Validation of a Modified Life-Space Assessment in Multimorbid Older Persons With Cognitive Impairment

Validation of a Modified Life-Space Assessment in Multimorbid Older Persons With Cognitive... Abstract Background and Objectives To investigate the validity, reliability, sensitivity to change, and feasibility of a modified University of Alabama at Birmingham Study of Aging Life-Space Assessment (UAB-LSA) in older persons with cognitive impairment (CI). Research Design and Methods The UAB-LSA was modified for use in persons with CI Life-Space Assessment for Persons with Cognitive Impairment (LSA-CI). Measurement properties of the LSA-CI were investigated using data of 118 multimorbid older participants with CI [mean age (SD): 82.3 (6.0) years, mean Mini-Mental State Examination score: 23.3 (2.4) points] from a randomized controlled trial (RCT) to improve motor performance and physical activity. Construct validity was asessed by Spearman’s rank (rs) and point-biseral correlations (rpb) with age, gender, motor, and cognitive status, psychosocial factors, and sensor-derived (outdoor) physical activity variables. Test–retest reliability was analyzed using intra-class correlation coefficients (ICCs). Sensitivity to change was determined by standardized response means (SRMs) calculated for the RCT intervention group. Results The LSA-CI demonstrated moderate to high construct validity, with significant correlations of the LSA-CI scores with (outdoor) physical activity (rs = .23–.63), motor status (rs = .27–.56), fear of falling-related psychosocial variables (rs = |.24–.44|), and demographic characteristics (rpb = |.27–.32|). Test–retest reliability was good to excellent (ICC = .65–.91). Sensitivity to change was excellent for the LSA-CI composite score (SRM = .80) and small to moderate for the LSA-CI subscores (SRM = .35–.60). A completion rate of 100% and a mean completion time of 4.1 min) documented good feasibility. Discussion and Implications The LSA-CI represents a valid, reliable, sensitive, and feasible interview-based life-space assessment tool in multimorbid older persons with CI. Assessment of Conditions/People, Clinical Trial Methods, Quantitative research methods, Measurement, Exercise/Physical Activity, Cognitive Impairment, Validation Introduction Community mobility has been conceptualized and measured in terms of life-space (Webber, Porter, & Menec, 2010), a concept which encompasses a concentric pattern of mobility zones from own bedroom to regions beyond city limits. Life-space measures quantify activity and location of mobility influenced by interaction between functional, cognitive, and psychosocial ability with social, economic and cultural aspects (Parker, Baker, & Allman, 2002). Restricted life-space mobility is associated with higher mortality (Kennedy et al., 2017), institutionalization (Sheppard, Sawyer, Ritchie, Allman, & Brown, 2013), lower quality of life (Bentley et al., 2013), and social engagement (Rosso, Taylor, Tabb, & Michael, 2013). Moreover, it has been identified as a predictor of cognitive decline (Crowe et al., 2008; Silberschmidt et al., 2017). Cognitive impairment (CI) in older persons increases the risk for mobility limitations (Pedersen et al., 2014), and is associated with loss of functional independence (Wadley et al., 2007) and reduced time spent out-of-home (Wettstein et al., 2015). The assessment of life space via questionnaires has been introduced in 1985 (May, Nayak, & Isaacs, 1985). Since then several questionnaires have been developed with the University of Alabama at Birmingham Study of Aging Life-Space Assessment (UAB-LSA) representing one of the most frequently used life-space mobility assessment tools in older adults (Chung, Demiris, & Thompson, 2015). The UAB-LSA was initially developed and validated for use in older community-dwelling persons without CI (Baker, Bodner, & Allman, 2003; Peel et al., 2005). In this population, the UAB-LSA was translated and validated in several languages (Auger et al., 2009; Curcio et al., 2013; Fristedt, Kammerlind, Bravell, & Fransson, 2016; Harada et al., 2010; Ji, Zhou, Liao, & Feng, 2015), proved for good to excellent test–retest reliability (Auger et al., 2009; Baker et al., 2003; Curcio et al., 2013; Ji et al., 2015; Kammerlind, Fristedt, Ernsth Bravell, & Fransson, 2014; Portegijs, Iwarsson, Rantakokko, Viljanen, & Rantanen, 2014), and demonstrated to be feasible (Auger et al., 2009; Peel et al., 2005; Portegijs et al., 2014). Sensitivity to change of the UAB-LSA has so far only been documented over time by natural course without statistical analysis (Baker et al., 2003). The UAB-LSA has already been used to assess life-space mobility in mixed populations including some persons with CI (Al Snih et al., 2012; Crowe et al., 2008; Fairhall et al., 2012; Silberschmidt et al., 2017; Tsutsumimoto et al., 2014); however, it has not yet been validated in, nor has it been adjusted to this population, which have shown recall bias and inaccuracy in retrospective self-reports (Shephard, 2003) as well as difficulties in self-reporting physical activity (PA) (Bhandari & Wagner, 2006; Sallis & Saelens, 2000). In addition, previous UAB-LSA validation studies have not yet conducted in multimorbid older persons with acute motor impairment, although this population represents a high-risk group for life-space restrictions (Baker et al., 2003; Brown et al., 2009; Crowe et al., 2008; Portegijs, Rantakokko, Viljanen, Sipila, & Rantanen, 2016). The aim of this study was therefore to validate a modified version of the UAB-LSA (Life-Space Assessment in Persons with Cognitive Impairment, LSA-CI) specifically developed for use in multimorbid persons with CI. Methods Study Design The present validation study was part of a double-blinded, randomized, placebo-controlled intervention trial (RCT) to improve motor performance and PA in older persons with mild to moderate CI recently discharged from geriatric rehabilitation (ISRCTN82378327). The RCT was performed according to the Helsinki declaration and was approved by the ethics committee of the Medical Department of the University of Heidelberg. Study Sample Participants were consequently recruited from rehabilitation wards of a German geriatric hospital. Individuals with Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975) scores of 17–26 indicating mild to moderate CI were included in the study (Monsch et al., 1995; O’Bryant et al., 2008; Thalmann et al., 2002). Further inclusion criteria were: age ≥65 years; ability to walk at least 4 m without a walking aid; residence within 30 kilometers of the study center; discharge to the patients’ home (i.e., no nursing home residents); no terminal disease; no delirium; German-speaking, and written informed consent. Descriptive Measures Demographic and clinical characteristics including age, gender, and comorbidity (number of diagnoses, medications) were documented at baseline from patient charts. A trained interviewer assessed falls in the previous year, cognitive status (MMSE) (Folstein et al., 1975), professional education (school education only vs. additional vocational training or academic studies), and psychosocial status for depression (Geriatric Depression Scale, 15-item version, GDS, Yesavage et al., 1982) and fear of falling (Falls Efficacy Scale-International, 7-item version, FES-I, Kempen et al., 2008; Fear of Falling Avoidance Behavior Questionnaire, FFABQ, Landers, Durand, Powell, Dibble, & Young, 2011). Motor status was assessed by the Short Physical Performance Battery (SPPB, Guralnik et al., 1994) and the Timed “Up & Go” (TUG, Podsiadlo & Richardson, 1991). Life-space Assessment University of Alabama at Birmingham Study of Aging Life-Space Assessment The UAB-LSA is an instrument to assess life-space mobility of the previous 4 weeks by the frequency of movements and assistance needed to travel via face-to-face or telephone interview. The activity area is classified into six hierarchically structured, concentric zones ranging from activity locations including a person’s bedroom (level 0), to a person`s home (level 1), area outside the house (level 2), the neighborhood (level 3), the home town (level 4), and beyond the person’s home town (level 5). A composite score of life-space mobility (LSA-C) is calculated by multiplying the levels reached (levels 0–5), with the frequency of activity within a level (1 = “less than 1 time per week”, 2 = “1–3 times per week”, 3 = “4–6 times per week”, 4 = “daily”) and the assistance needed to travel to the level (1 = “help of another person”, 1.5 = “use of assistive device only”, 2 = “no assistance”). The lowest LSA-C score of 0 indicates total immobility (bed-bound) and the maximum LSA-C score of 120 indicates daily independent out-of-town mobility. In addition, three LSA subscores can be calculated for (a) the maximum life-space level reached allowing equipment or personal assistance (LSA-M; range 0–5), (b) the maximum life-space level reached with equipment if needed but without personal assistance (LSA-E; range 0–5), and (c) the maximum life-space level reached independently without any assistance (LSA-I; range 0–5) (Baker et al., 2003). Modifications for Life-Space Assessment in Persons with Cognitive Impairment The assessment period covered by the UAB-LSA was reduced from 4 weeks to 1 week to prevent recall bias in persons with CI, thus the LSA-CI has a different scoring range for frequency (1 point: 1–3 times per week, 2 points: 4–6 times per week, and 3 points: daily), and consequently the composite score ranges from 0 (“totally bed-bound”) to 90 points (“traveled out of town every day without assistance”). The LSA-CI constitutes an interview-based and strictly standardized questionnaire, which was conducted face-to-face without participation of proxies or caregivers. A dementia-specific interview technique, originally developed for the assessment of PA in patients with CI, was implemented to prevent recall problems (Hauer et al., 2011). The strategy included an informal conversational approach to prevent fear of failure in comprehension and recall and to improve the completeness of reports, fostering memory by precise questions and response options, structuring the observation period by referring to daily routines and highlighting landmark events such as meals, daily/weekly habits, special events as visits, celebration, and summarizing the information (Bhandari & Wagner, 2006; Shephard, 2003) (the LSA-CI questionnaire form and a manual for assessment instruction and rationale are provided as supplementary material). Translation Process The translation from English into German language was performed according to a structured proceeding suggested by Beaton, Bombardier, Guillemin, and Ferraz (2000) (stages I–IV), including forward- and backward-translation by bilingual translators and tests in the target population in terms of comprehensibility. Assessment of Measurement Properties Construct Validity To analyze construct validity, correlations between the LSA-CI scores at baseline (LSA-CI-C, -M, -E, and -I) with demographic variables (age, gender), motor status (SPPB, gait speed from the SPPB, TUG), cognitive status (MMSE), and psychological status (GDS, FES-I, FFABQ) were calculated. These correlates were selected according to previous validation studies of the