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J N Morris

Publications and source records attributed to J N Morris.

At least 37 records · Page 2Linked to original sources
PubMed1999

Integrated health information systems based on the RAI/MDS series of instruments.

There is a growing need for an integrated health information system to be used in community, institutional and hospital based settings. For example, changes in the structure, process and venues of service delivery mean that individuals with similar needs may be cared for in a variety of different settings. Moreover, as people make transitions from one sector of the healthcare system to another, there is a need for comparable information to ensure continuity of care and reduced assessment burden. The RAI/MDS series of assessment instruments comprise an integrated health information system because they have consistent terminology, common core items, and a common conceptual basis in a clinical approach that emphasizes the identification of functional problems.

Canada↗
PubMed1999

Nursing home characteristics and the development of pressure sores and disruptive behaviour.

OBJECTIVE: To determine how nursing home characteristics affect pressure sores and disruptive behaviour. METHOD: Residents (n = 5518, aged > or =60 years) were selected from 70 nursing homes in the National Health Care chain. Homes were classified as high- or low-risk based on incidence tertiles of pressure sores or disruptive behaviour (1989-90). Point-prevalence and cumulative incidence of pressure sores and disruptive behaviour were examined along with other functional and service variables. RESULTS: The overall incidence of pressure sores was 11.4% and the relative risk was 4.3 times greater in high- than low-risk homes; for disruptive behaviour, the incidence was 27% and the relative risk was 7.1 times greater in the high-risk group. At baseline, fewer subjects in homes with a high risk of pressure sores were white or in restraints, but more had received physician visits monthly and had had problems with transfers and eating. High-risk homes also had fewer beds and used less non-licensed nursing staff time. At follow-up (1987-90), 52% of homes in the low-risk group and 35% of those in the high-risk group had maintained their risk status; low-risk homes were more likely to have rehabilitation and maintenance activities. Having multiple clinical risk factors was associated with more pressure sores in high- (but not low-) risk homes, suggesting a care-burden threshold. By logistic regression, the best predictor of pressure sores was a home's prior (1987-88) incidence status. Interestingly, 67% of homes with a high risk of pressure sores were also high-risk for disruptive behaviour, while only 27% of homes with a low risk of pressure sores were high-risk for disruptive behaviour. A threshold effect was also observed between multiple risk factors and behaviour. More homes with a high risk of disruptive behaviour (68%) remained at risk over 4 years, and the best predictor of outcome was a home's previous morbidity level. CONCLUSION: Nursing-home characteristics may have a greater impact than clinical factors on pressure sores and disruptive behaviour in long-stay, institutionalized elders.

Aged↗
PubMed1999

Nursing rehabilitation and exercise strategies in the nursing home.

BACKGROUND: The purpose of this study was to evaluate how weight training or nursing-based rehabilitative care programs in nursing homes impact on resident performance of Activities of Daily Living (ADL) and objectives tests of physical performance. METHODS: This study involved a quasi-experimental control, longitudinal comparison of functional status over a 10-month period, where baseline status was adjusted through a weighting procedure based on functional status, cognitive status, and age. All residents from six residential care nursing home facilities were eligible except those with a terminal prognosis, a projected stay of less than 90 days, or with health complications that prohibited contact. Homes were placed into matched triplets based on patient characteristics: two members of each triplet were randomly designated to be experimental sites, the third became the control site. Baseline data were available for 468 subjects, follow-up for 392. ADL self-performance measures derived from the Minimum Data Set, including indicators of early loss ADL, locomotion, and late loss ADL; a number of objective functional tests (including measures of balance, power, and endurance); and mood state as measured by the Geriatric Depression Scale. RESULTS: Mean ADL values in the two experimental groups declined at a significantly lower rate than did rates for the controls. Functional decline was also lower in more specific measures: locomotion, early loss ADL, and late loss ADL. CONCLUSIONS: With both interventions, facilities were able to implement a broad-based intervention that resulted in a significant reduction in ADL decline rates. A facility-wide nursing rehabilitation program can play a useful role in reversing functional decline, helping residents to maintain their involvement in a broad spectrum of ADL activities.

