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Functional capacity and risk of frailty syndrome in 85-year-old and older women living in nursing homes in Poland

Functional capacity and risk of frailty syndrome in 85-year-old and older women living in nursing... Risk of frailty syndrome in 85-year-old and older women Antonina Kaczorowska et al. Anthropological Review • Vol. 84(4), 395–404 (2021) Functional capacity and risk of frailty syndrome in 85-year-old and older women living in nursing homes in Poland 1 2 2 Antonina Kaczorowska , Anna Sebastjan , Małgorzata Kołodziej , 3 2 2 Sławomir Kozieł , Mariusz Tomczak , Zofia Ignasiak Institute of Health Sciences, University of Opole, Poland Department of Biostructure, University School of Physical Education in Wrocław, Poland Department of Anthropology, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wrocław, Poland AbstrAct : Maintaining sufficient physical fitness to prevent any limitations in performing activities of daily living and to be functionally independent is of great importance for both longevity and quality of life in older adults. Aim of the study was to evaluate functional physical fitness of women aged 85 years and older, residents of nursing homes, in the Polish population and to assess the risk of frailty syndrome. The study involved 17 women aged 85 years or older, residents of nursing homes in the Lower Silesian voivodeship. The Senior Fitness Test was used to assess functional fitness. The results of functional fitness tests were related to the standards for the elderly population in Poland and to the reference standards for maintaining independence. In addition, hand grip strength level was measured using a hand dynamometer, height and weight were measured, and BMI was calculated. 15-item version of the Geriatric Depression Scale was used to assess the level of depression. We used 3 of the 5 proposed criteria from the Cardiovascular Health Study Frailty Index to assess the presence of frailty syndrome: gait speed, level of hand grip strength, and the presence of depression. The results of the Senior Fitness Test demonstrate the low level of functional fitness of female nursing home residents. A large percentage of the women surveyed are below the standard values developed for Polish seniors. The weakest results were in the timed up and go test, with more than 94% of the women tested falling outside the standard ranges. The mean results of all samples do not meet the developed reference standards for maintaining independence. No non-frail person was found among the study participants and the vast majority were at risk for frailty syndrome. Most of the studied women do not meet functional fitness standards developed for the Polish population, as well as reference standards for maintaining independence. Nursing home residents over the age of 85 are at risk for frailty syndrome. Key words : frailty, physical fitness, older woman, healthy aging, institutional living Original Research Article Received: May 25, 2021; Revised: October 20, 2021; Accepted: October 21, 2021 DOI: 10.2478/anre-2021-0027 © 2021 Polish Anthropological Society 396 Antonina Kaczorowska et al. that related to activities of daily living) is Introduction the SFT by Rikli and Jones (2002). It is Maintaining sufficient physical fitness so widely used that standards for this test to prevent any limitations in perform- are already in place in many populations, ing activities of daily living and to be which greatly facilitates interpretation of functionally independent is very im- the score and inter-population compari- portant for both longevity and quality sons (Rikli and Jones 2002; Langhammer of life in older adults (CDC 2009; Motl and Kvalvik 2011; Marques et al. 2013; and McAuley 2010). Unwanted changes Ignasiak et al. 2020). occurring already in adulthood generate Frailty syndrome is associated with significant problems with movement, a high risk of adverse health outcomes, manipulations or changes in body com- especially in older age (Fried et al. 2001). position, especially loss of muscle mass Frailty results from aging-related decline and strength (Cawthon et al. 2011). Loss in physiological, as well as cognitive func- in terms of balance, strength, and gait tion, chronic stress, and impairments in efficiency, thus, translate into increased the effective performance of daily living limitations for these individuals (Patel et activities (Clegg and Young 2011; Xue al. 2006). Consequently, this contributes 2011). The development of frailty syn- to a more passive lifestyle and to an in- drome definition was first coined by by creased likelihood of morbidity, hospital- Fried et al. (2001). Age-related changes, ization and mortality (Pahor et al. 2014; both physiological and psychological, Hicks et al. 2012). are fundamental to the development of It has been argued that in order to frailty syndrome. These can either be achieve successful aging, it should involve prevented or reversed by therapeutic maintaining cognitive function (Rowe interventions based on physical activity and Kahn 1997) and physical fitness at when detected in the early stage of devel- optimal levels (Ralston 2018), among opment (Ignasiak et al. 2020). Although, other things. Spending time passively is other researchers (Martin and Ranhoff detrimental to physical and mental health 2021) have presented their scales, there (Tkatch et al. 2017) at any age, but espe- have been attempts to expand the frailty cially for the elderly. Adequate levels of studying method itself, as well as its defi - physical fitness play a fundamental role in nition, which is still unclear. The preva- the case of older people, as they prevent lence of frailty syndrome in Europe varies numerous diseases or disabilities and are widely across countries, and affects wom- essential to maintaining daily functions en more frequently, Furthermore, frailty at a satisfactory level. This is a condition syndrome appears to be related to social that is not dependent on the