ± 5.2
Women
134 (61.2)
114 (77.0)
P \ 0.001
Grip strength (kg) Men
30.9 ± 6.2
23.4 ± 5.6
Women
20.6 ± 4.6
16.1 ± 4.1
17.6 ± 17.9
8.2 ± 11.2
Unable to complete Tandem stance (s) Unable to complete Tandem walka Unable to complete Alternating step (s) Unable to complete 5 chair sit-to-stand (s) Able to perform with use of arms Unable to complete Usual gait speed (m/s) Use of canes or walkers
15 (6.8)
38 (25.8)
22.3 ± 9.6
15.8 ± 10.6
2 (0.9)
35 (23.6)
15.9 ± 6.5
19.2 ± 6.4
17 (7.8)
82 (55.4)
6.1 ± 2.6
7.4 ± 2.4
8 (3.7)
92 (62.2)
9.9 ± 3.9 2 (0.9)
13.5 ± 4.6 26 (17.6)
0 (0)
10 (6.8)
1.0
0.8
1.08 ± 0.30
0.69 ± 0.30
6 (5.5)
22 (14.9)
Physical performance scale Total score (range 0–20)
16.5 ± 3.0
9.9 ± 4.2
Upper-extremity strength (range 0–4) Lower-extremity strength (range 0–6)b
2.9 ± 1.1
1.9 ± 1.0
5.3 ± 1.1
2.9 ± 1.8
Ability to balance (range 0–6)c
5.0 ± 1.1
2.9 ± 1.7
Ability to walk (range 0–4) SPPB score (range 0–12)
3.3 ± 0.9
2.2 ± 1.0
10.8 ± 2.0
7.3 ± 3.5
0.6
0.4
Total PPS score (AUC=0.89; 95%CI: 0.86-0.92) SPPB score (AUC=0.81; 95%CI: 0.77-0.86) SF-36PF (AUC=0.76; 95%CI: 0.70-0.80)
0.2
0.0 0.0
0.2
0.4
0.6
0.8
1.0
1 - Specificity
Values are mean ± SD or n (%) of participants. All performance measures demonstrated significant differences between groups (P \ 0.001). P values were based on the v2 and Mann–Whitney U tests PPS physical performance scale, SPPB short physical performance battery a
Composite measure was calculated by summing the time and the number of mistakes
b
5 chair sit-to-stand and alternating step
c
Tandem stance, one-legged stance, and tandem walk
of activities including ADLs and IADLs (e.g., writing a sentence, simulated eating, simulated dressing, and picking up a penny), was highly correlated (r = 0.50–0.80) with functional status assessments (i.e., modified Rosow–Breslau, ADLs, IADLs) in a sample of 183 elderly outpatients with mean age of 79.0 years [28]. Sherman and Reuben [30] reported that the PPT (r = 0.37–0.46) and SPPB
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Fig. 1 Distribution of the total PPS score in individuals with LTC needs and those without LTC needs. PPS physical performance scale, LTC long-term care
Sensitivity
One-legged stance (s)
Fig. 2 The receiver operator curve (ROC) of the total PPS score, SPPB score, and SF 36 PF. PPS physical performance scale, SPPB short physical performance battery, SF-36PF 36-Item Short-Form Physical Function Subscale
(r = 0.42–0.48) were well correlated with ADLs, IADLs, and SF-36PF among 363 community-dwelling elderly adults with mean age of 75.9 years. Our study is consistent with previous reports in the moderate correlations observed between total PPS score and self-reported functional status based on ADLs (r = 0.55), IADLs (r = 0.62), and SF-36 PF (r = 0.53). Floor and ceiling effects are considered to be present when more than 15 % of respondents achieve the lowest or highest possible score, respectively [31]. A previous study reported that the continuous scale physical functional performance test (CS-PFP), consisting of a battery of 15 everyday tasks, showed no floor effect for LTC facility residents or ceiling effect for community dwellers [29].
