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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 58:M712-M714 (2003)
© 2003 The Gerontological Society of America

EDITORIAL

Editorial. Mobility Performance: A High-Tech Test for Geriatricians

John E. Morley

Division of Geriatric Medicine, Saint Louis University, and Geriatric Research, Education and Clinical Center, VA Medical Center, St. Louis, Missouri.

GERIATRICIANS classically spend more time with a patient during a visit and receive a lower level of reimbursement than most physicians. It has been somewhat humorously suggested that geriatrics needs the development of a G-scope—a high technology test that would provide reimbursement similar to an echocardiogram. In this issue of the Journal, Newman and colleagues (1) suggest that "walking performance is a valid indicator of physiologic reserve in older adults." Previously, Jylha and colleagues (2) found that both walking difficulty and walking speed were independent determinants of self-rated health. Abnormal mobility examination is an independent predictor of a fall (3,4). Slow walking speed is also a predictor of frailty (5), function (6), incontinence (7,8), and mortality (9). Walking is 1 of 5 items that identified persons having problems with instrumental and daily activities of daily living (10). These findings suggest that a careful, in-depth examination of gait velocity and characteristics should be an essential component of a geriatric assessment.

It has been suggested that walking speed is most strongly associated with leg strength and power rather than aerobic performance (11), with power being more important than strength (12). Lower extremity performance measures decline more rapidly than upper extremity performance, suggesting it is an excellent measure to predict functional deterioration (13). Specific physiological measures are related to the inability to walk distances (14–16). Long-distance walking (400 m) has been demonstrated to be useful to distinguish between persons at the high end of functional capacity (16). This is important as many older persons are performing their activities of daily living near their maximal capabilities (17). Thus a test that can distinguish this group from those with a high reserve level would be useful.

The causes of mobility impairment are multiple. Obviously muscle mass and strength (with strength being more important) play a major role in mobility (18–21). Alterations in muscle mass and strength are related, in part, to the decline in testosterone, Vitamin D, and growth hormone that occur with age (22–30). Older persons rely more on bone than muscle systems when stepping down, leading to a stiffer lower extremity compared with younger persons (31). Poor vascular flow to the legs can lead to impaired mobility (32). Low high-density lipoprotein cholesterol and high triglycerides are associated with impaired mobility (33). Ghosh and Aronow (34) have suggested that lipid-lowering drugs may have a role to play in the treatment of older persons with symptomatic peripheral artery disease. Alteration in bone and joint function can also lead to decreased mobility (35). The central nervous system plays an important role in mobility and fall prevention (36–40). Low cognitive performance is associated with mobility impairment (41,42). Temporal lobe atrophy, a common change seen with aging, is associated with mobility impairment (43). Another study showed that white matter, periventricular, and brain-stem lesions on magnetic resonance imaging were related to impaired motor skills (44). Cognitive demand causes an increase in postural instability in older persons (45). Alterations in psychological status can also alter mobility performance (32,38,39,44,46–48). Mobility decline represents an excellent example of how difficult it is to make a clear aging-disease dichotomy (49,50).

As has been so well documented in the pages of the Journal, an important reason to detect mobility decline early is that it is often related to a decline in physical activity (51–53). Exercise, both of the endurance and resistance types, can reverse the mobility decline (54–60). Exercise also enhances executive function and reduces brain tissue loss (61) and decreases depression (62). Thomas and colleagues (63) found that neuromuscular strength and function can be improved in persons with dementia who receive resistance-exercise training. However, some authorities have questioned whether the benefits of exercise can be maintained long term (64).