place of res- and cultural factors (Santos-Eggimann idence of the elderly (own home or com- et al. 2009; Bandeen-Roche et al. 2006; munity dwelling). Forms of physical ac- Puts et al. 2005). tivity should be tailored to the abilities of Elderly, single people with chronic individuals or groups . A prior assessment conditions often reside in nursing homes of functional fitness level is necessary in (Garner et al. 2018; Kauppi et al. 2018). order to assess fitness levels. In cases of Individuals in residential care who expe- the elderly, the currently most widely rience significant functional decline, loss used test to assess functional fitness (i.e., of independence, and feelings of loneli- Risk of frailty syndrome in 85-year-old and older women 397 ness, are particularly at risk of develop- from the nursing home director. Exclu- ing frailty syndrome and also disability sion criteria included (1) acute infections (Furtado et al. 2017). Nursing homes and diseases, (2) neoplastic diseases, (3) should provide an optimal quality of life fresh post-infarction status, (4) other for residents and ensure what is called medical contraindications to the study, active aging (Van Malderen et al. 2016). and (5) lack of written consent to par- Properly managed physical exercises are ticipate in the study. Due to the exclu- essential for active aging, conditioning sion criteria and lack of ability to move the individual to an appropriate level of independently and complete a functional physical fitness. Awareness of the need fitness test, 48 women over the age of 85 for physical activity classes is extreme- years were excluded from the study. ly important, both among personnel, as The Senior Fitness Test (Rikli and well as nursing home residents. Jones 2012) was used to assess function- The aim of this study was to evalu- al fitness. This test is designed for older ate functional physical fitness of women adults and consists of six fitness tests to aged 85 and older, residents of nursing assess upper and lower body strength homes, in a Polish population and to as- and flexibility, aerobic endurance, motor sess the risk of frailty syndrome. coordination and dynamic balance: 1. Arm curl – the number of forearm curls at the elbow joint with a 2.27 Material and methods kg weight was measured within 30 The study was conducted in 2018–2019 seconds. This is a test that assesses in nursing homes of the Lower Silesian upper body muscle strength. voivodeship. The research was carried 2. 30-second chair stand – the number of out in accordance with the Declaration of times a person stood up from a chair Helsinki, and followed good clinical prac- was measured in the given time. The tice guidelines. The Commission of Re- test assesses lower body strength. search of the University School of Phys- 3. Back scratch – reaching with hands be- ical Education, Wrocław, Poland granted hind the back until touching fingers approval for the research (approval date: – was measured with a ruler to the 2017). All study participants gave writ- nearest 0.5 cm. The test evaluates up- ten informed consent to participate in per body flexibility. the study. The study is a part of larger 4. Chair sit and reach – was measured with research that was retrospectively regis- a ruler to the nearest 0.5 cm. The test tered on the ISRCTN platform under the evaluates the flexibility of the lower number 18225729. body. The study included 17 women aged 5. 8-foot up and go – the time to complete 85 years and older, residents of nursing the test was measured to the near- homes in Lower Silesia. Inclusion criteria est hundredth of a second. The test were (1) age of 85 years and older, (2) is used to assess motor coordination no medical contraindications, (3) ability and dynamic balance. to move independently and complete a 6. 2-minute walk – the number of single functional fitness test, (4) normal verbal leg lifts while walking in place was contact, and (5) written consent to par- measured for 2 minutes. The test ticipate in the study, as well as approval evaluates aerobic endurance. 398 Antonina Kaczorowska et al. The study took place in the after- SECA 799 were also performed. For the noon since the participants mentally body height test, the participants tried and physically functioned best at this to adopt an upright posture. Body Mass time of the day. Before starting the test, Index (BMI) was calculated based on the participants were asked to perform these measurements. Some researchers each test part as well as possible. Perfor- have noted that calculating BMI for older mance of the test tasks was preceded by adults using body height may be incor- a demonstration. rect. Body height is often underestimat- The results of functional fitness tests ed due to degenerative changes in the were related to the standards for the el- spine and joints, and BMI is overestimat- derly population in Poland developed ed (Yilmaz et al. 2016). To avoid over- by Ignasiak et al. (2020). The following estimation of BMI, the participants tried score categories were adopted for all to adopt the most upright posture with tests: „Below normal” – for scores below hip and knee joints and spine as straight th the 25 percentile for all tests except the as possible. However, this was often not 8-foot up-and-go test measured in sec- possible due to contractures in the hip th onds, for scores above the 75 percentile and knee joints, as well as increased tho- on the 8-foot up-and-go test. All other racic kyphosis. values were taken as normal functional 15-item version of the Geriatric De- performance scores. The cutoff points pression Scale (GDS) was used to assess used for reduced functional fitness are the level of depression (Lesher and Ber- shown in Table 1. ryhill 1994). Result interpretation: The scores of the studied female nurs- – 0–5 points – no depression, ing home residents were also compared – 6–10 points – moderate depression, to the reference standards for maintain- – 11–15 – severe depression. ing independence developed for the