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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 61:1171-1176 (2006)
© 2006 The Gerontological Society of America

SPECIAL SECTION

Physical Activity Participation by Presence and Type of Functional Deficits in Older Women: The Women's Health and Aging Studies

Gerald J. Jerome1,3,, Thomas A. Glass, Michelle Mielke, Qian-Li Xue, Ross E. Andersen and Linda P. Fried

1 Department of Epidemiology and 2 Department of Biostatistics, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland.
3 Center on Aging and Health and 4 Department of Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland.

Address all correspondence to Gerald J. Jerome, PhD, Department of Kinesiology, Towson University, Towson, MD 21252. E-mail: gjerome{at}towson.edu


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Background. Physical activity is important for maintaining functional independence of older persons, especially for those with existing functional deficits. Since such deficits may pose barriers to activity, it would be instructive to examine activity patterns in relation to specific types of deficits to determine the amount and type of physical activity older women pursue. This study sought to identify categories of functional deficits associated with activity levels and evaluated the potential for older women to increase their physical activity levels.

Methods. Community-dwelling women, aged 70–79 years, from the Women's Health and Aging Studies I and II (N = 710), were assessed for self-reported physical activity, functional deficits and chronic conditions, along with objective measures of muscle strength. Both type (household chores, exercise, and recreational activity) and amount of physical activity (min/wk) were examined. Meeting physical activity recommendations was defined as ≥150 minutes per week of moderate intensity physical activity, and inactivity was defined as no weekly moderate intensity physical activity. Hierarchical categories of functional deficits were based on self-reported difficulty in four functional domains (i.e., mobility/exercise tolerance, upper extremity, higher functioning, and self-care), and self-reports ranged from no difficulty to difficulty in all four domains.

Results. The prevalence of inactivity and meeting activity recommendations were 14.4% and 12.7%, respectively. Severity of functional deficits was associated with increased risk of inactivity (adjusted odds ratios [ORsadj] = 3.14–17.61) and reduced likelihood of meeting activity recommendations (ORsadj =.11–.40). Even among those with higher functioning or self-care difficulties, 30% reported walking for exercise.

Conclusion. There was evidence that older women with functional deficits can remain physically active. However, for some of these women, meeting the recommended levels of activity may be unrealistic. Efforts to increase physical activity levels among older adults should include treatment or management of functional deficits, chronic conditions, and poor strength.

THE benefits of regular physical activity for older adults are well established (1,2). The Centers for Disease Control and Prevention (CDC), the U.S. Surgeon General, and the American College of Sports Medicine (ACSM) recommend that all adults engage in ≥30 minutes of moderate intensity physical activity on most days of the week to obtain health benefits (3). Unfortunately, older adults are more sedentary than younger adults and older women have higher rates of inactivity than older men (4). Alarmingly, 39.2% of women aged 70 and older report no leisure time physical activity (4).

Low physical activity is a risk factor for functional deficits (5). However, the latter can also be a barrier to regular physical activity. Rimmer (6) theorized that the functional loss underling disability results in increased effort needed to engage in physical activity. Consequently, disabled older adults may perceive submaximal tasks to be quite strenuous and associated with increased demand. This would further deter physical activity, creating a downward spiral (6). Among a population-based sample of older women, Brown and colleagues reported that disabled women were less likely than nondisabled women to meet physical activity recommendations (7). However, the authors did not adjust for possible confounders (e.g., sarcopenia) (8) or evaluate the severity of disability (7). A more in-depth understanding of the relationship between severity of functional deficits and activity levels could determine if the most disabled women are able to meet physical activity recommendations. Learning more about the women who have functional deficits but remain active could lead to improved ability to increase activity levels of this at-risk group. Unfortunately, little is known about the activity patterns of older women with functional deficits, including the types of activities in which they participate.

This investigation sought to describe the physical activity levels of community-dwelling older women across the full spectrum of physical functioning. Specifically, we examined the association between categories of functional deficits as defined by an established hierarchical classification (9,10) and the prevalence of both inactivity and of meeting the CDC/ACSM recommendations for physical activity (11). In addition, we examined the relationship between types and severity of functional deficits and participation in different types of physical activity.


