Research Report Companion Confidence in the Balance of Community-Dwelling Older Adults: Implications for Physical Activity Promotion James T. Cavanaugh, PT, PhD1; Julia C. Dunfey, PT, DPT2; Megan K. Wyand, PT, DPT3 ABSTRACT Background and Purpose: Positive social relationships may increase the intention of older adults to be physically active. In the presence of balance impairments, however, the potential influence of a familiar companion on an older adult’s physical activity is not well understood. The purpose of this preliminary investigation was to explore companion confidence in the balance capability of an older adult as a potential determinant of older adult physical activity. Methods: The study employed a cross-sectional design, in which 40 dyads formed by a community-dwelling older adult and his or her close companion (eg, family member, friend, and caregiver) were recruited as a sample of convenience. Older adults completed the Activities-Specific Balance Confidence (ABC) scale and the Physical Activity Survey for the Elderly (PASE). Companions completed a modified version of the ABC scale, in which they were asked to rate their confidence in the older adult’s balance. The agreement between and correspondence of paired ABC scores were analyzed using mean difference (95% confidence interval [CI]), dependent samples t test (α = 0.05), and the intraclass correlation coefficient 1-way random effects model. The Pearson product-moment correlation coefficient was used to characterize the relationship between companion confidence and older adult physical activity. Results: Older adults were more confident in their balance capability (mean ABCOlder Adult = 70.0; 95% CI = 62.8-77.2) than their companions (mean ABCCompanion = 60.2; 95% CI = 50.6-69.8). The difference between group mean scores was significant (mean difference = 9.8; 95% CI = 2.3-17.3, t (39) = 2.38; P = 0.02). Discordance increased as the mean of paired ABC scores diminished. ABC scores were also
significantly yet moderately associated (intraclass correlation coefficient (1,1) = 0.56; 95% CI = 0.31-0.74; P < 0.01). The association between ABCCompanion and PASE scores was stronger (r = 0.51; 95% CI = 0.23-0.79; P < 0.01) than the association between ABCOlder Adult and PASE scores (r = 0.33; 95% CI = 0.02-0.64; P = 0.04) and increased in cases for which companions were markedly less confident than older adults. Discussion and Conclusions: Older adults and their companions did not necessarily share similar confidence in the older adult’s balance capability. Companion confidence, especially when markedly less than older adult confidence, showed promise as a predictor of older adult physical activity. Study findings provided a foundation for future investigations that examine the effect of social relationships on the physical activity self-efficacy of older adults with balance impairments. Key Words: aging, balance, physical activity, self-efficacy, social relationships (J Geriatr Phys Ther 2014;37:121-126.)
INTRODUCTION
DOI: 10.1519/JPT.0b013e3182abe7c0
The promotion of physical activity is an important nonpharmaceutical strategy in chronic disease management.1 Physical activity interventions, whether targeting older adults2,3 or the general population,4 are thought to be vitally important for attenuating the risks for and ameliorating the consequences of many health conditions (eg, cardiovascular disease, obesity, diabetes, cancer, arthritis, and depression).5,6 Despite these efforts, older adults generally remain among the least physically active of any adult age group,6-8 with more than half not attaining the amount of physical activity recommended for their age.9 Numerous determinants of older adult physical activity have been identified, including many characteristics of the individual, social environment, physical environment, and cultural environment.10-12 For some older adults with balance impairments, however, self-imposed activity avoidance represents an additional determinant, given its association with falls, fear of falling, and low fall-related self-efficacy.13-18 Activity avoidance, in turn, has been associated with depression and social isolation.19-22 Strategies for addressing the unique barriers to physical activity among individuals with balance impairments are important considerations for health promotion and rehabilitation.