four Three out of five proposed criteria test samples by the test authors (Rikli from the Cardiovascular Health Study and Jones 2012). The level of hand grip Frailty Index were used to assess the strength (HGS) was then measured using presence of frailty syndrome (Fried et al. a hand dynamometer (JAMAR, Hand Dy- 2001). Individuals not meeting any crite- namometer USA). Measurements of so- rion did not have frailty syndrome. Indi- matic characteristics such as body height viduals meeting 1–2 criteria were judged (to the nearest 0.5 cm) using an anthro- as pre-frail, while those meeting 3–5 pometer SECA 799 and body weight (to criteria were considered to be frail. We the nearest 0.5 kg) using a medical scale used gait speed from the 8-foot up and go test, level of hand grip strength mea- sured with a hand dynamometer, and the Table 1. Cut-off points for reduced functional fit - ness assessed using the Senior Fitness Test set presence of depression as assessed by the (according to Ignasiak et al. 2020) for women Geriatric Depression Scale. Criteria for Age (years) 85+ gait speed frailty syndrome are sex- and 30-Second Chair Stand Test (no. of reps) < 10 height-dependent, and are ≥ 7 s (height ≤ Arm Curl Test (no. of reps) < 10 159 cm) and ≥ 6 s (height > 159 cm) for Chair Sit and-Reach Test (cm) < −6 women. Hand grip criteria for frailty syn- Back Scratch Test (cm) < −19 drome include the lowest 20% of scores, 8-Foot Up-and-Go Test (s) > 7.3 adjusted for sex and BMI: Risk of frailty syndrome in 85-year-old and older women 399 – ≤ 17 kg for BMI ≥ 23, The results demonstrated low functional – ≤ 17.3 kg for BMI 23.1–26, fitness level of female nursing home res - – ≤ 18 kg for BMI 26.1–29, idents. A large percentage of the partici- – ≤ 21 kg for BMI > 29. pants surveyed were below the standard Collected results were then subjected values developed for Polish seniors. The to statistical analysis. The distribution of worst results were obtained in the timed the variables was checked for normality up and go test, with more than 94% of using the Shapiro-Wilk test. The mean the participants tested falling outside the (x), standard deviation (SD), minimum standard ranges (Table 3). value (Min) and maximum value (Max) Next, the scores of the studied female were calculated. Calculations were per- nursing home residents were compared formed using Excel and Statistica 13.3. to the reference standards for maintain- ing independence developed for the four test samples by the test authors (Rikli Results and Jones 2012). The mean results of The mean age of the studied women was all samples did not meet the developed 90.75 ± 3.83 years. The mean BMI of the reference standards. The 8 ft up-and-go participants was 26.50, exceeding the test part showed the worst results, with overweight threshold. Age and somatic a mean score of more than double the de- characteristics are presented in Table 2. veloped standard, with more than 94% of The results of the five test parts were individuals failing to meet the standard compared to Polish criteria for the 85+ (Table 4). group (Ignasiak et al. 2020). Since Pol- The tests for assessing the risk of ish criteria include 6-minute gait test to frailty syndrome included hand grip assess aerobic capacity, and the women strength, gait speed, and presence of de- performed a 2-minute walk in place test, pression. The results were compared to it did not meet the mentioned criteria. frailty syndrome criteria. As many as 16 Table 2. Descriptive statistics of morphological trials of the surveyed women N=17 Variable X ± SD Min Max Age [years] 90.75 ± 3.830 085.00 098.08 Height [cm] 152.24 ± 6.3100 140.50 163.00 Weight [kg] 61.50 ± 10.86 046.00 088.00 BMI [kg/m ] 26.50 ± 4.160 020.24 035.25 Table 3. Comparison of Senior Fitness Test results to Polish criteria (according Ignasiak et al. 2020) N=17 Below Polish norm Test X ± SD n (%) Chair stand [reps] 8.24 ± 2.80 12 (70.5) Arm curl [reps] 10.76 ± 3.530 06 (35.3) Chair sit and reach [cm] −23.76 ± 12.44− 13 (76.4) Back scratch [cm] −13.85 ± 10.11− 10 (58.8) 8 ft up-and-go [s] 17.61 ± 8.820 16 (94.1) 400 Antonina Kaczorowska et al. Table 4. Comparison of mean Senior Fitness Test scores to criterion-reference fitness standard for maintain - ing physical independence (according Rikli and Jones 2012) Standard 85–89 Standard 90–94 Below the standard Test X ± SD years years n (%) Chair stand [reps] 8.24 ± 2.80 11 9 12 (70.5) Arm curl [reps] 10.76 ± 3.530 13 11 11 (64.7) 2-min walk [steps] 53.76 ± 20.69 70 60 11 (64.7) 8 ft up-and-go [s] 17.61 ± 8.820 7.1 8.0 16 (94.1) Table 5. Participants meeting the individual criteria tional physical fitness among female for frailty syndrome nursing home residents aged 85+. Most Participants meeting of the participants did not meet crite- Criterion criteria, n (%) ria developed for the Polish population Gait speed [s] 16 (94.1) (Ignasiak et al. 2020) and the reference Hand grip strenght [kg] 06 (35.3) measures for maintaining independence GDS 06 (35.3) (Rikili and Jones 2012). Women who are 90-years-old, single, have at least two chronic conditions, and Table 6. Number and percentage of pre-frail and frail participants require assistance often become resi- dents of nursing facilities (Kauppi et al. n (%) 2018). In case of such individuals, it is Pre-frail 1 criterion 7 (41.1) challenging to complete all the parts of 2 criteria 9 (52.9) a functional fitness test. Most studies on In all 16 (94.1) functional fitness in people over 85 years Frail 1 (5.9) are based on completing questionnaires participants met the criteria for frailty (Simonsson et al. 2020, Escourrou et al. syndrome in the gait speed test, 6 wom- 2020, Ćwirlej-Sozańska et al. 2020), in en met the criteria for frailty syndrome in which the subjective assessment may not hand grip strength, and similarly 6 wom- match the actual condition. The ages of en had depression (Table 5). the female nursing home residents we Among the participants, 16 women studied ranged from 85 to 98 years old, met one or two criteria