   METHODS
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 Methods
Results
 Discussion
 References
 
Study Population
The WHAS are prospective, observational studies designed to examine the causes and course of disability. Details have been previously published (12–14). Both studies used Health Care Financing Administration Medicare eligibility files to identify potential participants in 12 ZIP code areas in Eastern Baltimore City and County. Briefly, WHAS I recruited 1002 women representing the one-third most-disabled women (difficulty in ≥ two domains) from among women aged 65–101 years with a Mini-Mental State Examination (MMSE) (15) ≥18. WHAS II recruited 436 women from among the two-thirds highest functioning women (difficulty in < two domains) aged 70–79 years with MMSE ≥ 24. Functional deficits were defined as self-reported difficulty in any of the four domains of function listed below. These analyses combined data from the two WHAS and included women aged 70–79 years at baseline with MMSE ≥ 24 (N = 779). Women with missing data for grip strength (n = 26), quadriceps strength (n = 33), weight (n = 23), or physical activity (n = 14) were not included, resulting in 710 women (WHAS I, n = 300, WHAS II, n = 410) for these analyses.

Data Collection
Measures obtained at baseline included age, race, education level, physical activity, self-reported functional deficits (see below), and MMSE, as well as reports of physician diagnosis of any of 14 chronic diseases (arthritis, peripheral arterial disease, myocardial infarction, angina, congestive heart failure, diabetes, cancer, lung disease, stroke, hip fracture, osteoporosis, Parkinson's disease, and disc disease or spinal stenosis). The latter were validated with standardized medical record review, then clinically adjudicated using state-of-the-art disease algorithms (12).

Body mass index (BMI) was based on National Institutes of Health cutoff points (16) calculated from standardized measurement of height and weight (kg/m2). In 5.5% of the WHAS I women, standing height was not available (17) and was estimated from knee height (18). Dynamometers were used to measure maximal grip (JAMAR, model BK-7498; Fred Sammons Inc., Burr Ridge, IL) and quadriceps strength (Nicholas Manual Muscle Tester; model BK-7454; Fred Sammons, Inc. (8,12).

Physical Function
Functional deficits were defined as self-reported difficulty in one or more tasks within each of four functional domains: mobility/exercise tolerance (i.e., walking one-quarter mile, walking up 10 steps without resting, getting in and out of bed or chairs, and doing heavy housework); upper extremity (i.e., raising arms over head, using fingers to grasp or handle, and lifting or carrying 10 pounds); higher functioning (i.e., using the telephone, doing light housework, preparing meals, and shopping for personal items); and self-care (i.e., dressing, bathing , or showering, using the toilet, and eating) (12,19). Women often reported difficulty in several domains. Study participants were further differentiated into seven mutually exclusive categories: 1) no limitations, 2) upper extremity only, 3) mobility only, 4) both mobility and upper extremity, 5) higher functioning (not self-care), 6) self-care (not higher functioning), and 7) both higher functioning and self-care. Women in the latter three categories generally reported difficulties in upper extremity and mobility tasks as well, resulting in hierarchical categories. These categories can also be considered hierarchical because they describe women with difficulty in tasks reflecting worsening across the progressive disablement process (9,10,20).

Physical Activity
Physical activity was assessed through self-report indicating both the type of activity (i.e., walking for exercise, heavy household chores, heavy outdoor work, regular exercise, dancing, and bowling) and minutes per week spent in these moderate intensity physical activities using a modified version of the Minnesota Leisure Time Physical Activity Questionnaire (8,22–24). "Inactive" was defined as reporting 0 min/wk of moderate intensity physical activity. "Insufficient" was defined as >0 and <150 min/wk of moderate intensity physical activity. "Recommended" was defined as ≥150 min/wk of moderate intensity physical activity. Moderate intensity was defined as ≥3 metabolic equivalents (METs) (11) based on compendium MET values for each activity (25). These categories correspond with CDC/ACSM recommendations of ≥30 minutes of moderate intensity physical activity on most (5) days of the week (3) and with published work from the CDC (7).