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1Department of Physical Therapy, University of New England, Portland, Maine. 2Coastal Rehab, LLC, Cape Elizabeth, Maine. 3Spaulding Nursing and Therapy Center North End, Boston, Maine. This work was sponsored by the Department of Physical Therapy, University of New England, Portland, Maine. The authors declare no conflicts of interest. Address correspondence to: James T. Cavanaugh, PT, PhD, Department of Physical Therapy, University of New England, 716 Stevens Ave., Portland, ME 04103 ([email protected]). Robert Wellmon was the Decision Editor.
Copyright © 2014 The Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
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Positive social relationships with close companions (eg, spouse, partner, family member, or caregiver) seem to have a protective effect on physical function and physical disability23 and may increase the intention to be physically active and adherence to exercise classes.24,25 A possible explanation for this effect is that structure and function of social connections contribute to individual selfefficacy.26,27 The extent to which positive social relationships might influence the physical activity of older adults with balance impairments, especially those impairments that challenge fall-related self-efficacy and lead to physical activity restriction,17,28 has not been studied. To begin examining this issue, our first aim was to explore how confidence in an older adult’s balance capability might differ between 2 perspectives: that of the older adult and that of his or her close companion. Our second aim was to explore how companion confidence in the balance capability of an older adult might serve as a potential determinant of older adult physical activity. To conduct the study, we recruited older adult-–companion dyads and administered 2 versions of the Activities-Specific Balance Confidence (ABC) scale.29 Older adults completed the traditional version, whereas companions completed a modified version that we created specifically for this study. Older adults also completed the Physical Activities Scale for the Elderly (PASE).30 We hypothesized that perceptions of confidence in the older adult’s balance capability would be relatively similar, especially for pairs who spent substantial time together each week. We also hypothesized that companions with relatively higher confidence in the older adult’s balance capability would be associated with physically active older adults, whereas companions with relatively lower confidence would be paired with less physically active older adults.
METHODS Design and Participants The study employed a cross-sectional design in which dyads formed by a community-dwelling older adult and his or her close companion were recruited as a sample of convenience. Older adult participants were at least 60 years of age and identified their companion as “someone with whom they have spent at least 7 hours per week during the last month.” Dyads were recruited via word of mouth and posted flyers from the Greater Portland, Maine, area. Many were recruited at local independent living facilities. Every effort was made to recruit a range of companion types, that is, those who shared a residence with the older adult participant (eg, spouse, partner, and sibling) and those who did not (eg, extended family and friend). Dyads were excluded if either individual (1) was unable to speak English, (2) reported cognitive, memory, or communication impairments that limited his or her ability to complete 122
surveys, or (3) if the targeted older adult participant was nonambulatory. The Institutional Review Board for the Protection of Human Subjects at the University of New England approved the study. Data were collected from July through November 2011.
Measures Descriptive Measures We recorded the age and sex of each participant, whether dyad members shared a residence, the nature of the relationship (eg, spouse, friend, family member, and caregiver), the approximate number of hours per week spent together during the previous month, and the number of times the older adult participant had fallen in the previous year. To characterize older adult ambulatory mobility, we collected 2 trials of self-selected gait speed over a 3-m distance; assistive devices were allowed as needed.31
Activities-Specific Balance Confidence Scale The ABC is a 16-item survey that examines balance confidence during a series of progressively more challenging balance tasks, from ambulatory activities inside the home to walking in various community environments.29 Modeled after Bandura’s self-efficacy framework,27 respondents rate their confidence in response to the root question, “How confident are you that you will not lose your balance or become unsteady when you…?” Each item is rated from 0 (no confidence) to 100 (complete confidence). A total score is calculated as the mean of the individual item scores. In the original report of its development, the ABC scale demonstrated high internal consistency (Cronbach α = 0.96), test-retest reliability (r = 0.92), convergent and discriminative validity in comparison to scales of self-perceived physical ability and emotionality, and the ability to discriminate between seniors reporting high or low mobility.29 Additional evidence of its validity and reliability was later summarized.32 We administered the traditional ABC scale to older adult participants and generated a total score (ie, ABCOlder Adult). For companion participants, we modified the root question of the ABC scale to read, “How confident are you that [insert older adult name] will not lose [his / her] balance or become unsteady when [he/she]…?” The item list and scoring of the modified version remained unchanged, so as to produce a comparable score (ABCCompanion). To our knowledge, the modified version of the ABC scale was unique to this study and had not been validated previously.
