396
LETTERS TO THE EDITOR
FEBRUARY 2015–VOL. 63, NO. 2
COMPARISON OF EFFECTS OF RESISTANCE AND MULTICOMPONENT TRAINING ON FALLS PREVENTION IN INSTITUTIONALIZED ELDERLY WOMEN To the Editor: Falls are a major public health problem in older adults, causing high healthcare demand and expenses.1 At least 30% of people aged 65 and older fall every year, and this incidence is greater in institutionalized people.2 Age-related decreases in postural control and muscle strength have been identified as major risk factors for falls,3 so reducing fall risk in older adults is an important public health concern. Resistance training (RT) is considered to be the best training method to increase muscle strength and has also been found to be effective in preventing falls,4 but RT characteristics, especially the cost of equipment in care institutions, might make multicomponent training (MT) an efficient low-cost alternative. According to the literature, a variety of exercises involving gait, balance, coordination, strength training, and stretching can also enhance muscle strength, balance, and mobility in elderly adults, preventing falls,5 but most studies have been performed in healthy elderly individuals at low risk of falls. Studies performed with institutionalized elderly adults are less common, so the purpose of this study was to compare the effects of two short-term training programs on falls prevention in institutionalized elderly women.
METHODS Thirty-two institutionalized elderly women (aged 72.9 6.6 years) were randomly assigned to a RT group (n = 12), a MT group (n = 10), or a control group (n = 10). Exclusion criteria were systematic engagement in regular exercise of moderate to vigorous intensity for 20 minutes or more at least twice a week in the past 3 years and any medical or physical limitations for testing or training. A medical doctor checked for contraindications (e.g., neuromuscular diseases, stroke, serious heart sicknesses, implant, bypass). The University of Tr as-osMontes e Alto Douro review board for human investigation approved the study according to the Helsinki Declaration, and oral and written consent was obtained from each participant. Both training programs consisted of two sessions per week for 12 weeks. The RT protocol consisted of seven
JAGS
exercises: bench press, leg press, latissimus pull-down, leg extension, military press, leg curl, and arm curl (intensity varied progressively between 60% and 85% of one-repetition maximum, 2–3 sets of 6–12 repetitions). The MT protocol included aerobic exercise (15 to 20 minutes of walking and dancing), muscular endurance exercises (using resistance bands and free weights, 3 sets, 15–20 repetitions), balance and flexibility exercises (moderate intensity, perceived exertion of 12–13 points on Borg scale).6 Risk of falls for each participant was measured before and after training using the Timed Up & Go (TUG)7 and Functional Reach (FR)8 tests (Table 1). Both tests have been demonstrated to have high test–retest and interrater reliability in elderly populations.
RESULTS Analysis of variance (ANOVA) indicated a significant main effect of group (P < .001) on TUG and FR, with significant differences between both training groups and the control group. There were no differences between RT and MT. ANOVA also identified a significant main effect of time by group on TUG (P = .01) and FR (P < .001) in both training groups. Significant differences were observed between pre- and posttest in performance of the TUG (P = .01) and FR (P < .001) for both training groups.
DISCUSSION The main finding of the present study was that MT was as effective in preventing falls in institutionalized elderly women as RT. Twelve weeks of moderate to vigorous training significantly improved ability to adjust the center of gravity continuously over a moving base of support (measured by TUG) and to control movement of the center of gravity over a fixed base of support (measured by FR). In contrast, ability to perform functional tasks related to walking speed, balance, agility, and postural control worsened in the control group in just 12 weeks, suggesting that institutionalization is associated with a marked decrease in physical activity, which increases the risk of falling.9 Falling risk increases with declining upper and lower extremity muscle strength, agility, and dynamic balance performance, but it was recently concluded that agility and dynamic balance performance were most relevant to falling risk.10 There is consensus that RT is the best method of increasing lower and upper extremity muscle strength, but
Table 1. Pre- and Posttraining Values for the Timed Up & Go and Functional Reach Tests According to Group Resistance Training Group (n = 12)
Multicomponent Training Group (n = 10)
Control Group (n = 10)
Mean Standard Deviation Test
Pre
Post
Pre
Post
Pre
Post
Timed Up & Go, seconds Functional Reach, cm
13.40.3 70.92.7
11.20.2a 82.52.5a
14.40.5 65.14.7
11.80.3a 73.45.4a
16.11.3 58.53.0
17.31.7 48.43.0
Significant difference from pretraining values, P < .05.