for frailty syn- and their ability to complete the Senior drome, indicating that the participants Fitness Test parts alone was a positive had pre-frail syndrome. One woman was element. found to meet three criteria, meaning the The low scores obtained on the Se- presence of frailty syndrome. None of the nior Fitness Test by female nursing home studied women were non-frail. The re- residents may be due to significant lim - sults are presented in Table 6. itations in activities of daily living, such as shopping, meal preparation, etc. The study by Barber et al. (2015) found that Discussion physical activity levels of nursing home The primary objective of this study was residents were very low, while time spent to assess the functional physical fitness sitting was very long. According to Fish- of 85+ female nursing home residents. er, low physical activity levels were as- The results indicate a low level of func- sociated with living in nursing homes, Risk of frailty syndrome in 85-year-old and older women 401 and activity levels decreased as seniors and low activity level. In this study, gait aged (Fisher et al 2018). A large study speed was found to be at the lowest lev- of the European elderly population has el, with over 94% of participants meeting confirmed that sedentary lifestyles are a the criterion for frailty syndrome. Mus- significant risk factor for disease and may cle strength was at a higher level, with contribute to increased mortality. Televi- over 35% of the women surveyed lacking sion viewing time has been shown to be a muscle strength. risk factor for frailty syndrome and major The low fitness level of the studied functional limitations in elderly people females may be related to the generally (Garcia-Esquinas et al. 2017). Thus, it is lower level of physical activity among se- assumed that low levels of physical activ- niors in Poland. The current generation ity and sedentary lifestyles pose a serious of Polish seniors acquired their lifestyle risk for disability. habits and normal behaviors, including We used three criteria to assess the physical activity, in communist Poland. risk of frailty syndrome in female nursing During the communist era, Polish se- home residents aged 85+, as proposed by niors lived in a different cultural con- Fried et al. (2001). Our findings are dis - text than seniors in Western Europe and turbing, as we found no non-frail among North America, where the idea of active the female participants in the study, and aging was well established. In Poland, the vast majority were at risk for frailty old age is traditionally considered a pe- syndrome. riod of well-deserved rest, during which Institutionalized women who expe- people should cease their previous ac- rience significant functional decline and tivities. Hence, only a small percentage loss of independence are at increased risk of Polish seniors participate in physical of developing frailty syndrome and dis- activity classes. The results of the „Bridg- ability (Furtado et al. 2017). Increased ing the East – West Health Gap” research vulnerability to adverse events such as project, aimed at assessing health status, falls, hospitalizations, disability, institu- attitudes, and health behaviors among tionalization, or death are consequences the adult population of selected Cen- of frailty syndrome (Skalska 2016, Fried et tral, Eastern, and Western European al. 2001). Potential reversibility through countries, indicate a marked variation multidirectional prevention, in which in physical activity levels across individ- regular physical activity and proper diet ual countries. The highest percentage of are most important, is a significant char - respondents declaring high activity was acteristic of the frailty syndrome (Skalska reported in Western European countries 2016). This is why it is so important to (30.2% in Finland and 23.7% Spain), and identify the frailty syndrome threat in or- the lowest in post-communist countries der to take preventive action early. – Poland (6.4%) and Hungary (12.3%) In the study by Furtado et al. (2017) (Drygas et al. 2001). Similarly, a small who analyzed the prevalence of frail- percentage (12%) of Czech seniors par- ty syndrome among institutionalized ticipate in sports or physical exercises women, the largest number of partici- (Mudrak et al. 2016). The rationale for pants negatively rated three components the low levels of physical activity among of frailty syndrome – weakness (mus- older adults from Central and Eastern cle strength), slowdown (gait speed), European countries may be that seniors 402 Antonina Kaczorowska et al. from post-communist countries gener- Conflict of interest ally live in poorer socioeconomic condi- tions than seniors in Western European The authors declare no conflict of inter - and North American countries.Addition- ests. ally, Central and Eastern European se- niors tend to engage in behaviors that are Corresponding author less beneficial to health. This study also had some limitations. Anna Sebastjan, Department of Biostruc- A small number of women were studied. ture, University School of Physical Edu- This was due to the fact that a very small cation in Wrocław, Poland number of female nursing home resi- e-mail: anna.sebastjan@gmail.com dents aged 85+ were able to perform the functional fitness test independently. In References addition, only women participated in the Bandeen-Roche K, Xue QL, Ferrucci L, study. Women are living longer than men Walston J, Guralnik JM, et al. 2006. Phe- and there are significantly fewer men notype of frailty: characterization in the aged 85 and older in nursing homes. Women’s Health and Aging Studies. J Only a small number of female nurs- Gerontol A Biol Sci Med Sci 61(3):262–6. ing home residents over the age of 85 Barber SE, Forster A, Birch KM. 2015. Levels are capable of performing a functional and patterns of daily physical activity and fitness test. 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Functional capacity and risk of frailty syndrome in 85-year-old and older women living in nursing homes in Poland