Physical Activity Scale for the Elderly The PASE is a brief survey designed to measure physical activity in persons 65 years and older during leisure, household, and occupational activities occurring over the previous 7-day period.30 PASE item scores are calculated Volume 37 • Number 3 • July-September 2014
Copyright © 2014 The Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
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Procedures Trained research personnel collected descriptive data and administered the ABC scale to each older adult and companion dyad in a place convenient to them (eg the older adult’s home). Participants were sequestered from one another when completing the surveys to avoid influencing each other’s responses. Older adults also completed the PASE and underwent gait speed testing.
Data Analysis Data were analyzed using SPSS version 20 (SPSS Inc, Chicago, IL). Descriptive statistics (ie, mean, standard deviation [SD], and frequency) were used to characterize the sample. Gait speed was calculated as the mean of 2 trials. Time spent together and the number of falls in the previous year were characterized using the average reported value, to account for the possibility of recall error by either participant. For our first aim, we characterized the agreement between and correspondence of ABCOlder Adult and ABCCompanion scores using mean difference (95% confidence interval [CI]), dependent samples t test (α = 0.05), and the intraclass correlation coefficient 1-way random effects model. Because of a skewed distribution in the amount of time spent together, we used the relatively conservative, nonparametric Spearman ρ correlation coefficient to analyze its relationship to the differences in the ABC scores. We constructed a Bland–Altman plot35 and calculated the 95% limits of agreement to identify systematic bias in and outlier cases of marked difference in paired ABC scores. For our second aim, we analyzed the relationship between each ABC score and the PASE score of the older adult using the Pearson product-moment correlation coefficient (α = 0.05).
The sample contained 33 female and 7 male companions, who had a mean age ± SD of 69.2 ± 14.4 years. Two companions did not report their age. Twenty-five companions reported living with the older adult. Mean time spent per week together ± SD was 90.7 ± 62.3 hours, with 19 dyads reporting spending more than 100 hours per week together. Companions included 21 spouses, 11 children, 6 friends, and 2 unrelated caregivers. Older adults as a group were more confident in their balance capability (mean ABCOlder Adult= 70.0; 95% CI = 62.8-77.2; SD = 22.4; minimum = 14.4; maximum = 100.0) than the group of companions (mean ABCCompanion= 60.2; 95% CI = 50.6-69.8; SD = 30.0; minimum = 2.2; maximum = 99.7). The difference between group mean scores was significant (mean difference = 9.8; 95% CI = 2.3-17.3, t (39) = 2.38; P = 0.02). The 2 sets of scores were significantly yet moderately associated (intraclass correlation coefficient (1,1) = 0.56; 95% CI = 0.31-0.74; P < 0.001). Time spent together was not associated with the difference in ABC scores (ρ = 0.19; P = 0.25). Figure 1 features a Bland–Altman plot35 in which mean of paired scores (x-axis) was plotted against difference in paired ABC scores (y-axis). Positive differences (n = 25) indicated cases in which older adults were more confident in their balance capability than their companion (mean difference = 21.9; 95% CI = 13.5-30.3). Negative differences (n = 15) indicated cases in which companions were more confident in their older adult’s balance capability than 80 60
Difference in paired ABC scores
by multiplying either time spent (hours per week) or participation in (yes/no) each activity with empirically derived item weights. The total PASE score, which represents the sum of individual item scores, ranges from 0 to more than 400. In early publications, the PASE demonstrated good test-retest reliability (r = 0.75) and construct validity in relation to physical measures and self-perceptions of health status in samples of community-dwelling older adults.30,33 Additional evidence of its validity and reliability was summarized more recently.34
