Chair rise capacity and associated factors in older home-care clients

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1 UEF//eRepository DSpace Artikkelit Terveystieteiden tiedekunta 2017 Chair rise capacity and associated factors in older home-care clients Tiihonen M SAGE Publications info:eu-repo/semantics/article info:eu-repo/semantics/acceptedversion Authors All rights reserved Downloaded from University of Eastern Finland's erepository

2 / M. Tiihonen et al.chair rise capacity and associated factors in older home-care clients research-article2017 Scandinavian Journal of Public Health, 1 5 Short Communication Chair rise capacity and associated factors in older home-care clients MIIA TIIHONEN, SIRPA HARTIKAINEN & IRMA NYKÄNEN Kuopio Research Centre of Geriatric Care, School of Pharmacy, University of Eastern Finland, Finland Abstract Aims: The aim of this study was to investigate the ability of older home-care clients to perform the five times chair rise test and associated personal characteristics, nutritional status and functioning. Methods: The study sample included 267 home-care clients aged 75 years living in Eastern and Central Finland. The home-care clients were interviewed at home by home-care nurses, nutritionists and pharmacists. The collected data contained sociodemographic factors, functional ability (Barthel Index, IADL), cognitive functioning (MMSE), nutritional status (MNA), depressive symptoms (GDS-15), medical diagnoses and drug use. The primary outcome was the ability to perform the five times chair rise test. Results: Fiftyone per cent (n=135) of the home-care clients were unable to complete the five times chair rise test. Twenty-three per cent (n=64) of the home-care clients had good chair rise capacity ( 17 seconds). In a multivariate logistic regression analysis, fewer years of education (odds ratio [OR] = 1.11, 95% confidence interval [CI] ), lower ADL (OR = 1.54, 95% CI ) and low MNA scores (OR = 1.12, 95% CI ) and a higher number of co-morbidities (OR = 1.21, 95% CI ) were associated with inability to complete the five times chair rise test. Conclusions: Poor functional mobility, which was associated with less education, a high number of co-morbidities and poor nutritional status, was common among older home-care clients. To maintain and to prevent further decline in functional mobility, physical training and nutritional services are needed. (NutOrMed, ClinicalTrials.gov Identifier: NCT ) Key Words: Older people, home-care clients, physical functioning, chair rise capacity Introduction Chair rising is an important daily activity and requires lower extremity muscular strength and postural control [1,2]. Muscular strength correlates with functional tasks and activities of daily living and contributes to good postural control [2,3]. The chair rise test is a commonly used practical instrument designed to measure the muscular strength and postural control of older people [4,5]. Demand for home-care services increases with the ageing of the population and ensuing problems in functioning, mobility and activities of daily living [6]. Functional disabilities without enough supporting services may speed up the transition from home to residential care. Early recognition of physical disabilities is important for preventive intervention [7]. Modifiable lifestyle factors, such as nutrition and exercise, are the key factors modifying progression of disabilities [8]. Most previous studies have focused on describing home-care clients able to perform the five times test chair rise test and how to improve it [7]. The aim of this study was to assess the ability of older home-care clients to perform the five times chair rise test and associated personal characteristics, nutritional status and functioning. Methods The present study is a part of a population-based multidisciplinary intervention study, NutOrMed, which focused on nutritional, functional and oral health Correspondence: Miia Tiihonen, Kuopio Research Centre of Geriatric Care, School of Pharmacy, University of Eastern Finland, Kuopio, P.O.B 1627, FI Kuopio, Finland. miia.tiihonen@uef.fi (Date received 18 July 2016; reviewed 21 April 2017; accepted 29 May 2017) Author(s) 2017 Reprints and permissions: sagepub.co.uk/journalspermissions.nav DOI: journals.sagepub.com/home/sjp