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Risk of frailty syndrome in 85-year-old and older women Antonina Kaczorowska et al. Anthropological Review • Vol. 84(4), 395–404 (2021) Functional capacity and risk of frailty syndrome in 85-year-old and older women living in nursing homes in Poland 1 2 2 Antonina Kaczorowska , Anna Sebastjan , Małgorzata Kołodziej , 3 2 2 Sławomir Kozieł , Mariusz Tomczak , Zofia Ignasiak Institute of Health Sciences, University of Opole, Poland Department of Biostructure, University School of Physical Education in Wrocław, Poland Department of Anthropology, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wrocław, Poland AbstrAct : Maintaining sufficient physical fitness to prevent any limitations in performing activities of daily living and to be functionally independent is of great importance for both longevity and quality of life in older adults. Aim of the study was to evaluate functional physical fitness of women aged 85 years and older, residents of nursing homes, in the Polish population and to assess the risk of frailty syndrome. The study involved 17 women aged 85 years or older, residents of nursing homes in the Lower Silesian voivodeship. The Senior Fitness Test was used to assess functional fitness. The results of functional fitness tests were related to the standards for the elderly population in Poland and to the reference standards for maintaining independence. In addition, hand grip strength level was measured using a hand dynamometer, height and weight were measured, and BMI was calculated. 15-item version of the Geriatric Depression Scale was used to assess the level of depression. We used 3 of the 5 proposed criteria from the Cardiovascular Health Study Frailty Index to assess the presence of frailty syndrome: gait speed, level of hand grip strength, and the presence of depression. The results of the Senior Fitness Test demonstrate the low level of functional fitness of female nursing home residents. A large percentage of the women surveyed are below the standard values developed for Polish seniors. The weakest results were in the timed up and go test, with more than 94% of the women tested falling outside the standard ranges. The mean results of all samples do not meet the developed reference standards for maintaining independence. No non-frail person was found among the study participants and the vast majority were at risk for frailty syndrome. Most of the studied women do not meet functional fitness standards developed for the Polish population, as well as reference standards for maintaining independence. Nursing home residents over the age of 85 are at risk for frailty syndrome. Key words : frailty, physical fitness, older woman, healthy aging, institutional living Original Research Article Received: May 25, 2021; Revised: October 20, 2021; Accepted: October 21, 2021 DOI: 10.2478/anre-2021-0027 © 2021 Polish Anthropological Society 396 Antonina Kaczorowska et al. that related to activities of daily living) is Introduction the SFT by Rikli and Jones (2002). It is Maintaining sufficient physical fitness so widely used that standards for this test to prevent any limitations in perform- are already in place in many populations, ing activities of daily living and to be which greatly facilitates interpretation of functionally independent is very im- the score and inter-population compari- portant for both longevity and quality sons (Rikli and Jones 2002; Langhammer of life in older adults (CDC 2009; Motl and Kvalvik 2011; Marques et al. 2013; and McAuley 2010). Unwanted changes Ignasiak et al. 2020). occurring already in adulthood generate Frailty syndrome is associated with significant problems with movement, a high risk of adverse health outcomes, manipulations or changes in body com- especially in older age (Fried et al. 2001). position, especially loss of muscle mass Frailty results from aging-related decline and strength (Cawthon et al. 2011). Loss in physiological, as well as cognitive func- in terms of balance, strength, and gait tion, chronic stress, and impairments in efficiency, thus, translate into increased the effective performance of daily living limitations for these individuals (Patel et activities (Clegg and Young 2011; Xue al. 2006). Consequently, this contributes 2011). The development of frailty syn- to a more passive lifestyle and to an in- drome definition was first coined by by creased likelihood of morbidity, hospital- Fried et al. (2001). Age-related changes, ization and mortality (Pahor et al. 2014; both physiological and psychological, Hicks et al. 2012). are fundamental to the development of It has been argued that in order to frailty syndrome. These can either be achieve successful aging, it should involve prevented or reversed by therapeutic maintaining cognitive function (Rowe interventions based on physical activity and Kahn 1997) and physical fitness at when detected in the early stage of devel- optimal levels (Ralston 2018), among opment (Ignasiak et al. 2020). Although, other things. Spending time passively is other researchers (Martin and Ranhoff detrimental to physical and mental health 2021) have presented their scales, there (Tkatch et al. 2017) at any age, but espe- have been attempts to expand the frailty cially for the elderly. Adequate levels of studying method itself, as well as its defi - physical fitness play a fundamental role in nition, which is still unclear. The preva- the case of older people, as they prevent lence of frailty syndrome in Europe varies numerous diseases or disabilities and are widely across countries, and affects wom- essential to maintaining daily functions en more frequently, Furthermore, frailty at a satisfactory level. This is a condition syndrome appears to be related to social that is not dependent on the place of res- and cultural factors (Santos-Eggimann idence of the elderly (own home or com- et al. 2009; Bandeen-Roche et al. 2006; munity dwelling). Forms