40 20 0 –20 –40 –60 –80 0
10
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50
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70
80
90
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Mean of paired ABC scores
RESULTS The sample contained 22 female and 18 male older adult participants, who had a mean age ± SD of 80.7 ± 7.5 years. Mean gait speed ± SD was 0.82 ± 0.26 m/s. One dyad did not provide falls data; another dyad reported multiple daily falls; 22 dyads reported 0 falls. The median value of the resulting highly skewed distribution of older adult falls was 0.5. Journal of GERIATRIC Physical Therapy
Figure 1. Bland–Altman plot of the agreement between paired Activities-Specific Balance Confidence (ABC) scale scores as a function of their mean (n = 40). Positive differences indicate cases in which older adults were more confident in their balance capability than their companions. Negative differences indicate cases in which companions were more confident in their older adult’s balance capability than the older adult himself or herself. Dashed lines indicate 95% limits of agreement (a difference of ±46.9 in paired ABC scores). 123
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the older adult himself or herself (mean difference = 10.5; 95% CI = 4.6-16.4). Eleven dyads had ABC score differences more than 20. Four outlier dyads were identified in which the difference in paired ABC score was more than 46.9, the 95% limits of agreement. Each outlier dyad featured an older adult who was markedly more confident than his or her companion. Physical activity levels among older adult participants were variable and relatively low (mean PASE score = 81.7; 95% CI = 63.4-100.0; SD = 57.2; minimum = 2.25; maximum = 271.2). ABCOlder Adult was significantly yet weakly related to the PASE score (r = 0.33; 95% CI = 0.02-0.64; P = 0.04). The association between companion confidence in older adult balance capability and older adult physical activity was relatively stronger (r = 0.51; 95% CI = 0.23-0.79; P = 0.01). To further explore this relationship, we formed 2 subgroups using older adult–companion dyads with the greatest discrepancy in ABC scores. Subgroup A (n = 10) contained the most disparate cases in which older adults were more confident in their balance capability than their companion. Subgroup B (n = 10) contained the most disparate cases in which companions were more confident in the older adult’s balance capability than the older adult himself or herself. In a secondary analysis (Table 1), we determined that for subgroup A, ABCCompanion was significantly and more strongly related to the older adult PASE score (r = 0.70; 95% CI = 0.12-1.00; P = 0.02) than ABCOlder Adult (r = 0.42; 95% CI = −0.33-1.00; P = 0.23). In contrast, for subgroup B, the relationships between ABCCompanion and older adult PASE scores, and between ABCOlder Adult and PASE scores, were weak and not statistically significant.
DISCUSSION The purpose of this study was to explore companion confidence in the balance capability of an older adult as a potential determinant of older adult physical activity. We Table 1. Secondary Analysis of Balance Confidence and Physical Activity Data Subgroup A (n = 10)
Subgroup B (n = 10)
All (n = 40)
ABCOlder Adult (mean ± SD)
71.5 ± 22.5
67.3 ± 19.3
70.0 ± 22.4
ABCCompanion (mean ± SD)
30.4 ± 20.7
81.4 ± 18.8
60.2 ± 30.0
Corr (ABCOlder Adult, PASE)
r = 0.42; P = 0.23
r = 0.07; P = 0.84
r = 0.33; P = 0.04a
Corr (ABCCompanion, PASE)
r = 0.70; P = 0.02a
r = 0.02; P = 0.10
r = 0.51; P = 0.001a
Analysis Item
statistical significance (α = 0.05). Abbreviations: ABC, Activities-Specific Balance Confidence; corr, correlation; PASE, Physical Activity Scale for the Elderly; SD, standard deviation; subgroup A, ABCOlder Adult> > ABCCompanion; subgroup B, ABCCompanion> > ABCOlder Adult. aIndicates
124
