Anthony P. Marsh

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP®) developed a surgical risk calculator using data from 1.4 million patients and including 1557 unique Current Procedural Terminology (CPT) codes. Although this calculator demonstrated excellent performance in predicting postoperative mortality, morbidity, and six surgical complications, it was not developed specifically for use in older surgical patients who have worse surgical outcomes and additional unique risk factors compared to younger adults. We aimed to test the ability of a simple self-reported mobility tool to predict postoperative outcomes in the older surgical population compared to the NSQIP. We used data from a prospective cohort study that enrolled 197 older surgical patients (≥ 69 years) undergoing various elective surgeries and assessed 30-day surgical outcomes. Statistical models included data from the Mobility Assessment Tool-short form (MAT-sf) alone, covariates alone, and MAT-sf data and covariates. We used leave-one-out (LOO) cross-validation of the models within our cohort and compared their performance for predicting postoperative outcomes against the NSQIP calculator based on receiver operating characteristic area under the curve (ROC AUC). Patients with poor self-reported mobility experienced higher rates of postoperative complications and nursing home placement. There was no difference in performance between any of our models and the NSQIP calculator (p > 0.1), with AUC between 0.604 and 0.697 for predicting postoperative complications and 0.653 and 0.760 for predicting nursing home placement. All models also predicted a length of stay (LOS) similar to the actual LOS. Mobility assessment alone using MAT-sf can predict postoperative complications, nursing home placement, and LOS for older surgical patients, with accuracy comparable to that of the NSQIP calculator. The simplicity of this noninvasive risk assessment tool makes it an attractive alternative to the NSQIP calculator that requires 20 patient predictors and the planned procedure, or CPT code to predict the chance that patients will have 15 different adverse outcomes following surgery.

Among older persons, disability is often precipitated by intervening illnesses and injuries leading to hospitalization. In the Lifestyle Interventions and Independence for Elders (LIFE) Study, a structured moderate-intensity physical activity program, compared with a health education program, was shown to significantly reduce the amount of time spent with major mobility disability (MMD) over the course of 3.5 years. We aimed to determine whether the benefit of the physical activity program in promoting independent mobility was diminished in the setting of intervening hospitalizations. We analyzed data from a single-blinded, parallel group randomized trial (ClinicalTrials.gov: NCT01072500). In this trial, 1635 sedentary persons, aged 70–89 years, who had functional limitations but were able to walk 400 m, were randomized from eight US centers between February 2010 and December 2013: 818 to physical activity (800 received intervention) and 817 to health education (805 received intervention). Intervening hospitalizations and MMD, defined as the inability to walk 400 m, were assessed every 6 months for up to 3.5 years. For both the physical activity and health education groups, intervening hospitalizations were strongly associated with the initial onset of MMD and inversely associated with recovery from MMD, defined as a transition from initial MMD onset to no MMD. The benefit of the physical activity intervention did not differ significantly based on hospital exposure. For onset of MMD, the hazard ratios (HR) were 0.79 (95% confidence interval [CI] 0.58–1.1) and 0.77 (0.62–0.95) in the presence and absence of intervening hospitalizations, respectively (P-interaction, 0.903). For recovery of MMD, the magnitude of effect was modestly greater among participants who were hospitalized (HR 1.5, 95% CI 0.71–3.0) than in those who were not hospitalized (HR 1.2, 95% CI 0.88–1.7), but this difference did not achieve statistical significance (P-interaction, 0.670). Intervening hospitalizations had strong deleterious effects on the onset of MMD and recovery from MMD, but did not diminish the beneficial effect of the LIFE physical activity intervention in promoting independent mobility. To achieve sustained benefits over time, structured physical activity programs should be designed to accommodate acute illnesses and injuries leading to hospitalizations given their high frequency in older persons with functional limitations. ClinicalTrials.gov identifier NCT01072500 .

Objectives: To determine whether moderate‐intensity physical activity ( PA ) and health education ( HE ) are differentially associated with categories of hospitalizations or subgroups of participants. Design: Multicenter randomized controlled trial in which participants were randomized to a PA or HE program for an average of 2.6 years. Setting: Eight field centers. Participants: Sedentary men and women aged 70–89 with lower extremity physical limitations but able to walk 400‐m in 15 minutes or less (N = 1,635). Interventions: Structured, moderate‐intensity PA (n = 818) at a center (2×/wk) and at home (3–4×/wk) that included aerobic, strength, balance, and flexibility training or HE (n = 817) of educational workshops and upper extremity stretching exercises. Measurements: All‐cause inpatient hospitalizations ascertained at 6‐month intervals. Results: There were 1,458 hospitalizations (49.1% of PA , 44.4% of HE ; risk difference = 4.68%, 95% confidence interval ( CI ) = −0.18–9.54; hazard ratio ( HR ) = 1.16, 95% CI = 1.00–1.34). The intervention effect on incident hospitalization did not differ according to race, sex, Short Physical Performance Battery score, age, or history of cardiovascular disease or diabetes mellitus. PA was associated with higher rates of hospitalization in the middle baseline gait speed category, than HE (1.0 m/s: HR = 1.05, 95% CI = 0.67–1.65; interaction P = .005). Conclusion: A PA program in older adults at risk for mobility disability did not lead to a different risk of specific types of hospitalizations than a HE program overall. Baseline gait speed may be a marker for risk of hospitalization during a PA intervention, because individuals with moderate baseline gait speed in the PA group had slightly higher rates of hospitalization than those in the HE group. Trial Registration: ClinicalTrials.gov identifier: NCT01072500.