3 2 M. Tiihonen et al. interventions. The participants were home-care clients aged 75 years living in three Finnish cities in Eastern and Central Finland. A random sample of 250 homecare clients was taken from community I (105,141 inhabitants), a random sample of 75 home-care clients was taken from community II (20,224 inhabitants) and a total sample of 115 home-care clients came from community III (7524 inhabitants). Of these home-care clients, 300 gave written consent to participate, and a total of 267 were able to attend all of the baseline interviews in The home-care clients were interviewed at home by trained nurses, nutritionists, dental hygienists and pharmacists. If a home-care client had difficulty answering the questions, for example because of a cognitive impairment, the interview data were supplemented by interviewing a caregiver or home-care nurse. Details of the NutOrMed study design are described elsewhere [9]. The study protocol was approved by the Research Ethics Committee of the Northern Savo Hospital District. Physical performance Chair rise capacity was assessed with the timed five times chair rise test [4]. The home-care clients stood up from the chair (body straight and knees fully extend) and sat right back down into the chair (back touching the backrest of the chair) five times as fast as possible without using hands to help. The test started with the signal now and ended when the participant stood up for the fifth time. The height of the seat of the chair was about 45 cm. The chair had to have a backrest but no armrest. The duration of the performance was measured with a stopwatch with 0.1 second accuracy. The investigator demonstrated the test, and the home-care client tested one chair rise beforehand. During the test a solid leg position was secured, and the arms were to be kept folded across the chest. The home-care clients were divided into two groups on the basis of their ability to complete the chair rise test: able to perform the chair rise test and unable to perform it. The definition for unable to perform the chair rise test was inability to complete the test because of not being able either to stand up without the help of hands or to rise five times. For those home-care clients who were able to perform the chair rise test, the definition for good performance was five chair rises completed in <17 seconds according to previous studies [10,11]. Functioning and health status Sociodemographics, functioning, cognition and mood were determined in interviews by home-care nurses. Sociodemographics included years of education and living arrangements (living alone or living with spouse or relatives). Activities of daily living (ADL) were measured using the 10-item Barthel Index (scale 0 100) [12]. The Barthel Index assess the extent of independence while performing basic activities of daily living, such as eating, washing, getting around and sphincter control. Instrumental activities of daily living (IADL) were assessed with the eight-item Lawton and Brody Scale (scale 0 8) [13]. This measure includes questions on using the telephone, grocery shopping, preparation of meals, housekeeping, doing laundry, mode of transportation, taking care of drugs and managing money. Cognition was assessed by the Mini-Mental State Examination (MMSE; scale 0 30) and mood by the 15-item Geriatric Depression Scale (GDS-15) [14,15]. Higher scores indicate better functioning, cognitive functioning and mood. A nutritionist assessed nutritional status using the Mini Nutritional Assessment (MNA) [16], which has been designed to screen nutritional risk, especially in old people in different settings. The MNA is composed of four parts: (1) anthropometrical measurements, (2) global assessment, (3) dietary questionnaire and (4) subjective assessment. The full MNA test includes 18 questions, and the total score is 30 points. A score of <17 points indicates protein-energy malnutrition (PEM; in this study called undernutrition ). A score of points indicates that the person is at risk for PEM, and a score of >23.5 points classifies the subject as being well nourished. In this study, nutritional status was classified as follows: a MNA score of <24 indicates malnutrition or a risk of malnutrition. In regression analysis, MNA was used as a continuous variable. The medical diagnoses of the participants were verified by a physician specialised in geriatrics. A modified version of the Functional Comorbidity Index (FCI) was used to compute co-morbidity [17] using data on 13 medical conditions: (1) rheumatoid arthritis and other inflammatory connective tissue diseases, (2) osteoporosis, (3) diabetes, (4) chronic asthma or chronic obstructive pulmonary disease (COPD), (5) coronary artery disease, (6) heart failure, (7) myocardial infarction, (8) stroke, (9) depressive disorder, (10) visual impairment, (11) hearing impairment, (12) Parkinson s disease and (13) obesity (body mass index >30 kg/m 2 ). [18]. The presence of each of these conditions gave one score point, and a higher FCI sum score represented greater co-morbidity. The number of prescription and over-the-counter drugs used regularly and as needed (within last week) was recorded by a pharmacist on the basis of an in-home interview. Use of 10 drugs regularly or as needed was defined as excessive polypharmacy [19].