were fortunate to have recruited a sample of older adults who reported a range of balance confidence, consistent with individuals living with chronic health conditions representing a continuum from low to high functioning.36 Physical activity levels in the sample also varied, and the sample was relatively inactive in comparison to associated normative PASE values.37 Although the median number of reported falls among older adults was relatively low, the mean gait speed value suggested that many of them had an elevated risk of future adverse health events.31 Taken together, these sample characteristics supported both the internal validity of the correlation analyses (ie, a sufficient range of values for each variable) and the generalizability of the findings to the broader population of older adults with balance impairments. Our hypothesis that older adults and their companions would similarly perceive the older adults’ balance capability was not strongly supported as a general statement. Time spent together did not seem to be a contributing factor. Although paired ABC scores corresponded moderately across the sample, the amount of agreement seemed to depend somewhat on the mean of the paired ABC scores (Figure 1). All pairs reporting high confidence (ie, mean ABC scores >80) agreed relatively closely in their perceptions (ie, ABC score difference
significantly yet moderately associated (intraclass correlation coefficient (1,1) = 0.56; 95% CI = 0.31-0.74; P < 0.01). The association between ABCCompanion and PASE scores was stronger (r = 0.51; 95% CI = 0.23-0.79; P < 0.01) than the association between ABCOlder Adult and PASE scores (r = 0.33; 95% CI = 0.02-0.64; P = 0.04) and increased in cases for which companions were markedly less confident than older adults. Discussion and Conclusions: Older adults and their companions did not necessarily share similar confidence in the older adult’s balance capability. Companion confidence, especially when markedly less than older adult confidence, showed promise as a predictor of older adult physical activity. Study findings provided a foundation for future investigations that examine the effect of social relationships on the physical activity self-efficacy of older adults with balance impairments. Key Words: aging, balance, physical activity, self-efficacy, social relationships (J Geriatr Phys Ther 2014;37:121-126.)
INTRODUCTION
DOI: 10.1519/JPT.0b013e3182abe7c0
The promotion of physical activity is an important nonpharmaceutical strategy in chronic disease management.1 Physical activity interventions, whether targeting older adults2,3 or the general population,4 are thought to be vitally important for attenuating the risks for and ameliorating the consequences of many health conditions (eg, cardiovascular disease, obesity, diabetes, cancer, arthritis, and depression).5,6 Despite these efforts, older adults generally remain among the least physically active of any adult age group,6-8 with more than half not attaining the amount of physical activity recommended for their age.9 Numerous determinants of older adult physical activity have been identified, including many characteristics of the individual, social environment, physical environment, and cultural environment.10-12 For some older adults with balance impairments, however, self-imposed activity avoidance represents an additional determinant, given its association with falls, fear of falling, and low fall-related self-efficacy.13-18 Activity avoidance, in turn, has been associated with depression and social isolation.19-22 Strategies for addressing the unique barriers to physical activity among individuals with balance impairments are important considerations for health promotion and rehabilitation.
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1Department of Physical Therapy, University of New England, Portland, Maine. 2Coastal Rehab, LLC, Cape Elizabeth, Maine. 3Spaulding Nursing and Therapy Center North End, Boston, Maine. This work was sponsored by the Department of Physical Therapy, University of New England, Portland, Maine. The authors declare no conflicts of interest. Address correspondence to: James T. Cavanaugh, PT, PhD, Department of Physical Therapy, University of New England, 716 Stevens Ave., Portland, ME 04103 ([email protected]). Robert Wellmon was the Decision Editor.
