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AGING MEDICINE RobertPignolo,MD,PhD;MaryAnnForciea,MD;JerryC.Johnson,MD, SeriesEditors
Age-RelatedChangesoftheHumanEye,editedby CarloA.CavallottiandLucianoCerrulli, 2008
ClassicPapersinGeriatricMedicine,editedby RobertPignolo,MaryAnneForciea,andMonica Crane, 2008
EldercareTechnologyforClinicalPractitioners,editedby RobinA.FelderandMajdAlwan, 2008
HandbookofPainReliefinOlderAdults: AnEvidenceBasedApproach,editedby MichaelF.Gloth, 2004
MajdAlwan · RobinA.Felder Editors EldercareTechnology forClinicalPractitioners Editors MajdAlwan
RobinA.Felder CenterforAgingServices DepartmentofPathology Technologies(CAST) UniversityofVirginaHealth Washington,DC SciencesCenter Charlottesville,VA
SeriesEditors
RobertJ.Pignolo,MD,PhD
JerryC.Johnson,MD AssistantProfessorofMedicine ProfessorofMedicine DepartmentofMedicine Chief,DivisionofGeriatricMedicine DivisionofGeriatricMedicine SeniorFellow,InstituteonAging UniversityofPennsylvaniaHealthSystemUniversityofPennsylvaniaHealthSystem
MaryAnnForciea,MD ClinicalAssociateProfessorofMedicine DivisionofGeriatricMedicine UniversityofPennsylvaniaHealthSystem
ISBN:978-1-58829-898-0e-ISBN:978-1-59745-233-5
LibraryofCongressControlNumber:2007940426
c 2008HumanaPress,apartofSpringerScience+BusinessMedia,LLC Allrightsreserved.Thisworkmaynotbetranslatedorcopiedinwholeorinpartwithoutthewritten permissionofthepublisher(HumanaPress,999RiverviewDrive,Suite208,Totowa,NJ07512USA), exceptforbriefexcerptsinconnectionwithreviewsorscholarlyanalysis.Useinconnectionwithany formofinformationstorageandretrieval,electronicadaptation,computersoftware,orbysimilaror dissimilarmethodologynowknownorhereafterdevelopedisforbidden. Theuseinthispublicationoftradenames,trademarks,servicemarks,andsimilarterms,eveniftheyare notidentifiedassuch,isnottobetakenasanexpressionofopinionastowhetherornottheyaresubject toproprietaryrights.
Whiletheadviceandinformationinthisbookarebelievedtobetrueandaccurateatthedateofgoing topress,neithertheauthorsnortheeditorsnor thepublishercanacceptanylegalresponsibilityfor anyerrorsoromissionsthatmaybemade.Thepublishermakesnowarranty,expressorimplied,with respecttothematerialcontainedherein.
Printedonacid-freepaper. 987654321
springer.com
Preface Background :Themajorityofourincreasingelderadultpopulationrequiressome degreeofformaland/orinformalcarebecauseoflossoffunctionasaresultof failinghealth.AccordingtotheCentersforDiseaseControl(CDC),nearlythreequartersofelderadultssufferfromoneormorechronicdiseases.Examplesinclude arthritis,hypertension,anddiabetes,to nameafew.Thecostandburdenofcaring forelderadultsissteadilyincreasing.
ChangesintheMedicaresystemledtoashiftintheresponsibilityforcarefrom institutions(nursinghomes,etc.)tothecommunity(individualsandfamilies).The roleofinformalcaregiversinprovidingcaretotheelderadultpopulationhasgreatly increasedinthepasttwodecades.Consequently,informalcaregivershavecometo beviewedasanunpaidextensionofprofessionalcaregivers,providingmostofthe caretoelderadultsrequiringlong-termcare.Infact,nationaldatabasesderivedfrom differentsourceshaveprovidedunequivocal evidencethatfamilyandfriendsarethe solecareprovidersforaboutthree-quartersofallcommunity-dwellingelderadults. Informalcaregivershaveexperiencedincreasedphysicalburdensandemotional strainsbecauseofthisshiftinlong-term eldercareresponsibilities.Furthermore, healthcareprovidersarefacedwithashrinkingprofessionalcaregivingworkforce atthesametime.
Onthecontrary,theproportionoftheworld’spopulationofindividualsoverthe ageof60yearsisexpectedtodoubleby2030to20%.IntheUSA,thenumberof elderadultsisexpectedtogrowto108millionoverthenext15years,whichrepresents45%oftheadultpopulation.Elderadultscurrentlyaccountfor60%ofthe overallhealthcarespendingintheUSA.Appropriatemanagementofchronicdisease inolderadultscanreducetheUShealthcarebillbyupto50%.Furthermore,92% oftheseelderadultslivealoneintheirownapartments,homes,independentliving facilities,orassistedlivingfacilities, includingabout50%ofthose75yearsand older.Suchstatisticsdemonstrateanurgentneedforinnovativetelehealth/telecare toolsthatenableelderadultstoliveindependentlyandmaximizecaregivers’efficacybyprovidingtimelyhealthinformationanddeliveringmoreeffectivecare.This changeinthedemographicsanditspotentialeconomicimpactonindustrialized nationshaspromptedactiveresearchinautomatedsystemsforfunctionalandhealth statusmonitoringandassistance,enabledbyrecenttechnologicaladvancement.
Inthemeantime,advancesinsensor,communication,andinformationtechnologieshavecreatedopportunitiestodevelop noveltoolsenablingremotemanagementandmonitoringofchronicdiseases,emergencyconditions,andthedelivery ofhealthcare.In-homehealthassessmentandmonitoringhastheaddedbenefitof measuringindividualizedhealthstatusandreportingittotheprimarycareprovider andcaregiversalike,allowingtimelierandtargetedpreventiveinterventions.Health monitoringinhomeenvironmentscanbe accomplishedbya)ambulatorymonitors thatutilizewearablesensorsanddevices torecordphysiologicalsignals;b)sensorsembeddedinthehomeenvironmentandfurnishingstounobtrusivelycollect behavioralandphysiologicaldata;orc)acombinationofthetwo.
Aimandscope:Thisbookaddressestechnologiestargetedattheassessment, earlydetection,andthemitigationofcommongeriatricconditionsincludingdecline infunctionalabilities,gait,mobility,sleepdisturbance,visionimpairment,hearing loss,falls,andcognitivedecline.Thisbooknotonlydescribesthestateofboth embeddedandwearabletechnologies,includingtechnologiesunderresearchand onthebrinkoftranslationintoproducts,butalsofocusesonresearchshowingthe potentialutilityofthesetechnologiesinthefield.
Chapter1presentsanintroductionandreviewsthestatisticsthatmakeacompellingcasefordevelopmentandutilizationoftechnologiesforthegeriatriccare. Chapter2presentsacomprehensivereviewoffunctionalassessmentinstruments andpromisingtechnologiesusedinfunctionalassessmentofelders.Chapter3coversmobilityandgaitassessmenttechnologies,whereasChapter4reviewsmobility aidtechnologiesfortheelderly.InChapter5,wereviewsleepdisordersinolderage andsleepassessmenttechnologies,withemphasisonin-homeassessmenttechnologies.Chapter6presentsacomprehensivereviewofage-relatedchangesinvision andcorrectivetechnologies,whereasChapter7addressesthemanagementofhearinglossinolderage.Chapter8isdedicatedtofalls,falldetection,andfallpreventiontechnologies.Finally,Chapter9addressesemergingcomputer-basedcognitive assessmenttechnologies.
Webelieve,andhope,thatthisworkwillfillagapintheknowledgeandwillbe invaluabletoEldercarepractitioners,aswellasmedicalstudent studyingGeriatrics andinterestedingerotechnology,socialstudies,studentsstudyinggerontology andinterestedingerontechnology,andnursingstudentsinterestedinGeriatric Nursing,inadditiontoengineeringstudentsinterestedinEldercareTechnologies, andresearchersfromabroadspectrumofdisciplines,particularlythoseinterested infieldexperienceandtheend-user’sperspective.Thisvolumecomesatatime wheninterestinEldercareTechnologyandtheneedforeffectiveandappropriate technologiesespeciallyarepeaking.