a
JAGS
FEBRUARY 2015–VOL. 63, NO. 2
MT is promising and effective in frail institutionalized elderly adults, particularly by increasing agility and dynamic balance performance. MT is as effective in preventing potential falls in institutionalized elderly women as RT, has wide practical applicability, and is inexpensive to develop. Nelson Sousa, PhD Romeu Mendes, PhD Research Center in Sport Sciences, Health Sciences and Human Development, University of Tr as-os-Montes e Alto Douro, Vila Real, Portugal
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Sousa, Mendes: concept and design of the experiment, data analysis and interpretation, preparation of manuscript. Sponsor’s Role: None.
REFERENCES 1. Stevens JA, Corso PS, Finkelstein EA et al. The costs of fatal and non-fatal falls among older adults. Inj Prev 2006;12:290–295. 2. Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med 2002;18:141–158. 3. Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann Intern Med 1994;121:442–451. 4. Sousa N, Sampaio J. Effects of progressive strength training on the performance of the Functional Reach Test and the Timed Get-Up-and-Go Test in an elderly population from the rural north of Portugal. Am J Hum Biol 2005;17:746–775. 5. Alfieri FM, Riberto M, Gatz LS et al. Functional mobility and balance in community-dwelling elderly submitted to multisensory versus strength exercises. Clin Interv Aging 2010;5:181–185. 6. Garber CE, Blissmer B, Deschenes MR et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Med Sci Sports Exerc 2011;43:1334–1359. 7. Podsiadlo D, Richardson S. The, “Timed Up & Go”: A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142– 148. 8. Duncan P, Weiner D, Chandler J et al. Functional Reach: A new clinical measure of balance. J Gerontol A Biol Sci Med Sci 1990;45A:192– 197. 9. Mertz KJ, Lee DC, Sui X et al. Falls among adults: The association of cardiorespiratory fitness and physical activity with walking-related falls. Am J Prev Med 2010;39:15–24. 10. Toraman A, Yildirim NU. The falling risk and physical fitness in older people. Arch Gerontol Geriatr 2010;51:222–226.
COGNITIVE DECLINE AND POLYPHARMACY IN AN ELDERLY POPULATION To the Editor: The Department of Health and Human Services estimates that, by 2030, there will be 72.1 million individuals aged 65 and older in the United States.1 The prevalence of mild cognitive impairment (MCI) in the elderly population is between 3% and 19%, with an incidence of 8 to 58 per 1,000 per year and a risk of developing
LETTERS TO THE EDITOR
397
dementia of 11% to 33% over 2 years.2 The higher prevalence of chronic diseases makes this population more likely to be taking multiple medications. Polypharmacy, defined most commonly as the concomitant use of five or more medications, is a poorly studied factor in relation to MCI, but may play an important role.3 A follow-up study in a Finnish population of 294 elderly people between 2004 and 2007 recorded the use of medications and the cognitive function of participants.3 The authors observed that excessive polypharmacy, defined as the concomitant use of 10 or more medications, was associated with less cognitive capacity measured using the Mini-Mental State Examination (MMSE) than in a non-polypharmacy group. Considering the dearth of scientific studies analyzing the effects of polypharmacy on cognitive decline, particularly in the U.S. population, the current study examined data from the New Mexico Aging Process Study (NMAPS) to further investigate the effects of polypharmacy on cognitive status changes. A longitudinal cohort study was developed using the data from 572 participants from NMAPS to measure the effect of polypharmacy on MMSE scores and risk of MCI. Multivariable mixed linear regression models and generalized estimating equations were used to estimate these associations, adjusting for sex, age at baseline, Charlson Comorbidity Index (CCI), presence of the apolipoprotein (Apo)E e4 allele, body mass index (BMI), and hypertension. Most of the study subjects were female (63.6%), white (88.5%), and married (66.6%); 47.2% had 12 to 16 years of education, and 36.2% had more than 16 years of education. Polypharmacy was associated with a 0.11 0.09point lower MMSE score (P = .23) and a greater risk of MCI (odds ratio = 1.95, 95% confidence interval = 0.40– 9.43) (Table 1). Thus, even though the sample size was small, and the associations were not statistically significant, the results suggest that polypharmacy could be