Copyright © 2014 The Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
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Positive social relationships with close companions (eg, spouse, partner, family member, or caregiver) seem to have a protective effect on physical function and physical disability23 and may increase the intention to be physically active and adherence to exercise classes.24,25 A possible explanation for this effect is that structure and function of social connections contribute to individual selfefficacy.26,27 The extent to which positive social relationships might influence the physical activity of older adults with balance impairments, especially those impairments that challenge fall-related self-efficacy and lead to physical activity restriction,17,28 has not been studied. To begin examining this issue, our first aim was to explore how confidence in an older adult’s balance capability might differ between 2 perspectives: that of the older adult and that of his or her close companion. Our second aim was to explore how companion confidence in the balance capability of an older adult might serve as a potential determinant of older adult physical activity. To conduct the study, we recruited older adult-–companion dyads and administered 2 versions of the Activities-Specific Balance Confidence (ABC) scale.29 Older adults completed the traditional version, whereas companions completed a modified version that we created specifically for this study. Older adults also completed the Physical Activities Scale for the Elderly (PASE).30 We hypothesized that perceptions of confidence in the older adult’s balance capability would be relatively similar, especially for pairs who spent substantial time together each week. We also hypothesized that companions with relatively higher confidence in the older adult’s balance capability would be associated with physically active older adults, whereas companions with relatively lower confidence would be paired with less physically active older adults.
METHODS Design and Participants The study employed a cross-sectional design in which dyads formed by a community-dwelling older adult and his or her close companion were recruited as a sample of convenience. Older adult participants were at least 60 years of age and identified their companion as “someone with whom they have spent at least 7 hours per week during the last month.” Dyads were recruited via word of mouth and posted flyers from the Greater Portland, Maine, area. Many were recruited at local independent living facilities. Every effort was made to recruit a range of companion types, that is, those who shared a residence with the older adult participant (eg, spouse, partner, and sibling) and those who did not (eg, extended family and friend). Dyads were excluded if either individual (1) was unable to speak English, (2) reported cognitive, memory, or communication impairments that limited his or her ability to complete 122
surveys, or (3) if the targeted older adult participant was nonambulatory. The Institutional Review Board for the Protection of Human Subjects at the University of New England approved the study. Data were collected from July through November 2011.
Measures Descriptive Measures We recorded the age and sex of each participant, whether dyad members shared a residence, the nature of the relationship (eg, spouse, friend, family member, and caregiver), the approximate number of hours per week spent together during the previous month, and the number of times the older adult participant had fallen in the previous year. To characterize older adult ambulatory mobility, we collected 2 trials of self-selected gait speed over a 3-m distance; assistive devices were allowed as needed.31
Activities-Specific Balance Confidence Scale The ABC is a 16-item survey that examines balance confidence during a series of progressively more challenging balance tasks, from ambulatory activities inside the home to walking in various community environments.29 Modeled after Bandura’s self-efficacy framework,27 respondents rate their confidence in response to the root question, “How confident are you that you will not lose your balance or become unsteady when you…?” Each item is rated from 0 (no confidence) to 100 (complete confidence). A total score is calculated as the mean of the individual item scores. In the original report of its development, the ABC scale demonstrated high internal consistency (Cronbach α = 0.96), test-retest reliability (r = 0.92), convergent and discriminative validity in comparison to scales of self-perceived physical ability and emotionality, and the ability to discriminate between seniors reporting high or low mobility.29 Additional evidence of its validity and reliability was later summarized.32 We administered the traditional ABC scale to older adult participants and generated a total score (ie, ABCOlder Adult). For companion participants, we modified the root question of the ABC scale to read, “How confident are you that [insert older adult name] will not lose [his / her] balance or become unsteady when [he/she]…?” The item list and scoring of the modified version remained unchanged, so as to produce a comparable score (ABCCompanion). To our knowledge, the modified version of the ABC scale was unique to this study and had not been validated previously.
Physical Activity Scale for the Elderly The PASE is a brief survey designed to measure physical activity in persons 65 years and older during leisure, household, and occupational activities occurring over the previous 7-day period.30 PASE item scores are calculated Volume 37 • Number 3 • July-September 2014
Copyright © 2014 The Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
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Procedures Trained research personnel collected descriptive data and administered the ABC scale to each older adult and companion dyad in a place convenient to them (eg the older adult’s home). Participants were sequestered from one another when completing the surveys to avoid influencing each other’s responses. Older adults also completed the PASE and underwent gait speed testing.