While mobility impairment can be gauged relatively simply by performing a 400-meter or 6-minute walk or the up-and-go test together with careful observation of gait, such clinical skills are poorly reimbursed. My personal preference to determine gait, balance, and mobility in my own patients is to dance with them, a totally nonreimbursable procedure! While a careful clinical history and walking a patient up two flights of stairs has similar sensitivity to an exercise stress test, cardiologists have eschewed their clinical skills in favor of high-tech, highly reimbursable testing. Highly sophisticated computerized devices for gait testing have been developed (49,65). Utilization of tests such as these may well result in our ability to enhance early detection of functional deterioration in older persons and initiate early intervention. While geriatrics will always remain a high-touch specialty, there is a need to add high-technology touches or Kane's (66) prophecy of geriatricians becoming chronic care doctors may become a reality. Appropriate mobility assessment represents a futuristic view of modern geriatrics whose time has come.

Acknowledgments

Address correspondence to John E. Morley, MD, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 South Grand Boulevard, M238, St. Louis, MO 63104. E-mail: morley{at}slu.edu

References

  1. Newman AB, Haggerty CL, Kritchevsky SB, Nevitt MC, Simonsick EM. Walking performance and cardiovascular response: associations with age and morbidity—the Health, Aging and Body Composition Study. J Gerontol Med Sci.. 2003;58A:715-720.
  2. Jylha M, Guralnik JM, Balfour J, Fried LP. Walking difficulty, walking speed, and age as predictors of self-rated health: The women's health and aging study. J Gerontol Med Sci.. 2001;56A:M609-M617.[Abstract/Free Full Text]
  3. Covinsky KE, Kahana E, Kahana B, Kercher K, Schumacher JG, Justice AC. History and mobility exam index to identify community-dwelling elderly persons at risk of falling. J Gerontol Med Sci.. 2001;56A:M253-M259.[Abstract/Free Full Text]
  4. Gunter KB, White KN, Hayes WC, Snow CM. Functional mobility discriminates nonfallers from one-time and frequent fallers. J Gerontol Med Sci.. 2000;55A:M672-M676.[Abstract/Free Full Text]
  5. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol Med Sci.. 2001;56A:M146-M156.
  6. Brach JS, VanSwearingen JM. Physical impairment and disability: relationship to performance of activities of daily living in community-dwelling older men. Phys Ther.. 2002;82:752-761.[Abstract/Free Full Text]
  7. Miles TP, Palmer RF, Espino DV, Mouton CP, Lichtenstein MJ, Markides KS. New-onset incontinence and markers of frailty: data from the Hispanic established populations for epidemiologic studies of the elderly. J Gerontol Med Sci.. 2001;56A:M19-M24.[Abstract/Free Full Text]
  8. Palmer MH, Baumgarten M, Langenberg P, Carson JL. Risk factors for hospital-acquired incontinence in elderly female hip fracture patients. J Gerontol Med Sci.. 2002;57A:M672-M677.[Abstract/Free Full Text]
  9. Lan T-Y, Deeg DJH, Guralnik JM, Melzer D. Responsiveness of the Index of Mobility limitation: comparison with gait speed alone in the Longitudinal Aging Study Amsterdam. J Gerontol Med Sci.. 2003;58A:721-727.
  10. Bean JF, Kiely DK, Leveille SG, et al. The 6-minute walk test in mobility-limited elders: what is being measured? J Gerontol Med Sci.. 2002;57A:M751-M756.[Abstract/Free Full Text]
  11. Bean JF, Leveille SG, Kiely DK, Bandinelli S, Guralnik JM, Ferrucci L. A comparison of leg power and leg strength within the InCHIANTI study: which influences mobility more? J Gerontol Med Sci.. 2003;58A:728-733.