Activities of Daily Living↗
PubMed1999

Scaling ADLs within the MDS.

BACKGROUND: Dependency in activities of daily living (ADLs) is a reality within nursing homes, and we describe ADL measurement strategies based on items in the Minimum Data Set (MDS) and the creation and distributional properties of three ADL self-performance scales and their relationship to other measures. METHODS: Information drawn from four data sets for a multistep analysis was guided by four study objectives: (1) to identify the subcomponents of ADLs that are present in the MDS battery; (2) to demonstrate how these items could be aggregated within hierarchical and additive ADL summary scales; (3) to describe the baseline and longitudinal distributional properties of these scales in a large, seven-state MDS database; and (4) to evaluate how these scales relate to two external criteria. RESULTS: Prevalence and factor structure findings for seven MDS ADL self-performance variables suggest that these items can be placed into early, middle, and late loss ADL components. Two types of summary ADL self-performance measures were created: additive and hierarchical. Distributional properties of these scales are described, as is their relationship to two external ADL criteria that have been reported in prior studies: first as an independent variable predicting staff time involved in resident care; second as a dependent variable in a study of the efficacy of two programs to improve resident functioning. CONCLUSIONS: The new ADL summary scales, based on readily available MDS data, should prove useful to clinicians, program auditors, and researchers who use the MDS functional self-performance items to determine a resident's ADL status.

Activities of Daily Living↗
PubMed1999

Educational attainment, deprivation-affluence and self reported health in Britain: a cross sectional study.

STUDY OBJECTIVE: The level of material deprivation or affluence is strongly and independently correlated with all cause mortality at an area level, but educational attainment, after controlling for deprivation-affluence, remains strongly associated with coronary and infant mortality. This study investigated whether these relations hold at an individual level with self reported morbidity. DESIGN: Analysis of the cross sectional associations of self reported longstanding illness and "not good" or "fairly good" self assessed health with individual educational attainment in seven levels, adjusting for deprivation measures (economic status of head of household, car ownership, housing tenure, overcrowding). SETTING: The 1993 General Household Survey, a random sample of households in Great Britain. PARTICIPANTS: 11,634 subjects aged 22 to 69. MAIN RESULTS: After adjusting for household deprivation, lower educational attainment was significantly associated with longstanding illness in men (odds ratio 1.05 per education category, 95% CI 1.02 to 1.08), but not in women (odds ratio 1.01, 95% CI 0.98 to 1.04). The associations with "not good" or "fairly good" self assessed health were stronger and significant in both men and women (men 1.13, 95% CI 1.10 to 1.17; women 1.10, 95% CI 1.07 to 1.14). The findings were little changed by allowing for people in poor health becoming economically inactive. CONCLUSIONS: The associations of self reported health with deprivation-affluence are stronger than with educational attainment. However, educational attainment is associated with self assessed health in adulthood, independently of deprivation-affluence. Longstanding illness may be associated with educational attainment in men only. Educational attainment may be a marker for childhood socioeconomic circumstances, its association with health may result from occupational characteristics, or education may influence the propensity to follow health education advice.

Adult↗
PubMed1997

Development of the nursing home Resident Assessment Instrument in the USA.

BACKGROUND: the nursing home Resident Assessment Instrument (RAI) includes a set of core assessment items, known as the Minimum Data Set (MDS), for assessment and care screening and more detailed Resident Assessment Protocols in 18 areas that represent common problem areas or risk factors for nursing home residents. Its primary use is clinical, to assess residents on admission to the nursing home, at least annually thereafter and on any significant change in status and to develop individualized, restorative plans of care. AIM: to describe the content and development of the RAI, including US testing for MDS item reliability and validity of the RAI, and the results of a 4-year evaluation of the effects of its clinical use. CONCLUSIONS: the evaluation found that implementation of the RAI was associated with significant improvements in a variety of measures of process quality, resident functional outcomes and reduced hospitalization. Other uses of the RAI data in the USA-including payment using resident classification systems and, with RAI-based outcome-oriented quality indicators, quality assurance activities-and the status of RAI use in other countries are also summarized.

