This article appeared in Aging Today, November/December 1997, copyright American Society on Aging, 1997. It appeared in the newspaper's Research Today section, aupported by a grant from the AARP Andrus Foundation.

The challenge ahead for researchers who aim to improve the chances of elders to remain functionally viable and independent in their later years is in untangling and understanding the interplay of the many factors that lead to functional decline.

"Diseases often have . . . an indirect negative effect on performance through decline in appetite, inadequate intake of fluid and food, lowered muscle strength and balance and so on," explained Alvar Svanborg, University of Illinois (Chicago) professor emeritus and internationally renowned geriatric rehabilitation expert, in "Postponement of Aging," in the Encyclopedia of Gerontology (San Diego, Calif.: Academic Press, 1996). He continued, "Early and correct diagnosis and treatment has, therefore, been found to be even more important for old frail people than in younger individuals in order to prevent unnecessary functional decline."

One key issue is distinguishing disease and other abnormal conditions from the declines of aging itself. Svanborg said, "There are many reasons to believe that adequate healthcare should be one factor postponing not only decline in health but also age-related dysfunction."

Further, he noted in the June 1997 issue of Drugs and Aging, "It is only recently that adult medicine has begun to enhance our understanding of the biology of aging, to finding improved ways of differentiating between aging and disease and to developing interventions that postpone aging-related dysfunction." Once the effects of disease can be distinguished from the declines of aging alone, healthcare practitioners and medical science can focus more clearly on ways to keep elders functionally independents.

In a 1993 article in World Health Forum, Svanborg stressed, "Interventions aimed at promoting health and preventing disability should never be dismissed as too late." For example, the effects of an aging-related decline like bone loss can be forestalled through physical activity and adequate nutrition. Lifestyle factors also play an important role. Tobacco smoking and alcohol abuse have also been shown to reduce bone density, Svanborg observed.

Svanborg also noted that "Several studies have shown that systematic strength training can improve muscle strength and also speed of contraction." Comparative studies have shown that in training, inactive younger and older subjects improve proportionally the same, although older participants past age 60 start at a lower level because of age-related decline in muscle fibers and functional efficiency. Even for older elders aged 80 or more, he said, "Strength and speed of muscle contraction is crucial for prevention of falls."

The debilitating effects of hip fractures were underscored in a recent Indiana University School of Medicine study. It demonstrated, among other results, that participants aged 70 or older in the Longitudinal Study of Aging who had incurred hip fractures not only greatly increased the likelihood of subsequent hospitalization or death within one year of their fall but experienced a considerable rise in difficulties with activities of daily living (ADLs), daily household activities and limitations in upper- and lower-body functioning.

In "The Effect of Hip Fracture on Mortality, Hospitalization and Functional Status" (American Journal of Public Health, March 1997), Indiana's Fredric D. Wolinsky and coauthors stated, "There can be little doubt that after older adults suffer hip fractures, their health and health behavior deteriorates." The authors added that research still needs to clarify whether hip fracture initiates the decline or is "merely a marker showing that it has already nbegun."

They seemed to echo Svanborg in recommending a combination of "a well-coordinated and multidimensional intervention," a lifelong population strategy to increase bone density and an effort to minimize the likelihood of falling directly on the hip "by nutritional repletion and exercise interventions."

Another recent study showing the intertwining of factors that need to be understood looked at how the ability of elders to function well depends in part on their degree of "self-efficacy," or the confidence they have in performing a specific task, especially in completing an activity of daily living without falling.

In "Self-Efficacy, Physical Decline and Change in Functioning in Community-Living Elders" (Journal of Gerontology: Social Sciences, July 1996), Carlos F. Mendes de Leon and colleagues at Yale University followed up 18 months after an initial assessment with 846 subjects living in the community, aged 72 or older. Baseline tests included home interviews and physical evaluation by a trained research nurse; a query as to whether subjects needed help with activities of daily living; and a battery of physical performance tests, such as tapping each foot 10 times, walking 20 feet and bending over to pick up a pencil. Subjects also were measured by the Falls-Efficacy Scale concerning their confidence levels in performing 10 daily activities, such as housecleaning, bathing or hurrying to answer a telephone.

Almost half (46%) of the subjects showed at least some decline in physical capacity a year and a half after the first test, and about one in six (17%) experienced ADL difficulties. The investigators concluded that even for those who had declined, "high self-efficacy enables older adults to continue carrying out basic self-care activities when their ability to do so is challenged by diminished physical capacity."

They added, "High self-efficacy may enable individuals afflicted with chronic illnesses to better retain their ability to perform self-care behaviors successfully in spite of gradual losses in physical capacity." They recommended that self-efficacy training, such as efforts to increase awareness among elders of how they can adjust their behavior to cope better on their own, be added in various geriatric settings.

Mendes de Leon and coauthors assert, "Our study provides further impetus for the notion that psychosocial characteristics should be studied cojointly with, rather than independently of, physical determinants of functional decline." *

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