Cerebrovascular Mechanisms of Slow Gait and Falls
Principal Investigator: Lewis A. Lipsitz, M.D.
Falls and mobility problems are common causes of disability and death in elderly people, yet their causes are poorly understood. Slowing of gait is a prominent feature of human aging, even in the absence of specific diseases, and it is strongly associated with falls (1), dementia (2), and mortality (3). Recent studies by our group, supported by an NIA-funded program project grant called the MOBILIZE Boston Study (an acronym for the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston) have demonstrated significant relationships between abnormal blood flow to the brain, slow gait speed, and falls in elderly subjects. By measuring cerebral blood flow velocity (CBF) with transcranial Doppler ultrasonography (TCD) in a representative population-based cohort of 419 seniors living in the Boston metropolitan area, we have shown that:
These observations have led us to the overall hypothesis that alterations in the control of brain blood flow associated with aging and cardiovascular risk factors are associated with white matter damage to the brain, which ultimately results in slowing of gait, cognitive impairment, and their functional consequences such as falls.
This study will explore this hypothesis by performing TCD measurements of brain blood flow and MRI measurements of brain structures and functions in 100 elderly participants in the MOBILIZE Boston study (MBS). Our specific aims are:
These aims will be accomplished by recruiting 50 subjects with the lowest brain blood flow and 50 subjects with the highest brain blood flow when it was measured at the beginning of the MBS 6-8 years ago. We will invite these subjects to come to the IFAR Clinical Research Laboratory for repeat blood flow measurements, then obtain brain MRI studies at the Boston VA hospital. All of the proposed tests have been performed safely without complications in very elderly subjects previously participating in the MOBILIZE Boston Study and have been approved in the past by the IRB. MRIs for MOBILIZE Boston participants are already approved by the VA IRB and are being performed as part of Dr. Leveille's MOBILIZE Boston project that examines the effect of pain on falls. The current project will increase the number of MRI studies in the MOBILIZE Boston database, making it more valuable for these two projects, as well as future ancillary studies.
This study will provide novel information necessary for the early detection and ultimate prevention of cerebrovascular causes of falls and mobility impairments in elderly people. If abnormal brain blood flow is discovered to be a cause of falls, currently available interventions to increase brain blood flow, prevent cerebrovascular damage, grow new blood vessels, or build new neural pathways may be tested to prevent future falls.
Tai Chi training for older adults living in subsidized housing
PIs: Lewis A. Lipsitz, M.D.; Peter Wayne, Ph.D.
Elderly people living in low-income housing facilities represent one of our nation’s largest, most functionally impaired, economically disadvantaged, and understudied populations that account for a disproportionate share of Medicare spending. This project aims to improve the health and reduce the health care costs of this population by conducting a cluster randomized controlled trial of Tai Chi exercises vs. health education and social calls in 16 housing facilities in cities surrounding Boston. The proposal builds upon previously successful studies by Drs. Lipsitz, Wayne, and others showing multiple benefits of Tai Chi exercises in elderly people with a variety of diseases and disabilities. The proposed study aims are to determine the effects of Tai Chi exercises conducted at least twice weekly over a 1 year period on 1) functional performance measured by the Short Physical Performance Battery and 2) health care utilization and costs determined from Medicare claims data in poor, multiethnic, elderly residents of low income housing facilities. Secondary outcomes will include person-centered measures such as physical function, cognition, psychological well-being, falls, self-efficacy, and satisfaction. This study will also prepare the necessary training and protocol manuals for widespread dissemination of Tai Chi programs in housing facilities across the nation, and provide estimates of potential Medicare cost savings that can be used to justify future health insurance payments for this intervention.
Nonlinear Dynamics of Frailty
PI: Lewis A. Lipsitz, M.D.
The Aims of this NIA-funded project are 1) To determine cross-sectionally in a representative population of elderly people aged 70 years and over, whether there is a relationship between “frailty” and loss of complexity in the dynamics of multiple physiologic systems. 2) To determine whether a loss of complexity in cardiovascular, cerebrovascular, and/or balance dynamics, is associated with an impaired ability to adapt to common physiologic stresses imposed on these systems. 3) To determine longitudinally over a two-year follow-up period in the same population, whether reduced complexity in the dynamics of these physiologic systems at baseline, or loss of complexity in these systems over time, is predictive of the subsequent development of frailty, its component symptoms, and/or other measures of physical and cognitive functional decline
Evaluation of stochastic resonance insoles to Improve Mobility in Healthy Older Adults
PI: Lewis A. Lipsitz, M.D.