of physical ac- Puts et al. 2005). tivity should be tailored to the abilities of Elderly, single people with chronic individuals or groups . A prior assessment conditions often reside in nursing homes of functional fitness level is necessary in (Garner et al. 2018; Kauppi et al. 2018). order to assess fitness levels. In cases of Individuals in residential care who expe- the elderly, the currently most widely rience significant functional decline, loss used test to assess functional fitness (i.e., of independence, and feelings of loneli- Risk of frailty syndrome in 85-year-old and older women 397 ness, are particularly at risk of develop- from the nursing home director. Exclu- ing frailty syndrome and also disability sion criteria included (1) acute infections (Furtado et al. 2017). Nursing homes and diseases, (2) neoplastic diseases, (3) should provide an optimal quality of life fresh post-infarction status, (4) other for residents and ensure what is called medical contraindications to the study, active aging (Van Malderen et al. 2016). and (5) lack of written consent to par- Properly managed physical exercises are ticipate in the study. Due to the exclu- essential for active aging, conditioning sion criteria and lack of ability to move the individual to an appropriate level of independently and complete a functional physical fitness. Awareness of the need fitness test, 48 women over the age of 85 for physical activity classes is extreme- years were excluded from the study. ly important, both among personnel, as The Senior Fitness Test (Rikli and well as nursing home residents. Jones 2012) was used to assess function- The aim of this study was to evalu- al fitness. This test is designed for older ate functional physical fitness of women adults and consists of six fitness tests to aged 85 and older, residents of nursing assess upper and lower body strength homes, in a Polish population and to as- and flexibility, aerobic endurance, motor sess the risk of frailty syndrome. coordination and dynamic balance: 1. Arm curl – the number of forearm curls at the elbow joint with a 2.27 Material and methods kg weight was measured within 30 The study was conducted in 2018–2019 seconds. This is a test that assesses in nursing homes of the Lower Silesian upper body muscle strength. voivodeship. The research was carried 2. 30-second chair stand – the number of out in accordance with the Declaration of times a person stood up from a chair Helsinki, and followed good clinical prac- was measured in the given time. The tice guidelines. The Commission of Re- test assesses lower body strength. search of the University School of Phys- 3. Back scratch – reaching with hands be- ical Education, Wrocław, Poland granted hind the back until touching fingers approval for the research (approval date: – was measured with a ruler to the 2017). All study participants gave writ- nearest 0.5 cm. The test evaluates up- ten informed consent to participate in per body flexibility. the study. The study is a part of larger 4. Chair sit and reach – was measured with research that was retrospectively regis- a ruler to the nearest 0.5 cm. The test tered on the ISRCTN platform under the evaluates the flexibility of the lower number 18225729. body. The study included 17 women aged 5. 8-foot up and go – the time to complete 85 years and older, residents of nursing the test was measured to the near- homes in Lower Silesia. Inclusion criteria est hundredth of a second. The test were (1) age of 85 years and older, (2) is used to assess motor coordination no medical contraindications, (3) ability and dynamic balance. to move independently and complete a 6. 2-minute walk – the number of single functional fitness test, (4) normal verbal leg lifts while walking in place was contact, and (5) written consent to par- measured for 2 minutes. The test ticipate in the study, as well as approval evaluates aerobic endurance. 398 Antonina Kaczorowska et al. The study took place in the after- SECA 799 were also performed. For the noon since the participants mentally body height test, the participants tried and physically functioned best at this to adopt an upright posture. Body Mass time of the day. Before starting the test, Index (BMI) was calculated based on the participants were asked to perform these measurements. Some researchers each test part as well as possible. Perfor- have noted that calculating BMI for older mance of the test tasks was preceded by adults using body height may be incor- a demonstration. rect. Body height is often underestimat- The results of functional fitness tests ed due to degenerative changes in the were related to the standards for the el- spine and joints, and BMI is overestimat- derly population in Poland developed ed (Yilmaz et al. 2016). To avoid over- by Ignasiak et al. (2020). The following estimation of BMI, the participants tried score categories were adopted for all to adopt the most upright posture with tests: „Below normal” – for scores below hip and knee joints and spine as straight th the 25 percentile for all tests except the as possible. However, this was often not 8-foot up-and-go test measured in sec- possible due to contractures in the hip th onds, for scores above the 75 percentile and knee joints, as well as increased tho- on the 8-foot up-and-go test. All other racic kyphosis. values were taken as normal functional 15-item version of the Geriatric De- performance scores. The cutoff points pression Scale (GDS) was used to assess used for reduced functional fitness are the level of depression (Lesher and Ber- shown in Table 1. ryhill 1994). Result interpretation: The scores of the studied female nurs- – 0–5 points – no depression, ing home residents were also compared – 6–10 points – moderate depression, to the reference standards for maintain- – 11–15 – severe depression. ing independence developed for the four Three out of five proposed criteria test samples by the test authors (Rikli from the Cardiovascular Health Study and Jones 2012). The level of hand