Aged↗
PubMed1997

Efforts to establish the reliability of the Resident Assessment Instrument.

BACKGROUND: since its original implementation in the USA, the Resident Assessment Instrument (RAI) has been used in many countries in languages other than English. This paper describes the efforts that have been made to test the inter-rater reliability of the core set of items forming the minimum data set items in the USA and in non-English speaking countries (Denmark, Iceland, Italy, Japan, Sweden and Switzerland). RESULTS: a large proportion (from 70 to 96%) of the items in the RAI achieved an adequate to excellent level of reliability, with no substantial differences across countries. The RAI met the standard for good reliability (i.e. a kappa value of 0.6 or higher) in crucial areas of functional status, such as memory, activities of daily living self-performance and support, and bowel and bladder continence in most of the countries. Indicators of mood and behavioural problems achieved adequate reliability levels of 0.4 or higher.

Activities of Daily Living↗
PubMed1997

Low-care cases in long-term care settings: variation among nations.

METHOD: residents of long-term care settings without major activity of daily living (ADL) deficits are often referred to as 'low-care cases' and are deemed inappropriately placed in an institution. We compare the prevalence and characteristics of this population in Denmark, Iceland, Italy, Japan, Sweden and the USA, using the Resident Assessment Instrument Minimum Data Set. RESULTS: among the six nations, the percentage of low-care cases ranged from 27 to 52% using a broad definition of no physical assistance required in late-loss ADLs (bed mobility, toileting, transfer and eating). With a more narrow definition which additionally excludes those falling into the Resource Utilization Groups, version III categories of rehabilitation, clinically complex, impaired cognition and behaviour problems, the percentages seen range from 9 to 35%. Finally, 2-14% meet the most restrictive definition, which further excluded residents requiring any supervision in late-loss ADLs, with any deficits in early-loss ADLs (dressing or grooming) or needing medical and psychiatric supervision. CONCLUSION: although long-term care settings differ, making comparison by country difficult, the use of the same standard assessment form makes it possible to compare the many reasons for institutionalization.

Activities of Daily Living↗
PubMed1997

The OBRA-87 nursing home regulations and implementation of the Resident Assessment Instrument: effects on process quality.

OBJECTIVE: To characterize changes in key aspects of process quality received by nursing home residents before and after the implementation of the national nursing home Resident Assessment Instrument (RAI) and other aspects of the Omnibus Budget Reconciliation Act (OBRA) nursing home reforms. DESIGN: A quasi-experimental study using a complex, multistage probability-based sample design, with data collected before (1990) and after (1993) implementation of the RAI and other OBRA provisions. SETTING AND PARTICIPANTS: Two independent cohorts (n > 2000) of residents in a random sample of 254 nursing facilities located in metropolitan statistical areas in 10 states. INTERVENTION: OBRA-87 enhanced the regulation of nursing homes and included new requirements on quality of care, resident assessment, care planning, and the use of neuroleptic drugs and physical restraints. One of the key provisions, used to help implement the OBRA requirements in daily nursing home practice, was the mandatory use of a standardized, comprehensive system, known as the RAI, to assist in assessment and care planning. OBRA provisions went into effect in federal law on October 1, 1990, although delays issuing the regulations led to actual implementation of the RAI during the Spring of 1991. MEASUREMENTS AND ANALYSES: Research nurses spent an average of 4 days per facility in each data collection round, assessing a sample of residents, collecting data through interviews with and observations of residents, interviews with multiple shifts of direct staff caregivers for the sampled residents, and review of medical records, including physician's orders, treatment and care plans, nursing progress notes, and medication records. The RNs collected data on the characteristics of the sampled residents, on the care they received, and on facility practices. The effect of being a member of the 1990 pre-OBRA or the 1993 post-OBRA cohort was assessed on the accuracy of information in the residents' medical records, the comprehensiveness of care plans, and on other key aspects of process quality while controlling for any changes in resident case-mix. The data were analyzed using contingency tables and logistic regression and a special statistical software (SUDAAN) to assure proper variance estimation. RESULTS: Overall, the process of care in nursing homes improved in several important areas. The accuracy of information in residents' medical records increased substantially, as did the comprehensiveness of care plans. In addition, several problematic care practices declined during this period, including use of physical restraints (37.4 to 28.1% (P < .001)) and indwelling urinary catheters (9.8 to 7% (P < .001)). There were also increases in good care practices, such as the presence of advanced directives, participation in activities, and use of toileting programs for residents with bowel incontinence. These results were sustained after controlling for differences in the resident characteristics between 1990 and 1993. Other practices, such as use of antipsychotic drugs, behavior management programs, preventive skin care, and provision of therapies were unaffected, or the differences were not statistically significant, after adjusting for changes in resident case-mix. CONCLUSION: The OBRA reforms and introduction of the RAI constituted an unprecedented implementation of comprehensive geriatric assessment in Medicare- and Medicaid-certified nursing homes. The evaluation of the effects of these interventions demonstrates significant improvements in the quality of care provided to residents. At the same time, these findings suggest that more needs to be done to improve process quality. The results suggest the RAI is one tool that facility staff, therapists, pharmacy consultants, and physicians can use to support their continuing efforts to provide high quality of care and life to the nation's 1.7 million nursing home residents.

