Outdoor Mobility and Use of Adaptive or Maladaptive Walking Modifications among Older People

This is a self-archived version of an original article. This version may differ from the original in pagination and typographic details. Author(s): Title: Year: Version: Copyright: Rights: Rights url: Please cite the original version: CC BY-NC-ND 4.0 https://creativecommons.org/licenses/by-nc-nd/4.0/ Outdoor Mobility and Use of Adaptive or Maladaptive Walking Modifications among Older People © The Author(s) 2019 Accepted version (Final draft) Skantz, Heidi; Rantanen, Taina; Palmberg, Lotta; Rantalainen, Timo; Aartolahti, Eeva; Portegijs, Erja; Viljanen, Anne; Eronen, Johanna; Rantakokko, Merja Skantz, H., Rantanen, T., Palmberg, L., Rantalainen, T., Aartolahti, E., Portegijs, E., Viljanen, A., Eronen, J., & Rantakokko, M. (2020). Outdoor Mobility and Use of Adaptive or Maladaptive Walking Modifications among Older People. Journals of Gerontology Series A : Biological Sciences and Medical Sciences, 75(4), 806-812. https://doi.org/10.1093/gerona/glz172 2020 Accepted Manuscript © The Author(s) 2019. Published by Oxford University Press on behalf of The Gerontological Society of America. This is an Open Access article distributed under the terms of the Creative Commons Attribution- NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact [email protected] Outdoor Mobility and Use of Adaptive or Maladaptive Walking Modifications among Older People Heidi Skantz1, MSc, Taina Rantanen1, PhD, Lotta Palmberg1, MSc, Timo Rantalainen1, PhD, Eeva Aartolahti2, PhD, Erja Portegijs1, PhD, Anne Viljanen1, PhD, Johanna Eronen1, PhD & Merja Rantakokko3, PhD 1Faculty of Sport and Health Sciences, Gerontology Research Center, University of Jyväskylä, Jyväskylä, Finland 2Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland 3JAMK University of Applied Sciences, School of Health and Social Studies, Jyväskylä, Finland Address correspondence to: Heidi Skantz, MSc, Faculty of Sport and Health Sciences, Gerontology Research Center, University of Jyväskylä, PO Box 35, Viveca 275, 40014 Jyväskylä, Finland, E-mail: [email protected] Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/glz172/5540152 by Jyvaskyla University user on 01 August 2019 Accepted Manuscript 2 ABSTRACT Background: In old age, decline in functioning may cause changes in walking ability. Our aim was to study whether older people who report adaptive, maladaptive or no walking modifications differ in outdoor mobility. Methods: Community-dwelling people aged 75–90 years (N=848) were interviewed at baseline, of whom 761 participated in the 2-year follow-up. Walking modifications were assessed by asking the participants whether they had modified their way of walking 2 kilometers due to their health. Based on the responses, three categories were formed: no walking modifications (reference), adaptive (e.g., walking more slowly, using an aid) and maladaptive walking modifications (reduced frequency of walking, or having given up walking 2 km). Differences between these categories in life-space mobility, autonomy in participation outdoors and unmet physical activity need were analyzed using Generalized Estimation Equations (GEE) models. Results: Participants with maladaptive walking modifications (n=238) reported the most restricted life-space mobility (β -9.6, SE 2.5, p<0.001) and autonomy in participation outdoors (β 1.7, SE 0.6, p=0.004) and the highest prevalence of unmet physical activity need (OR 4.3, 95% CI 1.1–16.5) at baseline and showed a decline in these variables over time. Those with no walking modifications (n=285) at baseline exhibited the best values in all outdoor mobility variables and no change over time. Although at baseline those with adaptive walking modifications (n=325) resembled those with no modifications, their outdoor mobility declined over time. Conclusion: Adopting adaptive modifications may postpone decline in outdoor mobility whereas the use of maladaptive modifications has unfavorable consequences for outdoor mobility. Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/glz172/5540152 by Jyvaskyla University user on 01 August 2019 Accepted Manuscript 3 Keywords: Physical Activity, Functional Performance, Physical Function, Aging Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/glz172/5540152 by Jyvaskyla University user on 01 August 2019 Accepted Manuscript 4 INTRODUCTION Mobility can broadly be determined as a person’s ability to move independently from one place to another, either on foot or by using other forms of transportation1. Mobility is an important element and prerequisite of participation in valued activities and community life in old age2. While aging and age-related diseases and physical impairments affect mobility3-5, their impacts on individuals vary depending on their psychological6,7 resources and environmental demands8,9. Walking modifications are conscious or subconscious changes in walking which occur when older people start to experience functional decline. Typical self-reported walking modifications include reduced walking speed, resting during walking, using an aid, reducing walking frequency or giving up walking longer distances10. Earlier studies have reported that people who do not report walking difficulty but have modified their walking form an intermediate group between those with and without walking difficulties in terms of lower extremity performance and muscle strength10,11. In line with this, it has been shown that walking modifications may be viewed as preclinical signs of walking difficulties that identify people who are at increased risk for future walking difficulties11. According to Lawton and Nahemow’s ecological theory of aging12, in the adaptive stage a person has matched his/her individual capacity to the task or environmental demand. Some studies have indicated that walking modifications may also be advantageous as they help older people to reduce environmental press and hence continue participating in out-of-home activities despite functional decline13,14. To explore whether some walking modifications influence outdoor mobility more favorably than others, we divided self-reported walking modifications into adaptive and maladaptive modifications on a discretionary basis, drawing on the ecological theory of aging12. Adaptive walking modifications, such as using an aid or lowering walking speed, can be viewed as facilitators or enablers of walking when facing physiological Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/glz172/5540152 by Jyvaskyla University user on 01 August 2019 Accepted Manuscript 5 impairments. In contrast, we assumed that maladaptive walking modifications, such as giving up or reducing the frequency of walking longer distances, could have harmful consequences for outdoor mobility. The aim of this study was to compare changes in outdoor mobility over 2 years according to self-reported adaptive, maladaptive or no walking modifications at baseline. We studied outdoor mobility with respect to three outdoor mobility indicators: life-space mobility15, autonomy in out-of-home participation16 and unmet physical activity need17. These measures correlate with each other although they express different aspects of mobility. Life-space mobility refers to actual mobility behavior in daily life15 while autonomy in out-of-home participation indicates an individual’s level of satisfaction with their opportunities to move where and when they want16. Unmet physical activity need refers to a situation where people would like to increase their outdoor physical activity but perceive no opportunities to do so17. Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/glz172/5540152 by Jyvaskyla University user on 01 August 2019 Accepted Manuscript 6 METHODS Design and study participants The data for this observational study were drawn from data collected for the “Life-Space Mobility in Old Age” (LISPE) project, a 2-year prospective cohort study conducted between the years 2012–2014. A more detailed description of the LISPE study and non-respondent analysis have been reported previously18. Briefly, the study targeted community-dwelling people aged 75 to 90 years whose personal data were extracted from the Finnish population register based on their age and residence in the municipalities of Jyväskylä and Muurame (age-stratified random sample N = 2 550). Based on a preliminary review of potential participants’ street addresses, those living in assisted living facilities were excluded. In total, 2 269 persons were contacted to enquire about their willingness to take part in the study. The inclusion criteria were being community-dwelling, resident in the study area, willing to participate, and able to communicate and provide an informed consent. After exclusions, 848 participants were interviewed in their homes at baseline and 761 took part in the 2-year follow-up (drop-out rate 10 %). The Ethical Committee of the University of Jyväskylä approved the LISPE study project. Measurements Self-reported modifications in walking 2 kilometers (km) were studied at baseline with a validated assessment tool for capturing early signs of mobility decline10. Participants were asked: “Have you noticed any of the following changes when walking 2 kilometers due to your health or physical functioning?” Changes were listed as follows: walking slower, resting during walking, using an aid, reduced