Review Article • Salud pública Méx 60 (5) 10 June 2019Sep-Oct 2018 • https://doi.org/10.21149/9075   copy

Functional, nutritional and social factors associated with mobility limitations in the elderly: a systematic review

Factores funcionales, nutricionales y sociales asociados con las limitaciones de la movilidad en los ancianos: revisión sistemática

José Rodolfo Torres-de Araújo Rafael Rodolfo Tomaz-de Lima Ila Maria Ferreira-Bendassolli Kenio Costa-de Lima About the authors

Abstract:

Objective:

To systematically review the prevalence and incidence of mobility limitations in the elderly people and their associated factors.

Materials and methods:

Articles in the electronic literature were searched via PubMed, Scopus, Lilacs, SciELO, PAHO, MedCarib, Repidisca, Wholis, IBCES, PEDro, Medline and Bireme (2012-2016). The instrument STROBE was used to analyze the quality of the work and the PRISMA recommendation was used to structure the review.

Results:

Nine studies were included. The prevalence of mobility limitations ranged from 58.1 to 93.2% and the incidence ranged from 23 to 53.7%. Studies provided evidence of association of mobility limitations in the elderly population with high BMI, low 25-hydroxy vitamin D, sarcopenia, fragility, chronic pain, functional dependence, advanced age in women, low hip flexion, sedentary lifestyle, and social support difficulties.

Conclusion:

Mobility limitations in the elderly had high prevalence and incidence, and there was evidence of association with nutritional, functional and social factors.

Keywords:
aged; aging; mobility limitation; risk; etiology; association

Resumen:

Objetivo:

Revisar sistemáticamente la prevalencia e incidencia de las limitaciones de movilidad en los ancianos y sus factores asociados.

Material y métodos:

Se realizaron búsquedas de artículos en la literatura electrónica a través de PubMed, Scopus, Lilacs, SciELO, PAHO, MedCarib, Repidisca, Wholis, IBCES, PEDro, Medline y Bireme (2012-2016). El instrumento STROBE fue utilizado para analizar la calidad del trabajo y la recomendación de PRISMA para estructurar la revisión.

Resultados:

Se incluyeron nueve estudios. La prevalencia de limitaciones de movilidad varió de 58.1 a 93.2% y la incidencia de 23 a 53.7%. Los estudios aportaron evidencia de asociación de limitaciones de movilidad en los ancianos con alto IMC, 25-hidroxivitamina D baja, sarcopenia, fragilidad, dolor crónico, dependencia funcional, edad avanzada de las mujeres, flexión de cadera baja, sedentarismo y dificultades de apoyo social.

Conclusiones:

Las limitaciones de movilidad en los ancianos presentan alta prevalencia e incidencia, y hay evidencia de asociación con factores nutricionales, funcionales y sociales.

Palabras clave:
anciano; envejecimiento; limitación de la movilidad; riesgo; etiología; asociación

Introduction

The aging process of the population has become increasingly common in most of the countries in the world as a result of scientific, medical and technological advances in the last decades increasing life expectancy.11. Cocco AR, Naspolini AP, Grando FP, Volgoi N, Silva E, Medeiros PA, Lampert MA. A imobilidade em Instituição de LongaPermanência: Compreendendo o desafio vivenciado pelas equipes de saúde. Kairos. 2013;16(3):263-84 [cited January 14, 2016]. Available from: https://revistas.pucsp.br/index.php/kairos/article/view/18551/13737
https://revistas.pucsp.br/index.php/kair... Longevity raises concern about the quality of life of the older population because aging is often accompanied by a decline in physical, cognitive and sensory capacity, which may cause limit physical mobility.11. Cocco AR, Naspolini AP, Grando FP, Volgoi N, Silva E, Medeiros PA, Lampert MA. A imobilidade em Instituição de LongaPermanência: Compreendendo o desafio vivenciado pelas equipes de saúde. Kairos. 2013;16(3):263-84 [cited January 14, 2016]. Available from: https://revistas.pucsp.br/index.php/kairos/article/view/18551/13737
https://revistas.pucsp.br/index.php/kair... ,22. Camarano AA, Kanso S, Fernandes D. Envelhecimento Populacional, perda da capacidade laborativa e políticas públicas brasileiras entre 1992 e 2011. Rio de Janeiro: Instituto de Pesquisa Econômica Aplicada, 2013 [cited March 8, 2016]. Available from: http://ipea.gov.br/portal/images/stories/PDFs/TDs/td_1890.pdf
http://ipea.gov.br/portal/images/stories... ,33. Freedman VA. Research gaps in the demography of aging with disability. Disabil Health J. 2014;7(10):60-3. https://doi.org/10.1016/j.dhjo.2013.04.009
https://doi.org/10.1016/j.dhjo.2013.04.0... ,44. Putnam M, Molton IR, Truitt AR, Smith AE, Jensen MP. Measures of aging with disability in U.S. secondary data sets: results of a scoping review. Disabil Health J . 2016;9(1):5-10. https://doi.org/10.1016/j.dhjo.2015.07.002
https://doi.org/10.1016/j.dhjo.2015.07.0... Mobility is defined as the ability to move independently and safely from one place to another; it represents an essential aspect of daily life and favors the autonomy of older adults.55. Stenholm S, Shardell M, Bandinelli S, Guralnik JM, Ferrucci L. Physiological Factors Contributing to Mobility Loss Over 9 Years of Follow-Up-Results From the In CHIANTI Study. J Gerontol A Biol Sci Med Sci. 2015;70(5):591-7. https://doi.org/10.1093/gerona/glv004
https://doi.org/10.1093/gerona/glv004...