UAB-LSA, demonstrating construct validity by associations with age and gender (Harada et al., 2010; Peel et al., 2005), physical performance (Baker et al., 2003; Curcio et al., 2013; Fristedt et al., 2016; Ji et al., 2015; Peel et al., 2005), cognitive status (Curcio et al., 2013; Ji et al., 2015) and multiple psychosocial factors (Baker et al., 2003; Curcio et al., 2013; Ji et al., 2015; Peel et al., 2005). As previous observational studies in community-dwelling people reported that life-space mobility is associated with objectively measured PA (Portegijs, Tsai, Rantanen, & Rantakokko, 2015; Tsai et al., 2015), we additionally used sensor-derived PA and outdoor PA data (OPA) captured for 48 hours during the baseline assessment for validity testing. PA was measured by a small (5.1 × 3 × 1.6 cm), light (24 g), body-fixed motion sensor (PAMSys™, BioSensics, Cambridge, MA) attached to the participant’s sternum. The PAMSysTM is able to identify posture durations (i.e., minutes of lying, sitting, standing, and walking) and locomotion outcomes (i.e., number of walking steps and walking episodes) based on established and validated algorithms (Najafi et al., 2003). OPA variables were calculated based on PA data and data derived from a mobile Global Positioning System (GPS). In our study, we used a QStarz GPS-tracker (QStarz BT1000X, Qstarz International Co., Ltd., Taipei, Taiwan), an established device to assess spatial location of physical activity (Wu et al., 2010). The Software Personal Activity Location Measurement System (PALMS; available from: http://ucsd-palms-project.wikispaces.com/.) was used to merge the GPS and PA data. PALMS is valid for processing GPS data to objectively measured PA data (Carlson et al., 2015). OPA variables included being active outdoors (yes or no), mean outdoor walking duration and distance, number of outdoor walking episodes, and maximum distance from home. Test–retest Reliability To test for test–retest reliability, the LSA-CI assessment was conducted twice within two days for all participants at post-intervention by the same trained interviewer to exclude interrater variability. Sensitivity to Change Sensitivity to change was examined for the participants randomly assigned to the intervention group of a 12-week home-based interventional trial to improve motor performance and physical activity in geriatric patients with CI following rehabilitation. The intervention included exercises to promote functional balance and strength performance as well as various motivational strategies to promote physical activity (Bongartz et al., 2017). Feasibility Completion rate and completion time to fill out the questionnaire were documented at baseline to determine feasibility. In case of unrealistic self-reports and implausible participant statements data was not analyzed. In addition, LSA-CI scores at baseline were checked for floor and ceiling effects, which were considered present when more than 15% of the individuals achieve the highest or lowest score (McHorney & Tarlov, 1995). Statistical Analysis Descriptive data were presented as frequencies and percentages for categorical variables, and means and standard deviations or medians and ranges for continuous variables as appropriate. Spearman and point-biserial correlation coefficients were calculated to assess construct validity. Correlation coefficients (r) were interpreted as low (r < 0.2), moderate (r = 0.2–0.5), or high (r > 0.5) (Cohen, 1988). Intra-class correlation coefficients (ICC3,1 for absolute agreement) with 95% confidence intervals for the LSA-CI composite score and each subscore were used to analyze test–retest reliability. ICCs were interpreted as poor (<0.4), fair to good (≥ 0.4 ≤ 0.75), and excellent (>0.75) (Fleiss, 1986). Sensitivity to change was assessed using paired t-tests to test for significant within-group differences between baseline and post intervention assessment and standardized response means (SRMs) to quantify the magnitude of changes. SRMs were calculated as the difference in mean change scores divided by the SD of the change score (Katz, Larson, Phillips, Fossel, & Liang, 1992). SRMs were adjusted for the size of correlation coefficients between the baseline and post-intervention scores (Middel & van Sonderen, 2002) to use Cohen’s thresholds for effect sizes (trivial < 0.2, small ≥ 0.2 < 0.5, moderate ≥ 0.5 < 0.8, and large ≥ 0.8) (Cohen, 1988). A two-sided p-value of < 0.05 indicated statistical significance. All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 23 for Windows (IBM Corp., NY). Results Participants’ Characteristics Out of 1,981 persons screened for eligibility, 1,863 did not meet inclusion criteria due to MMSE criteria (n = 553; MMSE >26: n = 382, MMSE <17: n = 102, MMSE not feasible: n = 69), residence >30 km from study center (n = 241), medical contraindications (n = 217), being recruited for another trial (n = 211), inability to walk at least 4 m without a walking aid (n = 196), refusal to participate (n = 123), nursing home resident or admission (n = 113), or other reasons (n = 209; e.g., <65 years, lack of German language skills, transfer to another hospital). Thus, the total sample included 118 multimorbid, older, community-dwelling persons with mild to moderate CI with at least two chronic diseases, and predominantly orthopedic and cardiovascular diseases. Detailed participant characteristics are summarized in Table 1. Table 1. Participant Characteristics Characteristics  Total sample n = 118  Age, years, mean (SD)  82.3 (6.0)  Gender, female, n (%)  90 (76.3)  Professional education, n (%)   School education only  37 (31.4)   Vocational training or academic studies  81 (68.6)  Diagnoses, number, mean (SD)  11.4 (4.4)  Medications, number, mean (SD)  9.5 (3.5)  MMSE, score, mean (SD)  23.3 (2.4)  SPPB, total score, mean (SD)  5.2 (2.3)  Gait speed, m/s, mean (SD)a  0.45 (0.20)  TUG, s, median (range)b  20.5 (8.8–91.0)  At least one fall in the previous year, n (%)  79 (66.9)  FES-I, score, median (range)  11 (7–25)  FFABQ, score, mean (SD)  18.7 (12.6)  GDS, score, mean (SD)  5.3 (3.0)  Characteristics  Total sample n = 118  Age, years, mean (SD)  82.3 (6.0)  Gender, female, n (%)  90 (76.3)  Professional education, n (%)   School education only  37 (31.4)   Vocational training or academic studies  81 (68.6)  Diagnoses, number, mean (SD)  11.4 (4.4)  Medications, number, mean (SD)  9.5 (3.5)  MMSE, score, mean (SD)  23.3 (2.4)  SPPB, total score, mean (SD)  5.2 (2.3)  Gait speed, m/s, mean (SD)a  0.45 (0.20)  TUG, s, median (range)b  20.5 (8.8–91.0)  At least one fall in the previous year, n (%)  79 (66.9)  FES-I, score, median (range)  11 (7–25)  FFABQ, score, mean (SD)  18.7 (12.6)  GDS, score, mean (SD)  5.3 (3.0)  Note: GDS = Geriatric Depression Scale; FES-I = Falls Efficacy Scale-International, seven-item version; FFABQ = Fear of Falling Avoidance Behavior Questionnaire; MMSE = Mini-Mental State Examination; SPPB = Short-Physical-Performance-Battery; TUG = Timed “Up & Go”. aCalculated based on the SPPB gait speed test. bBased on data n = 113 as five participants were not able to complete the TUG due to physical limitations. View Large Table 1. Participant Characteristics Characteristics  Total sample n = 118  Age, years, mean (SD)  82.3 (6.0)  Gender, female, n (%)  90 (76.3)  Professional education, n (%)   School education only  37 (31.4)   Vocational training or academic studies  81 (68.6)  Diagnoses, number, mean (SD)  11.4 (4.4)  Medications, number, mean (SD)  9.5 (3.5)  MMSE, score, mean (SD)  23.3 (2.4)  SPPB, total score, mean (SD)  5.2 (2.3)  Gait speed, m/s, mean (SD)a  0.45 (0.20)  TUG, s, median (range)b  20.5 (8.8–91.0)  At least one fall in the previous year, n (%)  79 (66.9)  FES-I, score, median (range)  11 (7–25)  FFABQ, score, mean (SD)  18.7 (12.6)  GDS, score, mean (SD)  5.3 (3.0)  Characteristics  Total sample n = 118  Age, years, mean (SD)  82.3 (6.0)  Gender, female, n (%)  90 (76.3)  Professional education, n (%)   School education only  37 (31.4)   Vocational training or academic studies  81 (68.6)  Diagnoses, number, mean (SD)  11.4 (4.4)  Medications, number, mean (SD)  9.5 (3.5)  MMSE, score, mean (SD)  23.3 (2.4)  SPPB, total score, mean (SD)  5.2 (2.3)  Gait speed, m/s, mean (SD)a  0.45 (0.20)  TUG, s, median (range)b  20.5 (8.8–91.0)  At least one fall in the previous year, n (%)  79 (66.9)  FES-I, score, median (range)  11 (7–25)  FFABQ, score, mean (SD)  18.7 (12.6)  GDS, score, mean (SD)  5.3 (3.0)  Note: GDS = Geriatric Depression Scale; FES-I = Falls Efficacy Scale-International, seven-item version; FFABQ = Fear of Falling Avoidance Behavior Questionnaire; MMSE = Mini-Mental State Examination; SPPB = Short-Physical-Performance-Battery; TUG = Timed “Up & Go”. aCalculated based on the SPPB gait speed test. bBased on data n = 113 as five participants were not able to complete the TUG due to physical limitations. View Large Construct Validity The LSA-CI scores showed consistently moderate to high correlations with all OPA variables (r = .30–.63), with the lowest correlations for the Life-Space Assessment for Persons with Cognitive Impairment for the maximal life-space score (LSA-CI-M) (r = .30–.34) (Table 2). Moderate to high correlations of the LSA-CI scores were also found with almost all (15 of 16) PA variables addressing physical active behavior (i.e., standing, walking, number of walking episodes and steps) (r = .23–.60), whereas correlations with PA variables addressing sedentary behavior (i.e., lying, sitting) were consistently lower (r = −.06 to −.40). Overall, the lowest correlations with PA variables were found for the LSA-CI-M (r = −.06 to −.29). Except for the LSA-CI-M (r = |.05–.13|), LSA-CI scores showed moderate to high correlations with motor status (r = |.27–.56|) and fear of falling-related psychosocial variables (r = −.24 to −.44). For depressive symptoms, only low correlations were found (r = −.02 to −.16). The LSA-CI scores predominantly (3 out of 4) correlated only weakly with cognitive status (r = .02–.18). Except for the LSA-CI-M (r = |.13–.15|), demographic characteristics showed moderate correlations with the LSA-CI scores (r = |.27–.32|) with older and female participants demonstrating lower life-space mobility. Subgroup analyses for different cognitive status groups (i.e., MMSE >24 vs. ≤24 and >21 vs. ≤21) revealed no significant differences for any LSA-CI score (unpaired t-test: p = .137–.810). Table 2. Construct Validity for the Different Scores of the LSA-CI Variables (n = 117)  LSA-CI-C  LSA-CI-M  LSA-CI-E  LSA-CI-I  Demographic characteristics   Age, years  −.32**    −.15    −.31**    −.27**   Gender (0 = female, 1 = male)a  .28**    .13    .32**    .31**  Cognitive status   MMSE score  .18    .15    .21*    .02  Psychological status   GDS  −.11    −.16    −.11    −.02   FES-I  −.24**    −.12    −.12    −.25**   FFABQ  −.38**    −.15    −.35**    −.44**  Motor status   SPPB total score  .39**    .05    .30*    .52**   Gait speed  .41**    .13    .27**    .56**   TUG  −.40**    −.08    −.38**    −.52**  Physical activity   Lying (min)  −.13    −.07    −.25**    −.14   Sitting (min)  −.12    −.06    −.04    −.07   Standing (min)  .41**    .28**    .53**    .23*   Walking (min)  .55**    .27**    .58**    .51**   Walking episodes (n)  .40**    .16    .42**    .42**   Steps (n)  .59**    .29**    .60**    .53**  Outdoor physical activity   Being active outdoors? (0 = no, 1 = yes)a  .53**    .30**    .63**    .33**   Mean outdoor walking duration (s)  .54**    .31**    .62**    .37**   Mean walking distance outdoors (m)  .54**    .34**    .63**    .33**   Outdoor walking episodes (n)  .54**    .31**    .62**    .32**   Maximum distance from home (m)  .52**    .32**    .63**    .32**  Variables (n = 117)  LSA-CI-C  LSA-CI-M  LSA-CI-E  LSA-CI-I  Demographic characteristics   Age, years  −.32**    −.15    −.31**    −.27**   Gender (0 = female, 1 = male)a  .28**    .13    .32**    .31**  Cognitive status   MMSE score  .18    .15    .21*    .02  Psychological status   GDS  −.11    −.16    −.11    −.02   FES-I  −.24**    −.12    −.12    −.25**   FFABQ  −.38**    −.15    −.35**    −.44**  Motor status   SPPB total score  .39**    .05    .30*    .52**   Gait speed  .41**    .13    .27**    .56**   TUG  −.40**    −.08    −.38**    −.52**  Physical activity   Lying (min)  −.13    −.07    −.25**    −.14   Sitting (min)  −.12    −.06    −.04    −.07   Standing (min)  .41**    .28**    .53**    .23*   Walking (min)  .55**    .27**    .58**    .51**   Walking episodes (n)  .40**    .16    .42**    .42**   Steps (n)  .59**    .29**    .60**    .53**  Outdoor physical activity   Being active outdoors? (0 = no, 1 = yes)a  .53**    .30**    .63**    .33**   Mean outdoor walking duration (s)  .54**    .31**    .62**    .37**   Mean walking distance outdoors (m)  .54**    .34**    .63**    .33**   Outdoor walking episodes (n)  .54**    .31**    .62**    .32**   Maximum distance from home (m)  .52**    .32**    .63**    .32**  Note: Presented are Spearman rank correlation coefficients (rs), except for gender and being active outdoors. FFABQ = Fear of Falling Activity Avoidance Questionnaire; GDS = Geriatric Depression Scale; LSA-CI = Life-Space Assessment for Persons with Cognitive Impairment; LSA-CI = Life-Space Assessment for Persons with Cognitive Impairment; LSA-CI-C = composite life-space; LSA-CI-M = maximum life-space; LSA-CI-E = maximum life-space with equipment; LSA-CI-I = maximum independent life-space; MMSE = Mini-Mental State Examination; SPPB = Short-Physical Performance Battery; TUG = Timed “Up & Go”; FES-I = short Falls-Efficacy-Scale. Correlations coefficients (r): < .20 = low, .20–.50 = moderate, > .50 = high. aPoint-biserial correlation coefficients (rpb). *p < .05. **p < .01. View Large Table 2. Construct Validity for the Different Scores of the LSA-CI Variables (n = 117)  LSA-CI-C  LSA-CI-M  LSA-CI-E  LSA-CI-I  Demographic characteristics   Age, years  −.32**    −.15    −.31**    −.27**   Gender (0 = female, 1 = male)a  .28**    .13    .32**    .31**  Cognitive status   MMSE score  .18    .15    .21*    .02  Psychological status   GDS  −.11    −.16    −.11    −.02   FES-I  −.24**    −.12    −.12    −.25**   FFABQ  −.38**    −.15    −.35**    −.44**  Motor status   SPPB total score  .39**    .05    .30*    .52**   Gait speed  .41**    .13    .27**    .56**   TUG  −.40**    −.08    −.38**    −.52**  Physical activity   Lying (min)  −.13    −.07    −.25**    −.14   Sitting (min)  −.12    −.06    −.04    −.07   Standing (min)  .41**    .28**    .53**    .23*   Walking (min)  .55**    .27**    .58**    .51**   Walking episodes (n)  .40**    .16    .42**    .42**   Steps (n)  .59**    .29**    .60**    .53**  Outdoor physical activity   Being active outdoors? (0 = no, 1 = yes)a  .53**    .30**    .63**    .33**   Mean outdoor walking duration (s)  .54**    .31**    .62**    .37**   Mean walking distance outdoors (m)  .54**    .34**    .63**    .33**   Outdoor walking episodes (n)  .54**    .31**    .62**    .32**   Maximum distance from home (m)  .52**    .32**    .63**    .32**  Variables (n = 117)  LSA-CI-C  LSA-CI-M  LSA-CI-E  LSA-CI-I  Demographic characteristics   Age, years  −.32**    −.15    −.31**    −.27**   Gender (0 = female, 1 = male)a  .28**    .13    .32**    .31**  Cognitive status   MMSE score  .18    .15    .21*    .02  Psychological status   GDS  −.11    −.16    −.11    −.02   FES-I  −.24**    −.12    −.12    −.25**   FFABQ  −.38**    −.15    −.35**    −.44**  Motor status   SPPB total score  .39**    .05    .30*    .52**   Gait speed  .41**    .13    .27**    .56**   TUG  −.40**    −.08    −.38**    −.52**  Physical activity   Lying (min)  −.13    −.07    −.25**    −.14   Sitting (min)  −.12    −.06    −.04    −.07   Standing (min)  .41**    .28**    .53**    .23*   Walking (min)  .55**    .27**    .58**    .51**   Walking episodes (n)  .40**    .16    .42**    .42**   Steps (n)  .59**    .29**    .60**    .53**  Outdoor physical activity   Being active outdoors? (0 = no, 1 = yes)a  .53**    .30**    .63**    .33**   Mean outdoor walking duration (s)  .54**    .31**    .62**    .37**   Mean walking distance outdoors (m)  .54**    .34**    .63**    .33**   Outdoor walking episodes (n)  .54**    .31**    .62**    .32**   Maximum distance from home (m)  .52**    .32**    .63**    .32**  Note: Presented are Spearman rank correlation coefficients (rs), except for gender and being active outdoors. FFABQ = Fear of Falling Activity Avoidance Questionnaire; GDS = Geriatric Depression Scale; LSA-CI = Life-Space Assessment for Persons with Cognitive Impairment; LSA-CI = Life-Space Assessment for Persons with Cognitive Impairment; LSA-CI-C = composite life-space; LSA-CI-M = maximum life-space; LSA-CI-E = maximum life-space with equipment; LSA-CI-I = maximum independent life-space; MMSE = Mini-Mental State Examination; SPPB = Short-Physical Performance Battery; TUG = Timed “Up & Go”; FES-I = short Falls-Efficacy-Scale. Correlations coefficients (r): < .20 = low, .20–.50 = moderate, > .50 = high. aPoint-biserial correlation coefficients (rpb). *p < .05. **p < .01. View Large Test–Retest Reliability Correlations between the two LSA-CI assessments performed by the same interviewer within 2 days indicated good to excellent test–retest reliability for all LSA-CI scores, with ICCs ranging from 0.65 to 0.91 (Table 3). Table 3. Test–Retest Reliability of the LSA-CI Scores   Mean (SD)  ICC(3,1)  95% CI  Variable (na = 102)  First test session  Second test session  LSA-CI-C  29.7 (15.4)  29.0 (15.0)  0.91  0.87–0.94  LSA-CI-M  4.1 (1.1)  3.9 (1.1)  0.80  0.71–0.86  LSA-CI-E  2.8 (1.4)  2.6 (1.3)  0.65  0.53–0.75  LSA-CI-I  1.4 (1.6)  1.4 (1.5)  0.91  0.86–0.94    Mean (SD)  ICC(3,1)  95% CI  Variable (na = 102)  First test session  Second test session  LSA-CI-C  29.7 (15.4)  29.0 (15.0)  0.91  0.87–0.94  LSA-CI-M  4.1 (1.1)  3.9 (1.1)  0.80  0.71–0.86  LSA-CI-E  2.8 (1.4)  2.6 (1.3)  0.65  0.53–0.75  LSA-CI-I  1.4 (1.6)  1.4 (1.5)  0.91  0.86–0.94  Note: CI = confidence interval; LSA-CI = Life-Space Assessment for Persons with Cognitive Impairment; LSA-CI-C = composite life-space; LSA-CI-M = maximum life-space; LSA-CI-E = maximum life-space with equipment; LSA-CI-I = maximum independent life-space; ICC = intra-class correlation coefficient (<0.4 = poor, 0.4–0.74 = fair to good, >0.75 = excellent). aSample size was reduced due to the organization of the study and the timing of the assessment. View Large Table 3. Test–Retest Reliability of the LSA-CI Scores   Mean (SD)  ICC(3,1)  95% CI  Variable (na = 102)  First test session  Second test session  LSA-CI-C  29.7 (15.4)  29.0 (15.0)  0.91  0.87–0.94  LSA-CI-M  4.1 (1.1)  3.9 (1.1)  0.80  0.71–0.86  LSA-CI-E  2.8 (1.4)  2.6 (1.3)  0.65  0.53–0.75  LSA-CI-I  1.4 (1.6)  1.4 (1.5)  0.91  0.86–0.94    Mean (SD)  ICC(3,1)  95% CI  Variable (na = 102)  First test session  Second test session  LSA-CI-C  29.7 (15.4)  29.0 (15.0)  0.91  0.87–0.94  LSA-CI-M  4.1 (1.1)  3.9 (1.1)  0.80  0.71–0.86  LSA-CI-E  2.8 (1.4)  2.6 (1.3)  0.65  0.53–0.75  LSA-CI-I  1.4 (1.6)  1.4 (1.5)  0.91  0.86–0.94  Note: CI = confidence interval; LSA-CI = Life-Space Assessment for Persons with Cognitive Impairment; LSA-CI-C = composite life-space; LSA-CI-M = maximum life-space; LSA-CI-E = maximum life-space with equipment; LSA-CI-I = maximum independent life-space; ICC = intra-class correlation coefficient (<0.4 = poor, 0.4–0.74 = fair to good, >0.75 = excellent). aSample size was reduced due to the organization of the study and the timing of the assessment. View Large Sensitivity to Change LSA-CI scores were significantly different between baseline and post-intervention assessment (p ≤ .001). Small to large SRMs (range 0.35–0.80) over the intervention were found across the LSA-CI scores, with the highest SRM for the LSA-CI-C (0.80) while LSA-CI subscores reached lower SRMs (0.35–0.60) (Table 4). Table 4. Sensitivity to Change of the LSA-CI Scores   Mean (SD)  p-Value  SRM  Variable (na = 53)  Baseline  Post-intervention  LSA-CI-C  28.4 (14.0)  37.6 (14.5)  <.001  0.80  LSA-CI-M  3.9 (1.1)  4.5 (0.9)  .001  0.60  LSA-CI-E  3.0 (1.2)  3.3 (1.2)  <.001  0.35  LSA-CI-I  1.3 (1.5)  1.8 (1.6)  .001  0.43    Mean (SD)  p-Value  SRM  Variable (na = 53)  Baseline  Post-intervention  LSA-CI-C  28.4 (14.0)  37.6 (14.5)  <.001  0.80  LSA-CI-M  3.9 (1.1)  4.5 (0.9)  .001  0.60  LSA-CI-E  3.0 (1.2)  3.3 (1.2)  <.001  0.35  LSA-CI-I  1.3 (1.5)  1.8 (1.6)  .001  0.43  Note: LSA-CI = Life-Space Assessment for Persons with Cognitive Impairment; LSA-CI-C = composite life-space; LSA-CI-M = maximum life-space; LSA-CI-E = maximum life-space with equipment; LSA-CI-I = maximum independent life-space; SRM = standardized response mean (<0.2 = trivial, ≥0.2 < 0.5 = small, ≥0.5 <0.8 = moderate, ≥0.8 = large). aOnly participants randomly assigned to the intervention group and completing the intervention were included in the analyses. View Large Table 4. Sensitivity to Change of the LSA-CI Scores   Mean (SD)  p-Value  SRM  Variable (na = 53)  Baseline  Post-intervention  LSA-CI-C  28.4 (14.0)  37.6 (14.5)  <.001  0.80  LSA-CI-M  3.9 (1.1)  4.5 (0.9)  .001  0.60  LSA-CI-E  3.0 (1.2)  3.3 (1.2)  <.001  0.35  LSA-CI-I  1.3 (1.5)  1.8 (1.6)  .001  0.43    Mean (SD)  p-Value  SRM  Variable (na = 53)  Baseline  Post-intervention  LSA-CI-C  28.4 (14.0)  37.6 (14.5)  <.001  0.80  LSA-CI-M  3.9 (1.1)  4.5 (0.9)  .001  0.60  LSA-CI-E  3.0 (1.2)  3.3 (1.2)  <.001  0.35  LSA-CI-I  1.3 (1.5)  1.8 (1.6)  .001  0.43  Note: LSA-CI = Life-Space Assessment for Persons with Cognitive Impairment; LSA-CI-C = composite life-space; LSA-CI-M = maximum life-space; LSA-CI-E = maximum life-space with equipment; LSA-CI-I = maximum independent life-space; SRM = standardized response mean (<0.2 = trivial, ≥0.2 < 0.5 = small, ≥0.5 <0.8 = moderate, ≥0.8 = large). aOnly participants randomly assigned to the intervention group and completing the intervention were included in the analyses. View Large Feasibility No participant objected to the assessment procedure, and data documentation was comprehensive, with no missing responses for any LSA-CI item (i.e., 100% completion rate). We excluded 1 of 118 participants (0.8%) from the analysis, because of unrealistic statements, advanced disorientation, and confabulation. Mean completion time (SD) to assess the LSA-CI was 4.1 (2.2) min. No participant obtained the minimum or maximum LSA-CI-C score, with values ranging from 4.5 to 70.0 points, indicating no ceiling or floor effects for this score. No ceiling or floor effects were documented also for the LSA-CI-E, with no participant obtaining the minimum and only 12 participants (10.3%) obtaining the maximum