Advance Directives↗
PubMed1997

Association of the Resident Assessment Instrument (RAI) with changes in function, cognition, and psychosocial status.

OBJECTIVE: To evaluate the impact of the Resident Assessment Instrument (RAI) on changes in nursing home residents' functional status, cognitive status, and psychosocial well-being. DESIGN: A quasi-experiment involving the collection of longitudinal data on two cohorts of nursing home residents. One cohort was assessed before the implementation of the RAI, and the other was assessed after the implementation of the new assessment process. SETTING AND PARTICIPANTS: Over 2000 nursing home residents in 267 nursing homes located in 10 geographic areas were assessed during the pre-RAI period. In the post-RAI period, 2000 new residents in 254 of the same facilities were assessed. INTERVENTION: RAI implementation began in October 1990 and continued until October 1991. The RAI includes a structured, multidimensional resident assessment and problem identification system designed to form the basis for residents' care plans. MEASUREMENTS: All residents were assessed at baseline and at 6 months using the Minimum Data Set for Nursing Home Resident Assessment and Care Screening (MDS) and its protocols. All data were collected by research nurses employed and trained by the research team. RESULTS: Implementation of the RAI significantly reduced the rate of decline in seven of the nine outcomes under consideration. Reductions in improvement were also observed in all outcomes. In activities of daily living, social engagement, and cognitive function, the reduced decline far outweighed any reductions in improvement. In mood problems, problem behaviors, and understanding others, however, reductions in improvement were greater than any reductions in decline. Changes in the rates of decline and improvement were not uniform across all residents. CONCLUSION: The RAI may have improved the quality of care of nursing home residents by reducing overall rates of decline in important areas of resident function. However, this innovation may have generated trade-offs in that it may have reduced improvement rates in some areas of function. The system's implementation also seems to have focused staff's attention on the needs and strengths of specific subpopulations of residents. Revisions of the RAI must assist staff in generalizing their efforts to all residents and to increasing improvement rates, especially in areas related to mood and behavior.

Activities of Daily Living↗
PubMed1997

Effect of the National Resident Assessment Instrument on selected health conditions and problems.