Mobility limitations are frequent functional problems in elderly people, especially in the oldest ones (≥80 years old). The World Health Organization (WHO) states that about 20% of people over 70 and 50% of people over 85 have some type of disability or movement limitation.66. World Health Organization. Disability and rehabilitation WHO action plan 2006-2011. Geneva: WHO, 2006 [cited April 26, 2016]. Available from: http://www.who.int/disabilities/publications/dar_action_plan_2006to2011.pdf
http://www.who.int/disabilities/publicat... ,77. Tanjani PT, Akbarpour S, Ainy E, Soori H. Socio-demographic risk factors of mobility dysfunction and limitations in physical functioning disability among the elderly in Iran: A nationwide cross sectional survey. J Pak Med Assoc. 2015;65(10):1060-4. Although many risk factors and aspects associated with mobility limitations have been described in the literature,55. Stenholm S, Shardell M, Bandinelli S, Guralnik JM, Ferrucci L. Physiological Factors Contributing to Mobility Loss Over 9 Years of Follow-Up-Results From the In CHIANTI Study. J Gerontol A Biol Sci Med Sci. 2015;70(5):591-7. https://doi.org/10.1093/gerona/glv004
https://doi.org/10.1093/gerona/glv004... ,77. Tanjani PT, Akbarpour S, Ainy E, Soori H. Socio-demographic risk factors of mobility dysfunction and limitations in physical functioning disability among the elderly in Iran: A nationwide cross sectional survey. J Pak Med Assoc. 2015;65(10):1060-4. their relative importance and independent contribution to the long-term risk of loss of mobility is still unclear.33. Freedman VA. Research gaps in the demography of aging with disability. Disabil Health J. 2014;7(10):60-3. https://doi.org/10.1016/j.dhjo.2013.04.009
https://doi.org/10.1016/j.dhjo.2013.04.0...

Social, nutritional, and functional factors may be involved with mobility limitations. Mobility restrictions are generally associated with physical deconditioning, and they may have an impact on the functioning of physiological systems. The reduction of physiological reserves in older adults over the years facilitates functional limitations.88. Ribeiro CA, Silva DAM, Rizzo LA, Ventura MM. Immobility syndrome frequency in a geriatric ward. Geriatr Gerontol. 2011;5(3):136-9. Available from: http://ggaging.com/details/235/en-US/immobility-syndrome-frequence-in-a-geriatric-ward
http://ggaging.com/details/235/en-US/imm... However, mobility limitations may occur in several ways, such as difficulties to move, going up or down stairs. Over time, major restrictions involving the use of wheelchairs (using these with insecurity) or locomotion assistance devices may occur.

Also, these limitations referred as physical immobility by some studies are the opposite of “mobility” and they are the ten most frequent health problems among elderly people of both sexes, having some association with several levels of functional dependence.99. Clerencia-Sierra M, Calderón-Larrañaga A, Martínez-Velilla N, Vergara-Mitxeltorena I, Aldaz-Herce P, Poblador-Plou B, et al. Multimorbidity Patterns in Hospitalized Older Patients: Associations among Chronic Diseases and Geriatric Syndromes. PLoS One. 2015;10(7):e0132909. https://doi.org/10.1371/journal.pone.0132909
https://doi.org/10.1371/journal.pone.013... Nevertheless, some gaps need to be filled to understand what types of factors are most closely associated with the phenomenon. Given this context, this systematic review sought to identify evidence of prevalence, incidence, and factors associated with mobility limitations in the older adults.

Materials and methods

This is a systematic review of the last five years (2012-2016). The review investigated the evidence of the prevalence or incidence of mobility limitations in the elderly people and their associated factors.

Identification of relevant studies

Papers were sought in the following databases: PubMed, Scopus, Lilacs (Latin American and Caribbean Health Sciences Literature), SciELO (Scientific Electronic Library Online), PAHO (Pan American Health Organization), MedCarib (Caribbean Health Sciences Literature), Repidisca (Pan American Network for Information and Documentation in Sanitary Engineering and Environmental Sciences), Wholis (WHO Library Information System), IBECS (Spanish Bibliographical Index in Health Sciences), PEDro (Physiotherapy Evidence Database), MEDLINE (Medical Literature Analysis and Retrieval System Online) and Bireme (Latin American and Caribbean Center on Health Sciences Information). They were found by doing a search for the following terms: Mobility Limitation, Walking Difficulty, Dependent ambulation, Aged or Aging, Risk or Etiology, Measures of Association or Outcome.

Selection of studies

Those articles that assessed or identified mobility limitations in older people were included. Papers published in Portuguese, English, and Spanish were accepted. Studies of various types -observational, sectional, longitudinal, prospective, retrospective- and papers published in congress proceedings as well as dissertations were searched; theses and abstracts were excluded.

The instrument known as “Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)” was used to verify the items recommended in observational studies.1010. Malta M, Cardoso LO, Bastos FI, Magnanini MMF, Silva CMFP. STROBE initiative: guidelines on reporting observational studies. Rev Saúde Pública. 2010;44(3):559-65. https://doi.org/10.1590/S0034-89102010000300021
https://doi.org/10.1590/S0034-8910201000... This instrument lists information that should be present in the title, abstract, introduction, methodology, results, and discussion of scientific articles that describe observational studies, contributing to an adequate report of this type of study. Also, the recommendation of the “Main Items for Reporting Systematic Analyses and Meta-Analyses (PRISMA)” was followed to structure the review.1111. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med. 2009;6(7):e1000097. https://doi.org/10.1371/journal.pmed.1000097
https://doi.org/10.1371/journal.pmed.100... This recommendation consists of a set of items that help researchers to write systematic reviews and/or meta-analyses appropriately. The bibliographic research was carried out between November of 2015 and December of 2016.