Washington,DistrictofColumbia MajdAlwan Charlottesville,Virginia RobinA.Felder
Preface ...........................................................v
Contributors ......................................................ix
ListofAcronymsandAbbreviations .................................xi
1Introduction ...................................................1 RichardLindsay
2FunctionalAssessmentTechnologies ..............................5 MarilynRantz,MarjorieSkubic,KathrynBurks,JieYu, GeorgeDemiris,BrianK.Hensel,GregoryL.Alexander, ZhihaiHe,HarryW.Tyrer,MarcHamilton,JiaLee, andMarybethBrown
3MobilityandGaitAssessmentTechnologies .......................33 PatrickO.Riley,KateW.Paylo,andD.CaseyKerrigan
4IntelligentMobilityAidsfortheElderly ..........................53 GlennWasson,PradipSheth,CunjunHuang,andMajdAlwan
5SleepandSleepAssessmentTechnologies .........................77 StevenM.Koenig,DavidMack,andMajdAlwan
6VisionImpairmentAssessmentandAssistiveTechnologies ..........121 StanleyWoo
7ManagingHearingLossinOlderAdults: Assessment,Intervention, andTechnologiesforIndependenceandWellBeing .................143 MatthewH.Bakke,ClaireM.Bernstein,ScottJ.Bally, andJanetL.Pray
8Falls,FallPrevention,and FallDetectionTechnologies ..............187 PrabhuRajendran,AmyCorcoran,BruceKinosian, andMajdAlwan
Contributors VeredAharonson,Ph.D., Department ofSoftwareEngineering,TelAviv AcademicCollegeofEngineering, Afeka,Israel
GregoryL.Alexander,Ph.D.,R.N., AssistantProfessor,SinclairSchoolof Nursing,Columbia,MO
MajdAlwan,Ph.D., Director,Center forAgingServicesTechnologies (CAST),Washington,DC
MatthewH.Bakke,Ph.D., Associate Professor,GallaudetUniversity, DepartmentofHearing,Speechand LanguageSciences,Director, RehabilitationEngineeringResearch Center(RERC)onHearing Enhancement,Washington,DC
ScottJ.Bally,Ph.D., Associate Professor,GallaudetUniversity, DepartmentofHearing,Speechand LanguageSciences,Washington,DC
ClaireM.Bernstein,Ph.D., Research Audiologist,GallaudetUniversity, DepartmentofHearing,Speechand LanguageSciences,Washington,DC
MarybethBrown,Ph.D., Professor, PhysicalTherapy,SchoolofHealth Professions,Columbia,MO
KathrynBurks,R.N.,Ph.D., SchoolofNursing,Universityof Missouri,Columbia,MO
AmyCorcoran,M.D., Geriatric Fellow,DepartmentofMedicine, DivisionofGeriatrics,Universityof Pennsylvania,Philadelphia,PA
GeorgeDemiris,Ph.D., Associate Professor,Biobehavioral NursingandHealthSystems,Schoolof Nursing&Biomedicaland HealthInformatics,SchoolofMedicine, UniversityofWashington,Seattle,WA
MarcHamilton,Ph.D., Associate Professor,Biomedical Sciences,DaltonCardiovascular ResearchInvestigator&Collegeof VeterinaryMedicine,Universityof Missouri,Columbia,MO
ZhihaiHe,Ph.D., AssistantProfessor, DepartmentofElectricalandComputer Engineering,UniversityofMissouri, Columbia,MO
BrianK.Hensel,Ph.D.,M.S.P.H., Post-DoctoralFellowin HealthInformatics,Universityof Missouri-Columbia,Columbia,MO
CunjunHuang,Ph.D., Departmentof MechanicalandAerospace Engineering,UniversityofVirginia, Charlottesville,VA
D.CaseyKerrigan,M.D.,M.S., UniversityofVirginia,Schoolof Medicine,DepartmentofPhysical MedicineandRehabilitation, Charlottesville,VA
BruceKinosian,M.D., Associate Professor,DivisionsofGeneralInternal MedicineandGeriatrics,University ofPennsylvania,SchoolofMedicine, Philadelphia,PA
StevenM.Koenig,M.D.,FCCP, ProfessorofInternalMedicine, UniversityofVirginiaHealthSystem, TheDepartmentofInternalMedicine, DivisionofPulmonary&CriticalCare, Charlottesville,VA
AmosD.Korczyn,M.D.,B.Sc., Professor,SieratzkiChairofNeurology, Tel-AvivUniversityMedicalSchool, Ramat-Aviv,Israel
JiaLee,Ph.D.,R.N.,Assistant Professor,SinclairSchoolofNursing, Columbia,MO
RichardLindsay,M.D., Former ChairofGeriatricMedicine,School ofMedicine,UniversityofVirginia, Charlottesville,VA
DavidMack,M.S.,Ph.D., Graduate ResearchAssistant,Medical AutomationResearchCenter, UniversityofVerginia, Charlottesville,VA
KateW.Paylo,D.O., University ofVirginia,SchoolofMedicine, DepartmentofPhysicalMedicineand Rehabilitation,Charlottesville,VA
JanetL.Pray,Ph.D., Professor,GallaudetUniversity, DepartmentofSocialWork, Washington,DC
PrabhuRajendran,M.S., Graduate ResearchAssistant,Medical AutomationResearchCenter, UniversityofVirginia, Charlottesville,VA
MarilynRantz,R.N.,Ph.D.,F.A.A.N., Professor,SinclairSchoolofNursing andFamilyandCommunityMedicine, S406SinclairSchoolofNursing, UniversityofMissouri-Columbia, Columbia,MO
PatrickO.Riley,Ph.D., Research AssociateProfessor,Universityof Virginia,SchoolofMedicine, DepartmentofPhysical MedicineandRehabilitation, Charlottesville,VA
PradipSheth,Ph.D., Department ofMechanicalandAerospace Engineering,UniversityofVirginia, Charlottesville,VA
MarjorieSkubic,Ph.D., Associate Professor,Electricaland ComputerEngineeringDepartment, Columbia,MO
HarryW.Tyrer,Ph.D., Professor, DepartmentofElectrical andComputerEngineering,University ofMissouri,Columbia,MO
GlennWasson,Ph.D., Departmentof ComputerScience,Universityof Virginia,Charlottesville,VA
StanleyWoo,Ph.D., Clinical AssociateProfessor,Chief,LowVision RehabilitationServices,Director, CenterforSightEnhancement, UniversityofHoustonCollegeof Optometry,Houston,TX
JieYu,B.S.N.,R.N., DoctoralStudent, SinclairSchoolofNursing, Columbia,MO
ListofAcronymsandAbbreviations AASMAmericanAcademyofSleepMedicine
ABRAuditorybrainstemresponse
AD Alzheimer’sdisease
ADLsActivitiesofdailyliving
AGCAutomaticgaincontrol
AI Apneaindex
ALDAssistivelisteningdevices
ALSAssistivelisteningsystems
AMDAge-relatedmaculardegeneration
ARESApneaRiskEvaluationSystem
ASDAAmericanSleepDisordersAssociation
AVCAutomaticvolumecontrol
BCGBallistocardiogram
BPPVBenignparoxysmalpositionalvertigo
BOSBedOccupancySensors
BTEBehind-the-ear
BTSBioptictelescopicspectacle
CBSCharlesBonnetSyndrome
CCTVClosedcircuittelevisions
CDCCentersforDiseaseControl
CES-DCenterforEpidemiologicStudiesDepression
CICCompletely-in-the-canal
CLVTCertifiedlowvisiontherapist
CNACertifiednursingassistant
CPAPConstantPositiveAirwayPressure
CRTCathoderaytube
CSFContrastsensitivityfunction
CSOACommunicationSelf-AssessmentScalesforOlderAdults
DAQDataacquisition
DYSFamilialTorsionDystonia
ECGElectrocardiogram
EDSexcessivedaytimesleepiness
EEGElectroencephalogram
EGMElectromyography
EMG Electromyogram
ENG Electronystagmography
ETDRSEarlyTreatmentofDiabeticRetinopathyStudy
EV Eccentricviewing
FDA FoodandDrugAdministration
FEM Finiteelementmodel
FFT FastFouriertransform
FM Frequencymodulatedradiofrequencies
FRA FallRiskAssessment
FRT FunctionalReachTest
FSQ FunctionalStatusQuestionnaire
GRF Groundreactionforce
HAT HearingAssistanceTechnology
HATNAPHearingAssistiveTechnologyNeedsAssessmentProfile
HF Highfrequency
HI Hypopneaindex
HLAAHearingLossAssociationofAmerica
HRVI Heartratevariationindex
IADL Instrumentalactivitiesofdailyliving
IL Inductionloops
ILSA IndependentLifestyleAssistant
IR Infraredlight
ISI Intermittentsnoringindex
IT Informationtechnology
ITC In-the-canal
ITE In-the-ear
JND Just-noticeabledifference
LED Lightemittingdiodes
LPL Lipoproteinlipase
LVR Lowvisionrehabilitation
MARCMedicalAutomationResearchCenter
MCI Mildcognitiveimpairment
MET MetabolicEquivalentTest
MMSEMini-MentalStateExamination
MSLTMultiplesleeplatencytest
MU UniversityofMissouri
NAPSNon-invasiveAnalysisofPhysiologicalSignals
NIH NationalInstitutesofHealth
NEPANon-exercisephysicalactivity
NSF NationalSleepFoundation
OAE Otoacousticemissionstesting
OSAHSObstructivesleepapnea-hypopneasyndrome
OSA Obstructivesleepapnea
ODI Oxygendesaturationindex
PAPAWPush-rimactivatedpowerassistwheelchair
ListofAcronymsandAbbreviations
PFQ PhysicalFunctioningQuestionnaire
PLMS
PPT PhysicalPerformanceTest
PM POLY-MESAM
PSG Polysomnography
RERARespiratoryeffort-relatedarousal
ROC Rightoutercanthus
REM Rapideyemovement
RSVPRapidserialvisualpresentation
SCSB StaticChargeSensitiveBed
SDB Sleepdisorderedbreathing
SHHSSleepHealthHeartStudy
SIMBADSmartInactivityMonitorUsingArrayBasedDetectors
SL Sleeplatency
SPMSQShortPortableMentalStatusQuestionnaire
SPPB ShortPhysicalPerformanceBatterytest
TIB Timeinbed
TMJ Temporomandibularjoint
TRT Tinnitusretrainingtherapy
TST Totalsleeptime
TUG TimedUpandGo
UARSUpperairwayresistancesyndrome
ULF UltraLowFrequency
VMS Videomagnifiersystems
WOMACWesternOntarioandMcMasterUniversitiesOsteoarthritisIndex
Chapter1 Introduction RichardLindsay
Increasesinthenumberandproportionofourpopulationover age65,andthedynamicchangeswithintheagingpopulation itselfrepresentthemostdramaticchangeinAmericansociety inthiscentury.Andprojectionscallforadditionaldramatic grayingofAmericanwellintothetwenty-firstcentury.