OBJECTIVE: To evaluate the effect of the implementation of the National Resident Assessment Instrument (RAI) system on selected conditions representing outcomes for nursing home residents. DESIGN: Quasi-experimental, pre-/post-design, with assessments at baseline and 6-month follow-up. SAMPLE: Two thousand one hundred twenty-eight residents from 268 nursing homes in 10 states before RAI implementation, and 2,088 from 254 of the same nursing homes after implementation. MEASURES: From the full RAI Minimum Data Set, measures of dehydration, falls, decubitus, vision problems, stasis ulcer, pain, dental status (poor teeth), and malnutrition were examined at baseline and 6 months later. Poor nutrition was evaluated using a body mass index score below 20 and vision using a 4-level scale; other conditions were represented by their presence or absence. Decline and improvement were computed as the changes in level between baseline and follow-up, limiting the sample to those who could manifest each such change. MAIN RESULTS: Of eight health conditions representing poorer health status, dehydration and stasis ulcer had significantly lower prevalence after the implementation of the RAI (1993) compared with 1990. At the same time, there was an increase in the prevalence of daily pain. Fewer residents declined over 6 months in nutrition and vision after implementation. Although for these two conditions there were also significantly reduced rates of improvement, the net was an overall reduction in the 6-month rate of decline for all residents. Pain also demonstrated a decline in the postimplementation rate of improvement. The combined eight conditions showed reductions in the rates of both decline and improvement. CONCLUSIONS: Several outcomes for nursing home residents improved after implementation of the RAI. Of the four conditions for which there are significant declines in prevalence or outcome changes, three are specifically addressed in the care planning guidelines incorporated the RAI system (all except stasis ulcer, although there is a RAP for decubitus ulcer). Pain, the only other condition with a significant result --an increase in baseline prevalence--also has no RAP. Although the changes might be ascribed otherwise, they support the premise that the RAI has directly contributed to improved outcomes for nursing home residents.

Accidental Falls↗
PubMed1997

A commitment to change: revision of HCFA's RAI.

OBJECTIVE: To describe the reliability of new assessment items and their clinical utility as judged by experienced nurse assessors, based on the results from the field test of Version 2.0 of the Resident Assessment Instrument (RAI). DESIGN: Independent dual assessment of residents of nursing facilities by staff nurses using a draft of Version 2.0 of the minimum data set (MDS). SETTING AND PARTICIPANTS: A total of 187 randomly selected residents from 21 nursing homes in seven states volunteered to test Version 2.0 of the MDS. MEASUREMENT: The full array of MDS assessment items included measures in the following areas: Background information, cognitive patterns, communication/hearing, vision, mood and behavior, psychosocial well-being, physical functioning and structural problems, continence, disease diagnoses, health condition, oral/nutritional status, dental status, skin condition, activity pursuit patterns, medications, special treatments and procedures, and discharge potential and overall status. RESULTS: Evaluative data address issues of MDS item utility and reliability. For new items, almost all achieved a reasonably high-weighted Kappa interrater reliability; revised items also surpassed earlier items, and with the updated training materials, even the non-changed items had higher average reliability levels. Based on the success of the field test and the positive response of the industry, Version 2.0 of the RAI has been adopted, and HCFA has initiated a more long-range process to update further the RAI when necessary. CONCLUSION: Findings support the reliability and clinical utility of the new and revised assessment items incorporated by HCFA in Version 2.0 of the MDS.

Activities of Daily Living↗
PubMed1997

Comprehensive clinical assessment in community setting: applicability of the MDS-HC.

OBJECTIVE: To describe the results of an international trial of the home care version of the MDS assessment and problem identification system (the MDS-HC), including reliability estimates, a comparison of MDS-HC reliabilities with reliabilities of the same items in the MDS 2.0 nursing home assessment instrument, and an examination of the types of problems found in home care clients using the MDS-HC. DESIGN: Independent, dual assessment of clients of home-care agencies by trained clinicians using a draft of the MDS-HC, with additional descriptive data regarding problem profiles for home care clients. SETTING AND PARTICIPANTS: Reliability data from dual assessments of 241 randomly selected clients of home care agencies in five countries, all of whom volunteered to test the MDS-HC. Also included are an expanded sample of 780 home care assessments from these countries and 187 dually assessed residents from 21 nursing homes in the United States. MEASUREMENTS: The array of MDS-HC assessment items included measures in the following areas: personal items, cognitive patterns, communication/hearing, vision, mood and behavior, social functioning, informal support services, physical functioning, continence, disease diagnoses health conditions and preventive health measures, nutrition/hydration, dental status, skin condition, environmental assessment, service utilization, and medications. RESULTS: Forty-seven percent of the functional, health status, social environment, and service items in the MDS-HC were taken from the MDS 2.0 for nursing homes. For this item set, it is estimated that the average weighted Kappa is .74 for the MDS-HC and .75 for the MDS 2.0. Similarly, high reliability values were found for items newly introduced in the MDS-HC (weighted Kappa = .70). Descriptive findings also characterize the problems of home care clients, with subanalyses within cognitive performance levels. CONCLUSION: Findings indicate that the core set of items in the MDS 2.0 work equally well in community and nursing home settings. New items are highly reliable. In tandem, these instruments can be used within the international community, assisting and planning care for older adults within a broad spectrum of service settings, including nursing homes and home care programs. With this community-based, second-generation problem and care plan-driven assessment instrument, disability assessment can be performed consistently across the world.