Results

A total of 2 189 articles were found, whose abstracts were read. Whenever there were doubts about the content and subject searched, the article was read in full. Duplicated articles were then excluded, and the list of references of the chosen articles was analyzed for new studies. Thirteen articles were selected and submitted to STROBE10 (figure 1). In the end, nine articles were included in the study (table I).55. Stenholm S, Shardell M, Bandinelli S, Guralnik JM, Ferrucci L. Physiological Factors Contributing to Mobility Loss Over 9 Years of Follow-Up-Results From the In CHIANTI Study. J Gerontol A Biol Sci Med Sci. 2015;70(5):591-7. https://doi.org/10.1093/gerona/glv004
https://doi.org/10.1093/gerona/glv004... ,77. Tanjani PT, Akbarpour S, Ainy E, Soori H. Socio-demographic risk factors of mobility dysfunction and limitations in physical functioning disability among the elderly in Iran: A nationwide cross sectional survey. J Pak Med Assoc. 2015;65(10):1060-4.,99. Clerencia-Sierra M, Calderón-Larrañaga A, Martínez-Velilla N, Vergara-Mitxeltorena I, Aldaz-Herce P, Poblador-Plou B, et al. Multimorbidity Patterns in Hospitalized Older Patients: Associations among Chronic Diseases and Geriatric Syndromes. PLoS One. 2015;10(7):e0132909. https://doi.org/10.1371/journal.pone.0132909
https://doi.org/10.1371/journal.pone.013... ,1212. Houston DK, Neiberg RH, Tooze JA, Hausman DB, Johnson MA, Cauley JA, et al. Low 25-Hydroxyvitamin D Predicts the Onset of Mobility Limitation and Disability in Community-Dwelling Older Adults: The Health ABC Study. J Gerontol A Biol Sci Med Sci . 2013;68(2):181-7. https://doi.org/10.1093/gerona/gls136
https://doi.org/10.1093/gerona/gls136... ,1313. Alva MCV, Camacho MEI, Velázquez JD, Lazarevich I. The relationship between sarcopenia, undernutrition, physical mobility and basic activities of daily living in a group of elderly women of Mexico City. Nutr Hosp. 2013;28(2):514-21.https://doi.org/10.3305/nh.2013.28.2.6180
https://doi.org/10.3305/nh.2013.28.2.618... ,1414. Murphy RA, Reinders I, Register TC, Ayonayon HN, Newman AB, Satterfield S, et al. Associations of BMI and adipose tissue area and density with incident mobility limitation and poor performance in older adults. Am J Clin Nutr. 2014;99(5):1059-65. https://doi.org/10.3945/ajcn.113.080796
https://doi.org/10.3945/ajcn.113.080796... ,1515. Yeom HA, Baldwin CM, Lee MA, Kim SJ. Factors Affecting Mobility in Community-dwelling Older Koreans with Chronic Illnesses. Asian Nurs Res (Korean SocNursSci). 2015;9(1):7-13. https://doi.org/10.1016/j.anr.2014.09.005
https://doi.org/10.1016/j.anr.2014.09.00... ,1616. Gale CR, Cooper C, Sayer AA. Prevalence of frailty and disability: findings from the English Longitudinal Study of Ageing. Age Ageing. 2015;44(1):162-5. https://doi.org/10.1093/ageing/afu148
https://doi.org/10.1093/ageing/afu148... ,1717. Dellaroza MSG, Pimenta CAM, Duarte YA, Lebrão ML. Chronic pain among elderly residents in São Paulo, Brazil: prevalence, characteristics, and association with functional capacity and mobility (SABE Study). Cad Saúde Pública. 2013;29(2):325-34. https://doi.org/10.1590/S0102-311X2013000200019
https://doi.org/10.1590/S0102-311X201300...

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Figure 1
Selection of articles in the systematic review

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Table I
Characteristics of the studies selected by the systematic review

The studies had varied approaches and a higher percentage of women in their samples, and one study included only females in the sample.1313. Alva MCV, Camacho MEI, Velázquez JD, Lazarevich I. The relationship between sarcopenia, undernutrition, physical mobility and basic activities of daily living in a group of elderly women of Mexico City. Nutr Hosp. 2013;28(2):514-21.https://doi.org/10.3305/nh.2013.28.2.6180
https://doi.org/10.3305/nh.2013.28.2.618... Sample sizes ranged from 90 to 5 450 individuals, with a mean age between 69.1 and 82.1 years. This demonstrates the scope and extent of these studies, covering several age subgroups within the same life stage. The largest sample was seen in a “longitudinal population” study carried out in the United Kingdom (UK).1616. Gale CR, Cooper C, Sayer AA. Prevalence of frailty and disability: findings from the English Longitudinal Study of Ageing. Age Ageing. 2015;44(1):162-5. https://doi.org/10.1093/ageing/afu148
https://doi.org/10.1093/ageing/afu148...

Regarding the location, three studies were performed in North and Central America,1212. Houston DK, Neiberg RH, Tooze JA, Hausman DB, Johnson MA, Cauley JA, et al. Low 25-Hydroxyvitamin D Predicts the Onset of Mobility Limitation and Disability in Community-Dwelling Older Adults: The Health ABC Study. J Gerontol A Biol Sci Med Sci . 2013;68(2):181-7. https://doi.org/10.1093/gerona/gls136
https://doi.org/10.1093/gerona/gls136... ,1313. Alva MCV, Camacho MEI, Velázquez JD, Lazarevich I. The relationship between sarcopenia, undernutrition, physical mobility and basic activities of daily living in a group of elderly women of Mexico City. Nutr Hosp. 2013;28(2):514-21.https://doi.org/10.3305/nh.2013.28.2.6180
https://doi.org/10.3305/nh.2013.28.2.618... ,1414. Murphy RA, Reinders I, Register TC, Ayonayon HN, Newman AB, Satterfield S, et al. Associations of BMI and adipose tissue area and density with incident mobility limitation and poor performance in older adults. Am J Clin Nutr. 2014;99(5):1059-65. https://doi.org/10.3945/ajcn.113.080796
https://doi.org/10.3945/ajcn.113.080796... one study in South America,1717. Dellaroza MSG, Pimenta CAM, Duarte YA, Lebrão ML. Chronic pain among elderly residents in São Paulo, Brazil: prevalence, characteristics, and association with functional capacity and mobility (SABE Study). Cad Saúde Pública. 2013;29(2):325-34. https://doi.org/10.1590/S0102-311X2013000200019
https://doi.org/10.1590/S0102-311X201300... three studies in Europe55. Stenholm S, Shardell M, Bandinelli S, Guralnik JM, Ferrucci L. Physiological Factors Contributing to Mobility Loss Over 9 Years of Follow-Up-Results From the In CHIANTI Study. J Gerontol A Biol Sci Med Sci. 2015;70(5):591-7. https://doi.org/10.1093/gerona/glv004
https://doi.org/10.1093/gerona/glv004... ,99. Clerencia-Sierra M, Calderón-Larrañaga A, Martínez-Velilla N, Vergara-Mitxeltorena I, Aldaz-Herce P, Poblador-Plou B, et al. Multimorbidity Patterns in Hospitalized Older Patients: Associations among Chronic Diseases and Geriatric Syndromes. PLoS One. 2015;10(7):e0132909. https://doi.org/10.1371/journal.pone.0132909
https://doi.org/10.1371/journal.pone.013... ,1616. Gale CR, Cooper C, Sayer AA. Prevalence of frailty and disability: findings from the English Longitudinal Study of Ageing. Age Ageing. 2015;44(1):162-5. https://doi.org/10.1093/ageing/afu148
https://doi.org/10.1093/ageing/afu148... and two studies in Asia77. Tanjani PT, Akbarpour S, Ainy E, Soori H. Socio-demographic risk factors of mobility dysfunction and limitations in physical functioning disability among the elderly in Iran: A nationwide cross sectional survey. J Pak Med Assoc. 2015;65(10):1060-4.,1515. Yeom HA, Baldwin CM, Lee MA, Kim SJ. Factors Affecting Mobility in Community-dwelling Older Koreans with Chronic Illnesses. Asian Nurs Res (Korean SocNursSci). 2015;9(1):7-13. https://doi.org/10.1016/j.anr.2014.09.005
https://doi.org/10.1016/j.anr.2014.09.00... pointing out to a variety of population, mostly composed of older individuals.