Age-related loss of somatosensory function (tactile and proprioceptive senses) has been shown to be strongly predictive of a propensity to fall. It has been demonstrated in several biological systems, ranging from ion channels to sensory neurons to human psychophysics, that the presence of a particular sub-threshold level of noise can be used to enhance signal recognition and detection. This phenomenon is known as stochastic resonance (SR). Previous studies indicate that SR is potentially a viable technology to improve balance and gait if used in a therapeutic medical device. Noise-based devices, such as shoe insoles, may therefore enhance the control of dynamic balance activities and thus, enable those with reduced function to overcome mobility impairments caused by aging.
The purpose of this research study is to evaluate how applying small, sub-threshold vibrations to the bottom of the feet via shoe insoles affects balance and gait. The study also aims to determine if different levels of vibrations have different effects on functional outcomes, and if the level at which an individual can feel the vibrations changes throughout the day. The information collected from this study will be used to develop shoe insoles which may enhance balance and walking in older adults.
Mobility enhancement via noninvasive brain stimulation
PI: Brad Manor, Ph.D.
Mobility, defined as the ability to independently navigate one’s environment in order to complete activities of daily living, is not only dependent upon the peripheral neuromuscular, skeletal and cardiorespiratory systems, but also upon numerous brain networks and a host of cognitive functions. Transcranial direct current stimulation (tDCS) is a noninvasive, safe and inexpensive means of modulating brain tissue excitability. In healthy young adults, 20min of 2mA tDCS targeting the left prefrontal cortex (PFC)—a region involved in both cognitive and motor function—acutely increases attention, working memory and executive function, as well as cerebral perfusion and functional connectivity within known cognitive brain networks. Through collaboration with the Academy for Advanced Interdisciplinary Studies at Peking University, and funding from the National Natural Science Foundation of China, we are conducting a trial to identify the acute and chronic effects of tDCS on mobility and brain function in older adults
Identification of locomotor brain networks using fMRI
PI: Brad Manor, Ph.D.
Foot sole somatosensation is an important source of feedback for the control of gait and balance. The goal of this project is to enable investigation into the brain networks involved in processing and utilizing this source of afferent feedback, and how they are affected with aging and disease. To do so, we have developed an MRI-compatible stimulation system capable of applying controlled pressures to the entire foot sole that closely mimic those experienced when walking. Our effects to date have demonstrated that the application of walking-related foot sole pressure elicits a characteristic pattern of brain activation in healthy adults. Through several ongoing studies in collaboration with Peking University in Beijing, China, we are now examining 1) the effects of performing a simultaneous cognitive distraction task on the brain’s response to walking-related foot sole pressures, 2) the effects of age- and disease-related somatosensory impairments on the brain’s response to applied foot sole pressure, and 3) the capacity of noninvasive brain stimulation to augment the brain’s response to applied foot sole pressures.
Monitoring falls within the nursing home setting
PI: Lewis A. Lipsitz, M.D.
Falls comprise the leading cause of injury-related morbidity and mortality among adults over the age of 65. Currently, an automated method for accurately recording falls is not available. However, there are some new fall detection technologies available for older adults living alone for use in case of a fall where the patient cannot reach a phone to request outside assistance. One in particular is worn as a pendant and uses both a traditional patient-activated button as well as technology capable of detecting falls and automatically reporting them to the response center. In this way, it allows patients to prolong autonomy in their own home without the need for supervision.
From a scientific perspective, this technology may dramatically improve the quality of data recorded in an objective manner in a community or institutional setting where trained health care professionals are not available for documenting falls. In addition, data collection is not dependent upon patient reporting, recall or response rate, a significant limitation to previous methods of measurement. The primary objective of this exploratory study is to assess the validity of a modified system for detecting falls, as compared to falls reported by nursing staff, in a nursing home setting.
Prediction of Activity of Daily Living Disability in Older Adults
PI: Dae Kim, M.D.
This research is to develop and validate a practical clinical prediction model for activity of daily living disability in community-dwelling older adults, using data from the Cardiovascular Health Study and Established Populations for Epidemiologic Studies of the Elderly. The prediction model will compare self-reported health information, objective tests of cognitive and physical performance, and laboratory and non-invasive test results in their ability to predict activity of daily living disability. It is funded by the Charles A. King Trust Foundation Postdoctoral Fellowship Award.
Functional outcomes of older patients with severe aortic stenosis
PI: Dae Kim, M.D.
This prospective cohort study is a collaborative project between gerontology and interventional cardiology at Beth Israel Deaconess Medical Center. The objective is to examine the change in cognitive and physical function and activity of daily living disability in older patients with symptomatic severe aortic stenosis. Functional status and disability are assessed via repeated telephone interviews for 12 months. These outcomes will be compared between patients who are treated with transcatheter or surgical aortic valve replacement and patients who are treated conservatively. This research will also test a novel approach to combine functional outcomes with traditional outcomes of hospitalizations and mortality in testing the effectiveness of aortic valve replacement.