Gait Speed and Survival in Older Adults.


Context  Survival estimates help individualize goals of care for geriatric patients, but life tables fail to account for the great variability in survival. Physical performance measures, such as gait speed, might help account for variability, allowing clinicians to make more individualized estimates.

Objective  To evaluate the relationship between gait speed and survival.

Design, Setting, and Participants  Pooled analysis of 9 cohort studies (collected between 1986 and 2000), using individual data from 34 485 community-dwelling older adults aged 65 years or older with baseline gait speed data, followed up for 6 to 21 years. Participants were a mean (SD) age of 73.5 (5.9) years; 59.6%, women; and 79.8%, white; and had a mean (SD) gait speed of 0.92 (0.27) m/s.

Main Outcome Measures  Survival rates and life expectancy.

Results  There were 17 528 deaths; the overall 5-year survival rate was 84.8% (confidence interval [CI], 79.6%-88.8%) and 10-year survival rate was 59.7% (95% CI, 46.5%-70.6%). Gait speed was associated with survival in all studies (pooled hazard ratio per 0.1 m/s, 0.88; 95% CI, 0.87-0.90; P < .001). Survival increased across the full range of gait speeds, with significant increments per 0.1 m/s. At age 75, predicted 10-year survival across the range of gait speeds ranged from 19% to 87% in men and from 35% to 91% in women. Predicted survival based on age, sex, and gait speed was as accurate as predicted based on age, sex, use of mobility aids, and self-reported function or as age, sex, chronic conditions, smoking history, blood pressure, body mass index, and hospitalization.

Conclusion  In this pooled analysis of individual data from 9 selected cohorts, gait speed was associated with survival in older adults.

Remaining years of life vary widely in older adults, and physicians should consider life expectancy when assessing goals of care and treatment plans.1 However, life expectancy based on age and sex alone provides limited information because survival is also influenced by health and functional abilities.2 There are currently no well-established approaches to predicting life expectancy that incorporate health and function, although several models have been developed from individual data sources.3– 5 Gait speed, also often termed walking speed, has been shown to be associated with survival among older adults in individual epidemiological cohort studies6– 12 and has been shown to reflect health and functional status.13 Gait speed has been recommended as a potentially useful clinical indicator of well-being among the older adults.14 The purpose of this study is to evaluate the association of gait speed with survival in older adults and to determine the degree to which gait speed explains variability in survival after accounting for age and sex.

COMMENT

Gait speed, age, and sex may offer the clinician tools for assessing expected survival to contribute to tailoring goals of care in older adults. The accuracy of predictions based on these 3 factors appears to be approximately similar to more complex models involving multiple other health-related factors, or for age, sex, use of mobility aids, and functional status. Gait speed might help refine survival estimates in clinical practice or research because it is simple and informative.

Why would gait speed predict survival? Walking requires energy, movement control, and support and places demands on multiple organ systems, including the heart, lungs, circulatory, nervous, and musculoskeletal systems. Slowing gait may reflect both damaged systems and a high-energy cost of walking.13,39– 54 Gait speed could be considered a simple and accessible summary indicator of vitality because it integrates known and unrecognized disturbances in multiple organ systems, many of which affect survival. In addition, decreasing mobility may induce a vicious cycle of reduced physical activity and deconditioning that has a direct effect on health and survival.6

The association between gait speed and survival is known.6– 7,9– 12,55– 56 Prior analyses used single cohorts and presented results as relative rather than absolute risk, as done herein. Similarly, mortality prediction models have been developed.3– 5,57– 60 Some models use self-reported information but others also include physiological or performance data, for a total of 4 to more than 10 predictive factors. Only a few models assess overall predictive capacity using C statistics; the reported values are in the range found in the present study (published area under the curve range, 0.66-0.8261 vs this study, 0.717 and 0.737).