Mobility assessment

Physical mobility is one of the aspects addressed when assessing functional capacity. It is the independent and safe physical performance of individuals in space locomotion. Individuals who are insecure or have some degree of dependence on locomotion are classified as having mobility limitations. In the review, three studies evaluated mobility based on the difficulty of walking 400 m or climbing and going down 10 steps.55. Stenholm S, Shardell M, Bandinelli S, Guralnik JM, Ferrucci L. Physiological Factors Contributing to Mobility Loss Over 9 Years of Follow-Up-Results From the In CHIANTI Study. J Gerontol A Biol Sci Med Sci. 2015;70(5):591-7. https://doi.org/10.1093/gerona/glv004
https://doi.org/10.1093/gerona/glv004... ,1212. Houston DK, Neiberg RH, Tooze JA, Hausman DB, Johnson MA, Cauley JA, et al. Low 25-Hydroxyvitamin D Predicts the Onset of Mobility Limitation and Disability in Community-Dwelling Older Adults: The Health ABC Study. J Gerontol A Biol Sci Med Sci . 2013;68(2):181-7. https://doi.org/10.1093/gerona/gls136
https://doi.org/10.1093/gerona/gls136... ,1414. Murphy RA, Reinders I, Register TC, Ayonayon HN, Newman AB, Satterfield S, et al. Associations of BMI and adipose tissue area and density with incident mobility limitation and poor performance in older adults. Am J Clin Nutr. 2014;99(5):1059-65. https://doi.org/10.3945/ajcn.113.080796
https://doi.org/10.3945/ajcn.113.080796... One study evaluated the difficulty of walking 100 meters, going up stairs and performing activities of daily living.1616. Gale CR, Cooper C, Sayer AA. Prevalence of frailty and disability: findings from the English Longitudinal Study of Ageing. Age Ageing. 2015;44(1):162-5. https://doi.org/10.1093/ageing/afu148
https://doi.org/10.1093/ageing/afu148... The other studies used the 6-minute walking test (6MWT),1515. Yeom HA, Baldwin CM, Lee MA, Kim SJ. Factors Affecting Mobility in Community-dwelling Older Koreans with Chronic Illnesses. Asian Nurs Res (Korean SocNursSci). 2015;9(1):7-13. https://doi.org/10.1016/j.anr.2014.09.005
https://doi.org/10.1016/j.anr.2014.09.00... Barthel index,99. Clerencia-Sierra M, Calderón-Larrañaga A, Martínez-Velilla N, Vergara-Mitxeltorena I, Aldaz-Herce P, Poblador-Plou B, et al. Multimorbidity Patterns in Hospitalized Older Patients: Associations among Chronic Diseases and Geriatric Syndromes. PLoS One. 2015;10(7):e0132909. https://doi.org/10.1371/journal.pone.0132909
https://doi.org/10.1371/journal.pone.013... Euronut-SENECA guide,1313. Alva MCV, Camacho MEI, Velázquez JD, Lazarevich I. The relationship between sarcopenia, undernutrition, physical mobility and basic activities of daily living in a group of elderly women of Mexico City. Nutr Hosp. 2013;28(2):514-21.https://doi.org/10.3305/nh.2013.28.2.6180
https://doi.org/10.3305/nh.2013.28.2.618... self-report,55. Stenholm S, Shardell M, Bandinelli S, Guralnik JM, Ferrucci L. Physiological Factors Contributing to Mobility Loss Over 9 Years of Follow-Up-Results From the In CHIANTI Study. J Gerontol A Biol Sci Med Sci. 2015;70(5):591-7. https://doi.org/10.1093/gerona/glv004
https://doi.org/10.1093/gerona/glv004... ,77. Tanjani PT, Akbarpour S, Ainy E, Soori H. Socio-demographic risk factors of mobility dysfunction and limitations in physical functioning disability among the elderly in Iran: A nationwide cross sectional survey. J Pak Med Assoc. 2015;65(10):1060-4.,1717. Dellaroza MSG, Pimenta CAM, Duarte YA, Lebrão ML. Chronic pain among elderly residents in São Paulo, Brazil: prevalence, characteristics, and association with functional capacity and mobility (SABE Study). Cad Saúde Pública. 2013;29(2):325-34. https://doi.org/10.1590/S0102-311X2013000200019
https://doi.org/10.1590/S0102-311X201300... interview1212. Houston DK, Neiberg RH, Tooze JA, Hausman DB, Johnson MA, Cauley JA, et al. Low 25-Hydroxyvitamin D Predicts the Onset of Mobility Limitation and Disability in Community-Dwelling Older Adults: The Health ABC Study. J Gerontol A Biol Sci Med Sci . 2013;68(2):181-7. https://doi.org/10.1093/gerona/gls136
https://doi.org/10.1093/gerona/gls136... ,1616. Gale CR, Cooper C, Sayer AA. Prevalence of frailty and disability: findings from the English Longitudinal Study of Ageing. Age Ageing. 2015;44(1):162-5. https://doi.org/10.1093/ageing/afu148
https://doi.org/10.1093/ageing/afu148... (Houston and colleagues) in 2013,1212. Houston DK, Neiberg RH, Tooze JA, Hausman DB, Johnson MA, Cauley JA, et al. Low 25-Hydroxyvitamin D Predicts the Onset of Mobility Limitation and Disability in Community-Dwelling Older Adults: The Health ABC Study. J Gerontol A Biol Sci Med Sci . 2013;68(2):181-7. https://doi.org/10.1093/gerona/gls136
https://doi.org/10.1093/gerona/gls136... questionnaire,77. Tanjani PT, Akbarpour S, Ainy E, Soori H. Socio-demographic risk factors of mobility dysfunction and limitations in physical functioning disability among the elderly in Iran: A nationwide cross sectional survey. J Pak Med Assoc. 2015;65(10):1060-4. medical records and ADLs.99. Clerencia-Sierra M, Calderón-Larrañaga A, Martínez-Velilla N, Vergara-Mitxeltorena I, Aldaz-Herce P, Poblador-Plou B, et al. Multimorbidity Patterns in Hospitalized Older Patients: Associations among Chronic Diseases and Geriatric Syndromes. PLoS One. 2015;10(7):e0132909. https://doi.org/10.1371/journal.pone.0132909
https://doi.org/10.1371/journal.pone.013...