JohnW.Rowe,MD
“Iwanttoliveathome!”Thisphraseisutteredoverandoveragainbysenior citizens,andistheirpreference.Iamhopefulthatitwillbecomethepreferenceof morehealthcareprofessionals,insurers,andthosewhomakepolicy.Theconceptof aging-in-placehasbeendefinedas“livingwhereyouhavelivedformanyyears,or livinginanon-healthcareenvironment,usingproducts,servicesandconveniences toalloworenabletheelderlytonothavetomoveascircumstanceschange”[1]. Newsmarthometechnologyexistsintheformofemergencyassistancenotification,medicationreminders,fallprevention,anddetection.Thetechnologyallows forcontinuousmonitoringofpatientsandforgreatlyimprovedpsychosocialinteraction.Withthisasabackground,myintroductionwillreviewsomeofthefactors impacting“aginginplace” andthuswillindicatetheimportanceoftheauthor’s detailedreviewoftherolethattechnologycanplayinhelpingusreachourgoalsof betterhealthcarefortheelderlyandaginginplace.
ItisevidentthatthereisanAgingTsunamiunderwayanditisverycloseto reachingtheharborwheretsunamiscausethegreatestamountofdamage.The challengeforoursocietywillbehowwepreparefor,andmeet,thisagingwave anditsaccompanyingage-prevalentproblems.WilltheU.S.beabletoperfecta systemofhealthcarethatistrulyaffordable,responsive,caring,andavailablefor ourpopulationandparticularlytheelderly?
In1910,theaverageliveexpectancyforwomanwas47yearsofageandtodayit iscloseto80years;formentheaverage is72years.In1900,therewere3million elderlyoroneinevery25Americans.Thenumberhadincreased,by1994,to33.2 millionor1in8.By2030,1in5Americanswillbeover65years.Predictions,
RichardLindsay
FormerChairofGeriatricMedicine,SchoolofMedicine,UniversityofVirginia,Charlottesville,VA
e-mail:rwl3w@virginia.edu From: AgingMedicine,EldercareTechnologyforClinical
fromdemographers,indicatethatbytheyear2050theelderlywillnumbersome80 million.
ThemostrapidlygrowingsegmentintheU.S.populationisthose85yearsand older,whichgrew274%fromtheyears1960to1994.Thisgrouphasbeencalledthe “oldold”andnumberedsome3millionin1994.Itispredictedtonumber19million bytheyear2050,includingsurvivorsofthe“babyboom.”Thesebabyboomersare thebirthcohortbornbetween1946and1964whogaveatsunami-likepictureto theagingU.S.population.Thefirstofthebabyboomerswillturn65yearsoldin 2011,andpeopleaged65andoverareprojectedtorepresent20%ofthetotalU.S. populationin2030comparedwith12%in2003.Thissuddendramaticincreasein ourelderlypopulationhascalledintoquestionthesolvencyofthemajorentitlement programs:Medicare,Medicaid,andSocialSecurity.Thiswillstresstheabilityof ourhealthcaresystemtoprovidequalityservices.
This“oldold”subsetofthepopulationisalsotheonethatoftendemandsthe greatestoutlayofhealthcareresourcesbecausetheyareoftentheoneswiththe greatestfunctionalimpairmentandinneedofthelargestsupportnetwork.This functionalimpairmentislargelyduetoanincreaseinchronicdisease.About80% ofseniorshaveatleastonechronichealthcondition,and59%haveatleasttwo chronichealthconditionswhichoftenleadtodisability.Conditionsincludingarthritis,hypertension,heartdisease,diabetes,andrespiratorydisordersrepresentthenew focusonmedicine;thecareandmanagementofchronicillnesswhichfrequently takesplaceoutsideofhospitals.Chronicillnesseslendthemselvestomonitoringby thepatientand/ortheircaregiverandothermembersofthehealthcareteam.This offersnewandexcitingopportunitiestoapplytechnologyasyouwillseeasyou readthisbook.
Thereisoneotherimportantaspectoftheagingtsunamithatdeservescomment: thefactthatthenextgenerationofelderlywillbemuchmoreheterogeneousthan thelast.Therewillbeanexplosivegrowthinthepopulationofminorityelderly. Thewhiteelderlywilldoublebetween1990and2050andthenumbersofAfricanAmericanswilltriple.ThenumbersofolderHispanicsandAsianswillincreaseby afactoroffive.Thiswillneedtobetakenintoaccountwhendesigningprograms andhealthcarematerials,trainingpersonnel,andplacinginstructiononequipment ifthehealthcaretothesepopulationsistobesuccessful.
Theabsolutenumbersofelderlywhowillbeinneedofservicesandcarebrings metotheothercriticalpointinthisintroduction.ArecentInternationalCommission onGlobalAgingdeclared,“Themajorsocialcrisisofthetwenty-firstcenturywill betheby-productoflaborshortages”[2].Unlessthereareadequatenumbersof individualstrainedinthepropercareofgeriatricpatients,thewholesystemwillbe indanger.Thereareapproximately7,600certifiedgeriatriciansintheU.S.today. Estimatesputtheneedforgeriatriciansintheyear2030atapproximately36,000. ThetotalnumberofindividualsingeriatricfellowshiptrainingprogramsintheU.S. was334in2005.
Thesituationissimilarinnursing,withacurrentdramaticshortageofRNs andapredictionofanadditionalshortageofbetween800,000and1million registerednursesby2020.Thecurrentnursingforceisagingandmanyplantoretire
within10years.Otherprofessionalcareersthatplayakeyroleincaringforthe elderly,includingpharmacy,dentistry,chiropractic,podiatry, optometry,nutrition, andoccupationalandspeechtherapyallcouldfacepotentialpersonnelshortages orcouldbenefitfromadditionalgeriatriceducationalcontentintheirtrainingprograms.Thesedisciplinesarevitalmembersofthehealthcareteamfortheelderly andtheseshortagescouldfurthercompromisethemaintenanceoffunctionand healthforouragingpopulation.
ThesameproblemsfaceusinthesupplyandretentionofCertifiedNursingAssistants(CNAs)whogivethevastmajorityofhandsoncareinnursinghomes.Ata timewhenAmericanswanttoage-in-place andbecaredforathome,theagencies thatprovidethiscareareclosingorstrugglingbecauseofashortageofhomehealth aides.Giventhelongtrainingperiodsinvolvedinsomeofthesecareerpathsandthe lowwagescaleinothersandbeingawareofthealreadyexistentshortagesofthose caregiverswhodirectlyprovidethehandsoncareonlyservestoemphasizethecrisis natureofthesituation.Solutionsincludeattentiontoadditionalgeriatriccontentas arequirementforcertificationandlicensureandearlierexposureofhighschool studentstotherewardsofacareerinthemanyfieldsdiscussedabove.Wemustalso addresstheeconomicissuesofwagesandbenefits.Untilwesolvethepersonnel problem,otherdiscussionsaboutcarefortheelderlywillrepresentaclassiccaseof the“cartbeforethehorse”andnewprogramstocarefortheelderlywillbedestined tofailure.
Futureplanningmustalsoconsiderdevelopingdifferentwaysofprovidingcare indifferentsettings.Theroleoftechnologyinoffsettingpersonnelshortages,linkingthehomeandthehealthcaresystem,providingcontinuingeducationtopatients andcaregivers,decreasingtransportationusage,andmonitoringchronicillnesswill needfundingandfurtherresearch.Thegoalisbettercareandcostsaving.
Today,weareinthespaceageoftechnologyforthecareoftheelderly.We havemovedbeyondthesphygmomanometer,oralthermometer,wheelchairs,and walkers.Newdevelopmentsinsensorsthatallowfollowingpatient’sgaitmotion, sleep,vitalsigns,andlocationcanandwillprovidenewmeansofmonitoringand connectingthepatientwiththeirhealthcaresystem.Theinternetandelectronic systemsthatfacilitateinformationexchangefortheelderlypatientortheircaregiver areonlybeginningtobeutilizedandoffergreatpotential.Newassistivedevices canhelpcleanahouse,enhancepersonalsafety,andaidinmedicationcompliance. Theserepresentjustafewofthewaystechnologywillmeetthedemandof“Iwant tostayathome”.
Therearemanychallengesthathaveandwilldelaytechnology’sroleinthecare oftheelderly;includingreimbursementforusingtechnology,thedevelopmentof user-friendlydevicesandkeepingthetechnologyaffordable.Fortunately,thebaby boomershavegrownupwithtechnologyanduseitinmanyaspectsoftheirdaily lives,andthiswillfacilitateitsemployment.
Technologyisandwillbeamajorpartnerinthecareoftheelderlyandour healthcaresysteminthefuture.Thechallengeswillbeinprovidingadequate resourcesforcontinuingresearchintoitsapplicationinthecareoftheelderlyand developingstrongworkingrelationshipsbetweenthehealthcaresystemandthe
researchers.Theauthors’contributionscontainedinthisvolumerepresentsignificantstepstowardmeetingthesechallenges.
References
1.Aginginplace.Availableat:http://www.semiorresource.com/agingimpl.htm.AccessedAugust 21,2006.
2.MondaleW,HashimotoR,PohlKO.SummaryReportoftheco-chairmenandfindingsand recommendationsoftheCSISCommissiononGlobalAging.WashingtonDC:GlobalAging InitiativeCenterforStrategicandInternationalStudies;August29,2001.