grip Frailty Index were used to assess the strength (HGS) was then measured using presence of frailty syndrome (Fried et al. a hand dynamometer (JAMAR, Hand Dy- 2001). Individuals not meeting any crite- namometer USA). Measurements of so- rion did not have frailty syndrome. Indi- matic characteristics such as body height viduals meeting 1–2 criteria were judged (to the nearest 0.5 cm) using an anthro- as pre-frail, while those meeting 3–5 pometer SECA 799 and body weight (to criteria were considered to be frail. We the nearest 0.5 kg) using a medical scale used gait speed from the 8-foot up and go test, level of hand grip strength mea- sured with a hand dynamometer, and the Table 1. Cut-off points for reduced functional fit - ness assessed using the Senior Fitness Test set presence of depression as assessed by the (according to Ignasiak et al. 2020) for women Geriatric Depression Scale. Criteria for Age (years) 85+ gait speed frailty syndrome are sex- and 30-Second Chair Stand Test (no. of reps) < 10 height-dependent, and are ≥ 7 s (height ≤ Arm Curl Test (no. of reps) < 10 159 cm) and ≥ 6 s (height > 159 cm) for Chair Sit and-Reach Test (cm) < −6 women. Hand grip criteria for frailty syn- Back Scratch Test (cm) < −19 drome include the lowest 20% of scores, 8-Foot Up-and-Go Test (s) > 7.3 adjusted for sex and BMI: Risk of frailty syndrome in 85-year-old and older women 399 – ≤ 17 kg for BMI ≥ 23, The results demonstrated low functional – ≤ 17.3 kg for BMI 23.1–26, fitness level of female nursing home res - – ≤ 18 kg for BMI 26.1–29, idents. A large percentage of the partici- – ≤ 21 kg for BMI > 29. pants surveyed were below the standard Collected results were then subjected values developed for Polish seniors. The to statistical analysis. The distribution of worst results were obtained in the timed the variables was checked for normality up and go test, with more than 94% of using the Shapiro-Wilk test. The mean the participants tested falling outside the (x), standard deviation (SD), minimum standard ranges (Table 3). value (Min) and maximum value (Max) Next, the scores of the studied female were calculated. Calculations were per- nursing home residents were compared formed using Excel and Statistica 13.3. to the reference standards for maintain- ing independence developed for the four test samples by the test authors (Rikli Results and Jones 2012). The mean results of The mean age of the studied women was all samples did not meet the developed 90.75 ± 3.83 years. The mean BMI of the reference standards. The 8 ft up-and-go participants was 26.50, exceeding the test part showed the worst results, with overweight threshold. Age and somatic a mean score of more than double the de- characteristics are presented in Table 2. veloped standard, with more than 94% of The results of the five test parts were individuals failing to meet the standard compared to Polish criteria for the 85+ (Table 4). group (Ignasiak et al. 2020). Since Pol- The tests for assessing the risk of ish criteria include 6-minute gait test to frailty syndrome included hand grip assess aerobic capacity, and the women strength, gait speed, and presence of de- performed a 2-minute walk in place test, pression. The results were compared to it did not meet the mentioned criteria. frailty syndrome criteria. As many as 16 Table 2. Descriptive statistics of morphological trials of the surveyed women N=17 Variable X ± SD Min Max Age [years] 90.75 ± 3.830 085.00 098.08 Height [cm] 152.24 ± 6.3100 140.50 163.00 Weight [kg] 61.50 ± 10.86 046.00 088.00 BMI [kg/m ] 26.50 ± 4.160 020.24 035.25 Table 3. Comparison of Senior Fitness Test results to Polish criteria (according Ignasiak et al. 2020) N=17 Below Polish norm Test X ± SD n (%) Chair stand [reps] 8.24 ± 2.80 12 (70.5) Arm curl [reps] 10.76 ± 3.530 06 (35.3) Chair sit and reach [cm] −23.76 ± 12.44− 13 (76.4) Back scratch [cm] −13.85 ± 10.11− 10 (58.8) 8 ft up-and-go [s] 17.61 ± 8.820 16 (94.1) 400 Antonina Kaczorowska et al. Table 4. Comparison of mean Senior Fitness Test scores to criterion-reference fitness standard for maintain - ing physical independence (according Rikli and Jones 2012) Standard 85–89 Standard 90–94 Below the standard Test X ± SD years years n (%) Chair stand [reps] 8.24 ± 2.80 11 9 12 (70.5) Arm curl [reps] 10.76 ± 3.530 13 11 11 (64.7) 2-min walk [steps] 53.76 ± 20.69 70 60 11 (64.7) 8 ft up-and-go [s] 17.61 ± 8.820 7.1 8.0 16 (94.1) Table 5. Participants meeting the individual criteria tional physical fitness among female for frailty syndrome nursing home residents aged 85+. Most Participants meeting of the participants did not meet crite- Criterion criteria, n (%) ria developed for the Polish population Gait speed [s] 16 (94.1) (Ignasiak et al. 2020) and the reference Hand grip strenght [kg] 06 (35.3) measures for maintaining independence GDS 06 (35.3) (Rikili and Jones 2012). Women who are 90-years-old, single, have at least two chronic conditions, and Table 6. Number and percentage of pre-frail and frail participants require assistance often become resi- dents of nursing facilities (Kauppi et al. n (%) 2018). In case of such individuals, it is Pre-frail 1 criterion 7 (41.1) challenging to complete all the parts of 2 criteria 9 (52.9) a functional fitness test. Most studies on In all 16 (94.1) functional fitness in people over 85 years Frail 1 (5.9) are based on completing questionnaires participants met the criteria for frailty (Simonsson et al. 2020, Escourrou et al. syndrome in the gait speed test, 6 wom- 2020, Ćwirlej-Sozańska et al. 2020), in en met the criteria for frailty syndrome in which the subjective assessment may not hand grip strength, and similarly 6 wom- match the actual condition. The ages of en had depression (Table 5). the female nursing home residents we Among the participants, 16 women studied ranged from 85 to 98 years old, met one or two criteria for frailty syn- and their ability to complete the Senior drome, indicating that the participants Fitness Test parts alone was a positive had pre-frail