frequency of walking, and given up walking distances of 2 km. The response options were “yes” or “no” and participants were asked to report all walking modifications. Walking slower, resting during walking and using an aid were considered to reduce the task demands and indicate a striving to continue doing the task, and thus were Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/glz172/5540152 by Jyvaskyla University user on 01 August 2019 Accepted Manuscript 7 categorized as adaptive modifications. Those who reported adaptive walking modifications and also reduced frequency of walking were also categorized as using adaptive walking modifications. Having given up walking 2 km and, in the absence of adaptive modifications, reduced the frequency of walking 2 km distances, were considered to represent maladaptive modifications indicating reduced striving to continue the activity potentially stemming from task demands exceeding personal capacity. Life-space mobility was measured at baseline and at the 2-year follow-up using the Finnish version of the University of Alabama (UAB) Study of Aging Life-Space Assessment15,19. The Life-space Mobility Assessment captures the individual’s actual mobility performance in daily life during the preceding four weeks, taking into account all forms of mobility from walking to driving and using public transportation. Participants were asked on how many days per week (less than once a week, 1–3 times a week, 4–6 times a week or daily) they reached each lifespace level (bedroom, other rooms, outside home, neighborhood, town and beyond town), and if they needed help from others or assistive devices. A life-space composite score (range 0–120) comprising level, frequency and assistance needed was then calculated based on the participant’s responses15. Higher scores indicate greater life-space mobility. A change of more than ten points in the life-space mobility score is considered to indicate clinically meaningful change19. Autonomy in participation outdoors was measured using the relevant domain of the Impact on Participation and Autonomy Questionnaire (IPA) questionnaire. The IPA has been shown to be a reliable and valid instrument for assessing autonomy and participation in older populations16. The autonomy outdoors domain consists of five items: visiting relatives and friends, making trips and traveling, spending leisure time, meeting other people and living life the way one wants to. Each item is scored from 0 (very good possibilities) to 4 (very poor Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/glz172/5540152 by Jyvaskyla University user on 01 August 2019 Accepted Manuscript 8 possibilities), with a higher sum score indicating more autonomy restrictions in participation (range 0–20). Unmet physical activity need was measured using two questions: “Would you like to increase your level of outdoor physical activity?” and “Do you feel that you would have the opportunity to increase your level of outdoor physical activity if someone recommended you to do so?” The response options for each of these questions were “yes” and “no”. People wanting to increase their outdoor physical activity while perceiving no opportunity to do so were defined as experiencing unmet physical activity need17. Covariates were measured at baseline and selected based on existing knowledge on variables that correlate with mobility. Data on age and gender were gathered from the population register extract used as the basis for recruitment. During the home interview, the participants reported their years of education. Physician-diagnosed chronic conditions were elicited with a list of 22 specified chronic conditions followed by an open-ended question on other any other diseases the participant might have. Based on the responses, we calculated the number of chronic conditions20. Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression Scale, CES-D (range 0–60; higher scores indicate more depressive symptoms)21 and cognitive function was measured using the Mini-Mental State Examination (MMSE)22. Lower extremity function was assessed using the Short Physical Performance Battery (SPPB)23. The tests comprise standing balance (feet together, semi-tandem, full tandem), walking at normal gait speed for 2.44 m, and repeated chair rise (five times). Each test was scored from 0 to 4 and a sum score ranging from 0 to 12 calculated, with higher scores indicating better lower extremity function20. The sum score was calculated only for those who completed at least two of the three tests. Participants were categorized based on self-reported difficulties in walking 2 kilometers at Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/glz172/5540152 