Chapter2 FunctionalAssessmentTechnologies MarilynRantz,MarjorieSkubic,KathrynBurks,JieYu,GeorgeDemiris, BrianK.Hensel,GregoryL.Alexander,ZhihaiHe,HarryW.Tyrer, MarcHamilton,JiaLee,andMarybethBrown
2.1ImportanceofFunctionalAssessmentforOlderAdults Functionalwell-beingisasignificantfactorintheoverallhealthofolderpeople. TheWorldHealthOrganizationadvisorygroupstatedalmost40yearsagothat thehealthofolderadultswasbestmeasuredintermsoffunction[1].Generally speaking,functionasanoveralltermcanbedividedintothreecategories:physical,psychological,andsocialfunction[2].Thethreecomponentsinteractclosely andcontributetotheoverallconstructofwell-being.Acomprehensivegeriatric functionalassessmentisusuallycomposedofthesecomponents.Forexample,Nelsonandassociatesinterchangeablyusedtermsoffunction,functionalhealth,and functionalstatusastheyconductedacompletefunctionalassessmentusingseparate measuresofcomponents,suchasphysicalfunction,emotionalstatus,roleandsocial function,painandsocialsupport[3].
Thepurposeofthecomprehensivefunctionalassessmentamongtheelderlyis tobridgethegapbetweenpeople’sactualabilitiesandtheavailableresources[4]. Aregularfunctionalassessmentcanhelpclinicianseasilyidentifyolderpeople’s changesovertimesothateffectivestrategiescanbeimplementedinatimely mannertopreventorreduceseverenegativeoutcomes.Physicalfunctionisthekey factoroffunctionalassessment,anditissometimessynonymouswithfunctional statusorfunctioningincurrentliterature.Thegoalofthissectionistoexaminethe meaningofphysicalfunctionasitrelatestotheoverallfunctionalassessmentandto explorethesignificanceofphysicalfunctiontocomprehensivegeriatricfunctional assessment.
MarilynRantz
Professor,SinclairSchoolofNursingandFamilyandCommunityMedicine,S406SinclairSchool ofNursing,UniversityofMissouri-Columbia,Columbia,MO65211 e-mail:RantzM@HEALTH.MISSOURI.EDU
From: AgingMedicine,EldercareTechnologyforClinical Practitioners, Editedby:M.AlwanandR.Felder
2.1.1PhysicalFunction Physicalfunctionisacommonlyusedtermamongresearchers;however,thereare fewauthorswhohaveprovidedacleardefinitionofphysicalfunction.Oneexample byBrachandVanSwearingen[5]statesthatphysicalfunctionisassociatedwiththe abilitytoperformactivitiesofdailyliving(ADLs),instrumentalactivitiesofdaily living(IADLs),andmobilitytasks,whichareimportantforindependentlivingwithoutsubstantialrisksofinjury.McConnellandcolleagues[6]referredtophysical functionasthedegreeofdependencyinbasicADLsanddiscusseditsimportance onelders’qualityoflife.Similarly,Fitzpatricketal.[7]regardedphysicalfunction asthephysicalabilitytoengageindailyactivitiesrelatedtopersonalcare,socially definedroles,andrecreationalactivities.Thesedailyactivitiescouldbefurther classifiedintoADLs(basicself-careactivitiesthatincludedressing,bathing,personalhygiene,toileting,walking,eating, etc.),IADLs(activitiesandskillsneeded toliveindependentlyinthecommunitysuchasshopping,cooking,housekeeping, andhandlingfinances),basicphysicalmovements,andcomplexactions[8].In contrast,Whetstoneetal.[9]explainedphysicalfunctionasthedynamicchangingstatusofdependency,difficulty,andpreclinicalchangesacrossawiderangeof activities.
Althoughmostresearchersdidnotspecificallydefinetheconceptofphysical function,theirunderstandingsofthetermaredemonstratedbytheirchoicesofmeasurementinstruments.Forexample,Shimadaetal.[10]examinedphysicalfunction byevaluatingsubjects’balance,gait,andreactiontime.Balancewasevaluatedby one-legstandingtimeandtheFunctionalReachTest(FRT);gaitperformancewas measuredbywalkingspeedovera10-mdistanceandtheequipmentofWhole BodyReactionType-IIwasutilizedtoassessreactiontimetoanauditorystimulus(100Hz).Onthecontrary,Furnerandassociates[11]usedparticipants’selfreportofperformanceonADLsandIADLstoevaluatephysicalfunction.Some researcherschoosetocombinesubjectiveandobjectiveassessmentstoprovidea comprehensivedescriptionofthestatusofphysicalfunction.Forinstance,subjectivequestionnaires,suchasthephysicalfunctioningquestionnaire(PFQ)and performance-basedtests,whichincludea6-minwalktest,wereusedsimultaneouslytoevaluatethestatusofphysicalfunctionamongagroupofcardiacolder people[12].
Itseemsthattheseauthorshavedifferentunderstandingsofphysicalfunction; however,theyareconcernedaboutthesameconstruct.Mostauthorsinterpretphysicalfunctionaspeople’sactualphysical performanceabilitiesinsimplemovements, suchaswalkingandstanding,ortheirself-ratedabilitiesonADLsandIADLs. Additionally,mostagreethatthestatusofphysicalfunctionatacertaintimepoint inagingprocesscouldbeaffectedbysomephysiologicalandpathologicalconditions.Therefore,itseemsreasonabletoconcludethatphysicalfunctionrepresentsa person’scurrentabilitiestoparticipateindailyactivitiesrelatingtodifferentsocial roles.Specifically,anolderadult’sactualperformanceandselfreportsinsomebasic dailylifeactivities,ADLsandIADLs,canreflectthestatusofphysicalfunction.
2.1.2SignifcanceofPhysicalFunctionforOlderAdults Anappropriatelevelofphysicalfunctionplaysasignificantroleinactiveandindependentlivingfortheelderly,andregularassessmentswillmakeearlydetection andtimelyinterventionpossibletomaintainreasonableordelaythedeterioration ofphysicalfunction.Inthetrajectoryofaging,aperson’squalityoflifeisjudged moreoftenbytheabilitytomaintainindependenceandphysicalfunction,thanby anymedicaldiagnosis[13].However,lowerlevelofphysicalfunctionisalsoassociatedwithsignificantnegativehealthoutcomes,suchashospitalization,nursing homeadmission,falls,anddependency[14].Therefore,theassessmentofphysical functionisnotonlyakeycomponentoffunctionalassessmentbutanimportantpart ofcomprehensivegeriatricevaluation.
Physicalfunctioniscloselyassociatedwiththeothertwocomponentsoffunctionalassessments,socialandpsychologicalfunction,andsomegerontological studieshaveconfirmedsuchrelationships.Forexample,Cronin-Stubbsandcolleagues[15]conductedapopulation-basedlongitudinalstudyduringa6-yearperiod in3434community-dwellingolderpeopleand foundthatmilddepressivesymptoms wereassociatedwithanincreasedriskofbecomingphysicallydisabled.Similarly, datafromtheMacArthurStudiesofSuccessfulAgingidentifieddepressionasa riskfactorforphysicaldisability,whichwasassessedbyADLsScale.Resultsalso suggestedthatdepressionandphysicaldisabilitycouldinitiateaspiralingdeclinein bothphysicalandpsychologicalfunction[16].Consequently,cliniciansshouldkeep inmindthat,whileaddressingthesignificanceofphysicalfunctioningerontological care,socialandpsychologicalfunctionsandtheirinteractionsshouldnotbeoverlooked.Additionally,thecontributionofpaintophysicalfunctionanddepression cannotbeoverlooked.Often,painmanagementisthekeytoimprovingphysical functioninolderadults.
Someimportantclinicalimplicationsforeldercarecouldbedrawn.First,the assessmentsofphysicalfunctionshouldbecomprehensiveandindividualized.Cliniciansshouldnotonlybefamiliarwiththe knowledgeaboutphysicalfunction,but alsoaccuratelyevaluateanolderperson’slevelofphysicalfunctiononaregular basis.Secondly,becausetherearecloseinteractionsamongphysical,social,and psychologicalfunctions,progressiveeldercareprogramsshouldaddressphysical activityinvolvement,socialandintellectualengagement,andpainmanagement amongtheelderly.
2.1.3CommonHealthConditionsthatAffect FunctionalAbilities
Becausephysicalfunctionsignificantlyimpactstheabilitiesofolderadultstomaintainindependence,developingandimplementingstrategiestopreventordelaythe onsetofphysicaldisabilityisamajorpriority forclinicians.Identifyingcontributing
riskfactorstothedeteriorationoffunctionalabilitiesisanimportantstep.This sectionwillexploreriskfactorsfordeclinesofphysicalfunctionandtheirclose interactionswithfunctionalabilities.
Thedeclineinfunctionalabilitiesisnotjust dependentonchronologicalage, butiscloselyassociatedwithotherbiological,psychological,andsocialriskfactors[17].Forexample,Stuckandassociates[18]conductedameta-analysisof 78longitudinalstudiesexploringtheriskfactorsforphysicalfunctiondeclinein community-livingolderadults.Someconditions,suchascognitiveimpairment, depression,diseaseburden,poorself-ratedhealth,lowlevelofphysicalactivity,and functionallimitation,wereidentifiedascontributorswithhigheststrengthofevidence.Thefollowingsectionsdescribekeyriskfactorsrelatingtohealthconditions andrecentresearchfindingsineachareaarediscussed.