an important factor in cognitive decline. Other notable findings included the detrimental effects of male sex, CCI greater than 0, and the ApoE e4 allele on cognitive decline, although only the CCI was statistically significant. Furthermore, hypertension (treated) was significantly associated with higher MMSE scores. These results were consistent with the analyses done for MCI and for change in MMSE scores over time. The sampled population was unusually healthy and educated compared with the general U.S. population. The prevalence of diabetes mellitus (0.53%), hypertension (34.5%), and obesity (10.5%) in the studied sample were much lower than the prevalences of 26.9%, 71.6%, and 35.0%, respectively, described for those diseases in Americans aged 65 and older.4,5 According to the U.S. Department of Health and Human Services, the percentage of older people who completed high school rose from 28% to 71% between 1970 and 2003.6 Approximately 83% of the sample studied had completed a high school education, and taking into consideration that the recruitment process was between 1979 and 2003, it is possible to establish that this sample was unusually highly educated. These characteristics may limit the generalizability of these results to the U.S. population. Anticholinergic drugs and other drugs categorized as potentially inappropriate medications (PIMs) have been found to be strongly associated with cognitive impairment,
LETTERS TO THE EDITOR
FEBRUARY 2015–VOL. 63, NO. 2
COMPARISON OF EFFECTS OF RESISTANCE AND MULTICOMPONENT TRAINING ON FALLS PREVENTION IN INSTITUTIONALIZED ELDERLY WOMEN To the Editor: Falls are a major public health problem in older adults, causing high healthcare demand and expenses.1 At least 30% of people aged 65 and older fall every year, and this incidence is greater in institutionalized people.2 Age-related decreases in postural control and muscle strength have been identified as major risk factors for falls,3 so reducing fall risk in older adults is an important public health concern. Resistance training (RT) is considered to be the best training method to increase muscle strength and has also been found to be effective in preventing falls,4 but RT characteristics, especially the cost of equipment in care institutions, might make multicomponent training (MT) an efficient low-cost alternative. According to the literature, a variety of exercises involving gait, balance, coordination, strength training, and stretching can also enhance muscle strength, balance, and mobility in elderly adults, preventing falls,5 but most studies have been performed in healthy elderly individuals at low risk of falls. Studies performed with institutionalized elderly adults are less common, so the purpose of this study was to compare the effects of two short-term training programs on falls prevention in institutionalized elderly women.
METHODS Thirty-two institutionalized elderly women (aged 72.9 6.6 years) were randomly assigned to a RT group (n = 12), a MT group (n = 10), or a control group (n = 10). Exclusion criteria were systematic engagement in regular exercise of moderate to vigorous intensity for 20 minutes or more at least twice a week in the past 3 years and any medical or physical limitations for testing or training. A medical doctor checked for contraindications (e.g., neuromuscular diseases, stroke, serious heart sicknesses, implant, bypass). The University of Tr as-osMontes e Alto Douro review board for human investigation approved the study according to the Helsinki Declaration, and oral and written consent was obtained from each participant. Both training programs consisted of two sessions per week for 12 weeks. The RT protocol consisted of seven
JAGS
exercises: bench press, leg press, latissimus pull-down, leg extension, military press, leg curl, and arm curl (intensity varied progressively between 60% and 85% of one-repetition maximum, 2–3 sets of 6–12 repetitions). The MT protocol included aerobic exercise (15 to 20 minutes of walking and dancing), muscular endurance exercises (using resistance bands and free weights, 3 sets, 15–20 repetitions), balance and flexibility exercises (moderate intensity, perceived exertion of 12–13 points on Borg scale).6 Risk of falls for each participant was measured before and after training using the Timed Up & Go (TUG)7 and Functional Reach (FR)8 tests (Table 1). Both tests have been demonstrated to have high test–retest and interrater reliability in elderly populations.