Data Analysis
Analyses were performed using Intercooled Stata 8.2 for Windows (StataCorp, College Station, TX). Sampling weights (12) were used to provide population-based proportions. Women who reported difficulty in any task were classified as having functional deficits. Functional deficits were then disaggregated into the seven mutually exclusive domains described above. To assess the independent relationship of physical activity outcomes to each of the seven mutually exclusive domains, we constructed separate weighted logistic regression models for the two physical activity outcomes of interest (i.e., recommended, inactive). We also conducted separate analyses comparing women without task difficulty to those with some. Each regression adjusted for age (≤74 y), race, education (≥12 y of education), MMSE (<26), chronic conditions (≥2), BMI (≥30), grip strength (>18 kg), and quadriceps strength (>10 kg). Cut-points indicating poor muscle strength were based on previous WHAS I research (8). With respect to exposures, women reporting no difficulty or functional deficits served as the reference group in each logistic regression calculation. With respect to outcomes, the reference group for each logistic analysis was the total sample less the outcome group.


   RESULTS
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Discussion
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Baseline Characteristics
Only 12.7% of these older women met the recommended levels of physical activity, and 14.4% were inactive. Table 1 indicates that between 54%–79% of women were classified as insufficiently active. There were no significant differences in physical activity levels across age, race, or MMSE strata. There were differential physical activity levels across chronic condition, BMI, and strength strata. Women with at least two chronic conditions, heavier women, and those with lower strength were less active.


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  		Table 1. Population Estimates of Physical Activity Levels for Women Aged 70–79 Years by Selected Characteristics.

 
Functional Deficits and Types of Physical Activity
Participation in heavy household chores was reported most frequently followed by walking for exercise, with two exceptions (Table 2). Women who reported difficulty only in upper extremity tasks walked for exercise (70%) more frequently than they performed heavy household chores (65%). Those who reported difficulty in both higher functioning and self-care tasks reported similar frequencies of walking for exercise (30%) and performing heavy household chores (28%). The lowest participation rates were reported by women who indicated difficulty with higher functioning tasks.


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  		Table 2. Population Estimates of Participation in Specific Physical Activities Among Women Aged 70–79 Years Stratified by Functional Deficit Categories.

 
Functional Deficits and Physical Activity Levels
Only 6% of women who reported any deficit and 22% of those who reported no deficits met recommended physical activity levels (Table 1). Women who reported at least one deficit were more likely to be classified as inactive (23%) compared with those who reported no deficits (3%). None of the women reporting difficulty in both higher functioning and self-care met activity recommendations (Table 1).

Presence of any functional deficit was inversely associated with achieving recommended activity levels (adjusted odds ratio [ORadj] = 0.26) and directly associated with inactivity (ORadj = 6.54). There was an inverse stepwise association between severity of functional deficits and having obtained recommended levels of activity (Table 3). The crude associations between functional deficits and physical activity levels were either unchanged, or strengthened, after adjustment for baseline characteristics. The odds ratios for women who reported difficulty only in upper extremity tasks or only in mobility tasks ranged from ORsadj 0.32–0.40, whereas those reported difficulty in a) both upper extremity and mobility, b) higher functioning (not self-care), or c) self-care (not higher functioning) tasks had a stronger association (ORsadj 0.11–0.18). The strongest association was found among women who reported both higher functioning and self-care difficulty, as none of these women met recommended physical activity levels. Similarly, women who reported both higher functioning and self-care difficulty had the strongest likelihood of being inactive (ORadj = 17.61).


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  		Table 3. Association of Functional Deficit Categories with Physical Activity Levels Among Women Aged 70–79 Years.

 

   DISCUSSION
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 Methods
 Results
 Discussion
References
 
In this population-based study of older community-dwelling women, those with more severe functional deficits were also less active, even after controlling for health indicators such as poor strength and chronic conditions. These findings are congruent with previous research demonstrating that severity of functional deficits is associated with higher rates of inactivity (7,8). Roubenoff has reported similar results among older adults with rheumatoid arthritis and osteoarthritis (26), supporting the hypothesis that inactivity, disease, and poor strength initiate a downward spiral in health and function. This growing evidence raises the question of how to help women with functional deficits remain active and attenuate the hypothesized cascade of events.