2.1.4CognitiveImpairment Cognitivefunctionisanimportantfactorforphysicalfunctionortheabilitiesto maintainindependenceamongolderadults.Previousgerontologicalstudieshave confirmedtheassociationbetweencognitiveimpairmentandphysicalfunction. Greinerandassociates[19]investigatedtherelationshipofcognitivefunctiontoloss ofphysicalfunctionamongagroupofelderlyCatholicnuns.Resultsshowedthat participantswithlownormalcognitivescoresonMini-MentalStateExamination (MMSE)atbaselinehadtwicetheriskoflosingindependenceinADLsatfollowupcomparedwiththosewithhighnormalscores.Thiscloserelationshipbetween cognitiveimpairmentsandfunctionaldeclineisalsoidentifiedinotherpopulations, suchasnon-disabled,community-livingolderadultsandelderlyMexicanAmericans[20,21].
BesidesMMSE,whichisanoftenusedcognitivefunctioninstrumentinaging studies,Moritzetal.[22]foundconsistentresultsutilizinganothercognitiveassessmenttool,Pfeiffer’sshortportablementalstatusquestionnaire(SPMSQ).ThislongitudinalstudyrevealedpersistentandincidentalADLlimitationsoccurredmore frequentlyinolderpersonswithfourormoreerrorsonSPMSQ.Theresultnot onlyconfirmedtherelationshipbetweencognitivefunctionandphysicalabilities inADLs,butalsosuggestedcognitiveimpairmentmightbeasignificantpredictor oftheonsetofnewADLlimitations.Conclusionscouldbemadefromthesestudiesthatcognitiveimpairmentisanimportantcontributorfordeclinesinphysical functionandpredictstheonsetofADLlimitations,usingavarietyofassessment measures.
Accordingly,someimplicationscanbedrawnforgeriatricclinicians.They shouldnotonlybefamiliarwithcognitiveimpairment,whichactsasasignificant riskfactorforfunctionaldecline,butalsobeawareoftheknowledgethatsome cognitivefunctionaltestscanbeusedtoforecastservicesneededandtoplaninterventionstodelaytheonsetofADLlimitationsorplanstrategiestobestdealwith thelimitations[22].
2.1.5Depression Althoughtheprevalenceofmajordepressionisrelativelysmall(2%)amongolder community-livingpersons,ahighpercentage(12–15%)ofelderlycommunitydwellerssufferfromminordepressionorsignificantclinicaldepressivesymptoms [23].Asacrucialcontributortoolderpersons’well-beingandfunctionalstatus, thedetrimentaleffectsofdepressiononphysicalfunctionhavebeeninvestigatedin numerousagingstudies[24–26].
Penninxandassociates[26]conducteda4-yearprospectivecohortstudyexploringtheimpactofdepressivesymptomsonchangesofphysicalperformanceamong 1286oldercommunitydwellers.Aftercontrollingforotherconditions(suchas baselineperformancescore,healthstatus,andsocio-demographicfactors),they foundthathighlevelsofdepressivesymptoms[assessedbytheCenterforEpidemiologicStudiesDepressionScale(CES-D)],couldhighlypredictdeclineinphysicalfunction.ThesefindingswereconsistentwithresearchdonebyEverson-Rose etal.[25]substantiatingastrongcross-sectionalassociationbetweendepressive symptomsandoverallphysicalperformance.Callahanandcolleagues[27]also confirmedpreviousresearchfindingsthatolderpersonswithdepression(evaluated byCES-D)reportedgreaterfunctionalimpairmentthanthosewithoutdepressive symptoms.Furthermore,amulti-siterandomizedclinicaltrial[24]revealedthat effectivetreatmentofdepressivesymptomsbyacollaborativeprogramimproves physicalfunctionmorethanusualcare.
Thecloserelationshipbetweendepressionandphysicalfunctioncanshedlight onfutureclinicalpractice.Attentionshouldbepaidtothedetrimentaleffects ofdepressionondeclinesofphysicalfunction.Collaborativeeldercareprograms shouldbedevelopedtoaddressdepressionandinterruptthedownwardspiralofthe deteriorationofdepressionandphysicalperformance.
2.1.6LackofPhysicalActivity Lackofphysicalactivityisalsoindependentlyrelatedwithahigherriskfordeclines ofphysicalfunction[18].Studieshaveconfirmedrelationshipsbetweenphysical activityandfunctionalimpairment.Forexample,Seemanandcolleagues[28]found asignificantandindependentassociationbetweenbetterphysicalfunctionandparticipationinmoderateand/orstrenuousexerciseactivity.
Abundantstudieshaveexaminedtheeffectsofexerciseprogramsinhelping improvephysicalfunctionandmaintainindependence.Taylor-Piliaeandassociates [17]detectedthatTaiChiexercisecouldsignificantlyimprovebalance,upperand lowerbodymuscularstrength,endurance,andflexibility.Similarly,fromarandomizedandplacebo-controlledtrial,evenamongnursinghomefrailresidents, aprogressiveresistancetrainingwasfoundtoimpressivelyincreasemusclemass andimprovefunctionalperformanceingaitspeedandstair-climbingabilities[29]. Fronteraandassociates[30]alsodemonstratedthatregularresistancetrainingcould
significantlypromotethestrengthofextensorandflexormusclesinolderparticipants.Itisclearthatphysiologicalparameters,suchasbalance,gaitperformance, muscularstrength,endurance,andflexibilityareprerequisitestokeepanappropriatelevelofphysicalfunction[31].Increasingphysicalactivitythroughexercise programs,suchasTaiChiandresistancetraining,cansignificantlyimprovephysical function.
Anotherviewofimprovingphysicalfunctionisto increasenon-exercisephysical activity (NEPA).NEPAinvolvesallformsofphysicalactivityotherthanexercise. Mostofaperson’sNEPAisassociatedwithambulationforpracticalpurposesor movementsnotintendedforhealth,includingmanyformsof“puttering.”Examples ofNEPAthatmaybecriticalforpreservinghealthandvitalityincludethethousands oflightmovementspeopleassociatewithanindependentandvibrantlifestyle,such asvacuuming,dusting,walkingacrosstheroomtomanuallychangethetelevision channel,oradjusttheblinds.Totalenergyexpenditureislowinagingadults primarilybecauseoflessactivityorNEPA,notalowerbasalmetabolicrate[32,33], andmoretimespentinsedentaryactivitiesinvolvingsitting[34].Peopleoverthe ageof65yearstakealmostone-halfasmanystepsperdayasyoungerpeople. Remarkably,20%ofthoseagedabove65yearstakelessthan1000stepsperday, whereasonlyapproximately1%ofmiddle-agedpeoplelessthan65yearstake thisfewsteps[35].Takentogether,theseandotherstudiesofagingadultswith preclinicaldisability[36]haveledtothebeliefthatthereisaviciouscyclelinking inactivitywithmetabolicdisordersandlossofmobility.
Anemergingparadigmofgreatinteresttotheexercisephysiologyresearch communityrelatestohowsimplysittinginsteadofNEPAleadstoincreasedriskfor chronicdiseases;thetermcoinedforthisnewparadigmhasbeencalled“inactivity physiology”[37].Simplyput,thetimespentstandinginanyweight-bearingactivity (evenNEPA)portendstobeadeterminantofmultiplefunctionalanddiseaseendpointsrelevanttosuccessfulaging.Lowlevelsofhigh-densitylipoprotein(HDL) cholesterolareassociatedwithfunctionaldisabilityintheelderly[38].Inaddition, bonehealthisrelatedwiththetimeonesitsorstands[39–41].
Epidemiologicalcorrelationshaveassociateddailysittingtimewithmetabolic syndrome(lowHDLcholesterol,highplasmatriglycerides,hypertension,body fat,andinsulinresistanceorglucoseintolerance[42–44]).Foreachhourlessof dailytelevisionwatching,therewasa12–26%reductionintheincidenceofthe metabolicsyndrome[43].Theilleffect ofsittingwasindependentofwhether thepersonwasengagedintraditionalexercise[43,45].Therearemechanistic explanationsandinterventionalstudiesinanimalsforthoseassociations.Componentsofthemetabolicsyndrome,diabetes,andcardiovasculardiseasehave eachbeenlinkedinlargeparttoanenzymecalledlipoproteinlipase(LPL). Theinactivityfoundduringagingisassociatedwithsignificantlylowerlevels ofLPL[46,47].ThefunctionofLPLisstronglysuppressedtoonly5%of normallevelsafterreducedstandingandispreventablebyincreasedstanding andNEPA[48,49].NEPAmeasurementsandinterventionsintheelderlyor functionallyimpairedcouldthusbeespeciallyimportanttoimprovephysical function.
2.1.7OtherFactorsAffectingFunctionalAbilities
Someotherfactors,suchasco-morbidities,fewsocialcontacts,poorself-perceived health,smoking,andvisionimpairment,havealsobeenidentifiedincurrentliteratureasstronglyrelatedtophysicalfunctiondecline[18].Higherbodyweighthas beenrecognizedasanimportantriskfactorforlowereverydayphysicalfunctioning[50].Otherresearchershavealsorevealedthatfactorssuchaspositivemotivationandappropriatesocialrolescanpositivelyinfluencephysicalfunctionin performance-basedtests[51].
2.1.8Summary,FunctionalAbilities
Asanindispensablecomponentofindependentlivingwhileaging,physicalfunction isandhasalwaysbeentheintegralfocus ofclinicalgeriatriccare.Somecommon healthconditions,suchascognitiveimpairment,depression,andalackofphysical activity,whichsignificantlycontributetothedeclineofphysicalfunction,havebeen reviewed.Thesesignificantcontributingfactorsfordeclinesofphysicalfunction shouldbeidentifiedregularlytopreventordelayseveredeteriorationandshouldbe sufficientlyaddressedincomprehensivecareprograms.