  12. Onder G, Penninx BWJH, Lapuerta P, et al. Change in physical performance over time in older women: the Women's Health and Aging Study. J Gerontol Med Sci.. 2002;57A:M289-M293.[Abstract/Free Full Text]
  13. Lan TY, Melzer D, Tom BDM, Guralnik JM. Performance tests and disability: Developing an objective index of mobility-related limitation in older populations. J Gerontol Med Sci.. 2002;57A:M294-M301.[Abstract/Free Full Text]
  14. Saliba D, Orlando M, Wenger NS, Hays RD, Rubenstin LZ. Identifying a short functional disability screen for older persons. J Gerontol Med Sci.. 2000;55A:M750-M756.[Abstract/Free Full Text]
  15. Alexander NB, Dengel DR, Olson RJ, Krajewski KM. Oxygen uptake (VO2) kinetics and functional mobility performance in impaired older adults. J Gerontol Med Sci.. 2003;58A:734-739.
  16. Simonsick EM, Newman AB, Nevitt MC, et al. Measuring higher level physical function in well-functioning older adults: expanding familiar approaches in the health ABC study. J Gerontol Med Sci.. 2001;56A:M644-M649.[Abstract/Free Full Text]
  17. Hortobagyi T, Mizelle C, Beam S, DeVita P. Older adults perform activities of daily living near their maximal capabilities. J Gerontol Med Sci.. 2003;58A:453-460.
  18. Kwon IS, Oldaker S, Schrager M, Talbot LA, Fozard JL, Metter EJ. Relationship between muscle strength and the time taken to complete a standardized walk-turn-walk test. J Gerontol Biol Sci.. 2001;56:B398-B404.[Abstract/Free Full Text]
  19. Schlicht J, Camaione DN, Owen SV. Effect of intense strength training on standing balance, walking speed, and sit-to-stand performance in older adults. J Gerontol Med Sci.. 2001;56A:M281-M286.[Abstract/Free Full Text]
  20. Visser M, Harris TB, Fox KM, et al. Change in muscle mass and muscle strength after a hip fracture: relationship to mobility recovery. J Gerontol Med Sci.. 2000;55A:M634-M440.[Abstract/Free Full Text]
  21. Bootsma-van der Wiel A, Gussekloo J, de Craen AJM, van Exel E, Bloem BR, Westendrop RGJ. Common chronic diseases and general impairments as determinants of walking disability in the oldest-old population. J Am Geriatr Soc.. 2001;50:1405-1410.
  22. Kenny AM, Bellantonio S, Gruman CA, Acosta RD, Prestwood KM. Effects of transdermal testosterone on cognitive function and health perception in older men with low bioavailable testosterone levels. J Gerontol Med Sci.. 2002;57A:M321-M325.[Abstract/Free Full Text]
  23. Matsumoto AM. Andropause: clinical implications of the decline in serum testosterone levels with aging in men. J Gerontol Med Sci.. 2002;57A:M76-M99.[Free Full Text]
  24. Christmas C. O'Connor KG, Harman SM, et al. Growth hormone and sex steroid effects on bone metabolism and bone mineral density in healthy aged women and men. J Gerontol Med Sci.. 2002;57A:M12-M18.[Abstract/Free Full Text]
  25. Morley JE. Andropause: is it time for the geriatrician to treat it? J Gerontol Med Sci.. 2001;56A:M263-M265.[Free Full Text]
  26. Kenny AM, Prestwood KM, Gruman CA, Marcello KM, Raisz LG. Effects of transdermal testosterone on bone and muscle in older men with low bioavailable testosterone levels. J Gerontol Med Sci.. 2001;56A:M266-M272.[Abstract/Free Full Text]
  27. Baumgartner RN, Waters DL, Gallagher D, Morley JE, Garry PJ. Predictors of skeletal muscle mass in elderly men and women. Mech Ageing Dev.. 1999;107:123-136.[Medline]
  28. van den Beld AW, de Jong FH, Grobbee DE, Pols HAP, Lamberts SWJ. Measures of bioavailable serum testosterone and estradiol and their relationships with muscle strength, bone density, and body composition in elderly men. J Clin Endocrinol Metab.. 2000;85:3276-3282.[Abstract/Free Full Text]