Data Analysis Data were analyzed using SPSS version 20 (SPSS Inc, Chicago, IL). Descriptive statistics (ie, mean, standard deviation [SD], and frequency) were used to characterize the sample. Gait speed was calculated as the mean of 2 trials. Time spent together and the number of falls in the previous year were characterized using the average reported value, to account for the possibility of recall error by either participant. For our first aim, we characterized the agreement between and correspondence of ABCOlder Adult and ABCCompanion scores using mean difference (95% confidence interval [CI]), dependent samples t test (α = 0.05), and the intraclass correlation coefficient 1-way random effects model. Because of a skewed distribution in the amount of time spent together, we used the relatively conservative, nonparametric Spearman ρ correlation coefficient to analyze its relationship to the differences in the ABC scores. We constructed a Bland–Altman plot35 and calculated the 95% limits of agreement to identify systematic bias in and outlier cases of marked difference in paired ABC scores. For our second aim, we analyzed the relationship between each ABC score and the PASE score of the older adult using the Pearson product-moment correlation coefficient (α = 0.05).
The sample contained 33 female and 7 male companions, who had a mean age ± SD of 69.2 ± 14.4 years. Two companions did not report their age. Twenty-five companions reported living with the older adult. Mean time spent per week together ± SD was 90.7 ± 62.3 hours, with 19 dyads reporting spending more than 100 hours per week together. Companions included 21 spouses, 11 children, 6 friends, and 2 unrelated caregivers. Older adults as a group were more confident in their balance capability (mean ABCOlder Adult= 70.0; 95% CI = 62.8-77.2; SD = 22.4; minimum = 14.4; maximum = 100.0) than the group of companions (mean ABCCompanion= 60.2; 95% CI = 50.6-69.8; SD = 30.0; minimum = 2.2; maximum = 99.7). The difference between group mean scores was significant (mean difference = 9.8; 95% CI = 2.3-17.3, t (39) = 2.38; P = 0.02). The 2 sets of scores were significantly yet moderately associated (intraclass correlation coefficient (1,1) = 0.56; 95% CI = 0.31-0.74; P < 0.001). Time spent together was not associated with the difference in ABC scores (ρ = 0.19; P = 0.25). Figure 1 features a Bland–Altman plot35 in which mean of paired scores (x-axis) was plotted against difference in paired ABC scores (y-axis). Positive differences (n = 25) indicated cases in which older adults were more confident in their balance capability than their companion (mean difference = 21.9; 95% CI = 13.5-30.3). Negative differences (n = 15) indicated cases in which companions were more confident in their older adult’s balance capability than 80 60
Difference in paired ABC scores
by multiplying either time spent (hours per week) or participation in (yes/no) each activity with empirically derived item weights. The total PASE score, which represents the sum of individual item scores, ranges from 0 to more than 400. In early publications, the PASE demonstrated good test-retest reliability (r = 0.75) and construct validity in relation to physical measures and self-perceptions of health status in samples of community-dwelling older adults.30,33 Additional evidence of its validity and reliability was summarized more recently.34
40 20 0 –20 –40 –60 –80 0
10
20
30
40
50
60
70
80
90
100
Mean of paired ABC scores
RESULTS The sample contained 22 female and 18 male older adult participants, who had a mean age ± SD of 80.7 ± 7.5 years. Mean gait speed ± SD was 0.82 ± 0.26 m/s. One dyad did not provide falls data; another dyad reported multiple daily falls; 22 dyads reported 0 falls. The median value of the resulting highly skewed distribution of older adult falls was 0.5. Journal of GERIATRIC Physical Therapy
Figure 1. Bland–Altman plot of the agreement between paired Activities-Specific Balance Confidence (ABC) scale scores as a function of their mean (n = 40). Positive differences indicate cases in which older adults were more confident in their balance capability than their companions. Negative differences indicate cases in which companions were more confident in their older adult’s balance capability than the older adult himself or herself. Dashed lines indicate 95% limits of agreement (a difference of ±46.9 in paired ABC scores). 123