Understandingthesignificanceofphysicalfunctionandriskfactorsforfunctionaldeclinecanhelpthoseinterestedintechnologyasawaytohelpolderadults maintainorregainfunction.Technology shouldenhancetheon-goingassessmentof physicalfunctionthatisamajorfocusofclinicians.Itisourbeliefthattechnology holdsthecapacitytoenhanceclinicaleffectivenessbyearlydetectionofchangesin function,alertingcliniciansandprovidingfunctionalassessmentinformationabout functionalperformanceofolderadultsintheircare.
2.2CommonMeasuresofFunctionalAssessment Physicalfunctionisthebasisofoverallwell-beingamongtheelders,anditsaccurate andsensitivemeasurementisavitalcomponentingerontologicalcare.Avarietyof reliableandvalidphysicalfunctioninstrumentsexistincurrentliterature.Thereare threemainkindsofinstruments:self-reportandproxyreport,performance-based tests,andobjectivelaboratorytests.Thissectionwillexploreeachcategoryindividually.Representativemeasuresofeachgroupwillbediscussed,andtheircharacteristicswillbeexaminedandcompared.Finally,theappropriateuseofthese instrumentswillbediscussed.
2.2.1Self-ReportandProxyReport Self-reportandproxyreportassessmentsfocusonselforproxyperceptionof physicalfunction[14].Theyarebothrelativelyeasytoadministerandusually requirelittleinstructionforparticipants.Becauseself-reportassessmentsare
completedbysubjectsthemselves,informationabouttheoverallperceptionof theindividualregardingtheirhealthstatusandabilitytoperformcertainactivities areavailable[14].Incontrast,proxyreportsareexecutedbyfamilymembersor healthprofessionalsbasedontheirobservationofsubjects’performanceoncertain tasks.
Measuresthatdeterminesubjects’difficultyinperformingADLsandIADLs areoftenemployedinvariousstudiestomonitorthechangesinphysicalfunction. Forexample,therearedirectADLsandIADLsindices[52],aswellasmeasures suchasthefunctionalstatusquestionnaire(FSQ)thatincludespecificsections addressingtheseaspectsofphysicalfunction[53].Similarly,theWesternOntario andMcMasterUniversitiesOsteoarthritisIndex(WOMAC),adisease-specificmeasure,includesquestionsthatfocusonthesubject’sabilitytoperformADLsand IADLs[54–56].
Assessmentofpainandpainmanagementstrategiesareoftenoverlookedinself reportandproxyreportofphysicalfunction.Selfreportofpainandpainmanagementstrategiescanbereadilycompletedinsimpleperception-ratingscalessuchas thoserecommendedinresearch-basedclinicalpracticeguidelines[57].Asphysical functionisassessed,painandpainmanagementstrategiesshouldalsobesolicited.
2.2.2Performance-BasedTests Performance-basedtestsofphysicalfunctionareonesinwhichsubjectsareaskedto actuallyperformsomespecifictasksoractivitiesandareevaluatedusingstandardizedcriteria[13].Thesetestsaremuchmoreobjectiveandpsychometricallysound thanself-reportsandcanoffermoresensitiveandaccurateinformation.
Insteadofmeasuringthewholeconstructofphysicalfunction,mostperformancetestsaredividedintosubcategoriesandevaluateindividualcomponentsof physicalfunction,suchasbalance,gait, flexibility,andendurance[14].Accordingly,thestatusofphysicalfunctioncanbedrawnfromoverallperformanceon allorsomeofthesesubcategories.Forexample,ToramanandSahin[58]useda FunctionalFitnessBatterytoassessphysicalfunction.Componentsofthisbattery includelowerandupperbodystrength,bodyflexibility,aerobicendurance,agility, anddynamicbalance.Aerobicenduranceandlowerbodystrengtharemeasured bysimpleactivities,suchas6-minwalkandchair-stand[58].Similarly,Kenny etal.[59]usedtheshortphysicalperformancebatterytest(SPPB)toexaminethe efficacyofvitaminDsupplementationamongelders.Physicalfunctioninthisbatteryisassessedfromsubjects’performance onrisingfromachair,staticbalance,a 6-footwalk,thetimeup-and-gotest,andthetimedsupine-to-standtest.Rekeneire andassociates[60]alsoutilizedaseriesofperformance-basedteststostudyphysicalfunction.Inthisstudy,thetimedrepeatedchairstandwasusedtoassess lowerextremitystrengthand400maswellas2-minwalkwereusedtomeasure endurance.Subjects’statusofphysicalfunctionwasreflectedfromperformanceon thesetests.
Table2.1 SelectedInstrumentsComparisons
Strength
Itiseasyandquick toadministerand requireslittle trainingor equipment.An objective,reliable, andvalidtestfor quantifying functionalmobility.
Valid,reliable,and easytoadminister.
Limitation
Procedures, administrationtime
Itcouldnotmeasure changesof functionalmobility ineitherthefreely mobileorthevery dependent populations, althoughitcould identifythem.
Individualsstandup fromastandardarm chair(approximate heightof46cm), walk3m,turn,walk backtothechairand sitdownagain.10 minutes.
InstrumentnameAuthor,CitationConceptsmeasuredScoring
Physicalmobility.Timethewhole performance. < 20sec: independently mobileofbasic transfers;[20,30]: variesinphysical functionandfurther assessmentis needed; > 30sec: dependenceonhelp forbasictransfers andriskoffalls.
Podsiadlo,D., Richardson,S. (1991).Thetimed “Up&Go”:Atest ofbasicfunctional mobilityforfrail elderlyperson. Journalofthe AmericanGeriatrics Society 39:142–8.
Timedupandgo test(TUG)(61)
Cannotdifferentiate fromunmotivated fromincapable personsandtasks includedmaynotbe completemeasures offunctionalstatus.
Nine-itemscale: writeasentence, simulateeating,turn 360degrees,puton andremoveajacket, liftabook,andputit onashelf,pickupa pennyfromthefloor, a50-footwalktest andclimbstairs. Seven-itemscale: notincludethe stairs.10min.
Timeindividual tasks.Themaximum scoreis36forthe nine-itemtestand28 fortheseven-item test.
Upperfineand coarsemotor function,balance, mobility, coordination,and endurance.
Reuben,D.B.,Siu, A.L.(1990).An objectivemeasureof physicalfunctionof elderlyoutpatients: thephysical performancetest. Journalofthe AmericanGeriatrics Society 38:1105–12.
Physical performancetest (PPT)[62].
(continued)
Table2.1 (continued)
Strength
Asimpleand practical performancetest. Reliableand sensitiveto significantchanges usedinnormaldaily living.
Objective,valid,and reliablebalance measure.Easyto administerandsafe forolderpeople.
Limitation
Procedures, administrationtime
Theobservationsare crudeandmore variabilityamong individualscouldnot befound.
Itisatask performancetest. Participantsare askedtoperform specificmaneuvers aboutbalanceand gait.10–15minutes.
Theobservationsare crudeandsmall changescould hardlybedetected.
14performance- basedmeasures. 10–15min.
InstrumentnameAuthor,CitationConceptsmeasuredScoring
Balanceandgait.Maximumtotal scoreis28. < 19:a highriskfor falls;[19,24]:arisk forfalls.
Tinetti,M. E.(1986). Performance- orientedassessment ofmobilityproblems inelderlypatients. Journalofthe AmericanGeriatrics Society 34:119–26.
Tinetti assessmenttool (63)
Maximumscoreis 56. < 20:wheelchair bound;[21,40]: walkingwith assistance;[41,56]: independent.
Balance.
Berg,K., Wood-Dauphinee, S.,Williams,J.I., Gayton,D.(1989). Measuringbalance intheelderly: Preliminary developmentofan instrument. Physiotherapy Canada 41(6):304–11.
Bergbalance scale(64)
Fourwidelyusedperformance-basedassessmentsaresummarizedinTable2.1: Timedupandgo(TUG)test[61],physicalperformancetest(PPT)[62],Tinetti assessmenttool[63],andBergbalancescale[64].Specificinformation,suchas subscales,scoringcriteria,strength,andlimitationconcerningeachinstrumentare identifiedandcompared.
2.2.3LaboratoryTesting Physicalfunctionandphysicalfitnessareoftenusedinterchangeably;therefore, physicalfunctioncanalsobemeasuredinobjectivelaboratoryteststhatfocuson physicalfitness.Forexample,Rejeskietal.[12]combinedanobjectivelaboratory testofmetabolicequivalent(MET)levelwithself-reportquestionnaireanda6-min walktesttoassessphysicalfunctionintheelderly.Becausephysicalfitnesslaboratorytestsusuallyrequireexpensiveequipmentandspeciallytrainedtechnicians, theyarenotpracticalforroutinephysicalfunctionassessments.
2.2.4Summary,CommonMeasuresofFunctionalAssessment Appropriatemeasurementofphysicalfunctionintheelderlyrequiresmultifaceted measurementthataddressesthespecificattributesofthispopulationespeciallythe closeassociationofphysicalfunctionwithhealthstatus[14].Threemainkinds ofmeasurements,selfandproxyreports,performance-basedtests,andlaboratory testsarediscussed.Inaddition,thefourmostwidelyusedmeasurementtoolsare compared.Geriatriccliniciansandresearchersareencouragedtouseamultifaceted approachtomeasurephysicalfunctionbycombiningsubjectivemeasures,suchas selforproxyreportsandobjectiveinstruments,suchasperformance-basedtests.