  29. Iannuzzi-Sucich M, Prestwood KM, Kenny AM. Prevalence of sarcopenia and predictors of skeletal muscle mass in healthy, older men and women. J Gerontol Med Sci.. 2002;57A:M772-M777.[Abstract/Free Full Text]
  30. Zamboni M, Zoico E, Tosoni P, et al. Relation between vitamin D, physical performance, and disability in elderly persons. J Gerontol Med Sci.. 2002;57A:M7-M11.[Abstract/Free Full Text]
  31. DeVita P, Hortobagyi T. Age increases the skeletal versus muscular component of lower extremity stiffness during stepping down. J Gerontol Biol Sci.. 2000;55A:B593-B600.[Abstract/Free Full Text]
  32. Gardner AW, Katzel LI, Sorkin JD, et al. Improved functional outcomes following exercise rehabilitation in patients with intermittent claudication. J Gerontol Med Sci.. 2000;55A:M570-M577.[Abstract/Free Full Text]
  33. Guo XX, Matousek M, Sundh V, Steen B. Motor performance in relation to age, anthropometric characteristics, and serum lipids in women. J Gerontol Med Sci.. 2002;57A:M37-M44.[Abstract/Free Full Text]
  34. Ghosh S, Aronow A. Utilization of lipid-lowering drugs in elderly persons with increased serum low-density lipoprotein cholesterol associated with coronary artery disease, symptomatic peripheral arterial disease, prior stroke, or diabetes mellitus before and after an educational program on dyslipidemia treatment. J Gerontol Med Sci.. 2003;58A:432-435.
  35. Sicard Rosenbaum L, Light KE, Behrman AL. Gait, lower extremity strength, and self-assessed mobility after hip arthroplasty. J Gerontol Med Sci.. 2002;57A:M47-M51.[Abstract/Free Full Text]
  36. Sands LP, Yaffe K, Covinsky K, et al. Cognitive screening predicts magnitude of functional recovery from admission to 3 months after discharge in hospitalized elders. J Gerontol Med Sci.. 2003;58A:37-45.
  37. Njegovan V, Man-Son-Hing M, Mitchell SL, Molnar FJ. The hierarchy of functional loss associated with cognitive decline in older persons. J Gerontol Med Sci.. 2001;56A:M638-M643.[Abstract/Free Full Text]
  38. Grossberg GT, Desai AK. Management of Alzheimer's disease. J Gerontol Med Sci.. 2003;58A:331-353.
  39. Banks WA, Morley JE. Memories are made of this: recent advances in understanding cognitive impairments and dementia [Editorial]. J Gerontol Med Sci.. 2003;58A:314-321.
  40. Marquis S, Moore MM, Howieson DB, et al. Independent predictors of cognitive decline in healthy elderly persons. Arch Neurol.. 2001;59:601-606.
  41. Blaum CS, Ofstedal MB, Liang J. Low cognitive performance, comorbid disease, and task-specific disability: findings from a nationally representative survey. J Gerontol Med Sci.. 2002;57A:M523-M531.[Abstract/Free Full Text]
  42. Tabbarah M, Crimmins EM, Seeman TE. The relationship between cognitive and physical performance: MacArthur studies of successful aging. J Gerontol Med Sci.. 2002;57A:M228-M235.[Abstract/Free Full Text]
  43. Guo XX, Steen B, Matousek M, et al. A population-based study on brain atrophy and motor performance in elderly women. J Gerontol Med Sci.. 2001;56A:M633-M637.[Abstract/Free Full Text]
  44. Starr JM, Leaper SA, Murray AD, et al. Brain white matter lesions detected by magnetic resonance imaging are associated with balance and gait speed. J Neurol Neurosurg Psychiatr.. 2001;74:94-98.
  45. Brauer SG, Woollacott M, Shumway-Cook A. The interacting effects of cognitive demand and recovery of postural stability in balance-impaired elderly persons. J Gerontol Med Sci.. 2001;56A:M489-M496.[Abstract/Free Full Text]
