An article by Montserrat Mora Nieto
Professional College of Physiotherapists of the Community of Madrid ()
Aging is a physiological process influenced by multiple factors such as genetics, lifestyle, some diseases, the environment, which affects all dimensions of the human being: biological, cognitive, psychological, social…
Not all of us age in the same way, but we all suffer physiological changes with age that affect all our systems (nervous, endocrine, immune, musculoskeletal…), which causes a decrease in our physiological reserveswhich is why the way in which a disease or disorder can present itself is atypical.
The Older people need a more exhaustive assessment in comparison with the rest of adults to detect changes in their condition as quickly as possible, since the development of a disability, a situation of dependency, or in the worst case, even death will depend on this. And it is that, when certain factors coincide (weight loss, low activity, diseases…), older people are exposed to greater vulnerability to adverse situations, this is known as “fragility”.
Functional assessment plays a very important role when developing personalized treatment programs for each person.
The most widely used assessment in geriatrics is the so-called “Comprehensive Geriatric Assessment” (VIG), which includes an interdisciplinary assessment at the biomedical, functional, neuropsychological and social level, which allows comprehensive interventions that improve the quality of life and autonomy. It is from the fifties when the functional assessment is considered one of the best ways to assess the health status of the elderly (WHO), therefore it represents an essential component in the clinic and treatment.
Furthermore, it is considered a good adverse event predictor such as falls, hospitalization, institutionalization, clinical evolution or even mortality. At this point it is convenient to clarify that, by function, we mean the ability we have to act in our daily life, autonomously, with our preferences and interests.
One of the main triggers of frailty is the “sarcopenia”. With age, physiological changes occur at the musculoskeletal level that result in a loss of function, strength, and muscle mass which, if other factors such as lack of activity, physical fitness, sedentary lifestyle or obesity are added, can cause serious health problems and affect personal autonomy.
It is a predictable phenomenon that can be stopped or slowed down by controlling three factors: nutrition, activity and physical condition. Older people need to maintain at least a “functional physical condition”, a concept that Rikli and Jones (2001) define as “the physical capacity to carry out normal activities of daily living safely and independently and without excessive fatigue”. And it is that, functional physical condition is vital to maintain a good quality of life. Well, it determines the extent to which people can manage themselves with autonomy on a day-to-day basis and at a social level. In turn, movement is an essential component in the life of the elderly, since all their body systems work more efficiently when the person is active. On the contrary, when anomalies appear, they affect when performing daily tasks optimally.
When the older adult is altered or loses their ability to walk, or presents balance disorders, they are at high risk of suffering adverse effects or incidents that seriously affect their health. The functional evaluation is assessed through the execution of activities of daily living (ADL), for which there are different measurement tests:
- “Basic” (ABVD), related to self-care (eating, toilet training, dressing… (Barthel, Katz, Red Cross…)
- “Instrumental” (AIVD), which are those that allow us independence in the community and in which we interact with the environment (shopping, cooking, cleaning the house, managing finances…(Lawton-Brody…)
- “Advanced” (AAVD), which require more complex acts, such as: participating in leisure activities, religious, sports, work or transportation, (Rosow-Breslan…).
As a complement, the measures called “performance-based evaluation measures” of physical function, MEBE or MBE, which evaluate aspects related to alterations in the components involved in mobility, combined with others that evaluate the functional physical condition.
In general, they value muscle strength, joint amplitude, balance, resistance, power, transfers, mobility or gait, among others. They are tests in which the individual has to perform a specific task, which is evaluated in an objective, systematic and uniform manner, using already established predetermined criteria, such as the number of repetitions or the time spent in executing it.
These tests can be simple, a single test, or compound, several tests in a battery of tests. After the tests, data collection and subsequent analysis are required. These tests are very useful because with them minimal changes and states of fragility can be detected in the usual clinic quickly, easily, cheaply and objectively.