2.3OverviewofHome-BasedEldercareTechnologies toPromoteandAssessFunction Recentadvancesinsensorandinformationtechnologieshavemadeanimportant contributiontothecareofelderlypeople.Awidevarietyoftechnologiesanddevices havebeendevelopedtopromoteandsupporttheirindependentandsafeliving.In general,thesetechnologiescanbeclassifiedintotwobasiccategories:assistive devicesandmonitoringandresponsesystems.Thesetechnologiesanddevicesare oftencoupledtogetherintoasmarthomeenvironmentsoastoprovideanintegrated supportforindependentlivingofelderlypeople.
2.3.1AssistiveDevices
Functionaldeclineinmobilitymakesithardforolderadultstooperatemany smallappliancesathome.AttheGeorgia InstituteofTechnology,computervision
researchershaveprototypedtheGesturePendantasawearabledevicetocontrola varietyofhomeappliancesthroughsimplehandgestures[65].Arecentstudyshows thatcomputerizeddevicesareabletohelpapersonwithseveredementiacomplete someADLs,suchashandwashingorusingrecordedvoicesforcueing[66].For peoplewithseverememoryimpairment,thetechnologiesdevelopedattheUniversityofMichiganareabletoremindanolderpersonabouthisorherADLs[67]. Medicationcompliancedeviceshavealsobeendevelopedtoremindanolderadult totakemedicationattherighttimeandintherightdose[68].
2.3.2MonitoringandResponseSystem Individualswithmobility,cognitive,and sensoryimpairmentsmaynotbeable torecognizeandavoidunsafeconditions,oraskforhelpduringacrisissituation; monitoringsystemswithsensorscanhelpsatisfythisneed.Floorvibrationmonitors havebeendevelopedattheUniversityofVirginiatodetectpossiblefallsofolder adults[69].TechnologiesareavailabletomonitorADLtasksinthehomeusinga varietyofsensingtechnologies.Sensorsandswitchesattachedtovariousobjects, oropticalandaudiosensorsembeddedinthe environment,areusedtodetectwhich taskapersonisperforming[70,71].TheUniversityofVirginiaIn-HomeMonitoring Systemthatusesacombinationofwirelessmotionsensorstodetectmovementin areasofaperson’slivingspacecandifferentiatesuchADLactivitiesasshowering ormealpreparation.InferenceoftheADL activitiesisdoneinarule-basedapproach andhasbeenvalidatedinacommunityhomewithahealthyvolunteersubjectkeepingdetailedPDA-basedtime-stampedfieldnotes[72,73].Thesesameresearchers havealsodevelopedabedsensorformonitoringqualitativepulseandrespiration, aswellassleeprestlessness[74],whichcanprovidebasicindicatorsofhealth.
TigerPlaceisaninnovativeindependentlivingenvironmentof33apartments builtandoperatedbyAmericareofSikeston,MO,USA,inaffiliationwiththe UniversityofMissouri(MU)SinclairSchoolofNursingasaspecialfacilitywhere residentscantrulyageinplaceandneverfearbeingmovedtoatraditionalnursinghomeunlesstheychoosetodoso.WithcareprovidedbySinclairHomeCare andtheTigerCarewellnesscenterwithregisterednursecarecoordinationservices, residentsreceivepreventativeandearlyillnessrecognitionassistancethathave markedlyimprovedtheirlives.LinkswithMUstudents,faculty,andnearlyevery schoolorcollegeoncampusenrichthelivesofthestudentsandresidentsofTigerPlace.Researchprojectsareencouragedandresidentswhochoosetoparticipateare enjoyinghelpingwithdevelopingcuttingtechnologytohelpotherseniors’agein place.TheAginginPlaceProjectatMUrequiredlegislationin1999and2001to befullyrealized.SinclairHomeCareisaninnovativehomehealthagencyinitiated bytheSinclairSchoolofNursingspecifically tohelpolderadultsageinplacein theenvironmentoftheirchoice.
TheresidentsofTigerPlacehaveembracedtechnologyresearchtohelpthemand othersinthefutureageinplace.Manyofthemareparticipatinginon-goingresearch
withdevelopingsensortechnologytomeasureandinterpretADLs,detectfalls,and earlydetectionofillnessorchangesinchronichealthconditions.Asresearchers withfundingfromtheNationalScienceFoundationandAdministrationonAging, wearegratefultotheirwillingnesstohelpusaswepioneerthisimportantareaof eldercareandthedevelopmentoftechnologytohelpthemimproveandmaintain functionastheyageinplaceintheirhomes.
AtTigerPlacewehaveinstalledtheUniversityofVirginiamonitoringsystem withbed,motion,andstovesensorswirelesslyconnectedtoacomputerthatsends theeventinformationtoaserver.Countingtheeventsprovidesusefulinformation thatindicatesresidentmovementorabsenceofmovement.Inasense,thisprovides continuousfunctionalassessmentbecausetheresident’sactionstriggereventsthat arecollectedbythesensorandcounted.Theeventsareorganizedintoadisplayof countsofthevarioussensorsoverashortperiodoftime;typicallythemostconvenientisanhourorseveralhours.Moreover,sensorfiringscouldbegroupedand activitiescouldbeinferred.Thebedsensoractivitycountsperdayareshownin Fig.2.1;usingdailygraphscanrevealtrendsovertimethatmayindicatechanges inresidentphysicalcondition.Fromthebedsensor,greateractivitymaybedue toavarietyoffactorsincludingincorrectmedicinedosageandimpendingchange inhealth.Byexaminingthedata,apictureemergesofactivitiesoftheindividual. Byrelatingthehistogramdatafortheresidenttoresident’scommentsaboutthose eventspotentialcausesofeventscanbeinterpreted.
InthedisplayofbedrestlessnessdatainFig.2.1,adramaticchangeinresident conditioncanbeseen.ThisparticularresidenthadaheartattackaroundDecember20.Forseveraldaysfollowingtheevent,theresidentwasinthehospitaland noeventsappeared.Afterreturning,significantlyhigherrestlessnesslevelsindicatehealth-relatedproblems.InlatergraphsinFebruary,aftertheproblemswere addressed,thesubject’srestlessnesslevelsreturnedtolowlevelssimilartothe graphsbeforetheheartattack.
Clearly,thistechnologyispotentiallyusefultohealthcareproviders.First,it providesadditionalinformationtohealthcareprovidersbydisplayingaquickindicationoftheresident’swellbeing,andpossibledeviationsfromtheirindividual norm.Itcanprovidelovedonesaccesstoactivityinformationoftheirimportant elderfamilymember(iftheelderagrees)usingrelativelywell-establishedcommunicationsystemssuchaswebaccess.Thedataprovidealongitudinalrecordof activitythatcanbeexaminedforchanges.
Byrelatingthechangesinsensordatatospecificeventsofresidentactivity,a healthcareprovidercanobtainapictureofspecificfunctionaldecline.Onceidentified,functionaldeclinemaybeminimizedorhaltedbyappropriateinterventions suchasphysicaltherapy,changesinmedications,orothers.Earlydetectionand interventionbyhealthcareproviderscanextendtheleveloffunctionofaresident andpossiblyevenimproveit.Modelingindividualelder’sactivitieswithadvanced computationalintelligencetechniquescanenableinterpretationofthebaseline activityofindividualsandalerthealthcareprovidersofpotentialchangesfrom baseline.Significantdeviationsfromanindividual’snormmayindicatechanges thatrequireaction.
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BOOK VIII. CHAPTER I. THE OBJECT OF PHILOSOPHICAL AND THEOLOGICAL INQUIRY THE DISCOVERY OF TRUTH.
ut the most ancient of the philosophers were not carried away to disputing and doubting, much less are we, who are attached to the really true philosophy, on whom the Scripture enjoins examination and investigation. For it is the more recent of the Hellenic philosophers who, by empty and futile love of fame, are led into useless babbling in refuting and wrangling. But, on the contrary, the Barbarian philosophy, expelling all contention, said, “Seek, and ye shall find; knock, and it shall be opened unto you; ask, and it shall be given you.”[1318]
Accordingly, by investigation, the point proposed for inquiry and answer knocks at the door of truth, according to what appears. And on an opening being made through the obstacle in the process of investigation, there results scientific contemplation. To those who thus knock, according to my view, the subject under investigation is opened.
And to those who thus ask questions, in the Scriptures, there is given from God (that at which they aim) the gift of the God-given knowledge, by way of comprehension, through the true illumination of logical investigation. For it is impossible to find, without having sought; or to have sought, without having examined; or to have examined, without having unfolded and opened up the question by interrogation, to produce distinctness; or again, to have gone through the whole investigation, without thereafter receiving as the prize the knowledge of the point in question.
But it belongs to him who has sought, to find; and to him to seek, who thinks previously that he does not know. Hence drawn by desire to the discovery of what is good, he seeks thoughtfully, without love of strife or glory, asking, answering, and besides considering the statements made. For it is incumbent, in applying ourselves not only to the divine Scriptures, but also to common notions, to institute investigations, the discovery ceasing at some useful end.
For another place and crowd await turbulent people, and forensic sophistries. But it is suitable for him, who is at once a lover and disciple of the truth, to be pacific even in investigations, advancing by scientific demonstration, without love of self, but with love of truth, to comprehensive knowledge.
CHAPTER II. THE NECESSITY OF PERSPICUOUS DEFINITION. What better or clearer method, for the commencement of instruction of this nature, can there be than discussion of the term advanced, so distinctly, that all who use the same language may follow it? Is the term for demonstration of such a kind as the word Blityri, which is a mere sound, signifying nothing? But how is it that neither does the philosopher, nor the orator,—no more does the judge,—adduce demonstration as a term that means nothing; nor is any of the contending parties ignorant of the fact, that the meaning does not exist?