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the older adult himself or herself (mean difference = 10.5; 95% CI = 4.6-16.4). Eleven dyads had ABC score differences more than 20. Four outlier dyads were identified in which the difference in paired ABC score was more than 46.9, the 95% limits of agreement. Each outlier dyad featured an older adult who was markedly more confident than his or her companion. Physical activity levels among older adult participants were variable and relatively low (mean PASE score = 81.7; 95% CI = 63.4-100.0; SD = 57.2; minimum = 2.25; maximum = 271.2). ABCOlder Adult was significantly yet weakly related to the PASE score (r = 0.33; 95% CI = 0.02-0.64; P = 0.04). The association between companion confidence in older adult balance capability and older adult physical activity was relatively stronger (r = 0.51; 95% CI = 0.23-0.79; P = 0.01). To further explore this relationship, we formed 2 subgroups using older adult–companion dyads with the greatest discrepancy in ABC scores. Subgroup A (n = 10) contained the most disparate cases in which older adults were more confident in their balance capability than their companion. Subgroup B (n = 10) contained the most disparate cases in which companions were more confident in the older adult’s balance capability than the older adult himself or herself. In a secondary analysis (Table 1), we determined that for subgroup A, ABCCompanion was significantly and more strongly related to the older adult PASE score (r = 0.70; 95% CI = 0.12-1.00; P = 0.02) than ABCOlder Adult (r = 0.42; 95% CI = −0.33-1.00; P = 0.23). In contrast, for subgroup B, the relationships between ABCCompanion and older adult PASE scores, and between ABCOlder Adult and PASE scores, were weak and not statistically significant.
DISCUSSION The purpose of this study was to explore companion confidence in the balance capability of an older adult as a potential determinant of older adult physical activity. We Table 1. Secondary Analysis of Balance Confidence and Physical Activity Data Subgroup A (n = 10)
Subgroup B (n = 10)
All (n = 40)
ABCOlder Adult (mean ± SD)
71.5 ± 22.5
67.3 ± 19.3
70.0 ± 22.4
ABCCompanion (mean ± SD)
30.4 ± 20.7
81.4 ± 18.8
60.2 ± 30.0
Corr (ABCOlder Adult, PASE)
r = 0.42; P = 0.23
r = 0.07; P = 0.84
r = 0.33; P = 0.04a
Corr (ABCCompanion, PASE)
r = 0.70; P = 0.02a
r = 0.02; P = 0.10
r = 0.51; P = 0.001a
Analysis Item
statistical significance (α = 0.05). Abbreviations: ABC, Activities-Specific Balance Confidence; corr, correlation; PASE, Physical Activity Scale for the Elderly; SD, standard deviation; subgroup A, ABCOlder Adult> > ABCCompanion; subgroup B, ABCCompanion> > ABCOlder Adult. aIndicates
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were fortunate to have recruited a sample of older adults who reported a range of balance confidence, consistent with individuals living with chronic health conditions representing a continuum from low to high functioning.36 Physical activity levels in the sample also varied, and the sample was relatively inactive in comparison to associated normative PASE values.37 Although the median number of reported falls among older adults was relatively low, the mean gait speed value suggested that many of them had an elevated risk of future adverse health events.31 Taken together, these sample characteristics supported both the internal validity of the correlation analyses (ie, a sufficient range of values for each variable) and the generalizability of the findings to the broader population of older adults with balance impairments. Our hypothesis that older adults and their companions would similarly perceive the older adults’ balance capability was not strongly supported as a general statement. Time spent together did not seem to be a contributing factor. Although paired ABC scores corresponded moderately across the sample, the amount of agreement seemed to depend somewhat on the mean of the paired ABC scores (Figure 1). All pairs reporting high confidence (ie, mean ABC scores >80) agreed relatively closely in their perceptions (ie, ABC score difference