Activities of Daily Living↗
PubMed1997

The effect of specific medical conditions on functional decline.

OBJECTIVES: To examine how functional status among older community-dwelling residents differs over time between those with and those without specific medical conditions. DESIGN: Prospective cohort study. PARTICIPANTS: A total of 1060 community-dwelling Massachusetts residents aged 65 or older who were not totally functionally dependent at baseline assessment. MEASUREMENTS: Functional status, five medical conditions (heart problem, arthritis, diabetes, cancer, and stroke), and the total number of these five medical conditions. Assessments were done at baseline and at two annual follow-ups. RESULTS: Adjusted repeated measures analysis of covariance revealed a time difference (P < .001) for all five medical conditions and group differences for diabetes (P = .006) and stroke (P < .001). Functional abilities declined over time and those with specific medical conditions were more impaired initially, but the rate of decline did not significantly differ from those free of the condition. The presence of each additional medical condition resulted in additional impairment (P < .001), but the rate of decline over time did not differ by number of medical conditions. CONCLUSIONS: Efforts to reduce or prevent the development of specific medical conditions are essential to maintaining functional independence of older people as well as to reducing use of supportive services and admission rates to nursing homes. Particular attention should be directed toward preventing stroke since its consequences are the most functionally disabling.

Activities of Daily Living↗
PubMed1997

The prevalence of potentially remediable urinary incontinence in frail older people: a study using the Minimum Data Set.

OBJECTIVES: To use the Minimum Data Set (MDS) to describe the frequency and correlates of potentially treatable causes of urinary incontinence among a representative sample of American nursing home residents. To describe current management practices of urinary incontinence in the same population. DESIGN: Cross-sectional study using the dataset that was part of the Health Care Financing Administration (HCFA) evaluation of the MDS. SETTING: 270 Medicaid-certified nursing homes in 10 states. PARTICIPANTS: A total of 2014 nursing home residents 60 years or older (mean = 84.3 +/- 8.7), 75.5% women, 81.9% white, who lived in a nursing home during the fall of 1990 were randomly selected to sample a fixed number of residents for each facility based on facility size. MEASUREMENTS: Incontinence was defined as the presence of at least two episodes of urinary leakage per week in the previous 2 weeks. Management techniques (toileting, pads/briefs, catheters) were those listed in the MDS. Potentially remediable causes of urinary incontinence available in the MDS were: medications (antipsychotics, antidepressants, and antianxiety/hypnotics); congestive heart failure; diabetes mellitus; pedal edema; delirium; depression; and impairments in activities of daily living (ADLs) (transferring, locomotion, dressing, toileting; bedrails; trunk restraints; and chair restraints). RESULTS: Forty-nine percent of residents were incontinent. Of these, 84.0% were managed by pads/briefs, 38.7% by scheduled toileting, 3.5% by indwelling catheter, and 1.2% by external catheter. Of the potentially reversible causes, bivariate analysis revealed associations (P < .1) with use of antidepressants, antipsychotics, and antianxiety/hypnotics; delirium; bedrails; trunk restraints; chair restraints; and ADL impairment. Dementia was also associated with incontinence (P < .1). Multivariate analysis revealed that urinary incontinence was independently associated with impairment in ADLs (OR = 4.2; CI = 3.2,5.6), dementia (OR = 2.3;CI = 1.8,3.0), restraints-trunk (OR = 1.7; CI = 1.5,2.0), chair (OR = 1.4; CI = 1.2,1.6), bedrails (OR = 1.3; CI = 1.1,1.5), and use of antianxiety/hypnotic medications (OR = .7;CI = .5,1.0) (all P < .04). CONCLUSIONS: Current management practices for urinary incontinence are inconsistent with advocated guidelines. These data also confirm the association between incontinence and several potentially remediable conditions and suggest that, even in the nursing home setting, urinary incontinence may respond to efforts to improve conditions not directly related to bladder function. This study underscores the need to examine the impact on urinary incontinence of strategies to address such conditions.