4 Table I. Characteristic of the participants according to chair rise capacity. Chair rise capacity and associated factors in older home-care clients 3 Able to complete the five times chair rise test, 49.4% (n=132) Unable to complete the five times chair rise test, 50.6% (n=135) p-value Demographic characteristics Female, % (n) 77.3 (102) 67.6 (75) Age, M (SD) 83.8 (4.5) 85.1 (6.0) Education (years), M (SD) 8.9 (3.9) 7.6 (2.7) Living alone, % (n) 65.9 (85) 64.3 (83) Time in five times chair rise test, M (SD) 18.6 (9.05) n/a Functioning ADL, M (SD) 92.9 (10.0) 74.3 (22.1) <0.001 IADL, M (SD) 4.3 (2.1) 2.6 (1.8) <0.001 Cognitive decline (MMSE), M (SD) 24.3 (4.5) 22.0 (5.88) Health status Depressive symptoms (GDS-15 6), % (n) 32.6 (42) 57.3 (59) <0.001 Malnutrition or risk of malnutrition (MNA <24.0) 78.0 (103) 93.3 (125) <0.001 FCI, M (SD) 2.6 (1.8) 3.2 (1.8) Diagnosis Diabetes, % (n) 29.8 (39) 30.6 (39) Cardiovascular disease, % (n) 59.8 (79) 63.7 (86) Stroke, % (n) 17.6 (23) 34.3 (46) Asthma/COPD, % (n) 20.6 (27) 20.9 (23) Clinical depression, % (n) 10.7 (14) 15.7 (21) Dementia, % (n) 42.7 (56) 40.3 (54) Excessive polypharmacy (use of 10 drugs or more), % (n) 50.0 (66) 57.8 (78) SD: standard deviation; IADL: Instrumental Activities of Daily Living; IADL: Activities of Daily Living (Barthel); MMSE: Mini Mental State Examination; MNA: Mini Nutritional Assessment; GDS-15: Geriatric Depression Scale; FCI: Functional Comorbidity Index; COPD: chronic obstructive pulmonary disease. Statistical analysis The characteristics of the home-care clients were summarized using percentages, means and standard deviations (SD). The chi-square test and the t-test were used for statistical comparisons between home-care clients able to complete the five times chair rise test and homecare clients unable to complete it. Multivariate logistic regression analysis was employed to compare homecare clients able to complete the chair rise test and home-care clients unable to complete it. The data were analysed using IBM SPSS Statistics for Windows v19.0 (IBM Corp., Armonk, NY). Results A total of 267 home-care clients participated, of whom 72% (n=193) were women (Table I). The mean age of the participants was 84.5 years (SD=5.2 years). The chair rise test was completed by 49.4% (n=132) of the home-care clients. The mean chair rise test time for those home-care clients able to complete the test was 18.6 seconds (SD=9.05). Of the home-care clients who were able, 23% (n=64) had good chair rise capacity ( 17 seconds). On the other hand, 50.6% (n=135) of the homecare clients were unable to complete the five times chair rise test (Table I). Home-care clients unable to complete chair rise test more often had fewer years of education, lower ADL, IADL, MMSE and MNA scores, higher number of co-morbidities and a history of stroke than those able to complete the five times chair rise test. In the multivariate logistic regression analysis, fewer years of education (odds ratio [OR]=1.11, 95% confidence interval [CI] ), lower ADL (OR=1.54, 95% CI ) and MNA scores (OR=1.12, 95% CI ) and a higher number of co-morbidities (OR=1.21, 95% CI ) were associated with the inability to complete the chair rise test (Table II). Discussion The inability to complete the five times chair rise test was common among home-care clients, and it was associated with less education, a high number of comorbidities and poor nutritional status. Home-care clients inability to complete the five times chair rise test has not been described previously. The proportion of people with the inability to complete the five times chair rise test was 15% higher than in a previous Finnish study among older people [11], which is concerning, since chair rise difficulty predicts a decline in mobility and a risk of falling [3,20]. Buatois et al. found that in addition to the inability to