RESULTS Analysis of variance (ANOVA) indicated a significant main effect of group (P < .001) on TUG and FR, with significant differences between both training groups and the control group. There were no differences between RT and MT. ANOVA also identified a significant main effect of time by group on TUG (P = .01) and FR (P < .001) in both training groups. Significant differences were observed between pre- and posttest in performance of the TUG (P = .01) and FR (P < .001) for both training groups.
DISCUSSION The main finding of the present study was that MT was as effective in preventing falls in institutionalized elderly women as RT. Twelve weeks of moderate to vigorous training significantly improved ability to adjust the center of gravity continuously over a moving base of support (measured by TUG) and to control movement of the center of gravity over a fixed base of support (measured by FR). In contrast, ability to perform functional tasks related to walking speed, balance, agility, and postural control worsened in the control group in just 12 weeks, suggesting that institutionalization is associated with a marked decrease in physical activity, which increases the risk of falling.9 Falling risk increases with declining upper and lower extremity muscle strength, agility, and dynamic balance performance, but it was recently concluded that agility and dynamic balance performance were most relevant to falling risk.10 There is consensus that RT is the best method of increasing lower and upper extremity muscle strength, but
Table 1. Pre- and Posttraining Values for the Timed Up & Go and Functional Reach Tests According to Group Resistance Training Group (n = 12)
Multicomponent Training Group (n = 10)
Control Group (n = 10)
Mean Standard Deviation Test
Pre
Post
Pre
Post
Pre
Post
Timed Up & Go, seconds Functional Reach, cm
13.40.3 70.92.7
11.20.2a 82.52.5a
14.40.5 65.14.7
11.80.3a 73.45.4a
16.11.3 58.53.0
17.31.7 48.43.0
Significant difference from pretraining values, P < .05.
a
JAGS
FEBRUARY 2015–VOL. 63, NO. 2
MT is promising and effective in frail institutionalized elderly adults, particularly by increasing agility and dynamic balance performance. MT is as effective in preventing potential falls in institutionalized elderly women as RT, has wide practical applicability, and is inexpensive to develop. Nelson Sousa, PhD Romeu Mendes, PhD Research Center in Sport Sciences, Health Sciences and Human Development, University of Tr as-os-Montes e Alto Douro, Vila Real, Portugal
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Sousa, Mendes: concept and design of the experiment, data analysis and interpretation, preparation of manuscript. Sponsor’s Role: None.
REFERENCES 1. Stevens JA, Corso PS, Finkelstein EA et al. The costs of fatal and non-fatal falls among older adults. Inj Prev 2006;12:290–295. 2. Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med 2002;18:141–158. 3. Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann Intern Med 1994;121:442–451. 4. Sousa N, Sampaio J. Effects of progressive strength training on the performance of the Functional Reach Test and the Timed Get-Up-and-Go Test in an elderly population from the rural north of Portugal. Am J Hum Biol 2005;17:746–775. 5. Alfieri FM, Riberto M, Gatz LS et al. Functional mobility and balance in community-dwelling elderly submitted to multisensory versus strength exercises. Clin Interv Aging 2010;5:181–185. 6. Garber CE, Blissmer B, Deschenes MR et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Med Sci Sports Exerc 2011;43:1334–1359. 7. Podsiadlo D, Richardson S. The, “Timed Up & Go”: A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142– 148. 8. Duncan P, Weiner D, Chandler J et al. Functional Reach: A new clinical measure of balance. J Gerontol A Biol Sci Med Sci 1990;45A:192– 197. 9. Mertz KJ, Lee DC, Sui X et al. Falls among adults: The association of cardiorespiratory fitness and physical activity with walking-related falls. Am J Prev Med 2010;39:15–24. 10. Toraman A, Yildirim NU. The falling risk and physical fitness in older people. Arch Gerontol Geriatr 2010;51:222–226.