by Jyvaskyla University user on 01 August 2019 Accepted Manuscript 15 performance underlie the result. An earlier study has shown that, e.g., fear of falling or fear of crime, living alone, and ambient conditions such as poor weather correlate with lower outdoor mobility and especially affect people with lower physical capabilities26. Another recent study suggested that older people who tenaciously pursue their goals but are also able to change them when needed, report better possibilities to participate in outdoor activities and are more often able to maintain their outdoor mobility at a higher level7. Moreover, some features of the environment may restrict possibilities for outdoor activities17,27,28 while others may support the use of assistive devices or provide places to rest during the outdoor activity. However, precisely how environmental features influence the choice of walking modifications warrants further study. Another departure from earlier studies is that our analysis included people who reported walking difficulties. Previous studies have used self-reported walking modifications as indicators of preclinical disability and assessed them solely among those without walking difficulty to establish which came first11,29. However, our aim was to evaluate whether some modifications could postpone or help maintain outdoor mobility among people who may experience walking difficulties but who are nevertheless able to continue walking. It is possible that some older people interpret the use of walking modifications as difficulties in walking30, and thus the distinction between walking modifications and walking difficulties may be artificial. For example, a person who needs to rest when walking longer distances will likely report difficulty walking longer distances, even though optimizing the performance by resting in the middle of it helps to maintain the ability to walk longer distances. There might also be differences in reporting walking difficulties between those who have recently experienced pronounced functional decline and those whose functional ability has decreased over a longer period of time31. In our sensitivity analyses, we excluded participants who reported that they were no longer able to walk 2 km independently or with help from others from the GEE models. Although most of the exclusions were from the category of maladaptive walking modifications, the results did not materially change. Consequently, we believe that the actual inability to walk does not explain the differences observed between the walking Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/glz172/5540152 by Jyvaskyla University user on 01 August 2019 Accepted Manuscript 16 modification categories. Some individuals had stopped walking 2 km distances even though they could have continued walking. The strengths of this study include the large population-based sample of community-dwelling older people. In addition, the possibility to utilize 2-year follow-up data in longitudinal analyses allowed us to study changes in three outdoor mobility variables in three walking modifications categories. Moreover, our categorization of walking modifications into adaptive and maladaptive was based on a selfreported walking modifications measure that has been shown to be a validated and reliable indicator of preclinical disability10. Use of three different outdoor mobility variables that are conceptually different from walking difficulty or walking modifications enabled us to acquire knowledge that will help lay the foundation for actions to prevent or delay mobility limitation and restrictions on participation. However, the study also has its limitations. We did not have an opportunity to study the reasons behind the use of walking modifications. In addition, all the covariates in the models were assessed at baseline and changes in them were not accounted for. The findings of the study indicate that categorizing walking modifications into 2 categories – adaptive and maladaptive – was meaningful as it showed that some older people may postpone age-related decline in outdoor mobility by using adaptive walking modifications whereas for others the use of maladaptive walking modifications reduces their outdoor mobility. Since the majority of people experience age-related functional decline, it is important to identify their individual mobility needs in order to support their full participation in society. Encouraging the use of adaptive walking modifications when needed and designing age-friendly environments, e.g., by providing suitable transportation options and opportunities to rest when walking outdoors, may help older people to maintain their life-space mobility and autonomy to participate in outdoor activities, and protect them from unmet physical activity need. Future studies should bear in mind that different walking modifications may have different effects on people. Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/glz172/5540152 by Jyvaskyla University user on 01 August 2019 Accepted Manuscript 17 CONFLICT OF INTEREST Ta.R. serves on the Journal of Gerontology: Medical Sciences editorial board. Otherwise, the authors declare no conflicts of interest. FUNDING This work was supported by the European Research Council (grant number 693045 to Ta.R.); the Academy of Finland (grant number 255403 to Ta.R.); the Ministry of Education and Culture (to M.R. and Ta.R.); and the University of Jyväskylä. The financial sponsors were not involved in the design, implementation, analyses, or reporting of the results. ACKNOWLEDGMENT The Gerontology Research Center (GEREC) is a joint effort between the University of Jyväskylä and University of Tampere, Finland. REFERENCES 1. 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Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/glz172/5540152 by Jyvaskyla University user on 01 August 2019 Accepted Manuscript 22 Table 1. Participant Characteristics by 2 Kilometer Walking Modifications at Baseline (N = 848) Note: CES-D = Center for Epidemiologic Studies Depression Scale, MMSE = Mini-Mental State Examination, SPPB = Short Physical Performance Battery. a: Tested with one-way analysis of variance. b: Tested with chi-square test. Characteristics No walking modifications (n = 285) Adaptive walking modifications (n = 325) Maladaptive walking modifications (n = 238) P-value Mean (SD) Mean (SD) Mean (SD) Age, years 78.9 (3.7) 80.9 (4.2) 82.3 (4.2) < 0.001 a Education, years 10.3 (4.5) 9.5 (4.0) 8.8 (3.8) < 0.001 a No. of chronic conditions 3.3 (2.0) 4.6 (2.4) 5.3 (2.5) < 0.001 a CES-D, score 7.4 (5.8) 10.2 (6.3) 11.6 (7.9) < 0.001 a MMSE, score 26.6 (2.5) 26.1 (2.9) 25.7 (3.0) < 0.001 a SPPB, score 10.8 (1.4) 9.7 (2.00) 8.1 (3.3) < 0.001 a Women, % (n) 54 (154) 64 (209) 69 (163) 0.002 b Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/glz172/5540152 by Jyvaskyla University user on 01 August 2019 Accepted Manuscript 23 Table 2. Changes in Life-Space Mobility Scores over 2-Year Period by Walking Modification Category among Community-Dwelling People Aged 75–90 Years at Baseline Note: Reference category: no walking modifications. Model 1: Adjusted for age and gender, Model 2: Adjusted for age, gender, years of education, number of chronic conditions, depressive symptoms and cognitive function, Model 3: Adjusted for age, gender, years of education, number of chronic conditions, depressive symptoms, cognitive function and lower extremity function. Statistically significant values are bolded. Baseline 2-year follow-up Model 1 Model 2 Model 3 Category n = 792 Mean (SD) n = 757 Mean (SD) β (SE) Group Difference, p Group x Time, p β (SE) Group Difference, p Group x Time, p β (SE) Group Difference, p Group x Time, p No walking modifications 77.3 (15.6) 76.4 (17.2) Ref. Ref. Ref. Adaptive walking modifications 63.9 (17.9) 58.4 (18.8) -5.2 (2.4) 0.026 0.001 -2.7 (2.4) 0.223 0.001 -0.8 (2.4) 0.739 0.001 Maladaptive walking modifications 49.1 (18.1) 44.3 (18.6) -18.2 (2.5) <0.001 0.009 -14.8 (2.5) <0.001 0.010 -9.6 (2.5) <0.001 0.010 Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/glz172/5540152 by Jyvaskyla University user on 01 August 2019 Accepted Manuscript 24 Table 3. Changes in Autonomy in Participation Outdoors Scores over 2-Year Period by Walking Modification Category among Community- Dwelling People Aged 75–90 Years at Baseline Note: Reference category: no walking modifications. Model 1: Adjusted for age and gender, Model 2: Adjusted for age, gender, years of education, number of chronic conditions, depressive symptoms and cognitive function, Model 3: Adjusted for age, gender, years of education, number of chronic conditions, depressive symptoms, cognitive function and lower extremity function. Statistically significant values are bolded. Baseline 2-year follow-up Model 1 Model 2 Model 3 Category n = 792 Mean (SD) n = 748 Mean (SD) β (SE) Group Difference, p Group x Time, p β (SE) Group Difference, p Group x Time, p β (SE) Group Difference, p Group x Time, p No walking modifications 4.5 (3.00) 4.8 (3.4) Ref. Ref. Ref. Adaptive walking modifications 6.1 (3.3) 7.2 (3.6) 0.4 (0.5) 0.338 0.003 -0.3 (0.4) 0.577 0.003 -0.5 (0.4) 0.271 0.003 Maladaptive walking modifications 8.2 (4.3) 8.7 (4.0) 3.2 (0.6) <0.001 0.957 2.3 (0.6) <0.001 0.962 1.7 (0.6) 0.004 0.971 Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/glz172/5540152 by Jyvaskyla University user on 01 August 2019