Aging Clin Exp Res (2014) 26:269–278
275
Table 4 Sensitivity and specificity of PPS and SPPB for identifying LTC needs
Physical performance scale Total score
SPPB score
Cutoff value
Sensitivity (%)
Specificity (%)
Sum of sensitivity and specificity
12
67
93
160
13
71
88
159
14
80
84
165
15
85
76
161
16
88
68
156
17 7
91 41
59 95
150 136
8
46
90
140
9
55
85
141
10
66
80
147
11
76
78
153
12
86
60
146
PPS physical performance scale, SPPB short physical performance battery
Table 5 The PPS, SPPB, and SF-36PF at baseline and at 12 weeks (n = 49) Baseline
12 weeks
P value
Effect size
14.3 ± 3.5
15.5 ± 3.7
0.001
0.34
Upper-extremity strength (range 0–4)
2.5 ± 1.2
2.6 ± 1.1
0.686
0.08
Lower-extremity strength (range 0–6)a
4.6 ± 1.3
4.9 ± 1.2
0.033
0.23
Ability to balance (range 0–6)b
4.5 ± 1.2
4.9 ± 1.3
0.016
0.33
Ability to walk (range 0–4)
2.8 ± 0.9
3.1 ± 0.9
0.004
0.33
SPPB score (range 0–12)
9.6 ± 2.4
10.2 ± 2.5
0.015
0.25
SF-36PF
61.3 ± 20.2
63.9 ± 19.0
0.709
0.18
Physical performance scale Total score (range 0–20)
Values are mean ± SD. P values were based on the Wilcoxon signedrank test PPS physical performance scale, SPPB short physical performance battery, SF-36PF 36-item Short-Form physical function subscale a
5 chair sit-to-stand and alternating step
b
Tandem stance, one-legged stance, and tandem walk
However, this battery requires measurements of 15 activities of daily living and takes approximately 45 min to administer to community-dwelling older adults and
60–75 min to LTC facility residents. Thus, CS-PFP may be limited in community and home settings. Total PPS score demonstrated no floor effect and minimal ceiling effect (8.7 %) in our study subjects. By contrast, SPPB score demonstrated a substantial ceiling effect (41.1 %), with 59.8 % of maximum scores recorded in individuals without LTC needs (data not shown). Guralnik et al. [8] reported that among 1,122 community-dwelling men and women aged 71 or older, 10.6 %of participants had the highest possible SPPB score of 12. This difference in distribution may arise from marked differences in performance criteria for the functional status categories [11, 18, 19] arising from differences in physical characteristics, culture, and lifestyle [20, 21].Therefore, the scaling of the PPS from a reference population of older Japanese adults can provide basic physical information about those at the very lowest functional levels. Total PPS score in our study demonstrated a higher level of AUC discrimination between individuals with and without LTC needs than SPPB score or SF-36 PF. The difference in AUCs between the PPS and SPPB was 13 %, with a small overlap between the 95 % CIs of total PPS score (lower 95 % CI, 0.86) and SPPB score (upper 95 % CI, 0.86). To our knowledge, no comparative studies have determined the discriminative capacity of a summary performance score for care requirements established by the LTC insurance system. However, a previous study found that a summary performance score incorporating walking speed, one-leg standing, and grip strength was more useful for older people (over 75 years) than younger people (aged 65–74 years) in predicting the onset of functional dependence, suggesting that at advanced age, physical performance becomes more critical for maintaining an independent life than at younger ages and stressing the importance of functional evaluation in a clinical setting even at advanced ages. In our study, the PPS included grip strength and complex tests of lower-extremity performance. The simple test for upper-extremity performance, handgrip strength, is a useful marker of frailty and an important predictor of disability in community-dwelling older adults [9, 12]. Taekema et al. [32] reported that lower handgrip strength predicted an accelerated decline in ADL disability and cognition, and thus contributes to increasing dependency in old age. Therefore, measuring handgrip strength can be useful to identify those ‘‘oldest old’’ patients at risk for future decline in clinical geriatric practice. In 7,250 community-dwelling non-disabled French women aged 75 years or older, after adjustment for multiple potential confounding factors, poor SPPB and lower handgrip strength were independent predictors of mortality [33].Moreover, grip strength is a good indicator of overall nursing home transfer,
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276
fracture, and functional change (e.g., decline in ADLs per 100 days) in older adult residents in residential care and assisted living facilities [34]. Tandem stance is 1 of 3 positions comprising the SPPB balance scale [7] and is also included in the Berg Balance Scale [35] and the Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT)-4 scale [25]. Rossiter-Fornff et al. [25] reported that the FICSIT-4 scale with the addition of the one-legged stance to the FICSIT battery of stance tests (parallel, semi-tandem, and tandem) is useful to discriminate balance over a wide range of health status levels. While SPPB is a composite measure of static balance, chair stand, and gait speed, the PPS includes upper-extremity strength and a comprehensive range of tests of sufficiently varying difficulty (e.g., dynamic balance, alternating step) to predict changes in physical abilities along the entire