  46. Blazer DG. Depression in late life: review and commentary. J Gerontol Med Sci.. 2003;58A:249-265.
  47. Draganich LF, Zacny J, Klafta J, Karrison T. The effects of antidepressants on obstructed and unobstructed gait in healthy elderly people. J Gerontol Med Sci.. 2001;56A:M36-M41.
  48. Lemke MR, Wendorff T, Mieth B, Buhl K, Linnemann M. Spatiotemporal gait patterns during over ground locomotion in major depression compared with healthy controls. J Psychiat Res.. 2000;34:277-283.[Medline]
  49. Auvinet B, Berrut G, Touzard C, et al. Gait abnormalities in elderly fallers. J Aging Phys Activ.. 2003;11:40-52.
  50. Blumenthal HT. The aging-disease dichotomy: true or false? J Gerontol Med Sci.. 2003;58A:138-145.
  51. Bortz WM. A conceptual framework of frailty: a review. J Gerontol Med Sci.. 2002;57A:M283-M288.[Abstract/Free Full Text]
  52. Morley JE, Flaherty JH. It's never too late: health promotion and illness prevention in older persons. J Gerontol Med Sci.. 2002;57A:M338-M342.[Free Full Text]
  53. Hubert HB, Bloch DA, Oehlert JW, Fries JF. Lifestyle habits and compression of morbidity. J Gerontol Med Sci.. 2002;57A:M347-M351.[Abstract/Free Full Text]
  54. Evans WJ. Exercise as the standard of care for elderly people. J Gerontol Med Sci.. 2002;57A:M260-M261.[Free Full Text]
  55. Singh MAF. Exercise comes of age: Rationale and recommendations for a geriatric exercise prescription. J Gerontol Med Sci.. 2002;57A:M262-M282.[Free Full Text]
  56. DiPietro L. Physical activity in aging: changes in patterns and their relationship to health and function. J Gerontol Med Sci.. 2001;56:(Spec Issue 2): 13-22.[Abstract/Free Full Text]
  57. Carmeli E, Kessel S, Coleman R, Ayalon M. Effects of a treadmill walking program on muscle strength and balance in elderly people with Down syndrome. J Gerontol Med Sci.. 2002;57A:M106-M110.[Abstract/Free Full Text]
  58. Dubbert PM, Cooper KM, Kirchner KA, Meydrech EF, Bilbrew D. Effects of nurse counseling on walking for exercise in elderly primary care patients. J Gerontol Med Sci.. 2002;57A:M733-M740.[Abstract/Free Full Text]
  59. Westerterp KR, Meijer EP. Physical activity and parameters of aging: A physiological perspective. J Gerontol Med Sci.. 2001;56:(Spec Issue 2): 71-12.
  60. Brandon LJ, Gaasch DA, Boyette LW, Lloyd AM. Effects of long-term resistive training on mobility and strength in older adults with diabetes. J Gerontol Med Sci.. 2003;58A:740-745.
  61. Colcombe SJ, Erickson KI, Slade JM, Covey CJ, Agrawal SK, Doerr CE. Effect of strength and power training on physical function in community-dwelling older adults. J Gerontol Med Sci.. 2003;58A:171-175.
  62. Singh NA, Clements KM, Singh MAF. The efficacy of exercise as a long-term antidepressant in elderly subjects: a randomized, controlled trial. J Gerontol Med Sci.. 2001;56A:M497-M504.[Abstract/Free Full Text]
  63. Thomas VS, Hageman PA. Can neuromuscular strength and function in people with dementia be rehabilitated using resistance-exercise training? Results from a preliminary intervention study. J Gerontol Med Sci.. 2003;58A:746-751.
  64. Keysor JJ, Jette AM. Have we oversold the benefit of late-life exercise? J Gerontol Med Sci.. 2001;56A:M412-M423.[Abstract/Free Full Text]
  65. Churchill AJG, Halligan PW, Wade DT. RIVCAM: A simple video-based kinematic analysis for clinical disorders of gait. Comput Meth Progr Biomed.. 2002;69:197-209.
  66. Kane RL. The future history of geriatrics: geriatrics at the crossroads. J Gerontol Med Sci.. 2002;57A:M803-M805.[Free Full Text]




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