These results also have important implications for older women with regard to current physical activity recommendations (11). We found evidence that older women with functional deficits can and do remain physically active despite these deficits. However, for some of these women, meeting the recommended level of activity (i.e., ≥150 min/wk of moderate intensity physical activity) may be unrealistic. In this study, many women with functional deficits met activity guidelines, yet none of the women with difficulties in both higher functioning and self-care achieved the recommended levels of activity. The potential for the latter group of older women to become more active is suggested by our findings that a subset of women with difficulties in both higher functioning and self-care reported some moderately intense physical activity. As new physical activity guidelines evolve for older adults, policymakers may want to consider recommendations that vary depending on severity of functional deficits and tailored prescriptions based on patient health and function.

This evidence suggests potential benefits of clinicians working with older patients who have functional deficits to help them increase and maintain their activity levels. Because these results indicate that poor strength, chronic conditions, and functional deficits were associated with inactivity in older women, a multifactorial approach appears appropriate. Clinicians should refer women to community-based resources to increase or maintain activity levels in concert with treatment or management of chronic conditions and rehabilitation for functional deficits and poor strength. Examples of effective physical activity promotion programs designed specifically for frail older adults can be found in the work of Nelson (27) and Fiatarone (28). Patient self-care programs designed for those with chronic conditions may be an ideal setting to promote more active lifestyles (29,30), but additional research is needed to determine whether such self-management programs would be as beneficial for adults with severe functional deficits.

In our data, the most common sources of regular physical activity among these older women included walking for exercise and heavy household chores. This suggests the possibility that activities such as walking, which are often done with others, have the added advantage of reinforcing social integration. Household chores may be a source of pride that reinforces a sense of continued productivity and independence. As such, clinicians can emphasize those physical activities that involve productive or social roles coupled with physical activity. This approach is congruent with a lifestyle intervention approach (31) that encourages patients to accumulate activity throughout the day. Alternative interventions such as social engagement through volunteering in the community could also help older women maintain their activity levels, and may attract those who might otherwise eschew exercise programs (32). Herein were practical approaches to increasing activity levels with older adults. However, as of yet, the most effective approach to increasing activity levels among women with different functional deficits is not known.

We acknowledge that our investigation has several limitations. First, our study may not generalize to men or women in other age ranges. Additionally, our study is unable to directly assess Rimmer's theory of spiraling decline (6) due to the cross-sectional nature of this study. A more objective measure of physical activity (e.g., accelerometers) across multiple weeks could improve the accuracy and reliability of our activity classifications. Lastly, WHAS I studied disabled, community-dwelling older women, a population that is often undersampled (12). To the extent that study participation rates were lower in the least active women with severe functional deficits, our results would be biased toward higher estimated activity.

Summary
Our findings indicated that a majority of older women had alarmingly low levels of activity, and that many women with functional deficits were sedentary. Although severity of functional deficits was significantly associated with higher rates of inactivity and lower rates of meeting physical activity recommendations, women from a wide range of functional abilities appear capable of moderate intensity physical activity. Developing ways to introduce regular physical activity into the lives of these women should represent a serious public health priority (33). We also need to understand factors that enable some older women to remain physically active at appropriate levels, despite functional deficits.

The efforts to increase activity levels among community-dwelling women with functional deficits should take into consideration that health problems such as functional deficits, chronic conditions, and poor strength remain significant barriers to an active lifestyle. The health care community must increase focus on developing novel programs to build on the adaptive potential of older adults. This important work may offer the opportunity to be regularly active, regardless of functional deficits or disease.


   Acknowledgments
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This study was supported by the NIH-NIA grants N01-AG-1-2112, R01AG011703, R37AG19905 and T32AG000247, and by the Johns Hopkins University School of Medicine General Clinical Research Center grant M01-RR00052, from the National Center for Research Resources/NIH.


   Footnotes
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Decision Editor: Darryl Wieland, PhD, MPH

Received January 27, 2006

Accepted July 11, 2006


   References
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