The strengths of this study are the very large sample of individual participant data from multiple diverse populations of community-dwelling elders who were followed up for many years and use of consistent measures of performance and outcome. We provide survival estimates for a broad range of gait speeds and calculate absolute rates and median years of survival. Compared with prior studies that were too small to assess potential effect modification by age, sex, race/ethnicity, and other subgroups, we were able to assess multiple subgroup effects with substantial power. This study has the limitations of observational research; it cannot establish causal relationships and is vulnerable to various forms of healthy volunteer bias. The participating study cohorts, while large and diverse, do not represent the universe of possible data. Our survival estimates should be validated in additional data sets. Only 1 of the 9 studies was based in clinical practice,21 and advanced dementia is rare in populations who are competent to consent for research. However, median years of survival in this study resemble estimates for US adults across the sex and age range assessed.62 We were unable to assess the association of physical activity with survival in pooled analyses because measures of activity were highly variable across studies. Also, participants in these studies had no prior knowledge about the meaning of walking speed. In clinical use, participants might walk differently if they are aware of the implications of the results. Although this study provides information on survival, further work is needed to examine associations of other important pooled outcomes such as disability and health care use and to examine effects in populations more completely based in clinical practice.

Because gait speed can be assessed by nonprofessional staff using a 4-m walkway and a stopwatch,21 it is relatively simple to measure compared with many medical assessments. Nevertheless, methodological issues such as distance and verbal instructions remain.63– 64 Self-report is an alternative to gait speed for reflecting function. However, significant challenges remain in the use of self-report as well, such as choice of items and reliability, some of which can be addressed by emerging techniques such as computer adaptive testing based on item-response theory.65 The results found herein suggest that gait speed appears to be especially informative in older persons who report either no functional limitations or only difficulty with instrumental ADLs and may be less helpful for older adults who already report dependence in basic ADLs. The research studies analyzed herein used trained staff to measure gait speed. Staff in clinical settings would need initial training and may produce more variable results. Long-distance walks have become accepted in some medical fields and may contribute information beyond short walks.66– 68 However, the longer distance and time to perform the test may limit feasibility in many clinical settings. Although the sample size of very slow walkers was small, our data suggest that there may be a subpopulation who walk very slowly but survive for long periods. It would be valuable to further characterize this subgroup.

Although the gait speed–survival relationship seems continuous across the entire range, cut points may help interpretation. Several authors have proposed that gait speeds faster than 1.0 m/s suggest healthier aging while gait speeds slower than 0.6 m/s increase the likelihood of poor health and function.7,21 Others propose one cutoff around 0.8 m/s.13 In our data, predicted life expectancy at the median for age and sex occurs at about 0.8 m/s; faster gait speeds predict life expectancy beyond the median. Perhaps a gait speed faster than 1.0 m/s suggests better than average life expectancy and above 1.2 m/s suggests exceptional life expectancy, but additional research will be necessary to determine this relationship.

How might gait speed be used clinically? First, gait speed might help identify older adults with a high probability of living for 5 or 10 more years, who may be appropriate targets for preventive interventions that require years for benefit. Second, gait speed might be used to identify older adults with increased risk of early mortality, perhaps those with gait speeds slower than 0.6 m/s. In these patients, further examination is targeted at potentially modifiable risks to health and survival. A recommended evaluation and management of slow walking includes cardiopulmonary, neurological and musculoskeletal systems.6,18 Third, gait speed might promote communication. Primary clinicians might characterize an older adult as likely to be in poor health and function because the gait speed is 0.5 m/s. In research manuscripts, baseline gait speed might help to characterize the overall health of older research participants. Fourth, gait speed might be monitored over time, with a decline indicating a new health problem that requires evaluation. Fifth, gait speed might be used to stratify risks from surgery or chemotherapy. Finally, medical and behavioral interventions might be assessed for their effect on gait speed in clinical trials. Such true experiments could then evaluate causal pathways to determine whether interventions that improve gait speed lead to improvements in function, health, and longevity.

The data provided herein are intended to aid clinicians, investigators, and health system planners who seek simple indicators of health and survival in older adults. Gait speed has potential to be implemented in practice, using a stop watch and a 4-m course. From a standing start, individuals are instructed to walk at their usual pace, as if they were walking down the street, and given no further encouragement or instructions. The data in this article can be used to help interpret the results. Gait speed may be a simple and accessible indicator of the health of the older person.

Source: JAMA