Prevalence, incidence, and factors associated with mobility limitations

The studies indicated a prevalence of mobility limitations in the elderly person ranging from 58.1 to 93.2%, and an incidence varying between 23 and 53.7% (table II). Only one study identified “mobility disability” (22% incidence).

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Table II
Evidence for the factors associated with mobility limitations in the elderly people based on studies selected by the systematic review

Most of the studies used a variety of statistical analyses to demonstrate the factors associated with mobility limitations. However, there were logistic regression analyses in most of the research.

The study with the largest sample (5 450 older adults)1616. Gale CR, Cooper C, Sayer AA. Prevalence of frailty and disability: findings from the English Longitudinal Study of Ageing. Age Ageing. 2015;44(1):162-5. https://doi.org/10.1093/ageing/afu148
https://doi.org/10.1093/ageing/afu148... found that fragile older adults had a greater incidence of physical mobility limitation, and the study with the smaller sample (90 older adults)1313. Alva MCV, Camacho MEI, Velázquez JD, Lazarevich I. The relationship between sarcopenia, undernutrition, physical mobility and basic activities of daily living in a group of elderly women of Mexico City. Nutr Hosp. 2013;28(2):514-21.https://doi.org/10.3305/nh.2013.28.2.6180
https://doi.org/10.3305/nh.2013.28.2.618... showed an association with sarcopenia. Studies with samples of over one thousand elderly people showed association with nutritional, functional and social factors, while those with samples of less than one thousand elderly people showed a stronger association with functional factors (table II).

The social factors that may place the elderly population with mobility limitations at a higher risk of developing disabilities include family composition by other individuals, precarious financial situation and lack of housing.77. Tanjani PT, Akbarpour S, Ainy E, Soori H. Socio-demographic risk factors of mobility dysfunction and limitations in physical functioning disability among the elderly in Iran: A nationwide cross sectional survey. J Pak Med Assoc. 2015;65(10):1060-4.

According to the review, mobility limitations in advanced ages can act as a cause of illnesses as they affect the reduction of functional reserves in the elderly person (functional dependence)99. Clerencia-Sierra M, Calderón-Larrañaga A, Martínez-Velilla N, Vergara-Mitxeltorena I, Aldaz-Herce P, Poblador-Plou B, et al. Multimorbidity Patterns in Hospitalized Older Patients: Associations among Chronic Diseases and Geriatric Syndromes. PLoS One. 2015;10(7):e0132909. https://doi.org/10.1371/journal.pone.0132909
https://doi.org/10.1371/journal.pone.013... and they can also be a consequence when physical and metabolic compromises generate weakness and fragility (sarcopenia, sedentary lifestyle, high BMI, low 25-hydroxyvitamin D).1212. Houston DK, Neiberg RH, Tooze JA, Hausman DB, Johnson MA, Cauley JA, et al. Low 25-Hydroxyvitamin D Predicts the Onset of Mobility Limitation and Disability in Community-Dwelling Older Adults: The Health ABC Study. J Gerontol A Biol Sci Med Sci . 2013;68(2):181-7. https://doi.org/10.1093/gerona/gls136
https://doi.org/10.1093/gerona/gls136... ,1313. Alva MCV, Camacho MEI, Velázquez JD, Lazarevich I. The relationship between sarcopenia, undernutrition, physical mobility and basic activities of daily living in a group of elderly women of Mexico City. Nutr Hosp. 2013;28(2):514-21.https://doi.org/10.3305/nh.2013.28.2.6180
https://doi.org/10.3305/nh.2013.28.2.618... ,1414. Murphy RA, Reinders I, Register TC, Ayonayon HN, Newman AB, Satterfield S, et al. Associations of BMI and adipose tissue area and density with incident mobility limitation and poor performance in older adults. Am J Clin Nutr. 2014;99(5):1059-65. https://doi.org/10.3945/ajcn.113.080796
https://doi.org/10.3945/ajcn.113.080796... ,1515. Yeom HA, Baldwin CM, Lee MA, Kim SJ. Factors Affecting Mobility in Community-dwelling Older Koreans with Chronic Illnesses. Asian Nurs Res (Korean SocNursSci). 2015;9(1):7-13. https://doi.org/10.1016/j.anr.2014.09.005
https://doi.org/10.1016/j.anr.2014.09.00...

