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Mrs.
F. lived alone and independently at 78, but was beginning to go out
less and less. Gradually worsening arthritis limited her activity
even inside the house. She had osteoporosis, and when she fell on
the stairs and broke her hip, the rehabilitation program was only
partly successful. Her activity became even more limited. After a
second fall, she entered a nursing home where she became depressed.
Antidepressant drugs made her lightheaded and dizzy, and she fell
again, breaking her other hip. In the hospital, she was too weak to
participate in a rehabilitation program, and, returning to the nursing
home, became chronically bedbound. |
How Can Frailty
Be Prevented?
Hypothetical but typical, the case of Mrs. F. illustrates the progression
of one of the most serious health problems affecting people age 65 and over.
Frailty can be defined simply as an impairment in the physical abilities
needed to live independently, but it is usually the sum of many impairments-in
muscle strength, in posture and balance, in gait, and in bone mass and quality.
In terms of everyday living, these
impairments are critical. Climbing ten steps is difficult for 32 percent
of persons over age 75 living at home; 40 percent have difficulty walking
one-fourth of a mile and 22 percent cannot lift 10 pounds. These percentages
translate into millions of older people with some limitations in such
activities - the so-called activities of daily living or ADLs.
The public health impact of frailty
is enormous. A major cause underlying the need for long-term care, it
afflicts more than 3.25 million older Americans at an annual cost of at
least $54 billion. But disability in old age is not inevitable. In fact
disability rates fell during the 1980s, according to the Institute's National
Long-Term Care Survey. While the general population of people age 65 and
over rose by 14.7 percent between 1982 and 1989, the number of people
chronically disabled or in nursing homes grew by only 9,2 percent. This
means that the proportion of people with disability fell and that there
were hundreds of thousands fewer disabled people than expected. The finding
has given impetus to the search for ways to manage and reduce disability.
Mrs. F.'s progressive frailty,
for example, might have been prevented or reversed at several points.
One of these was before she developed osteoporosis, a condition in which
bones become thin and fragile. Osteoporosis contributes to numerous cases
of frailty, especially among women, but studies suggest that it can be
prevented or at least alleviated through exercise, nutrition, and for
some women, hormone replacement therapy.
Mrs. F.'s first fall also could
have been prevented. Researchers have found that simple and practical
measures, like muscle-strengthening exercises, balance training, and protective
devices, do prevent falls. Interim findings from eight clinical trials
known as FICSIT (short for "Frailty and Injuries: Cooperative Studies
of Intervention Techniques") show that these and other measures can reduce
falls by at least 30 percent.
Techniques to prevent frailty may
work at any age. Studies in Boston have shown that even 90-year-olds can
improve muscle strength and mobility after simple weight-training exercises.
These exercises to live without walkers or wheelchairs, to climb stairs,
and to carry out daily activities more independently than they had before
they entered the exercise program.
Staying Independent
Another front in the campaign to prevent frailty and maintain independence
is research on self-care methods. These include specific behaviors - such
as getting up and down from chairs with special movements-and use of equipment
like walkers. Data from the National Long-Term Care Survey showed that
the use of special equipment rose sharply during the 1980s. Use of shower
seats and tub stools, for instance, increased by 65.9 percent and use
of raised toilets by 148 percent.
People also care for themselves
by making changes in their environment, some of them as simple as keeping
cooking utensils on a counter instead of in cupboards. Self-care techniques
often allow older people to live independently, even in the face of significant
functional limitations, and to lower costs of personal long-term care.
Driving is another major factor
in staying independent, and research has uncovered a way older drivers
may be able to drive more safely for longer. A study in Birmingham, Alabama,
found that older people who have a wider field of view - what has been
called their "useful field of view" (UFOV) - are less likely to be in
crashes than people with narrow UFOVs.
These investigators also found
that a simple intervention can expand older peoples' useful field of view.
The research suggests that policies that restrict driving privileges based
on age or simple vision tests may not be appropriate and that driving
skills and safety among older people can be improved.
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| Rose
Karsh, 90 years old, testified before Congress about the benefits
of an NIA-sponsored exercise study at the Hebrew Rehabilitation Center
for Aged: "When I finished the study I was able to lift 50 pounds
with each leg which surprised me very much at my age. After the test
was over I was able to walk around the center without any assistance...
It made me feel younger and gayer." |
Nutrition
and Frailty
Dietary deficiencies are not uncommon among older people and may increase
the risk of frailty and disease. Researchers at NIA and in Boston
have found that many elderly people consume less than two-thirds the
recommended daily amounts of vitamins E and B6, iron, calcium, magnesium,
and zinc. Such deficiencies are an issue of special concern at NIA
and other public health agencies, which are exploring the possibility
of nutritional screening for older people.
A closer look at vitamin
and mineral deficiencies among the elderly is now underway through
the National Health and Nutrition Examination Survey (NHANES III).
A special, NIA-sponsored supplement to this large scale survey is
collecting information from people age 75 and over for the first
time. Data on nutritional status will come from physical examinations,
while questionnaires will probe a variety of social issues. The
survey will determine, for instance, what proportion of their incomes
people need for food, how many need help with food preparation and
shopping. The results will help guide nutrition policy and services
as the elderly population grows in coming decades.
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A major cause of frailty is cardiovascular disease.
Here a researcher at NIA's Baltimore laboratories studies blood
flow velocity using Doppler ultrasonography. His research is part
of the Institute's Vascular Initiative, a group of studies that
are probing the relationship between blood vessel stiffness and
cardiovascular disease.
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What older people eat may be a key factor influencing survival. An NIA
grantee at the University of California is analyzing data from the first
NHANES survey and its follow-up studies to see what impact living arrangements
have on survival of the elderly. Once of the variables he will be looking
at is diet - for instance the diet of people living alone - to see whether
it influences the relationship between living arrangements and survival.
He'll also be looking at economic status, health behaviors, social support,
psychological well-being, and health status. This study is expected to
have important implications for social policy and intervention programs.
For example, it could help guide programs to improve the quality of life
for the large proportion of older people who live alone.
Meanwhile, other scientists
are exploring the effect of various nutrients on the biology of aging.
They have found, for example, that aging skin does not respond to sunlight
(a source of vitamin D) as well as younger skin. This may be one of the
factors contributing to high rates of osteoporosis. Now researchers at
a nursing home in Boston and elsewhere are seeing exactly how much sunshine
a year elderly people need to get a healthy amount of vitamin D and how
fluorescent lighting compares to sunlight in promoting vitamin D synthesis.
They hope this will lead to guidelines for nursing homes and other long-term
care facilities, both regarding the amount of sunlight needed by people
who can get outside and use of fluorescent lighting for those who cannot.
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What Causes Disability
Among Women?
Like Mrs. F, millions of people age 65 and over are
somewhat disabled. We know the 22 percent of women age 65 and over
need assistance in daily activities, that two-thirds of all disabled
older people are women, and that current estimated costs in health
care for people with disabilities are $65 billion annually.
What we don't
know yet are all of the causes of disability, how they interact,
and what makes it get better or worse. Answers to these questions
will be forthcoming from the NIA-sponsored Women's Health and Aging
Study, which is examining nearly 29 different diseases and disorders
and their impact on disability.
Begun in
1992, the 7-year study will be looking at conditions ranging form
major killers like coronary heart disease to problems that can restrict
everyday activities, such as arthritis and hearing loss. Included
in this study are cognitive impairments and mental illnesses, such
as depression, to learn their impact on disability.
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