Assessing volume of physical activity (PA) in older adults is critical to understanding the role that PA has on health outcomes and the effectiveness of treatment interventions to increase PA. The purpose of this study was to investigate the psychometric properties of a novel computer-animated self-report questionnaire designed to assess walking activity of older adults: the Mobility Assessment Tool for Walking—the MAT-W. We recruited 249 older adults (66.9±4.7 years, 71% female, 32% black) with cardiovascular disease and/or metabolic syndrome as part of the Cooperative Lifestyle Intervention Program-II study. Participants completed the MAT-W at baseline and after 6 months of a walking and weight loss ( n = 78) or weight loss only ( n = 69) intervention. Test–retest reliability was assessed in 31 participants. Walking speed at usual and fast pace was measured using a GAITRite mat, and 7-day accelerometry data were collected at baseline and 6 months. The mCHAMPS5, a modified version of a widely used self-report PA questionnaire, was completed at baseline. The test–retest reliability of MAT-W was excellent (intraclass correlation coefficient > .85). The MAT-W was correlated with mCHAMPS5 (Spearman r = .66, p < .001) and moderate/vigorous levels of PA as assessed by accelerometry (Spearman r = .65, p < .001) and was responsive to an intervention-induced change in PA at 6 months when comparing the Cooperative Lifestyle Intervention Program-II walking and weight loss group with the weight loss only group ( p < .001). The MAT-W is a brief, reliable, and valid tool to assess PA and has promise for the assessment of walking behavior in older adults under free-living conditions.

Background. Performance-based and self-report instruments of physical function are frequently used and provide complementary information. Identifying older adults with a mismatch between actual and perceived function has utility in clinical settings and in the design of interventions. Using novel, video-animated technology, the objective of this study was to develop a self-report measure that parallels the domains of objective physical function assessed by the Short Physical Performance Battery (SPPB)—the virtual SPPB (vSPPB). Methods. The SPPB, vSPPB, the self-report Pepper Assessment Tool for Disability, the Mobility Assessment Tool-short form, and a 400-m walk test were administered to 110 older adults (mean age = 80.6±5.2 years). One-week test–retest reliability of the vSPPB was examined in 30 participants. Results. The total SPPB (mean [±SD] = 7.7±2.8) and vSPPB (7.7±3.2) scores were virtually identical, yet moderately correlated (r = .601, p < .05). The component scores of the SPPB and vSPPB were also moderately correlated (all p values <.01). The vSPPB (intraclass correlation = .963, p < .05) was reliable; however, individuals with the lowest function overestimated their overall lower extremity function while participants of all functional levels overestimated their ability on chair stands, but accurately perceived their usual gait speed. Conclusion. In spite of the similarity between the SPPB and vSPPB, the moderate strength of the association between the two suggests that they offer unique perspectives on an older adult’s physical function.

Improving muscle strength and power may mitigate the effects of sarcopenia, but it is unknown if this improves an older adult's ability to recover from a large postural perturbation. Forward tripping is prevalent in older adults and lateral falls are important due to risk of hip fracture. We used a forward and a lateral single-step balance recovery task to examine the effects of strength training (ST) or power (PT) training on single-step balance recovery in older adults. Twenty older adults (70.8±4.4 years, eleven male) were randomly assigned to either a 6-week (three times/week) lower extremity ST or PT intervention. Maximum forward (FLean_max) and lateral (LLean_max) lean angle and strength and power in knee extension and leg press were assessed at baseline and follow-up. Fifteen participants completed the study (ST =7, PT =8). Least squares means (95% CI) for ΔFLean_max (ST: +4.1° [0.7, 7.5]; PT: +0.6° [–2.5, 3.8]) and ΔLLean_max (ST: +2.2° [0.4, 4.1]; PT: +2.6° [0.9, 4.4]) indicated no differences between groups following training. In exploratory post hoc analyses collapsed by group, ΔFLean_max was +2.4° (0.1, 4.7) and ΔLLean_max was +2.4° (1.2, 3.6). These improvements on the balance recovery tasks ranged from ~15%–30%. The results of this preliminary study suggest that resistance training may improve balance recovery performance, and that, in this small sample, PT did not lead to larger improvements in single-step balance recovery compared to ST.

We assessed the variability in the number of repetitions completed at submaximal loads in three resistance tasks in older (N=32, 16 female, 74.3±5.4 years) and younger (N=16, 8 female, 22.8±1.8 years) men and women. One repetition maximum (1RM) was determined on two separate visits on three tasks: leg press (LP), leg extension (LE), and bicep curl (BC). Subjects then completed repetitions to failure on each of the three tasks during two visits, a minimum of 48 hours apart, at either 60% 1RM or 80% 1RM. High reliability for all 1RM assessments was observed. Greater muscular strength was observed in younger compared to older men and women on all tasks (PP=0.0258). We did not observe any abnormal blood pressure responses to either the 1RM testing or maximal repetition testing sessions. Considerable interindividual variability was observed in the number of repetitions completed by younger and older men and women at relative intensities typical of resistance training programs. Practitioners should give consideration to individual variability when attempting to maximize the benefits of resistance training.

In previous work, we described the development of an 81-item video-animated tool for assessing mobility. In response to criticism levied during a pilot study of this tool, we sought to develop a new version built upon a flexible framework for designing and administering the instrument.