Terms used to express the context of the mobility limitations

In the case of physical mobility, most of the studies (eight studies)55. Stenholm S, Shardell M, Bandinelli S, Guralnik JM, Ferrucci L. Physiological Factors Contributing to Mobility Loss Over 9 Years of Follow-Up-Results From the In CHIANTI Study. J Gerontol A Biol Sci Med Sci. 2015;70(5):591-7. https://doi.org/10.1093/gerona/glv004
https://doi.org/10.1093/gerona/glv004... ,77. Tanjani PT, Akbarpour S, Ainy E, Soori H. Socio-demographic risk factors of mobility dysfunction and limitations in physical functioning disability among the elderly in Iran: A nationwide cross sectional survey. J Pak Med Assoc. 2015;65(10):1060-4.,1212. Houston DK, Neiberg RH, Tooze JA, Hausman DB, Johnson MA, Cauley JA, et al. Low 25-Hydroxyvitamin D Predicts the Onset of Mobility Limitation and Disability in Community-Dwelling Older Adults: The Health ABC Study. J Gerontol A Biol Sci Med Sci . 2013;68(2):181-7. https://doi.org/10.1093/gerona/gls136
https://doi.org/10.1093/gerona/gls136... ,1313. Alva MCV, Camacho MEI, Velázquez JD, Lazarevich I. The relationship between sarcopenia, undernutrition, physical mobility and basic activities of daily living in a group of elderly women of Mexico City. Nutr Hosp. 2013;28(2):514-21.https://doi.org/10.3305/nh.2013.28.2.6180
https://doi.org/10.3305/nh.2013.28.2.618... ,1414. Murphy RA, Reinders I, Register TC, Ayonayon HN, Newman AB, Satterfield S, et al. Associations of BMI and adipose tissue area and density with incident mobility limitation and poor performance in older adults. Am J Clin Nutr. 2014;99(5):1059-65. https://doi.org/10.3945/ajcn.113.080796
https://doi.org/10.3945/ajcn.113.080796... ,1515. Yeom HA, Baldwin CM, Lee MA, Kim SJ. Factors Affecting Mobility in Community-dwelling Older Koreans with Chronic Illnesses. Asian Nurs Res (Korean SocNursSci). 2015;9(1):7-13. https://doi.org/10.1016/j.anr.2014.09.005
https://doi.org/10.1016/j.anr.2014.09.00... ,1616. Gale CR, Cooper C, Sayer AA. Prevalence of frailty and disability: findings from the English Longitudinal Study of Ageing. Age Ageing. 2015;44(1):162-5. https://doi.org/10.1093/ageing/afu148
https://doi.org/10.1093/ageing/afu148... ,1717. Dellaroza MSG, Pimenta CAM, Duarte YA, Lebrão ML. Chronic pain among elderly residents in São Paulo, Brazil: prevalence, characteristics, and association with functional capacity and mobility (SABE Study). Cad Saúde Pública. 2013;29(2):325-34. https://doi.org/10.1590/S0102-311X2013000200019
https://doi.org/10.1590/S0102-311X201300... used the descriptor “mobility limitation” to refer to the difficulties of locomotion. However, one research also mentions the term “immobility” being treated and understood within the same context as mobility limitations.99. Clerencia-Sierra M, Calderón-Larrañaga A, Martínez-Velilla N, Vergara-Mitxeltorena I, Aldaz-Herce P, Poblador-Plou B, et al. Multimorbidity Patterns in Hospitalized Older Patients: Associations among Chronic Diseases and Geriatric Syndromes. PLoS One. 2015;10(7):e0132909. https://doi.org/10.1371/journal.pone.0132909
https://doi.org/10.1371/journal.pone.013...

Discussion

Mobility, i.e. the ability to move, is an important indicator of functional independence in older adults. It is inevitable to the instinct of human survival, allowing the organisms to access the means to integrate coexistence and basic health conditions. This review summarized the evidence of the prevalence, incidence and associated factors of mobility limitations in older adults, and showed a high prevalence and incidence of such limitations, expected among older populations.77. Tanjani PT, Akbarpour S, Ainy E, Soori H. Socio-demographic risk factors of mobility dysfunction and limitations in physical functioning disability among the elderly in Iran: A nationwide cross sectional survey. J Pak Med Assoc. 2015;65(10):1060-4.,99. Clerencia-Sierra M, Calderón-Larrañaga A, Martínez-Velilla N, Vergara-Mitxeltorena I, Aldaz-Herce P, Poblador-Plou B, et al. Multimorbidity Patterns in Hospitalized Older Patients: Associations among Chronic Diseases and Geriatric Syndromes. PLoS One. 2015;10(7):e0132909. https://doi.org/10.1371/journal.pone.0132909
https://doi.org/10.1371/journal.pone.013... ,1414. Murphy RA, Reinders I, Register TC, Ayonayon HN, Newman AB, Satterfield S, et al. Associations of BMI and adipose tissue area and density with incident mobility limitation and poor performance in older adults. Am J Clin Nutr. 2014;99(5):1059-65. https://doi.org/10.3945/ajcn.113.080796
https://doi.org/10.3945/ajcn.113.080796... ,1515. Yeom HA, Baldwin CM, Lee MA, Kim SJ. Factors Affecting Mobility in Community-dwelling Older Koreans with Chronic Illnesses. Asian Nurs Res (Korean SocNursSci). 2015;9(1):7-13. https://doi.org/10.1016/j.anr.2014.09.005
https://doi.org/10.1016/j.anr.2014.09.00... However, the variety of forms of mobility evaluation worked as a limiting factor in the study.

Limitations become more significant in older people (aged 80 years or more), indicating that this age group is vulnerable to the development of movement limitations. Aging and diminishing physiological reserves increase the risk of disease and disability through a progressive loss of adaptability to changes during life.1818. Díaz-Venegas C, Vega S, Wong R. Transitions in activities of daily living in Mexico, 2001-2012. Salud Publica Mex. 2015;57(1):S54-61. https://doi.org/10.21149/spm.v57s1.7590
https://doi.org/10.21149/spm.v57s1.7590... Regular physical activity reduced daytime fatigue; such activity and improved sleep quality may represent robust strategies to preserve mobility in the elderly population.1515. Yeom HA, Baldwin CM, Lee MA, Kim SJ. Factors Affecting Mobility in Community-dwelling Older Koreans with Chronic Illnesses. Asian Nurs Res (Korean SocNursSci). 2015;9(1):7-13. https://doi.org/10.1016/j.anr.2014.09.005
https://doi.org/10.1016/j.anr.2014.09.00... ,1616. Gale CR, Cooper C, Sayer AA. Prevalence of frailty and disability: findings from the English Longitudinal Study of Ageing. Age Ageing. 2015;44(1):162-5. https://doi.org/10.1093/ageing/afu148
https://doi.org/10.1093/ageing/afu148... ,1717. Dellaroza MSG, Pimenta CAM, Duarte YA, Lebrão ML. Chronic pain among elderly residents in São Paulo, Brazil: prevalence, characteristics, and association with functional capacity and mobility (SABE Study). Cad Saúde Pública. 2013;29(2):325-34. https://doi.org/10.1590/S0102-311X2013000200019
https://doi.org/10.1590/S0102-311X201300...