5 4 M. Tiihonen et al. Table II. Logistic regression analysis comparing home-care clients able to complete the five times chair rise to home-care clients unable to complete the five-time chair rise test. Variables Univariate OR (95% CI) Multivariate OR (95% CI) Sex (female) 0.61 ( ) Age (years) 1.05 ( ) a Education (years) 1.09 ( ) a 1.11 ( ) a ADL (score) 1.50 ( ) a 1.54 ( ) a MNA (score) 1.19 ( ) a 1.12 ( ) a GDS-15 (score) 1.18 ( ) a FCI 1.22 ( ) a 1.21 ( ) a Heart disease 1.18 ( ) Stroke 2.45 ( ) a Asthma/COPD 1.06 ( ) Diabetes 1.04 ( ) Dementic disease 0.90 ( ) Excessive polypharmacy 1.37 ( ) Multivariate analysis: Forward Wald selection. Only variables that entered the model are shown. a p-value <0.05. OR: odds ratio; CI: confidence interval; ADL: Activities of Daily Living (Barthel). complete the chair rise test, longer chair rise test times were also associated with recurrent falls. A new finding was that among home-care clients, chair rise capacity was associated with malnutrition or a risk of malnutrition. This is an important finding because the number of home-care clients is rapidly growing, and the prevalence of risk of malnutrition/ malnutrition is very high among this vulnerable population [21]. Similar kinds of positive associations between MNA nutritional status and lower body strength as assessed with the chair stand test have been shown among older people in a study of non-insulindependent diabetics [22]. The impact of nutrition on muscle health during ageing has been investigated in recent years, especially the role of adequate protein intake [23]. Therefore, maintaining a good nutritional status is critical to preserving muscular strength and functional capacity among older people. We also found an association between less education and the inability to complete the chair rise test. This association between less education and functional limitations among older people is in accordance with the findings of Welmer et al. among community dwellers aged years [24] and might be explained by lower income and an unhealthy lifestyle which may result in greater morbidity [25]. Burton et al. reviewed physical activity interventions among home-care clients [7]. Seven out of eight reviewed studies showed improvement in at least one outcome measured during physical activity intervention. Most of the studies included balance and strength exercise interventions. However, evidence of maintaining sufficient physical functioning in older people with a wide range of health problems is limited because of the small sample sizes and different interventions and outcome measures [7]. How these interventions should be incorporated into home-care services needs to be solved. It seems to be challenging for home-care personnel to activate their clients physical functioning. This has not been included in their traditional responsibilities. So, home-care personnel need training and guidance to be able to support home-care clients individual needs in maintaining mobility and functionality. The strengths of this study are its populationbased design, the use of validated instruments and its multidisciplinary approach. The three municipalities involved represent the Finnish population of homecare clients; the sex- and age-related coverage of home care is in accordance with the statistics of the National Institute for Health and Welfare [26]. We did not use exclusion criteria regarding age, morbidity or functionality. We used only the five times chair rise test to assess physical performance, which has proven to be a good predictor of mobility disability in older adults [10,11]. Due to the cross-sectional nature of this study, we are not able to determine the causality between factors and physical status. Half of the home-care clients were unable to perform the five times chair rise test. This poor functional ability was associated with poor nutritional status and a high number of co-morbidities. To prevent functional and mobility disabilities, the future challenge is to provide regular functional and nutritional screening, physical training and meal services exclusive to the vulnerable group of home-care clients. Declaration of conflicting interests The authors declare that there is no conflict of interest.

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