syndrome. One woman was element. found to meet three criteria, meaning the The low scores obtained on the Se- presence of frailty syndrome. None of the nior Fitness Test by female nursing home studied women were non-frail. The re- residents may be due to significant lim - sults are presented in Table 6. itations in activities of daily living, such as shopping, meal preparation, etc. The study by Barber et al. (2015) found that Discussion physical activity levels of nursing home The primary objective of this study was residents were very low, while time spent to assess the functional physical fitness sitting was very long. According to Fish- of 85+ female nursing home residents. er, low physical activity levels were as- The results indicate a low level of func- sociated with living in nursing homes, Risk of frailty syndrome in 85-year-old and older women 401 and activity levels decreased as seniors and low activity level. In this study, gait aged (Fisher et al 2018). A large study speed was found to be at the lowest lev- of the European elderly population has el, with over 94% of participants meeting confirmed that sedentary lifestyles are a the criterion for frailty syndrome. Mus- significant risk factor for disease and may cle strength was at a higher level, with contribute to increased mortality. Televi- over 35% of the women surveyed lacking sion viewing time has been shown to be a muscle strength. risk factor for frailty syndrome and major The low fitness level of the studied functional limitations in elderly people females may be related to the generally (Garcia-Esquinas et al. 2017). Thus, it is lower level of physical activity among se- assumed that low levels of physical activ- niors in Poland. The current generation ity and sedentary lifestyles pose a serious of Polish seniors acquired their lifestyle risk for disability. habits and normal behaviors, including We used three criteria to assess the physical activity, in communist Poland. risk of frailty syndrome in female nursing During the communist era, Polish se- home residents aged 85+, as proposed by niors lived in a different cultural con- Fried et al. (2001). Our findings are dis - text than seniors in Western Europe and turbing, as we found no non-frail among North America, where the idea of active the female participants in the study, and aging was well established. In Poland, the vast majority were at risk for frailty old age is traditionally considered a pe- syndrome. riod of well-deserved rest, during which Institutionalized women who expe- people should cease their previous ac- rience significant functional decline and tivities. Hence, only a small percentage loss of independence are at increased risk of Polish seniors participate in physical of developing frailty syndrome and dis- activity classes. The results of the „Bridg- ability (Furtado et al. 2017). Increased ing the East – West Health Gap” research vulnerability to adverse events such as project, aimed at assessing health status, falls, hospitalizations, disability, institu- attitudes, and health behaviors among tionalization, or death are consequences the adult population of selected Cen- of frailty syndrome (Skalska 2016, Fried et tral, Eastern, and Western European al. 2001). Potential reversibility through countries, indicate a marked variation multidirectional prevention, in which in physical activity levels across individ- regular physical activity and proper diet ual countries. The highest percentage of are most important, is a significant char - respondents declaring high activity was acteristic of the frailty syndrome (Skalska reported in Western European countries 2016). This is why it is so important to (30.2% in Finland and 23.7% Spain), and identify the frailty syndrome threat in or- the lowest in post-communist countries der to take preventive action early. – Poland (6.4%) and Hungary (12.3%) In the study by Furtado et al. (2017) (Drygas et al. 2001). Similarly, a small who analyzed the prevalence of frail- percentage (12%) of Czech seniors par- ty syndrome among institutionalized ticipate in sports or physical exercises women, the largest number of partici- (Mudrak et al. 2016). The rationale for pants negatively rated three components the low levels of physical activity among of frailty syndrome – weakness (mus- older adults from Central and Eastern cle strength), slowdown (gait speed), European countries may be that seniors 402 Antonina Kaczorowska et al. from post-communist countries gener- Conflict of interest ally live in poorer socioeconomic condi- tions than seniors in Western European The authors declare no conflict of inter - and North American countries.Addition- ests. ally, Central and Eastern European se- niors tend to engage in behaviors that are Corresponding author less beneficial to health. This study also had some limitations. Anna Sebastjan, Department of Biostruc- A small number of women were studied. ture, University School of Physical Edu- This was due to the fact that a very small cation in Wrocław, Poland number of female nursing home resi- e-mail: anna.sebastjan@gmail.com dents aged 85+ were able to perform the functional fitness test independently. In References addition, only women participated in the Bandeen-Roche K, Xue QL, Ferrucci L, study. Women are living longer than men Walston J, Guralnik JM, et al. 2006. Phe- and there are significantly fewer men notype of frailty: characterization in the aged 85 and older in nursing homes. Women’s Health and Aging Studies. J Only a small number of female nurs- Gerontol A Biol Sci Med Sci 61(3):262–6. ing home residents over the age of 85 Barber SE, Forster A, Birch KM. 2015. Levels are capable of performing a functional and patterns of daily physical activity and fitness test. 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Journal

Anthropological Review – de Gruyter

Published: Jan 1, 2022

Keywords: frailty; physical fitness; older woman; healthy aging; institutional living

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