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Is falls risk an independent contributor to everyday problem solving as measured by the EPT in community-dwelling… McCaw, Lindsay; Gartly, Barbara; Nelson, Sarah 2011-08

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IS FALLS RISK AN INDEPENDENT CONTRIBUTOR TO EVERYDAY PROBLEM SOLVING AS MEASURED BY THE EPT IN COMMUNITY-DWELLING SENIORS?  Lindsay McCaw, Barbara Gartly and Sarah Nelson BACKGROUND AGING POPULATION ?     Aging =     falls risk [1] ? 30% over 65yrs will experience 1 or more falls every year [2] ? Decreased quality of life [3] ? Direct cost of medical care associated with falls in Canada exceeds 2.4 BILLION [3] FALLS ? Risk Factors: ? Increasing age ? Decreased ability to participate in activities of daily living ? Muscular weakness ? Balance problems  ? Intrinsic vs Extrinsic [9]    ? Medications ? Past and current level of physical activity ? Functional limitations ? Visual impairments [2,5-8]   COGNITION ? Key risk factor [2] ? Impaired vs normal = 2x risk [2] ? Prospectively predicts falls in community dwelling and nursing home residents [10] EXECUTIVE FUNCTION ? Defintion: higher order cognitive processes that control, integrate and fine tune the more basic mental functions [11-12] ? Sub-processes: set-shifting, working memory, dual tasking, planning, organizing, self-monitoring [11, 13-14] ? Inter-related [13] ? Impaired Executive Functioning without impaired global cognition [11, 15] EVIDENCE ? Well-established relationship between poor executive function and falls risk among the elderly  ? Nevitt et al. [16] ? Lord & Fitzpatrick [17] ? Rapport  [18] ? Further Support [11, 19-20] GLOBAL EXECUTIVE FUNCTION ? Problem solving [21-22] ? Instrumental Activities of Daily Living (IADLs)[23,21] ? Measurement ? Self report [24, 25] ? Observed [24] EVERYDAY PROBLEMS TEST (EPT) ? Objective, performance-based ? Domains ? Reliability 0.94  ? Test-retest reliability 0.94  ? Validity:  ? self-ratings of IADLs (r=0.23, p<0.05) ? spousal scoring of IADLs (r=0.24, p<0.05) [24, 26]  PURPOSE ? Purpose: examine the relationship between global executive functioning and falls risk  ? Determine independent contribution of falls risk to EPT score ? Hypothesis: Increased falls risk will correlated with lowers scores on the EPT  METHODS PARTICIPANTS ? Subset of Brain Power Study [27] ? 101 Community-dwelling women  ? Age: 65-75  ? Inclusion and exclusion criteria  DESCRIPTIVE VARIABLES ? Age ? Years of School ? Global Cognition ? Mood INDEPENDENT VARIABLE ? Physiological Profile Assessment (PPA) - falls risk [1] ? 5 validated measures of physiological function ? Visual contrast sensitivity ? Proprioception ? Reaction time ? Isometric quadriceps strength ? Postural sway ? Scores: ? <0 = low risk ? 0-1 = mild risk ? 1-2 = moderate risk ? >2 = high risk DEPENDENT VARIABLE ? EPT- global executive functioning [26] ? Covers 7 domains  ? Medication use  ? Shopping ? Transportation ? Meal preparation ? Telephone use ? Household management  ? Financial management ? 42 item multiple choice test given by administrator ? One point for each correct answer ? Standardized guidelines and format  STATISTICAL ANALYSIS ? Data was analyzed using SPSS Windows 17.0 ? Pearson Product Moment Coefficient ? EPT, PPA, years of school, age, MMSE, GDS ? Multiple Linear Regression Model ? To determine independent contribution of falls risk to EPT  ? Variables statistically controlled RESULTS DESCRIPTIVE VARIABLES Table 1 reports the descriptive statistics for our variables of interest. Overall this group of community dwelling senior women had a PPA score of 0.4 indicating a mild falls risk.    CORRELATION COEFFICIENTS ? Table 2. Pearson Product Moment Coefficients Between EPT, Age, Years of School, MMSE, GDS, And PPA Table 2 shows the correlation coefficients of those variables included in the multi-variable regression model. Of theses variables, years of school, MMSE score and PPA score were significantly associated with EPT score ( p  < .01).   