Activities of Daily Living↗
PubMed1997

Walking to health.

Walking is a rhythmic, dynamic, aerobic activity of large skeletal muscles that confers the multifarious benefits of this with minimal adverse effects. Walking, faster than customary, and regularly in sufficient quantity into the 'training zone' of over 70% of maximal heart rate, develops and sustains physical fitness: the cardiovascular capacity and endurance (stamina) for bodily work and movement in everyday life that also provides reserves for meeting exceptional demands. Muscles of the legs, limb girdle and lower trunk are strengthened and the flexibility of their cardinal joints preserved; posture and carriage may improve. Any amount of walking, and at any pace, expends energy. Hence the potential, long term, of walking for weight control. Dynamic aerobic exercise, as in walking, enhances a multitude of bodily processes that are inherent in skeletal muscle activity, including the metabolism of high density lipoproteins and insulin/glucose dynamics. Walking is also the most common weight-bearing activity, and there are indications at all ages of an increase in related bone strength. The pleasurable and therapeutic, psychological and social dimensions of walking, whilst evident, have been surprisingly little studied. Nor has an economic assessment of the benefits and costs of walking been attempted. Walking is beneficial through engendering improved fitness and/or greater physiological activity and energy turnover. Two main modes of such action are distinguished as: (i) acute, short term effects of the exercise; and (ii) chronic, cumulative adaptations depending on habitual activity over weeks and months. Walking is often included in studies of exercise in relation to disease but it has seldom been specifically tested. There is, nevertheless, growing evidence of gains in the prevention of heart attack and reduction of total death rates, in the treatment of hypertension, intermittent claudication and musculoskeletal disorders, and in rehabilitation after heart attack and in chronic respiratory disease. Walking is the most natural activity and the only sustained dynamic aerobic exercise that is common to everyone except for the seriously disabled or very frail. No special skills or equipment are required. Walking is convenient and may be accommodated in occupational and domestic routines. It is self-regulated in intensity, duration and frequency, and, having a low ground impact, is inherently safe. Unlike so much physical activity, there is little, if any, decline in middle age. It is a year-round, readily repeatable, self-reinforcing, habit-forming activity and the main option for increasing physical activity in sedentary populations. Present levels of walking are often low. Familiar social inequalities may be evident. There are indications of a serious decline of walking in children, though further surveys of their activity, fitness and health are required. The downside relates to the incidence of fatal and non-fatal road casualties, especially among children and old people, and the deteriorating air quality due to traffic fumes which mounting evidence implicates in the several stages of respiratory disease. Walking is ideal as a gentle start-up for the sedentary, including the inactive, immobile elderly, bringing a bonus of independence and social well-being. As general policy, a gradual progression is indicated from slow, to regular pace and on to 30 minutes or more of brisk (i.e. 6.4 km/h) walking on most days. These levels should achieve the major gains of activity and health-related fitness without adverse effects. Alternatively, such targets as this can be suggested for personal motivation, clinical practice, and public health. The average middle-aged person should be able to walk 1.6 km comfortably on the level at 6.4 km/h and on a slope of 1 in 20 at 4.8 km/h, however, many cannot do so because of inactivity-induced unfitness. The physiological threshold of 'comfort' represents 70% of maximum heart rate. (ABSTRACT TRUNCATED)

Cardiovascular Diseases↗