Philosophers, in fact, present demonstration as having a substantial existence, one in one way, another in another. Therefore, if one would treat aright of each question, he cannot carry back the discourse to another more generally admitted fundamental principle than what is admitted to be signified by the term by all of the same nation and language.
Then, starting from this point, it is necessary to inquire if the proposition has this signification or not. And next, if it is demonstrated to have, it is necessary to investigate its nature accurately, of what kind it is, and whether it ever passes over the class assigned. And if it suffices not to say, absolutely, only that which one thinks (for one’s opponent may equally allege, on the other side, what he likes); then what is stated must be confirmed. If the decision of it be carried back to what is likewise matter of dispute, and the decision of that likewise to another disputed point, it will go on adinfinitum, and will be incapable of demonstration. But if the belief of a point that is not admitted be carried back to one admitted by all, that is to be made the commencement of instruction. Every term, therefore, advanced for discussion is to be converted into an expression that is admitted by those that are parties in the discussion, to form the starting point for instruction, to
lead the way to the discovery of the points under investigation. For example, let it be the term “sun” that is in question. Now the Stoics say that it is “an intellectual fire kindled from the waters of the sea.” Is not the definition, consequently, obscurer than the term, requiring another demonstration to prove if it be true? It is therefore better to say, in the common and distinct form of speech, “that the brightest of the heavenly bodies is named the sun.” For this expression is more credible and clearer, and is likewise admitted by all.
CHAPTER III. DEMONSTRATION DEFINED. Similarly, also, all men will admit that demonstration is discourse, [1319] agreeable to reason, producing belief in points disputed, from points admitted.
Now, not only demonstration and belief and knowledge, but foreknowledge also, are used in a twofold manner. There is that which is scientific and certain, and that which is merely based on hope.
In strict propriety, then, that is called demonstration which produces in the souls of learners scientific belief. The other kind is that which merely leads to opinion. As also, both he that is really a man, possessing common judgment, and he that is savage and brutal,—each is a man. Thus also the Comic poet said that “man is graceful, so long as he is man.” The same holds with ox, horse, and dog, according to the goodness or badness of the animal. For by looking to the perfection of the genus, we come to those meanings that are strictly proper. For instance, we conceive of a physician who is deficient in no element of the power of healing, and a Gnostic who is defective in no element of scientific knowledge.
Now demonstration differs from syllogism; inasmuch as the point demonstrated is indicative of one thing, being one and identical; as we say that to be with child is the proof of being no longer a virgin. But what is apprehended by syllogism, though one thing, follows from several; as, for example, not one but several proofs are adduced of Pytho having betrayed the Byzantines, if such was the fact. And to draw a conclusion from what is admitted is to syllogize; while to draw a conclusion from what is true is to demonstrate.
So that there is a compound advantage of demonstration: from its assuming, for the proof of points in question, true premisses, and from its drawing the conclusion that follows from them. If the first
have no existence, but the second follow from the first, one has not demonstrated, but syllogized. For, to draw the proper conclusion from the premisses, is merely to syllogize. But to have also each of the premisses true, is not merely to have syllogized, but also to have demonstrated.
And to conclude, as is evident from the word, is to bring to the conclusion. And in every train of reasoning, the point sought to be determined is the end, which is also called the conclusion. But no simple and primary statement is termed a syllogism, although true; but it is compounded of three such, at the least,—of two as premises, and one as conclusion.
Now, either all things require demonstration, or some of them are self-evident. But if the first, by demanding the demonstration of each demonstration we shall go on ad infinitum; and so demonstration is subverted. But if the second, those things which are self-evident will become the starting points [and fundamental grounds] of demonstration.
In point of fact, the philosophers admit that the first principles of all things are indemonstrable. So that if there is demonstration at all, there is an absolute necessity that there be something that is selfevident, which is called primary and indemonstrable.
Consequently all demonstration is traced up to indemonstrable faith.
It will also turn out that there are other starting points for demonstrations, after the source which takes its rise in faith,—the things which appear clearly to sensation and understanding. For the phenomena of sensation are simple, and incapable of being decompounded; but those of understanding are simple, rational, and primary. But those produced from them are compound, but no less clear and reliable, and having more to do with the reasoning faculty than the first. For therefore the peculiar native power of reason, which we all have by nature, deals with agreement and disagreement. If, then, any argument be found to be of such a kind,
as from points already believed to be capable of producing belief in what is not yet believed, we shall aver that this is the very essence of demonstration.
Now it is affirmed that the nature of demonstration, as that of belief, is twofold: that which produces in the souls of the hearers persuasion merely, and that which produces knowledge.
If, then, one begins with the things which are evident to sensation and understanding, and then draw the proper conclusion, he truly demonstrates. But if [he begin] with things which are only probable and not primary, that is evident neither to sense nor understanding, and if he draw the right conclusion, he will syllogize indeed, but not produce a scientific demonstration; but if [he draw] not the right conclusion, he will not syllogize at all.
Now demonstration differs from analysis. For each one of the points demonstrated, is demonstrated by means of points that are demonstrated; those having been previously demonstrated by others; till we get back to those which are self-evident, or to those evident to sense and to understanding; which is called Analysis. But demonstration is, when the point in question reaches us through all the intermediate steps. The man, then, who practises demonstration, ought to give great attention to the truth, while he disregards the terms of the premisses, whether you call them axioms, or premisses, or assumptions. Similarly, also, special attention must be paid to what suppositions a conclusion is based on; while he may be quite careless as to whether one choose to term it a conclusive or syllogistic proposition.
For I assert that these two things must be attended to by the man who would demonstrate—to assume true premisses, and to draw from them the legitimate conclusion, which some also call “the inference,” as being what is inferred from the premisses.
Now in each proposition respecting a question, there must be different premisses, related, however, to the proposition laid down; and what is advanced must be reduced to definition. And this
definition must be admitted by all. But when premisses irrelevant to the proposition to be established are assumed, it is impossible to arrive at any right result; the entire proposition—which is also called the question of its nature—being ignored.
In all questions, then, there is something which is previously known,—that which being self-evident is believed without demonstration; which must be made the starting point in their investigation, and the criterion of apparent results.
CHAPTER IV. TO PREVENT AMBIGUITY, WE MUST BEGIN WITH CLEAR DEFINITION.
For every question is solved from pre-existing knowledge. And the knowledge pre-existing of each object of investigation is sometimes merely of the essence, while its functions are unknown (as of stones, and plants, and animals, of whose operations we are ignorant), or [the knowledge] of the properties, or powers, or (so to speak) of the qualities inherent in the objects. And sometimes we may know some one or more of those powers or properties,—as, for example, the desires and affections of the soul,—and be ignorant of the essence, and make it the object of investigation. But in many instances, our understanding having assumed all these, the question is, in which of the essences do they thus inhere; for it is after forming conceptions of both—that is, both of essence and operation —in our mind, that we proceed to the question. And there are also some objects, whose operations, along with their essences, we know, but are ignorant of their modifications.
Such, then, is the method of the discovery [of truth]. For we must begin with the knowledge of the questions to be discussed. For often the form of the expression deceives and confuses and disturbs the mind, so that it is not easy to discover to what class the thing is to be referred; as, for example, whether the fœtus be an animal. For, having a conception of an animal and a fœtus, we inquire if it be the case that the fœtus is an animal; that is, if the substance which is in the fœtal state possesses the power of motion, and of sensation besides. So that the inquiry is regarding functions and sensations in a substance previously known. Consequently the man who proposes the question is to be first asked, what he calls an animal. Especially is this to be done whenever we find the same term applied to various purposes; and we must examine whether what is signified by the term is disputed, or admitted by all. For were one to say that he calls whatever grows and is fed an animal, we shall have again to ask further, whether he considered plants to be animals; and then,
after declaring himself to this effect, he must show what it is which is in the fœtal state, and is nourished.
For Plato calls plants animals, as partaking the third species of life alone, that of appetency.[1320] But Aristotle, while he thinks that plants are possessed of a life of vegetation and nutrition, does not consider it proper to call them animals; for that alone, which possesses the other life—that of sensation—he considers warrantable to be called an animal. The Stoics do not call the power of vegetation, life.
Now, on the man who proposes the question denying that plants are animals, we shall show that he affirms what contradicts himself. For, having defined the animal by the fact of its nourishment and growth, but having asserted that a plant is not an animal, it appears that he says nothing else than that what is nourished and grows is both an animal and not an animal.
Let him, then, say what he wants to learn. Is it whether what is in the womb grows and is nourished, or is it whether it possesses any sensation or movement by impulse? For, according to Plato, the plant is animate, and an animal; but according to Aristotle, not an animal, for it wants sensation, but is animate. Therefore, according to him, an animal is an animate sentient being. But according to the Stoics, a plant is neither animate nor an animal; for an animal is an animate being. If, then, an animal is animate, and life is sentient nature, it is plain that what is animate is sentient. If, then, he who has put the question, being again interrogated if he still calls the animal in the fœtal state an animal on account of its being nourished and growing, he has got his answer.
But were he to say that the question he asks is, whether the fœtus is already sentient, or capable of moving itself in consequence of any impulse, the investigation of the matter becomes clear, the fallacy in the name no longer remaining. But if he do not reply to the interrogation, and will not say what he means, or in respect of what consideration it is that he applies the term “animal” in propounding