spectrum of functioning [36].Therefore, the PPS is more likely than the SPPB alone to discriminate a high risk of functional dependence in individuals requiring community-based long-term care within a public LTC insurance system. To identify the risk of functional decline and necessity for LTC in older adults, criterion reference points can be used in clinical practice (12, 14). Our study found that the optimal cut-off value for the total PPS score was 14, and the PPS had the highest sensitivity (80 %) and specificity (84 %) in identifying LTC needs. Thus, this cut-off point may be used in other settings due to its high sensitivity and specificity. The optimal cut-off value for the SPPB with the highest sensitivity (76 %) and specificity (78 %) in identifying LTC needs was 11. In previous studies, an SPPB score of 9 was associated with progressively higher risk of disability [8]. Again, this difference may be due to differences in physical characteristics, culture, and lifestyle. Like vital signs such as body weight or blood pressure, physical performance measures may offer a powerful mechanism to understand the healthcare needs of older adults [37]. Despite its short term, our observational study demonstrated that the PPS could detect meaningful small changes in older adults at high risk of requiring care based on the LTC insurance system. The mean total PPS score, SPPB, and most subscale scores improved significantly (effect size, 0.23–0.34). These results are similar to those obtained in a previous systematic review [38]. The upper-extremity strength test was the only subscale not significantly changed by physical exercise. In a previous study, the upperextremity strength test also failed to detect such changes [39], although the handgrip strength test for upper-
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extremity function is a highly useful marker of frailty and important predictor of disability. Further research may provide a better understanding of the importance of handgrip strength as a physical performance screening tool and the appropriateness of handgrip strength as a sensitive measure for intervention studies. Taken together, the PPS provides more information about physical abilities relative to the SPPB and appears clinically useful as a comprehensive assessment tool in communities of older adults at high risk of requiring care based on the LTC insurance system. The present study has several limitations. First, our use of the PPS among older community-dwelling volunteers in a primary care setting may not be applicable to populations in nursing homes, hospitals, and other institutions. Second, our findings were based on crosssectional data, which did not allow us to evaluate the predictive capacity of various functions considered in the study, and which may have limited the generalizability of the results. Finally, the observational study, which examined sensitivity to change, did not include a control group. Further research is needed to confirm the capacity of the PPS to detect changes in randomized controlled trials and cohort studies. In conclusion, the PPS demonstrated concurrent validity with self-reported functional status reflected by ADLs, IADLs, and SF-36PF. Although the PPS is slightly more timeconsuming than the SPPB inmost clinical settings, the PPS has the capacity to discriminate between groups and is sensitive to functional changes. These findings suggest that the PPS may be a useful tool for identifying functional status decline and recovery in older adults. Thus, the PPS may help to guide the implementation of interventions that have been effective in clinical trials in LTC settings in Japanese communities aged 75 years and older. Investigators and clinicians are encouraged to consider using this measure to examine outcomes in clinical settings and for clinical trials that examine the overall functional impact of interventions. Acknowledgments We are very grateful to the subjects for their enthusiastic participation during measurements. The study was supported by the Japan Society for the Promotion of Science (Grant-inAid for Scientific Research (A) # 19200047). Conflict of interest
Appendix See Table 6.
None.
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Table 6 Test items and scoring categories for the physical performance scale Components of physical performance
Test items
Upper-extremity strength
Grip strength
Lower-extremity strength
Scoring categories
5 chair sit-to-stand
Men
Women
4
C33 kg
C22 kg
3
28–32.9 kg
18–21.9 kg
2
24–27.9 kg
16–17.9 kg
1
\24 kg
\16 kg
0
Unable to grip
Unable to grip
4
B10.0 s
3
10.1–12.5 s
2
[12.5 s (able to do 5 chair stands without use of arms)
1
Able to do 5 chair stands with use of arms Unable to stand
0 Alternating step
Ability to balance
Ability to walk
2
B8.5 s
1
[8.5 s
0
Unable to step C10 and C30 s
One-legged stance and full tandem stance
4
Full tandem stance
3
C15 s
Full tandem stance and semi-tandem stance
2
C10 s
Full tandem stance and semi-tandem stance and side-by-side stance
1
\10 and C10 and C10 s
Side-by-side stance
0
\10 s or unable to complete
Tandem walk
2
B18.5
1 0
[18.5 Unable to complete
4
C1.0 m/s
3
0.80–0.99 m/s
Usual gait speed
Total score
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