score. For the LSA-CI-M, we found no floor effect (no participant with the minimum score) but a ceiling effect, with 35 participants (29.9%) obtaining the maximum score. For the LSA-CI-I, no ceiling (n = 5 [4.3%] with the maximum score) but a floor effect was identified, with 58 participants (49.6%) obtaining the minimum score. Discussion Although older persons with CI represent a high-risk group for life-space restrictions, established interview-based life-space assessment instruments have not yet been adjusted or validated for use in this population. The presented study is the first to modify one of the most frequently used life-space assessment tools (UAB-LSA) for persons with CI and to evaluate its measurement properties in multimorbid older persons with mild to moderate CI. Construct Validity Our results indicated moderate to high construct validity of the LSA-CI with measures of demographic characteristics, motor status, fear of falling-related psychosocial factors, and PA and OPA. Lower life-space mobility was associated with female sex, higher age, lower motor status, pronounced fear of falling-related variables, and higher levels of physical active behavior, which is consistent with previous UAB-LSA validation studies (Baker et al., 2003; Curcio et al., 2013; Fristedt et al., 2016; Harada et al., 2010; Ji et al., 2015; Peel et al., 2005) or cohort studies investigating life-space mobility (Portegijs et al., 2015; Tsai et al., 2015) in community-dwelling older people without CI. We found that motor status was one of the strongest variables associated with LSA-CI scores, confirming results of previous UAB-LSA validation studies, which also reported higher correlations for measures of motor status compared to demographic variables, psychosocial status, and cognitive status (Baker et al., 2003; Curcio et al., 2013; Peel et al., 2005). As previously described for older people without CI (May et al., 1985; Peel et al., 2005), our results documented that physical functioning represents a main determinant of life space mobility also in multimorbid older people with CI. High correlations were also found among the variables documenting physical active behavior. As expected from previous cohort studies (Portegijs et al., 2015; Tsai et al., 2015), higher life-space mobility was associated with being more physically active (higher PA and OPA) in our study (e.g., higher number of steps, longer outdoor walking distance, being active outdoors). These results might be explained by the facts that (1) for reaching higher levels of the concentric zones within the life-space concept (e.g., outside bedroom, neighborhood) a certain level of (outdoor) PA is necessary and (2) the OPA variables also addressed activity and location of mobility as made by the LSA-CI. Sedentary behavior was not associated with life-space mobility, which was previously shown by (Tsai et al., 2015), indicating that sedentary persons may use more motorized transportation to reach comparable life-space levels or physical active persons organize their daily life within the immediate surrounding. A number of papers have found out similar results for physical activity. Sedentary behavior and low physical activity seem to be independent predictors of worse health outcomes (DiPietro, Jin, Talegawkar, & Matthews, 2017; Klenk et al., 2016; Patel et al., 2010). To the best of our knowledge, our study was the first that successfully demonstrated construct validity of an interview-based life-space assessment instrument based on objectively, sensor-derived PA and OPA behavior. Previous UAB-LSA validation studies in community-dwelling elderly reported moderate correlations of life-space mobility with participants’ cognitive status (Ji et al., 2015; Peel et al., 2005). In contrast to these studies, these correlations were considerably lower in our cognitively impaired participants. The lower correlations may be related to the relatively small range of cognitive status in our sample, as we included solely persons with mild to moderate CI and excluded those with more severe or without CI. Previous UAB-LSA validation studies included a large number of community-dwelling elderly (n = 100–998; >65 years) without taking into account the cognitive status for an inclusion criterion, which may have resulted in wide-ranging cognitive performance levels among their samples and potentially also in the higher correlations found in these studies. We found lowest correlations of life-space mobility with depressive symptoms. Previous findings for associations of life-space mobility and depressive symptoms in older people without CI have been ambiguous (Baker et al., 2003; Curcio et al., 2013; Ji et al., 2015; Peel et al., 2005; Polku et al., 2015; Umstattd Meyer, Janke, & Beaujean, 2014). Our results suggest that there seems to be no association of life-space mobility and despressive symptoms in community-dwelling older people with CI. Across all correlates used for testing construct validity, we found the lowest correlations for the maximal life-space score (LSA-CI-M), which is in line with the results reported in previous UAB-LSA validation studies (Baker et al., 2003; Fristedt et al., 2016). This can be explained by the fact that the LSA-CI-M does not consider a person’s own ability to independently reach the maximum life-space (i.e., without personal assistance or equipment). Thus, this score documents a different aspect of life-space mobility which may rather be determined by the availability and the use of assistance from persons or equipment than by personal characteristics such as age, gender, or motor, cognitive and psychological status, or by PA behavior, which may explain the lower correlations (Baker et al., 2003; Fristedt et al., 2016). Test–Retest Reliability The LSA-CI demonstrated good to excellent test–retest reliability (ICC = 0.65–0.91) in our sample of multimorbid older people with CI. These reliability results are similar (ICC = 0.72–0.96) (Auger et al., 2009; Baker et al., 2003; Ji et al., 2015; Kammerlind et al., 2014; Portegijs et al., 2014) or even better (ICC = 0.37–0.70) (Curcio et al., 2013) compared to those reported for the UAB-LSA in older persons without CI. The overall good reliability of the LSA-CI might be particularly related to the specific strategy to prevent recall bias as used for the LSA-CI (i.e., shorter assessment period; highly-standardized interview technique), which is highly relevant in older persons with CI. Sensitivity to Change For use in clinical settings, it is essential that assessment instruments are able to detect changes over time or effects of intervention studies. To our knowledge, this is the first study that evaluated sensitivity to change of a life-space mobility assessment instrument within an interventional trial including a statistical analysis as suggested for evaluation of responsiveness (Terwee, Dekker, Wiersinga, Prummel, & Bossuyt, 2003). The significant improvements with a large effect size for the LSA-CI-C score demonstrated the high potential of the LSA-CI to adequately reproduce changes in life-space mobility induced by an intervention on motor performance and physical activity. The LSA-CI subscores seemed to be less sensitive, as documented by the lower effect sizes. This may be related to the smaller scoring range of these scores (range 0–5) compared to the LSA-CI-C (range 0–90) and to the ceiling and floor effects observed for the subscores LSA-CI-M and -I, which generally limit the ability to detect changes over time (Beaton, Bombardier, Katz, & Wright, 2001). Feasibility Feasibility of the LSA-CI was excellent in our sample of multimorbid older persons with CI. No participant refused the assessment and life-space mobility could be documented adequately. Although cognitively impaired persons show a variety of limitations regarding the recall of behavior, participants’ statements were plausible, except for only one person. These excellent results may be related to the modifications made on the recall period covered by the LSA-CI (only 1 week instead of 4 weeks) and to the use of specific, highly structured face-to-face interview technique, which has been previously demonstrated to be effective in promoting recall and assessing physical activity in older persons with CI (Hauer et al., 2011). Despite the potential challenges of cognitively impaired persons to recall retrospective information, the completion time for the LSA-CI was brief and similar to that reported for the UAB-LSA in older persons without CI (about 5 min) (Peel et al., 2005). The LSA-CI showed excellent instrument coverage with no floor and ceiling effects for the LSA-CI-C score, indicating that this score covers a wide range of life-space mobility levels without being limited in upper and lower levels even in this vulnerable study sample with relevant motor and CIs. The floor and ceiling effects observed for the subscores LSA-CI-M and LSA-CI-E were consistent with those reported in cognitive intact persons (Auger et al., 2009). The floor effect found for the LSA-CI-I documented the vulnerable status of our study sample as most of the participants were not able to leave the bed without equipment or personal assistance. The ceiling effects for the LSA-CI-M may be explained by its relation to social support (Baker et al., 2003; Fristedt et al., 2016). In this study, community-dwelling persons post-hospitalization were analyzed, discharged to their homes and thus adequately supplied with assistance to remain in their homes, which could explain the large life-space. Limitations Results may be marginally influenced by preceding hospitalization of the subjects which is associated with decreasing life-space and varying recovery rates (Brown et al., 2009). The participants were selected according to the inclusion criteria of the intervention study in which the participants were recruited representing former geriatric patients discharged from ward-based rehabilitation to their homes. Although severely impaired persons were excluded in this intervention study, the recruitment of former rehab patients may have influenced results of the presented validation. Conclusions The presented study demonstrated good to excellent measurement properties of the LSA-CI representing a modified version of the established UAB-LSA specifically adjusted to older persons with CI. Despite the potential challenges in the assessment of retrospective information in this population, the LSA-CI has shown to be a valid, reliable, sensitive, and feasible questionnaire to assess life-space mobility in multimorbid older people with mild to moderate CI. Supplementary Material Supplementary data are available at The Gerontologist online. Funding This work was supported by the “Sozialministerium Baden-Württemberg” (Ministry of Social Affairs Baden-Württemberg, Germany) and the “Kommunalverband für Jugend und Soziales Baden-Württemberg” (Municipal Association for Youth and Social Affairs in Baden-Württemberg, Germany) (grant no: 80221-208-009-01-01). Funders had no role in study concept and design, data collection, analysis and interpretation, and preparation of the manuscript. Conflict of interest None reported. References Al Snih, S., Peek, K. M., Sawyer, P., Markides, K. S., Allman, R. M., & Ottenbacher, K. J. ( 2012). Life-space mobility in Mexican Americans aged 75 and older. Journal of the American Geriatrics Society , 60( 3), 532– 537. doi: 10.1111/j.1532-5415.2011.03822.x Google Scholar CrossRef Search ADS PubMed  Auger, C., Demers, L., Gélinas, I., Routhier, F., Jutai, J., Guérette, C., & Deruyter, F. ( 2009). 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Validation of a Modified Life-Space Assessment in Multimorbid Older Persons With Cognitive Impairment