Women presented a higher prevalence of limitations than men. Moreover, difficulties related to social support (family composition, satisfaction with the financial situation and the housing tenure) proved to be associated with disability and limited physical mobility.77. Tanjani PT, Akbarpour S, Ainy E, Soori H. Socio-demographic risk factors of mobility dysfunction and limitations in physical functioning disability among the elderly in Iran: A nationwide cross sectional survey. J Pak Med Assoc. 2015;65(10):1060-4. Social support is important to prevent health implications by providing favorable conditions for the quality of life of both the elderly people and their caregivers. Especially among the less favored financially elderly individuals, lack of support is associated with restrictions on movement and functional dependence.1919. Anjos KF, Boery RNSO, Pereira R, Pedreira LC, Vilela ABA, Santos VC, Rosa Dde O. Association between social support and quality of life of relative caregivers of elderly dependents. Ciên Saude Colet. 2015;20(5):1321-30. https://doi.org/10.1590/1413-81232015205.14192014
https://doi.org/10.1590/1413-81232015205...

Other authors mentioned that sedentary and low-income older adults had a high risk of developing mobility limitations, along with the risk of fatigue, sleep deficit and decreased motor system response to movement.1515. Yeom HA, Baldwin CM, Lee MA, Kim SJ. Factors Affecting Mobility in Community-dwelling Older Koreans with Chronic Illnesses. Asian Nurs Res (Korean SocNursSci). 2015;9(1):7-13. https://doi.org/10.1016/j.anr.2014.09.005
https://doi.org/10.1016/j.anr.2014.09.00... Other factors including high BMI and poor physical performance were also shown to be associated with mobility limitations.1414. Murphy RA, Reinders I, Register TC, Ayonayon HN, Newman AB, Satterfield S, et al. Associations of BMI and adipose tissue area and density with incident mobility limitation and poor performance in older adults. Am J Clin Nutr. 2014;99(5):1059-65. https://doi.org/10.3945/ajcn.113.080796
https://doi.org/10.3945/ajcn.113.080796... Elderly people with high fat accumulation have more limitations to move and carry out the basic activities of daily living (ADL).2020. Silva NA, Menezes TN, Melo RL, Pedraza DF. Handgrip strength and flexibility and their association with anthropometric variables in the elderly. Rev Assoc Med Bras. 2013;59(2):128-35.https://doi.org/10.1016/j.ramb.2012.10.002
https://doi.org/10.1016/j.ramb.2012.10.0...

Both low weight and obesity are associated with a high risk of developing mobility impairments in older people.1919. Anjos KF, Boery RNSO, Pereira R, Pedreira LC, Vilela ABA, Santos VC, Rosa Dde O. Association between social support and quality of life of relative caregivers of elderly dependents. Ciên Saude Colet. 2015;20(5):1321-30. https://doi.org/10.1590/1413-81232015205.14192014
https://doi.org/10.1590/1413-81232015205... Older people with low weight and malnutrition experience significant levels of movement limitations. On the other hand, the increased intermuscular adipose tissue is positively associated with mobility limitation among the elderly of both sexes.1414. Murphy RA, Reinders I, Register TC, Ayonayon HN, Newman AB, Satterfield S, et al. Associations of BMI and adipose tissue area and density with incident mobility limitation and poor performance in older adults. Am J Clin Nutr. 2014;99(5):1059-65. https://doi.org/10.3945/ajcn.113.080796
https://doi.org/10.3945/ajcn.113.080796... Thus, nutritional status is a factor independently and positively associated with functional impairment of mobility and disability.2121. Corona LP, Pereira de Brito TR, Nunes DP, da Silva-Alexandre TS, Ferreira-Santos JL, de Oliveira-Duarte YA, Lebrão ML. Nutritional status and risk for disability in instrumental activities of daily living in older Brazilians. Public Health Nutr. 2014;17(2):390-5. https://doi.org/10.1017/S1368980012005319
https://doi.org/10.1017/S136898001200531...

In this context, one study pointed out that the incidence of malnutrition is high in elderly patients with sarcopenia, indicating the association of sarcopenia with limited physical mobility, especially with the difficulty of going up stairs.1313. Alva MCV, Camacho MEI, Velázquez JD, Lazarevich I. The relationship between sarcopenia, undernutrition, physical mobility and basic activities of daily living in a group of elderly women of Mexico City. Nutr Hosp. 2013;28(2):514-21.https://doi.org/10.3305/nh.2013.28.2.6180
https://doi.org/10.3305/nh.2013.28.2.618... Sarcopenia is a common clinical condition among the elderly population. It is a syndrome characterized by progressive and generalized loss of skeletal mass and muscle strength and function, and when this condition coexists with excess body fat, it is defined as sarcopenic obesity.2222. Rosenberg IH. Sarcopenia: Origins and clinical relevance. Clin Geriatr Med. 2011;27(3):337-9. https://doi.org/10.1016/j.cger.2011.03.003
https://doi.org/10.1016/j.cger.2011.03.0... ,2323. Santos VR, Gomes IC, Bueno DR, Christofaro DGD, Freitas IF, Gobbo LA. Obesity, sarcopenia, sarcopenic obesity and reduced mobility in Brazilian older people aged 80 years and over. Einstein. 2017;15(4):435-40.https://doi.org/10.1590/S1679-45082017AO4058
https://doi.org/10.1590/S1679-45082017AO... Both sarcopenia2424. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing . 2010;39(4):412-23. https://doi.org/10.1093/ageing/afq034
https://doi.org/10.1093/ageing/afq034... and sarcopenic obesity2525. Zamboni M, Mazzali G, Fantin F, Rossi A, Di Francesco V. Sarcopenic obesity: a new category of obesity in the elderly. Nutr Metab Cardiovasc Dis. 2008;18(5):388-95. https://doi.org/10.1016/j.numecd.2007.10.002
https://doi.org/10.1016/j.numecd.2007.10... are associated with reduced mobility in older people. Thereby, older people with strength and balance restrictions are at a considerable risk of developing mobility limitations.