Some of the advantages of these evidence are:
- Direct, objective and quantifiable observation
- Avoid disagreements between the opinions of the caregivers and the elderly regarding their condition
- Very sensitive to any change in the patient’s condition
- Strong predictors of falls, institutionalization and death
- They can detect pre-frailty states even without the person having any type of disability
- They require little cognitive function for their performance, so they can be used with people with cognitive impairment
- It individualizes the disability, thus allowing interventions more adapted to the needs of the patient, personalizing the treatment
On the contrary, some disadvantages are:
- Little cognitive function required
- It takes a little training to be able to perform them
- Some may carry some risk of falling, physical fatigue, or lack of collaboration on the part of the patient to perform it.
Some of the most used tests are: SPPB, SFT, Duncan’s functional range, gait speed, getting up from a chair, time up and go or get up and go, Tinetti… which we will define.
SPPB, “Short Physical Performance Battery”
Evaluates the functional level of the lower extremities. It consists of performing three tests:
Balance (in three positions): feet together, semi-tandem and tandem
walking speed: normally a distance of 4 meters
get up and sit down in a chair five times
The total score of the SPPB, sum of the three sub-tests. It ranges from 0 (worst performance) to 12 (best performance). It is very sensitive, so changes in 1 point have clinical significance. Scores: 0-3: severe limitation; 4-6: moderate limitation; 7-9: slight limitation; 10-12: minimal limitation. Low scores have a high predictive value for disability, loss of mobility, hospitalization, institutionalization, and death.
This test is used primarily in the elderly, but it may also be a beneficial tool to use in the management of patients with cardiovascular disease.
SFT, “Senior fitness test”
Very complete, since the tests that make up the battery include a good number of components associated with functional independence. They can be performed on people of different ages (between 60 and 94 years) and levels of physical and functional capacity, since this battery covers a wide range, from the most fragile to the elite, and it is also easy to apply.
It has reference values expressed in percentiles for each of the tests (obtained from a large study carried out on 7,000 people), which allows us to compare the results with people of the same sex and age. For this reason it is also used in the field of research as well as in that of practical application.
Test:
1. Sitting down and getting up from a chair
2. Push-ups
3. Two minute walk
4. Chair trunk flexion
5. Clasp your hands behind your back
6. Get up, walk around and sit down again.
*6 minute walk test. Skip the 2-minute walk test if this test is applied.
“Duncan’s Functional Scope”
It measures the maximum displacement of the line of gravity within the base of support of the body. It mainly evaluates balance, since it measures the limits of stability in standing. It consists of measuring the distance that a person can reach with their arms extended forward while standing, keeping the base of support fixed. The cut point is 15 cm.
“Speed of walking”
It is very easy to execute, very simple to apply and interpret, and it is an excellent predictor of alterations in walking and mobility. It is very used. It consists of measuring the speed of the march when traveling a short distance, normally 4-5 meters, at a normal pace. Other distances can be used if required by the patient’s condition (2.5-10-20m). In general, times of less than 1m/s are considered the cut-off point for fragility, although they may vary depending on age and sex.
“Time of Incorporation of a chair”
It consists of measuring the time it takes the patient to get up from a chair without help. Normal values correspond to less than 1 sg.
“Time up and go”, “Get up and go”
It measures the time it takes a person to get up from a chair, walk ten feet, turn around, walk back to the chair, and sit down. Using the usual support products for your mobility, assess mobility and static and dynamic balance. Less than 10 s: normal mobility; between 11 and 20 sg: normal limits for the elderly and frail disabled people; more than 20 s: high risk of falls, the person needs support; and more than 30 s: severely altered.
·“Tinetti”
It assesses the risk of falls and has two parts: balance and gait, asking the patient for different movements and activities. Each item is scored from 0 to 2. Maximum balance score 16 and gait score 12 points. Both results are added, those below 19 points indicate high risk of falls, between 19 and 24 medium risk, between 25 and 28 low risk.
For any of these tests, it is important to know and take into account the cut-off points that determine states of frailty. Functional assessment plays a very important role when developing treatment programs as it allows the creation of personalized treatments, adapted to the real needs of the patient, in addition to assessing their effectiveness. In this sense, the commitment and continuous training of professionals who carry out their activity in the field of geriatrics is necessary.
Bibliography
· White paper on frailty, (International Association of Gerontology and Geriatrics, 2011)
Consensus document…