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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0016-9013
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10.1093/geront/gnx214
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Abstract

Abstract Background and Objectives To investigate the validity, reliability, sensitivity to change, and feasibility of a modified University of Alabama at Birmingham Study of Aging Life-Space Assessment (UAB-LSA) in older persons with cognitive impairment (CI). Research Design and Methods The UAB-LSA was modified for use in persons with CI Life-Space Assessment for Persons with Cognitive Impairment (LSA-CI). Measurement properties of the LSA-CI were investigated using data of 118 multimorbid older participants with CI [mean age (SD): 82.3 (6.0) years, mean Mini-Mental State Examination score: 23.3 (2.4) points] from a randomized controlled trial (RCT) to improve motor performance and physical activity. Construct validity was asessed by Spearman’s rank (rs) and point-biseral correlations (rpb) with age, gender, motor, and cognitive status, psychosocial factors, and sensor-derived (outdoor) physical activity variables. Test–retest reliability was analyzed using intra-class correlation coefficients (ICCs). Sensitivity to change was determined by standardized response means (SRMs) calculated for the RCT intervention group. Results The LSA-CI demonstrated moderate to high construct validity, with significant correlations of the LSA-CI scores with (outdoor) physical activity (rs = .23–.63), motor status (rs = .27–.56), fear of falling-related psychosocial variables (rs = |.24–.44|), and demographic characteristics (rpb = |.27–.32|). Test–retest reliability was good to excellent (ICC = .65–.91). Sensitivity to change was excellent for the LSA-CI composite score (SRM = .80) and small to moderate for the LSA-CI subscores (SRM = .35–.60). A completion rate of 100% and a mean completion time of 4.1 min) documented good feasibility. Discussion and Implications The LSA-CI represents a valid, reliable, sensitive, and feasible interview-based life-space assessment tool in multimorbid older persons with CI. Assessment of Conditions/People, Clinical Trial Methods, Quantitative research methods, Measurement, Exercise/Physical Activity, Cognitive Impairment, Validation Introduction Community mobility has been conceptualized and measured in terms of life-space (Webber, Porter, & Menec, 2010), a concept which encompasses a concentric pattern of mobility zones from own bedroom to regions beyond city limits. Life-space measures quantify activity and location of mobility influenced by interaction between functional, cognitive, and psychosocial ability with social, economic and cultural aspects (Parker, Baker, & Allman, 2002). Restricted life-space mobility is associated with higher mortality (Kennedy et al., 2017), institutionalization (Sheppard, Sawyer, Ritchie, Allman, & Brown, 2013), lower quality of life (Bentley et al., 2013), and social engagement (Rosso, Taylor, Tabb, & Michael, 2013). Moreover, it has been identified as a predictor of cognitive decline (Crowe et al., 2008; Silberschmidt et al., 2017). Cognitive impairment (CI) in older persons increases the risk for mobility limitations (Pedersen et al., 2014), and is associated with loss of functional independence (Wadley et al., 2007) and reduced time spent out-of-home (Wettstein et al., 2015). The assessment of life space via questionnaires has been introduced in 1985 (May, Nayak, & Isaacs, 1985). Since then several questionnaires have been developed with the University of Alabama at Birmingham Study of Aging Life-Space Assessment (UAB-LSA) representing one of the most frequently used life-space mobility assessment tools in older adults (Chung, Demiris, & Thompson, 2015). The UAB-LSA was initially developed and validated for use in older community-dwelling persons without CI (Baker, Bodner, & Allman, 2003; Peel et al., 2005). In this population, the UAB-LSA was translated and validated in several languages (Auger et al., 2009; Curcio et al., 2013; Fristedt, Kammerlind, Bravell, & Fransson, 2016; Harada et al., 2010; Ji, Zhou, Liao, & Feng, 2015), proved for good to excellent test–retest reliability (Auger et al., 2009; Baker et al., 2003; Curcio et al., 2013; Ji et al., 2015; Kammerlind, Fristedt, Ernsth Bravell, & Fransson, 2014; Portegijs, Iwarsson, Rantakokko, Viljanen, & Rantanen, 2014), and demonstrated to be feasible (Auger et al., 2009; Peel et al., 2005; Portegijs et al., 2014). Sensitivity to change of the UAB-LSA has so far only been documented over time by natural course without statistical analysis (Baker et al., 2003). The UAB-LSA has already been used to assess life-space mobility in mixed populations including some persons with CI (Al Snih et al., 2012; Crowe et al., 2008; Fairhall et al., 2012; Silberschmidt et al., 2017; Tsutsumimoto et al., 2014); however, it has not yet been validated in, nor has it been adjusted to this population, which have shown recall bias and inaccuracy in retrospective self-reports (Shephard, 2003) as well as difficulties in self-reporting physical activity (PA) (Bhandari & Wagner, 2006; Sallis & Saelens, 2000). In addition, previous UAB-LSA validation studies have not yet conducted in multimorbid older persons with acute motor impairment, although this population represents a high-risk group for life-space restrictions (Baker et al., 2003; Brown et al., 2009; Crowe et al., 2008; Portegijs, Rantakokko, Viljanen, Sipila, & Rantanen, 2016). The aim of this study was therefore to validate a modified version of the UAB-LSA (Life-Space Assessment in Persons with Cognitive Impairment, LSA-CI) specifically developed for use in multimorbid persons with CI. Methods Study Design The present validation study was part of a double-blinded, randomized, placebo-controlled intervention trial (RCT) to improve motor performance and PA in older persons with mild to moderate CI recently discharged from geriatric rehabilitation (ISRCTN82378327). The RCT was performed according to the Helsinki declaration and was approved by the ethics committee of the Medical Department of the University of Heidelberg. Study Sample Participants were consequently recruited from rehabilitation wards of a German geriatric hospital. Individuals with Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975) scores of 17–26 indicating mild to moderate CI were included in the study (Monsch et al., 1995; O’Bryant et al., 2008; Thalmann et al., 2002). Further inclusion criteria were: age ≥65 years; ability to walk at least 4 m without a walking aid; residence within 30 kilometers of the study center; discharge to the patients’ home (i.e., no nursing home residents); no terminal disease; no delirium; German-speaking, and written informed consent. Descriptive Measures Demographic and clinical characteristics including age, gender, and comorbidity (number of diagnoses, medications) were documented at baseline from patient charts. A trained interviewer assessed falls in the previous year, cognitive status (MMSE) (Folstein et al., 1975), professional education (school education only vs. additional vocational training or academic studies), and psychosocial status for depression (Geriatric Depression Scale, 15-item version, GDS, Yesavage et al., 1982) and fear of falling (Falls Efficacy Scale-International, 7-item version, FES-I, Kempen et al., 2008; Fear of Falling Avoidance Behavior Questionnaire, FFABQ, Landers, Durand, Powell, Dibble, & Young, 2011). Motor status was assessed by the Short Physical Performance Battery (SPPB, Guralnik et al., 1994) and the Timed “Up & Go” (TUG, Podsiadlo & Richardson, 1991). Life-space Assessment University of Alabama at Birmingham Study of Aging Life-Space Assessment The UAB-LSA is an instrument to assess life-space mobility of the previous 4 weeks by the frequency of movements and assistance needed to travel via face-to-face or telephone interview. The activity area is classified into six hierarchically structured, concentric zones ranging from activity locations including a person’s bedroom (level 0), to a person`s home (level 1), area outside the house (level 2), the neighborhood (level 3), the home town (level 4), and beyond the person’s home town (level 5). A composite score of life-space mobility (LSA-C) is calculated by multiplying the levels reached (levels 0–5), with the frequency of activity within a level (1 = “less than 1 time per week”, 2 = “1–3 times per week”, 3 = “4–6 times per week”, 4 = “daily”) and the assistance needed to travel to the level (1 = “help of another person”, 1.5 = “use of assistive device only”, 2 = “no assistance”). The lowest LSA-C score of 0 indicates total immobility (bed-bound) and the maximum LSA-C score of 120 indicates daily independent out-of-town mobility. In addition, three LSA subscores can be calculated for (a) the maximum life-space level reached allowing equipment or personal assistance (LSA-M; range 0–5), (b) the maximum life-space level reached with equipment if needed but without personal assistance (LSA-E; range 0–5), and (c) the maximum life-space level reached independently without any assistance (LSA-I; range 0–5) (Baker et al., 2003). Modifications for Life-Space Assessment in Persons with Cognitive Impairment The assessment period covered by the UAB-LSA was reduced from 4 weeks to 1 week to prevent recall bias in persons with CI, thus the LSA-CI has a different scoring range for frequency (1 point: 1–3 times per week, 2 points: 4–6 times per week, and 3 points: daily), and consequently the composite score ranges from 0 (“totally bed-bound”) to 90 points (“traveled out of town every day without assistance”). The LSA-CI constitutes an interview-based and strictly standardized questionnaire, which was conducted face-to-face without participation of proxies or caregivers. A dementia-specific interview technique, originally developed for the assessment of PA in patients with CI, was implemented to prevent recall problems (Hauer et al., 2011). The strategy included an informal conversational approach to prevent fear of failure in comprehension and recall and to improve the completeness of reports, fostering memory by precise questions and response options, structuring the observation period by referring to daily routines and highlighting landmark events such as meals, daily/weekly habits, special events as visits, celebration, and summarizing the information (Bhandari & Wagner, 2006; Shephard, 2003) (the LSA-CI questionnaire form and a manual for assessment instruction and rationale are provided as supplementary material). Translation Process The translation from English into German language was performed according to a structured proceeding suggested by Beaton, Bombardier, Guillemin, and Ferraz (2000) (stages I–IV), including forward- and backward-translation by bilingual translators