LINEAR REGRESSION DISCUSSION RECAP ? Falls risk independently contributes to global executive function as measured by the EPT   ? First study that has examined the independent contribution of falls risk to global executive function in community-dwelling older adults   PAST STUDIES-DIFFERENCES ? Correlation between EPT and GDS ? We found no significant correlation to exist ? Cahn-Wiener [28] reported depression as a significant contributor to observed IADL performance ? We: Excluded participants with clinical depression ? Correlation between EPT and Age ? We found no significant correlation to exist ? Marsiske and Willis [29] found age to account for 17% of the variance on EPT ? We: used a univariate model , Willis used multivariate model  PAST STUDIES-SIMILARITIES ? Increased falls risk is associated with decreased executive function ? Consistently recognized in the literature [1,30] NOVEL FINDINGS ? Even mild falls risk is associated with reduced everyday problem solving ability IMPORTANCE ? Decreased score on EPT may represent difficulties performing IADLs [28,31] ? Willis [26] competence in performing IADLs is essential to independent living within the community ? Inability to adequately achieve these tasks of daily living has been associated with: [21,32]] ? Institutionalization ? Decreased quality of life ? Increased mortality  IMPLICATIONS-SCREENING ? Need comprehensive screening for executive functioning when working with seniors ? Earlier identification of those having difficulties managing IADLs IMPLICATIONS-INTERVENTION ? Currently interventions tend to focus on physical barriers to independence [15] ? However, ability to problem solve is also necessary for independence ? Clinicians need to focus on both the physical and ability to problem solve   LIMITATIONS ? Cross-sectional design therefore unable to establish causality/directionality ? Current evidence suggests that reduced physical function and cognitive function are co-occurring conditions ? Population: generally healthy community-dwelling female seniors between ages of 65-75 FURTHER RESEARCH ? Establish causality ? More heterogeneous population ? Feasibility of EPT use for clinicians  REFERENCES ? 1 Lord SR, Menz HB, Tiedemann A. A physiological profile approach to falls risk assessment and prevention. Phys Ther 2003;83(3):237.  ? 2 Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988;319(26):1701-1707.  ? 3 Angus E, Albert T, Ch?nard D, Shariatmadar A, Pickett W, Hartling, L and The Hygeia Group. The economic burden of unintentional injury in Canada. 1998.  ? 4 Baker S, O?Neil B, Ginsburg M, Guohua L. The injury fact book. 2nd ed. New York: Oxford University Press; 1992.  ? 5 Graafmans W, Ooms M, Hofstee H, Bezemer P, Bouter L, Lips P. Falls in the elderly: a prospective study of risk factors and risk profiles. Am J Epidemiol 1996;143(11):1129.  ? 6 Kosk K, Luukinen H, Laippala P, KIVEL? SL. Physiological factors and medications as predictors of injurious falls by elderly people: a prospective population-based study. Age Ageing 1996;25(1):29.  ? 7 Paganini-Hill A, Chao A, Ross RK, Henderson BE. Exercise and other factors in the prevention of hip fracture: the Leisure World study. Epidemiology 1991:16-25.  ? 8 Jaglal SB, Kreiger N, Darlington G. Past and recent physical activity and risk of hip fracture. Am J Epidemiol 1993;138(2):107.  ? 9 Stevens JA, Olson S. Reducing falls and resulting hip fractures among older women. Home Care Provid 2000;5(4):134-141.  ? 10 Hien LTT, Cumming RG, Cameron ID, Chen JS, Lord SR, March LM, et al. Atypical antipsychotic medications and risk of falls in residents of aged care facilities. J Am Geriatr Soc 2005;53(8):1290-1295.  ? 11 Liu-Ambrose TY, Ashe MC, Graf P, Beattie BL, Khan KM. Increased risk of falling in older community-dwelling women with mild cognitive impairment. Phys Ther 2008 Dec;88(12):1482-1491.  ? 12 Wylie SA, Ridderinkhof KR, Eckerle MK, Manning CA. Inefficient response inhibition in individuals with mild cognitive impairment. Neuropsychologia 2007;45(7):1408-1419.  ? 13 Miyake A, Emerson MJ, Friedman, NP. Assessment of executive functions in clinical settings: Problems and recommendations. Semin Speech Lang 2000;21(2):169-183. ? 14 Murray LL, Ramage AE. Assessing the executive function abilities of adults with neurogenic communication disorders. Semin Speech Lang 2000;21(1):153-168.  ? 15 Hausdorff JM, Doniger GM, Springer S, Yogev G, Simon ES, Giladi N. A common cognitive profile in elderly fallers and in patients with Parkinson's disease: the prominence of impaired executive function and attention. Exp Aging Res 2006 Oct-Dec;32(4):411-429.  ? 16 Nevitt MC, Cummings SR, Hudes ES. Risk factors for injurious falls: a prospective study. J Gerontol 1991;46(5):M164.  ? 17 Lord SR, Fitzpatrick RC. Choice Stepping Reaction Time. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 2001;56(10):M627.  ? 18 Rapport LJ, Hanks RA, Millis SR, Deshpande SA. Executive functioning and predictors of falls in the rehabilitation setting. Arch Phys Med Rehabil 1998 Jun;79(6):629-633.  ? 19 Anstey KJ, Wood J, Kerr G, Caldwell H, Lord SR. Different cognitive profiles for single compared with recurrent fallers without dementia. Neuropsychology 2009 Jul;23(4):500-508.  ? 20 Liu-Ambrose T, Pang MY, Eng JJ. Executive function is independently associated with performances of balance and mobility in community-dwelling older adults after mild stroke: implications for falls prevention. Cerebrovasc Dis 2007;23(2-3):203-210.  ? 21 Burton CL, Strauss E, Hultsch DF, Hunter MA. Cognitive functioning and everyday problem solving in older adults. Clin Neuropsychol 2006 Sep;20(3):432-452.  ? 22 Springer S, Giladi N, Peretz C, Yogev G, Simon ES, Hausdorff JM. Dual-tasking effects on gait variability: the role of aging, falls, and executive function. Movement Disorders 2006;21(7):950-957.    ? 23 Liu-Ambrose TY, Ashe MC, Graf P, Beattie BL, Khan KM. Increased risk of falling in older community-dwelling women with mild cognitive impairment. Phys Ther 2008 Dec;88(12):1482-1491.  ? 24 Diehl M, Willis SL, Schaie KW. Everyday problem solving in older adults: observational assessment and cognitive correlates. Psychol Aging 1995 Sep;10(3):478-491.  ? 25 Ford AB, Folmar SJ, Salmon RB, Medalie JH, Roy AW, Galazka SS. Health and function in the old and very old. Journal of the American Geriatrics Society 1988;36:187-197.  ? 26 Willis SL. Everyday cognitive competence in elderly persons: Conceptual issues and empirical findings. Gerontologist 1996;36(5):595.  ? 27 Liu-Ambrose T, Nagamatsu LS, Graf P, Beattie BL, Ashe MC, Handy TC. Resistance training and executive functions: a 12-month randomized controlled trial. Arch Intern Med 2010;170(2):170.  ? 28 Cahn-Weiner DA, Malloy PF, Boyle PA, Marran M, Salloway S. Prediction of functional status from neuropsychological tests in community-dwelling elderly individuals. Clin Neuropsychol 2000.  ? 29 Marsiske M, Willis SL. Dimensionality of everyday problem solving in older adults. Psychology & Aging 1995;10:269-283.  ? 30 Di Fabio RP, Zampieri C, Henke J, Olson K, Rickheim D, Russell M. Influence of elderly executive cognitive function on attention in the lower visual field during step initiation. Gerontology 2005 Mar-Apr;51(2):94-107.  ? 31 Willis SL, Allen-Burge R, Dolan MM, Bertrand RM, Yesavage J, Taylor JL. Everyday problem solving among individuals with Alzheimer's disease. Gerontologist 1998;38(5):569.  ? 32 Ganguli M, Dodge HH, Mulsant BH. Rates and predictors of mortality in an aging, rural, community-based cohort: the role of depression. Arch Gen Psychiatry 2002;59(11):1046.    QUESTIONS 


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