COGNITIVE DECLINE AND POLYPHARMACY IN AN ELDERLY POPULATION To the Editor: The Department of Health and Human Services estimates that, by 2030, there will be 72.1 million individuals aged 65 and older in the United States.1 The prevalence of mild cognitive impairment (MCI) in the elderly population is between 3% and 19%, with an incidence of 8 to 58 per 1,000 per year and a risk of developing
LETTERS TO THE EDITOR
397
dementia of 11% to 33% over 2 years.2 The higher prevalence of chronic diseases makes this population more likely to be taking multiple medications. Polypharmacy, defined most commonly as the concomitant use of five or more medications, is a poorly studied factor in relation to MCI, but may play an important role.3 A follow-up study in a Finnish population of 294 elderly people between 2004 and 2007 recorded the use of medications and the cognitive function of participants.3 The authors observed that excessive polypharmacy, defined as the concomitant use of 10 or more medications, was associated with less cognitive capacity measured using the Mini-Mental State Examination (MMSE) than in a non-polypharmacy group. Considering the dearth of scientific studies analyzing the effects of polypharmacy on cognitive decline, particularly in the U.S. population, the current study examined data from the New Mexico Aging Process Study (NMAPS) to further investigate the effects of polypharmacy on cognitive status changes. A longitudinal cohort study was developed using the data from 572 participants from NMAPS to measure the effect of polypharmacy on MMSE scores and risk of MCI. Multivariable mixed linear regression models and generalized estimating equations were used to estimate these associations, adjusting for sex, age at baseline, Charlson Comorbidity Index (CCI), presence of the apolipoprotein (Apo)E e4 allele, body mass index (BMI), and hypertension. Most of the study subjects were female (63.6%), white (88.5%), and married (66.6%); 47.2% had 12 to 16 years of education, and 36.2% had more than 16 years of education. Polypharmacy was associated with a 0.11 0.09point lower MMSE score (P = .23) and a greater risk of MCI (odds ratio = 1.95, 95% confidence interval = 0.40– 9.43) (Table 1). Thus, even though the sample size was small, and the associations were not statistically significant, the results suggest that polypharmacy could be an important factor in cognitive decline. Other notable findings included the detrimental effects of male sex, CCI greater than 0, and the ApoE e4 allele on cognitive decline, although only the CCI was statistically significant. Furthermore, hypertension (treated) was significantly associated with higher MMSE scores. These results were consistent with the analyses done for MCI and for change in MMSE scores over time. The sampled population was unusually healthy and educated compared with the general U.S. population. The prevalence of diabetes mellitus (0.53%), hypertension (34.5%), and obesity (10.5%) in the studied sample were much lower than the prevalences of 26.9%, 71.6%, and 35.0%, respectively, described for those diseases in Americans aged 65 and older.4,5 According to the U.S. Department of Health and Human Services, the percentage of older people who completed high school rose from 28% to 71% between 1970 and 2003.6 Approximately 83% of the sample studied had completed a high school education, and taking into consideration that the recruitment process was between 1979 and 2003, it is possible to establish that this sample was unusually highly educated. These characteristics may limit the generalizability of these results to the U.S. population. Anticholinergic drugs and other drugs categorized as potentially inappropriate medications (PIMs) have been found to be strongly associated with cognitive impairment,