and tests in the target population in terms of comprehensibility. Assessment of Measurement Properties Construct Validity To analyze construct validity, correlations between the LSA-CI scores at baseline (LSA-CI-C, -M, -E, and -I) with demographic variables (age, gender), motor status (SPPB, gait speed from the SPPB, TUG), cognitive status (MMSE), and psychological status (GDS, FES-I, FFABQ) were calculated. These correlates were selected according to previous validation studies of the UAB-LSA, demonstrating construct validity by associations with age and gender (Harada et al., 2010; Peel et al., 2005), physical performance (Baker et al., 2003; Curcio et al., 2013; Fristedt et al., 2016; Ji et al., 2015; Peel et al., 2005), cognitive status (Curcio et al., 2013; Ji et al., 2015) and multiple psychosocial factors (Baker et al., 2003; Curcio et al., 2013; Ji et al., 2015; Peel et al., 2005). As previous observational studies in community-dwelling people reported that life-space mobility is associated with objectively measured PA (Portegijs, Tsai, Rantanen, & Rantakokko, 2015; Tsai et al., 2015), we additionally used sensor-derived PA and outdoor PA data (OPA) captured for 48 hours during the baseline assessment for validity testing. PA was measured by a small (5.1 × 3 × 1.6 cm), light (24 g), body-fixed motion sensor (PAMSys™, BioSensics, Cambridge, MA) attached to the participant’s sternum. The PAMSysTM is able to identify posture durations (i.e., minutes of lying, sitting, standing, and walking) and locomotion outcomes (i.e., number of walking steps and walking episodes) based on established and validated algorithms (Najafi et al., 2003). OPA variables were calculated based on PA data and data derived from a mobile Global Positioning System (GPS). In our study, we used a QStarz GPS-tracker (QStarz BT1000X, Qstarz International Co., Ltd., Taipei, Taiwan), an established device to assess spatial location of physical activity (Wu et al., 2010). The Software Personal Activity Location Measurement System (PALMS; available from: http://ucsd-palms-project.wikispaces.com/.) was used to merge the GPS and PA data. PALMS is valid for processing GPS data to objectively measured PA data (Carlson et al., 2015). OPA variables included being active outdoors (yes or no), mean outdoor walking duration and distance, number of outdoor walking episodes, and maximum distance from home. Test–retest Reliability To test for test–retest reliability, the LSA-CI assessment was conducted twice within two days for all participants at post-intervention by the same trained interviewer to exclude interrater variability. Sensitivity to Change Sensitivity to change was examined for the participants randomly assigned to the intervention group of a 12-week home-based interventional trial to improve motor performance and physical activity in geriatric patients with CI following rehabilitation. The intervention included exercises to promote functional balance and strength performance as well as various motivational strategies to promote physical activity (Bongartz et al., 2017). Feasibility Completion rate and completion time to fill out the questionnaire were documented at baseline to determine feasibility. In case of unrealistic self-reports and implausible participant statements data was not analyzed. In addition, LSA-CI scores at baseline were checked for floor and ceiling effects, which were considered present when more than 15% of the individuals achieve the highest or lowest score (McHorney & Tarlov, 1995). Statistical Analysis Descriptive data were presented as frequencies and percentages for categorical variables, and means and standard deviations or medians and ranges for continuous variables as appropriate. Spearman and point-biserial correlation coefficients were calculated to assess construct validity. Correlation coefficients (r) were interpreted as low (r < 0.2), moderate (r = 0.2–0.5), or high (r > 0.5) (Cohen, 1988). Intra-class correlation coefficients (ICC3,1 for absolute agreement) with 95% confidence intervals for the LSA-CI composite score and each subscore were used to analyze test–retest reliability. ICCs were interpreted as poor (<0.4), fair to good (≥ 0.4 ≤ 0.75), and excellent (>0.75) (Fleiss, 1986). Sensitivity to change was assessed using paired t-tests to test for significant within-group differences between baseline and post intervention assessment and standardized response means (SRMs) to quantify the magnitude of changes. SRMs were calculated as the difference in mean change scores divided by the SD of the change score (Katz, Larson, Phillips, Fossel, & Liang, 1992). SRMs were adjusted for the size of correlation coefficients between the baseline and post-intervention scores (Middel & van Sonderen, 2002) to use Cohen’s thresholds for effect sizes (trivial < 0.2, small ≥ 0.2 < 0.5, moderate ≥ 0.5 < 0.8, and large ≥ 0.8) (Cohen, 1988). A two-sided p-value of < 0.05 indicated statistical significance. All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 23 for Windows (IBM Corp., NY). Results Participants’ Characteristics Out of 1,981 persons screened for eligibility, 1,863 did not meet inclusion criteria due to MMSE criteria (n = 553; MMSE >26: n = 382, MMSE <17: n = 102, MMSE not feasible: n = 69), residence >30 km from study center (n = 241), medical contraindications (n = 217), being recruited for another trial (n = 211), inability to walk at least 4 m without a walking aid (n = 196), refusal to participate (n = 123), nursing home resident or admission (n = 113), or other reasons (n = 209; e.g., <65 years, lack of German language skills, transfer to another hospital). Thus, the total sample included 118 multimorbid, older, community-dwelling persons with mild to moderate CI with at least two chronic diseases, and predominantly orthopedic and cardiovascular diseases. Detailed participant characteristics are summarized in Table 1. Table 1. Participant Characteristics Characteristics  Total sample n = 118  Age, years, mean (SD)  82.3 (6.0)  Gender, female, n (%)  90 (76.3)  Professional education, n (%)   School education only  37 (31.4)   Vocational training or academic studies  81 (68.6)  Diagnoses, number, mean (SD)  11.4 (4.4)  Medications, number, mean (SD)  9.5 (3.5)  MMSE, score, mean (SD)  23.3 (2.4)  SPPB, total score, mean (SD)  5.2 (2.3)  Gait speed, m/s, mean (SD)a  0.45 (0.20)  TUG, s, median (range)b  20.5 (8.8–91.0)  At least one fall in the previous year, n (%)  79 (66.9)  FES-I, score, median (range)  11 (7–25)  FFABQ, score, mean (SD)  18.7 (12.6)  GDS, score, mean (SD)  5.3 (3.0)  Characteristics  Total sample n = 118  Age, years, mean (SD)  82.3 (6.0)  Gender, female, n (%)  90 (76.3)  Professional education, n (%)   School education only  37 (31.4)   Vocational training or academic studies  81 (68.6)  Diagnoses, number, mean (SD)  11.4 (4.4)  Medications, number, mean (SD)  9.5 (3.5)  MMSE, score, mean (SD)  23.3 (2.4)  SPPB, total score, mean (SD)  5.2 (2.3)  Gait speed, m/s, mean (SD)a  0.45 (0.20)  TUG, s, median (range)b  20.5 (8.8–91.0)  At least one fall in the previous year, n (%)  79 (66.9)  FES-I, score, median (range)  11 (7–25)  FFABQ, score, mean (SD)  18.7 (12.6)  GDS, score, mean (SD)  5.3 (3.0)  Note: GDS = Geriatric Depression Scale; FES-I = Falls Efficacy Scale-International, seven-item version; FFABQ = Fear of Falling Avoidance Behavior Questionnaire; MMSE = Mini-Mental State Examination; SPPB = Short-Physical-Performance-Battery; TUG = Timed “Up & Go”. aCalculated based on the SPPB gait speed test. bBased on data n = 113 as five participants were not able to complete the TUG due to physical limitations. View Large Table 1. Participant Characteristics Characteristics  Total sample n = 118  Age, years, mean (SD)  82.3 (6.0)  Gender, female, n (%)  90 (76.3)  Professional education, n (%)   School education only  37 (31.4)   Vocational training or academic studies  81 (68.6)  Diagnoses, number, mean (SD)  11.4 (4.4)  Medications, number, mean (SD)  9.5 (3.5)  MMSE, score, mean (SD)  23.3 (2.4)  SPPB, total score, mean (SD)  5.2 (2.3)  Gait speed, m/s, mean (SD)a  0.45 (0.20)  TUG, s, median (range)b  20.5 (8.8–91.0)  At least one fall in the previous year, n (%)  79 (66.9)  FES-I, score, median (range)  11 (7–25)  FFABQ, score, mean (SD)  18.7 (12.6)  GDS, score, mean (SD)  5.3 (3.0)  Characteristics  Total sample n = 118  Age, years, mean (SD)  82.3 (6.0)  Gender, female, n (%)  90 (76.3)  Professional education, n (%)   School education only  37 (31.4)   Vocational training or academic studies  81 (68.6)  Diagnoses, number, mean (SD)  11.4 (4.4)  Medications, number, mean (SD)  9.5 (3.5)  MMSE, score, mean (SD)  23.3 (2.4)  SPPB, total score, mean (SD)  5.2 (2.3)  Gait speed, m/s, mean (SD)a  0.45 (0.20)  TUG, s, median (range)b  20.5 (8.8–91.0)  At least one fall in the previous year, n (%)  79 (66.9)  FES-I, score, median (range)  11 (7–25)  FFABQ, score, mean (SD)  18.7 (12.6)  GDS, score, mean (SD)  5.3 (3.0)  Note: GDS = Geriatric Depression Scale; FES-I = Falls Efficacy Scale-International, seven-item version; FFABQ = Fear of Falling Avoidance Behavior Questionnaire; MMSE = Mini-Mental State Examination; SPPB = Short-Physical-Performance-Battery; TUG = Timed “Up & Go”. aCalculated based on the SPPB gait speed test. bBased on data n = 113 as five participants were not able to complete the TUG due to physical limitations. View Large Construct Validity The LSA-CI scores showed consistently moderate to high correlations with all OPA variables (r = .30–.63), with the lowest correlations for the Life-Space Assessment for Persons with Cognitive Impairment for the maximal life-space score (LSA-CI-M) (r = .30–.34) (Table 2). Moderate to high correlations of the LSA-CI scores were also found with almost all (15 of 16) PA variables addressing physical active behavior (i.e., standing, walking, number of walking episodes and steps) (r = .23–.60), whereas correlations with PA variables addressing sedentary behavior (i.e., lying, sitting) were consistently lower (r = −.06 to −.40). Overall, the lowest correlations with PA variables were found for the LSA-CI-M (r = −.06 to −.29). Except for the LSA-CI-M (r = |.05–.13|), LSA-CI scores showed moderate to high correlations with motor status (r = |.27–.56|) and fear of falling-related psychosocial variables (r = −.24 to −.44). For depressive symptoms, only low correlations were found (r = −.02 to −.16). The LSA-CI scores predominantly (3 out of 4) correlated only weakly with cognitive status (r = .02–.18). Except for the LSA-CI-M (r = |.13–.15|), demographic characteristics showed moderate correlations with the LSA-CI scores (r = |.27–.32|) with older and female participants demonstrating lower life-space mobility. Subgroup analyses for different cognitive status groups (i.e., MMSE >24 vs. ≤24 and >21 vs. ≤21) revealed no significant differences for any LSA-CI score (unpaired t-test: p = .137–.810). Table 2. Construct Validity for the Different Scores of the LSA-CI Variables (n = 117)  LSA-CI-C  LSA-CI-M  LSA-CI-E  LSA-CI-I  Demographic characteristics   Age, years  −.32**    −.15    −.31**    −.27**   Gender (0 = female, 1 = male)a  .28**    .13    .32**    .31**  Cognitive status   MMSE score  .18    .15    .21*    .02  Psychological status   GDS  −.11    −.16    −.11    −.02   FES-I  −.24**    −.12    −.12    −.25**   FFABQ  −.38**    −.15    −.35**    −.44**  Motor status   SPPB total score  .39**    .05    .30*    .52**   Gait speed  .41**    .13    .27**    .56**   TUG  −.40**    −.08    −.38**    −.52**  Physical activity   Lying (min)  −.13    −.07    −.25**    −.14   Sitting (min)  −.12    −.06    −.04    −.07   Standing (min)  .41**    .28**    .53**    .23*   Walking (min)  .55**    .27**    .58**    .51**   Walking episodes (n)  .40**    .16    .42**    .42**   Steps (n)  .59**    .29**    .60**    .53**  Outdoor physical activity   Being active outdoors? (0 = no, 1 = yes)a  .53**    .30**    .63**    .33**   Mean outdoor walking duration (s)  .54**    .31**    .62**    .37**   Mean walking distance outdoors (m)  .54**    .34**    .63**    .33**   Outdoor walking episodes (n)  .54**    .31**    .62**    .32**   Maximum distance from home (m)  .52**    .32**    .63**    .32**  Variables (n = 117)  LSA-CI-C  LSA-CI-M  LSA-CI-E  LSA-CI-I  Demographic characteristics   Age, years  −.32**    −.15    −.31**    −.27**   Gender (0 = female, 1 = male)a  .28**    .13    .32**    .31**  Cognitive status   MMSE score  .18    .15    .21*    .02  Psychological status   GDS  −.11    −.16    −.11    −.02   FES-I  −.24**    −.12    −.12    −.25**   FFABQ  −.38**    −.15    −.35**    −.44**  Motor status   SPPB total score  .39**    .05    .30*    .52**   Gait speed  .41**    .13    .27**    .56**   TUG  −.40**    −.08    −.38**    −.52**  Physical activity   Lying (min)  −.13    −.07    −.25**    −.14   Sitting (min)  −.12    −.06    −.04    −.07   Standing (min)  .41**    .28**    .53**    .23*   Walking (min)  .55**    .27**    .58**    .51**   Walking episodes (n)  .40**    .16    .42**    .42**   Steps (n)  .59**    .29**    .60**    .53**  Outdoor physical activity   Being active outdoors? (0 = no, 1 = yes)a  .53**    .30**    .63**    .33**   Mean outdoor walking duration (s)  .54**    .31**    .62**    .37**   Mean walking distance outdoors (m)  .54**    .34**    .63**    .33**   Outdoor walking episodes (n)  .54**    .31**    .62**    .32**   Maximum distance from home (m)  .52**    .32**    .63**    .32**  Note: Presented are Spearman rank correlation coefficients (rs), except for gender and being active outdoors. FFABQ = Fear of Falling Activity Avoidance Questionnaire; GDS = Geriatric Depression Scale; LSA-CI = Life-Space Assessment for Persons with Cognitive Impairment; LSA-CI = Life-Space Assessment for Persons with Cognitive Impairment; LSA-CI-C = composite life-space; LSA-CI-M = maximum life-space; LSA-CI-E = maximum life-space with equipment; LSA-CI-I = maximum independent life-space; MMSE = Mini-Mental State Examination; SPPB = Short-Physical Performance Battery; TUG = Timed “Up & Go”; FES-I = short Falls-Efficacy-Scale. Correlations coefficients (r): < .20 = low, .20–.50 = moderate, > .50 = high. aPoint-biserial correlation coefficients (rpb). *p < .05. **p < .01. View Large Table 2. Construct Validity for the Different Scores of the LSA-CI Variables (n = 117)  LSA-CI-C  LSA-CI-M  LSA-CI-E  LSA-CI-I  Demographic characteristics   Age, years  −.32**    −.15    −.31**    −.27**   Gender (0 = female, 1 = male)a  .28**    .13    .32**    .31**  Cognitive status   MMSE score  .18    .15    .21*    .02  Psychological status   GDS  −.11    −.16    −.11    −.02   FES-I  −.24**    −.12    −.12    −.25**   FFABQ  −.38**    −.15    −.35**    −.44**  Motor status   SPPB total score  .39**    .05    .30*    .52**   Gait speed  .41**    .13    .27**    .56**   TUG  −.40**    −.08    −.38**    −.52**  Physical activity   Lying (min)  −.13    −.07    −.25**    −.14   Sitting (min)  −.12    −.06    −.04    −.07   Standing (min)  .41**    .28**    .53**    .23*   Walking (min)  .55**    .27**    .58**    .51**   Walking episodes (n)  .40**    .16    .42**    .42**   Steps (n)  .59**    .29**    .60**    .53**  Outdoor physical activity   Being active outdoors? (0 = no, 1 = yes)a  .53**    .30**    .63**    .33**   Mean outdoor walking duration (s)  .54**    .31**    .62**    .37**   Mean walking distance outdoors (m)  .54**    .34**    .63**    .33**   Outdoor walking episodes (n)  .54**    .31**    .62**    .32**   Maximum distance from home (m)  .52**    .32**    .63**    .32**  Variables (n = 117)  LSA-CI-C  LSA-CI-M  LSA-CI-E  LSA-CI-I  Demographic characteristics   Age, years  −.32**    −.15    −.31**    −.27**   Gender (0 = female, 1 = male)a  .28**    .13    .32**    .31**  Cognitive status   MMSE score  .18    .15    .21*    .02  Psychological status   GDS  −.11    −.16    −.11    −.02   FES-I  −.24**    −.12    −.12    −.25**   FFABQ  −.38**    −.15    −.35**    −.44**  Motor status   SPPB total score  .39**    .05    .30*    .52**   Gait speed  .41**    .13    .27**    .56**   TUG  −.40**    −.08    −.38**    −.52**  Physical activity   Lying (min)  −.13    −.07    −.25**    −.14   Sitting (min)  −.12    −.06    −.04    −.07   Standing (min)  .41**    .28**    .53**    .23*   Walking (min)  .55**    .27**    .58**    .51**   Walking episodes (n)  .40**    .16    .42**    .42**   Steps (n)  .59**    .29**    .60**    .53**  Outdoor physical activity   Being active outdoors? (0 = no, 1 = yes)a  .53**    .30**    .63**    .33**   Mean outdoor walking duration (s)  .54**    .31**    .62**    .37**   Mean walking distance outdoors (m)  .54**    .34**    .63**    .33**   Outdoor walking episodes (n)  .54**    .31**    .62**    .32**   Maximum distance from home (m)  .52**    .32**    .63**    .32**  Note: Presented are Spearman rank correlation coefficients (rs), except for gender and being active outdoors. FFABQ = Fear of Falling Activity Avoidance Questionnaire; GDS = Geriatric Depression Scale; LSA-CI = Life-Space Assessment for Persons with Cognitive Impairment; LSA-CI = Life-Space Assessment for Persons with Cognitive Impairment; LSA-CI-C = composite life-space; LSA-CI-M = maximum life-space; LSA-CI-E = maximum life-space with equipment; LSA-CI-I = maximum independent life-space; MMSE = Mini-Mental State Examination; SPPB = Short-Physical Performance Battery; TUG = Timed “Up & Go”; FES-I = short Falls-Efficacy-Scale. Correlations coefficients (r): < .20 = low, .20–.50 = moderate, > .50 = high. aPoint-biserial correlation coefficients (rpb). *p < .05. **p < .01. View Large Test–Retest Reliability Correlations between the two LSA-CI assessments performed by the same interviewer within 2 days indicated good to excellent test–retest reliability for all LSA-CI scores, with ICCs ranging from 0.65 to 0.91 (Table 3). Table 3. Test–Retest Reliability of the LSA-CI Scores   Mean (SD)  ICC(3,1)  95% CI  Variable (na = 102)  First test session  Second test session  LSA-CI-C  29.7 (15.4)  29.0 (15.0)  0.91  0.87–0.94  LSA-CI-M  4.1 (1.1)  3.9 (1.1)  0.80  0.71–0.86  LSA-CI-E  2.8 (1.4)  2.6 (1.3)  0.65  0.53–0.75  LSA-CI-I  1.4 (1.6)  1.4 (1.5)  0.91  0.86–0.94    Mean (SD)  ICC(3,1)  95% CI  Variable (na = 102)  First test session  Second test session  LSA-CI-C  29.7 (15.4)  29.0 (15.0)  0.91  0.87–0.94  LSA-CI-M  4.1 (1.1)  3.9 (1.1)  0.80  0.71–0.86  LSA-CI-E  2.8 (1.4)  2.6 (1.3)  0.65  0.53–0.75  LSA-CI-I  1.4 (1.6)  1.4 (1.5)  0.91  0.86–0.94  Note: CI = confidence interval; LSA-CI = Life-Space Assessment for Persons with Cognitive Impairment; LSA-CI-C = composite life-space; LSA-CI-M = maximum life-space; LSA-CI-E = maximum life-space with equipment; LSA-CI-I = maximum independent life-space; ICC = intra-class correlation coefficient (<0.4 = poor, 0.4–0.74 = fair to good, >0.75 = excellent). aSample size was reduced due to the organization of the study and the timing of the assessment. View Large Table 3. Test–Retest Reliability of the LSA-CI Scores   Mean (SD)  ICC(3,1)  95% CI  Variable (na = 102)  First test session  Second test session  LSA-CI-C  29.7 (15.4)  29.0 (15.0)  0.91  0.87–0.94  LSA-CI-M  4.1 (1.1)  3.9 (1.1)  0.80  0.71–0.86  LSA-CI-E  2.8 (1.4)  2.6 (1.3)  0.65  0.53–0.75  LSA-CI-I  1.4 (1.6)  1.4 (1.5)  0.91  0.86–0.94    Mean (SD)  ICC(3,1)  95% CI  Variable (na = 102)  First test session  Second test session  LSA-CI-C  29.7 (15.4)  29.0 (15.0)  0.91  0.87–0.94  LSA-CI-M  4.1 (1.1)  3.9 (1.1)  0.80  0.71–0.86  LSA-CI-E  2.8 (1.4)  2.6 (1.3)  0.65  0.53–0.75  LSA-CI-I  1.4 (1.6)  1.4 (1.5)  0.91  0.86–0.94  Note: CI = confidence interval; LSA-CI = Life-Space Assessment for Persons with Cognitive Impairment; LSA-CI-C = composite life-space; LSA-CI-M = maximum life-space; LSA-CI-E = maximum life-space with equipment; LSA-CI-I = maximum independent life-space; ICC = intra-class correlation coefficient (<0.4 = poor, 0.4–0.74 = fair to good, >0.75 = excellent). aSample size was reduced due to the organization of the study and the timing of the assessment. View Large Sensitivity to Change LSA-CI scores were significantly different between baseline and post-intervention assessment (p ≤ .001). Small to large SRMs (range 0.35–0.80) over the intervention were found across the LSA-CI scores, with the highest SRM for the LSA-CI-C (0.80) while LSA-CI subscores reached lower SRMs (0.35–0.60) (Table 4). Table 4. Sensitivity to Change of the LSA-CI Scores   Mean (SD)  p-Value  SRM  Variable (na = 53)  Baseline  Post-intervention  LSA-CI-C  28.4 (14.0)  37.6 (14.5)  <.001  0.80  LSA-CI-M  3.9 (1.1)  4.5 (0.9)  .001  0.60  LSA-CI-E  3.0 (1.2)  3.3 (1.2)  <.001  0.35  LSA-CI-I  1.3 (1.5)  1.8 (1.6)  .001  0.43    Mean (SD)  p-Value  SRM  Variable (na = 53)  Baseline  Post-intervention  LSA-CI-C  28.4 (14.0)  37.6 (14.5)  <.001  0.80  LSA-CI-M  3.9 (1.1)  4.5 (0.9)  .001  0.60  LSA-CI-E  3.0 (1.2)  3.3 (1.2)  <.001  0.35  LSA-CI-I  1.3 (1.5)  1.8 (1.6)  .001  0.43  Note: LSA-CI = Life-Space Assessment for Persons with Cognitive Impairment; LSA-CI-C = composite life-space; LSA-CI-M = maximum life-space; LSA-CI-E = maximum life-space with equipment; LSA-CI-I = maximum independent life-space; SRM = standardized response mean (<0.2 = trivial, ≥0.2 < 0.5 = small, ≥0.5 <0.8 = moderate, ≥0.8 = large). aOnly participants randomly assigned to the intervention group and completing the intervention were included in the analyses. View Large Table 4. Sensitivity to Change of the LSA-CI Scores   Mean (SD)  p-Value  SRM  Variable (na = 53)  Baseline  Post-intervention  LSA-CI-C  28.4 (14.0)  37.6 (14.5)  <.001  0.80  LSA-CI-M  3.9 (1.1)  4.5 (0.9)  .001  0.60  LSA-CI-E  3.0 (1.2)  3.3 (1.2)  <.001  0.35  LSA-CI-I  1.3 (1.5)  1.8 (1.6)  .001  0.43    Mean (SD)  p-Value  SRM  Variable (na = 53)  Baseline  Post-intervention  LSA-CI-C  28.4 (14.0)  37.6 (14.5)  <.001  0.80  LSA-CI-M  3.9 (1.1)  4.5 (0.9)  .001  0.60  LSA-CI-E  3.0 (1.2)  3.3 (1.2)  <.001  0.35  LSA-CI-I  1.3 (1.5)  1.8 (1.6)  .001  0.43  Note: LSA-CI = Life-Space Assessment for Persons with Cognitive Impairment; LSA-CI-C = composite life-space; LSA-CI-M = maximum life-space; LSA-CI-E = maximum life-space with equipment; LSA-CI-I = maximum independent life-space; SRM = standardized response mean (<0.2 = trivial, ≥0.2 < 0.5 = small, ≥0.5 <0.8 = moderate, ≥0.8 = large). aOnly participants randomly assigned to the intervention group and completing the intervention were included in the analyses. View Large Feasibility No participant objected to the assessment procedure, and data documentation was comprehensive, with no missing responses for any LSA-CI item (i.e., 100% completion rate). We excluded 1 of 118 participants (0.8%) from