A prospective cohort study in the United States found an association of mobility limitations in the older adults with low 25-hydroxy vitamin D levels. With this, elderly with 25 (OH) D <50 and 50 to <75 nmol/L presented a higher risk of developing mobility limitation, highlighting that inefficient nutritional intake represents a factor favoring mobility limitations. The prevention or treatment of low 25 (OH) D may provide a way to reduce the burden of mobility impairment among the elderly.1212. Houston DK, Neiberg RH, Tooze JA, Hausman DB, Johnson MA, Cauley JA, et al. Low 25-Hydroxyvitamin D Predicts the Onset of Mobility Limitation and Disability in Community-Dwelling Older Adults: The Health ABC Study. J Gerontol A Biol Sci Med Sci . 2013;68(2):181-7. https://doi.org/10.1093/gerona/gls136
https://doi.org/10.1093/gerona/gls136...

In the case of physiological mobility markers, the most important predictors are the older age among women, restricted hip flexion, the presence of primitive reflexes, and tremor.55. Stenholm S, Shardell M, Bandinelli S, Guralnik JM, Ferrucci L. Physiological Factors Contributing to Mobility Loss Over 9 Years of Follow-Up-Results From the In CHIANTI Study. J Gerontol A Biol Sci Med Sci. 2015;70(5):591-7. https://doi.org/10.1093/gerona/glv004
https://doi.org/10.1093/gerona/glv004... The prevention of loss of mobility with aging should focus on the prevention and treatment of neuromuscular deficiencies. Therefore, understanding diverse factors is necessary to identify the best means to avoid the onset of deficiencies and disabilities.

In the face of the evidence presented, mobility limitations are perceived to be associated with several levels of functional dependence and they are more often present in older people, even though the possibility of development in younger and comorbid older people cannot be ruled out.99. Clerencia-Sierra M, Calderón-Larrañaga A, Martínez-Velilla N, Vergara-Mitxeltorena I, Aldaz-Herce P, Poblador-Plou B, et al. Multimorbidity Patterns in Hospitalized Older Patients: Associations among Chronic Diseases and Geriatric Syndromes. PLoS One. 2015;10(7):e0132909. https://doi.org/10.1371/journal.pone.0132909
https://doi.org/10.1371/journal.pone.013... ,2626. Danielewicz AL, Barbosa AR, Del Duca GF. Nutritional status, physical performance and functional capacity in an elderly population in southern Brazil. Rev Assoc Med Bras . 2014;60(3):242-8. https://doi.org/10.1590/1806-9282.60.03.0013
https://doi.org/10.1590/1806-9282.60.03.... ,2727. Fischer U, Muller M, Strobl R, Bartoszek G, Meyer G, Grill E. Prevalence of functioning and disability in older patients with joint contractures: a cross-sectional study. Eur J Phys Rehabil Med. 2015;51(3):269-79.,2828. Vetrano DL, Foebel AD, Marengoni A, Brandi V, Collamati A, Heckman GA, et al. Chronic diseases and geriatric syndromes: The different weight of comorbidity. Eur J Intern Med. 2016;27(1):62-7. https://doi.org/10.1016/j.ejim.2015.10.025
https://doi.org/10.1016/j.ejim.2015.10.0... Limitations may be the cause or consequence of comorbidities acquired throughout life. However, the associated factors are several, ranging from aspects related to loss of strength, balance and muscular power to nutritional inefficiencies and impaired social support.2929. Fontes AP, Botelho MA, Fernandes AA. The functioning of the oldest old (≥75 years): concepts, profiles and opportunities of a heterogeneous group. Rev Bras Geriatr Gerontol. 2013;16(1):91-107. https://doi.org/10.1590/S1809-98232013000100010
https://doi.org/10.1590/S1809-9823201300... ,3030. Lima KC, Veras RP, Caldas CP, Motta LB, Bonfada D, Santos MM, et al. Effectiveness of intervention programs in primary care for the robust elderly. Salud Publica Mex . 2015;57(3):265-74. https://doi.org/10.21149/spm.v57i3.7566
https://doi.org/10.21149/spm.v57i3.7566...

Conclusions

It was concluded that mobility limitations in older adults are a highly prevalent natural phenomenon of the aging process, and there is evidence of association with nutritional factors and difficulties of social support, as well as functional factors (functional dependence, sedentary lifestyle, among others). Furthermore, mobility limitations can be the cause or consequence of illnesses.

In this perspective, the evidence shows that these limitations must be investigated, studied and understood in a multifactorial approach, in order to allow science to advance in the understanding of their implications for the health of the elderly population.

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    Murphy RA, Reinders I, Register TC, Ayonayon HN, Newman AB, Satterfield S, et al Associations of BMI and adipose tissue area and density with incident mobility limitation and poor performance in older adults. Am J Clin Nutr. 2014;99(5):1059-65. https://doi.org/10.3945/ajcn.113.080796
    » https://doi.org/10.3945/ajcn.113.080796
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    Yeom HA, Baldwin CM, Lee MA, Kim SJ. Factors Affecting Mobility in Community-dwelling Older Koreans with Chronic Illnesses. Asian Nurs Res (Korean SocNursSci). 2015;9(1):7-13. https://doi.org/10.1016/j.anr.2014.09.005
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    Díaz-Venegas C, Vega S, Wong R. Transitions in activities of daily living in Mexico, 2001-2012. Salud Publica Mex. 2015;57(1):S54-61. https://doi.org/10.21149/spm.v57s1.7590
    » https://doi.org/10.21149/spm.v57s1.7590
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    Anjos KF, Boery RNSO, Pereira R, Pedreira LC, Vilela ABA, Santos VC, Rosa Dde O. Association between social support and quality of life of relative caregivers of elderly dependents. Ciên Saude Colet. 2015;20(5):1321-30. https://doi.org/10.1590/1413-81232015205.14192014
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    Silva NA, Menezes TN, Melo RL, Pedraza DF. Handgrip strength and flexibility and their association with anthropometric variables in the elderly. Rev Assoc Med Bras. 2013;59(2):128-35.https://doi.org/10.1016/j.ramb.2012.10.002
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Publication Dates

  • Publication in this collection
    10 June 2019
  • Date of issue
    Sep-Oct 2018

History

  • Received
    04 Sept 2017
  • Accepted
    12 Apr 2018
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This is an open-access article distributed under the terms of the Creative Commons Attribution License
Instituto Nacional de Salud Pública Cuernavaca - Morelos - Mexico
E-mail: spm@insp3.insp.mx
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