the analysis, because of unrealistic statements, advanced disorientation, and confabulation. Mean completion time (SD) to assess the LSA-CI was 4.1 (2.2) min. No participant obtained the minimum or maximum LSA-CI-C score, with values ranging from 4.5 to 70.0 points, indicating no ceiling or floor effects for this score. No ceiling or floor effects were documented also for the LSA-CI-E, with no participant obtaining the minimum and only 12 participants (10.3%) obtaining the maximum score. For the LSA-CI-M, we found no floor effect (no participant with the minimum score) but a ceiling effect, with 35 participants (29.9%) obtaining the maximum score. For the LSA-CI-I, no ceiling (n = 5 [4.3%] with the maximum score) but a floor effect was identified, with 58 participants (49.6%) obtaining the minimum score. Discussion Although older persons with CI represent a high-risk group for life-space restrictions, established interview-based life-space assessment instruments have not yet been adjusted or validated for use in this population. The presented study is the first to modify one of the most frequently used life-space assessment tools (UAB-LSA) for persons with CI and to evaluate its measurement properties in multimorbid older persons with mild to moderate CI. Construct Validity Our results indicated moderate to high construct validity of the LSA-CI with measures of demographic characteristics, motor status, fear of falling-related psychosocial factors, and PA and OPA. Lower life-space mobility was associated with female sex, higher age, lower motor status, pronounced fear of falling-related variables, and higher levels of physical active behavior, which is consistent with previous UAB-LSA validation studies (Baker et al., 2003; Curcio et al., 2013; Fristedt et al., 2016; Harada et al., 2010; Ji et al., 2015; Peel et al., 2005) or cohort studies investigating life-space mobility (Portegijs et al., 2015; Tsai et al., 2015) in community-dwelling older people without CI. We found that motor status was one of the strongest variables associated with LSA-CI scores, confirming results of previous UAB-LSA validation studies, which also reported higher correlations for measures of motor status compared to demographic variables, psychosocial status, and cognitive status (Baker et al., 2003; Curcio et al., 2013; Peel et al., 2005). As previously described for older people without CI (May et al., 1985; Peel et al., 2005), our results documented that physical functioning represents a main determinant of life space mobility also in multimorbid older people with CI. High correlations were also found among the variables documenting physical active behavior. As expected from previous cohort studies (Portegijs et al., 2015; Tsai et al., 2015), higher life-space mobility was associated with being more physically active (higher PA and OPA) in our study (e.g., higher number of steps, longer outdoor walking distance, being active outdoors). These results might be explained by the facts that (1) for reaching higher levels of the concentric zones within the life-space concept (e.g., outside bedroom, neighborhood) a certain level of (outdoor) PA is necessary and (2) the OPA variables also addressed activity and location of mobility as made by the LSA-CI. Sedentary behavior was not associated with life-space mobility, which was previously shown by (Tsai et al., 2015), indicating that sedentary persons may use more motorized transportation to reach comparable life-space levels or physical active persons organize their daily life within the immediate surrounding. A number of papers have found out similar results for physical activity. Sedentary behavior and low physical activity seem to be independent predictors of worse health outcomes (DiPietro, Jin, Talegawkar, & Matthews, 2017; Klenk et al., 2016; Patel et al., 2010). To the best of our knowledge, our study was the first that successfully demonstrated construct validity of an interview-based life-space assessment instrument based on objectively, sensor-derived PA and OPA behavior. Previous UAB-LSA validation studies in community-dwelling elderly reported moderate correlations of life-space mobility with participants’ cognitive status (Ji et al., 2015; Peel et al., 2005). In contrast to these studies, these correlations were considerably lower in our cognitively impaired participants. The lower correlations may be related to the relatively small range of cognitive status in our sample, as we included solely persons with mild to moderate CI and excluded those with more severe or without CI. Previous UAB-LSA validation studies included a large number of community-dwelling elderly (n = 100–998; >65 years) without taking into account the cognitive status for an inclusion criterion, which may have resulted in wide-ranging cognitive performance levels among their samples and potentially also in the higher correlations found in these studies. We found lowest correlations of life-space mobility with depressive symptoms. Previous findings for associations of life-space mobility and depressive symptoms in older people without CI have been ambiguous (Baker et al., 2003; Curcio et al., 2013; Ji et al., 2015; Peel et al., 2005; Polku et al., 2015; Umstattd Meyer, Janke, & Beaujean, 2014). Our results suggest that there seems to be no association of life-space mobility and despressive symptoms in community-dwelling older people with CI. Across all correlates used for testing construct validity, we found the lowest correlations for the maximal life-space score (LSA-CI-M), which is in line with the results reported in previous UAB-LSA validation studies (Baker et al., 2003; Fristedt et al., 2016). This can be explained by the fact that the LSA-CI-M does not consider a person’s own ability to independently reach the maximum life-space (i.e., without personal assistance or equipment). Thus, this score documents a different aspect of life-space mobility which may rather be determined by the availability and the use of assistance from persons or equipment than by personal characteristics such as age, gender, or motor, cognitive and psychological status, or by PA behavior, which may explain the lower correlations (Baker et al., 2003; Fristedt et al., 2016). Test–Retest Reliability The LSA-CI demonstrated good to excellent test–retest reliability (ICC = 0.65–0.91) in our sample of multimorbid older people with CI. These reliability results are similar (ICC = 0.72–0.96) (Auger et al., 2009; Baker et al., 2003; Ji et al., 2015; Kammerlind et al., 2014; Portegijs et al., 2014) or even better (ICC = 0.37–0.70) (Curcio et al., 2013) compared to those reported for the UAB-LSA in older persons without CI. The overall good reliability of the LSA-CI might be particularly related to the specific strategy to prevent recall bias as used for the LSA-CI (i.e., shorter assessment period; highly-standardized interview technique), which is highly relevant in older persons with CI. Sensitivity to Change For use in clinical settings, it is essential that assessment instruments are able to detect changes over time or effects of intervention studies. To our knowledge, this is the first study that evaluated sensitivity to change of a life-space mobility assessment instrument within an interventional trial including a statistical analysis as suggested for evaluation of responsiveness (Terwee, Dekker, Wiersinga, Prummel, & Bossuyt, 2003). The significant improvements with a large effect size for the LSA-CI-C score demonstrated the high potential of the LSA-CI to adequately reproduce changes in life-space mobility induced by an intervention on motor performance and physical activity. The LSA-CI subscores seemed to be less sensitive, as documented by the lower effect sizes. This may be related to the smaller scoring range of these scores (range 0–5) compared to the LSA-CI-C (range 0–90) and to the ceiling and floor effects observed for the subscores LSA-CI-M and -I, which generally limit the ability to detect changes over time (Beaton, Bombardier, Katz, & Wright, 2001). Feasibility Feasibility of the LSA-CI was excellent in our sample of multimorbid older persons with CI. No participant refused the assessment and life-space mobility could be documented adequately. Although cognitively impaired persons show a variety of limitations regarding the recall of behavior, participants’ statements were plausible, except for only one person. These excellent results may be related to the modifications made on the recall period covered by the LSA-CI (only 1 week instead of 4 weeks) and to the use of specific, highly structured face-to-face interview technique, which has been previously demonstrated to be effective in promoting recall and assessing physical activity in older persons with CI (Hauer et al., 2011). Despite the potential challenges of cognitively impaired persons to recall retrospective information, the completion time for the LSA-CI was brief and similar to that reported for the UAB-LSA in older persons without CI (about 5 min) (Peel et al., 2005). The LSA-CI showed excellent instrument coverage with no floor and ceiling effects for the LSA-CI-C score, indicating that this score covers a wide range of life-space mobility levels without being limited in upper and lower levels even in this vulnerable study sample with relevant motor and CIs. The floor and ceiling effects observed for the subscores LSA-CI-M and LSA-CI-E were consistent with those reported in cognitive intact persons (Auger et al., 2009). The floor effect found for the LSA-CI-I documented the vulnerable status of our study sample as most of the participants were not able to leave the bed without equipment or personal assistance. The ceiling effects for the LSA-CI-M may be explained by its relation to social support (Baker et al., 2003; Fristedt et al., 2016). In this study, community-dwelling persons post-hospitalization were analyzed, discharged to their homes and thus adequately supplied with assistance to remain in their homes, which could explain the large life-space. Limitations Results may be marginally influenced by preceding hospitalization of the subjects which is associated with decreasing life-space and varying recovery rates (Brown et al., 2009). The participants were selected according to the inclusion criteria of the intervention study in which the participants were recruited representing former geriatric patients discharged from ward-based rehabilitation to their homes. Although severely impaired persons were excluded in this intervention study, the recruitment of former rehab patients may have influenced results of the presented validation. Conclusions The presented study demonstrated good to excellent measurement properties of the LSA-CI representing a modified version of the established UAB-LSA specifically adjusted to older persons with CI. Despite the potential challenges in the assessment of retrospective information in this population, the LSA-CI has shown to be a valid, reliable, sensitive, and feasible questionnaire to assess life-space mobility in multimorbid older people with mild to moderate CI. Supplementary Material Supplementary data are available at The Gerontologist online. Funding This work was supported by the “Sozialministerium Baden-Württemberg” (Ministry of Social Affairs Baden-Württemberg, Germany) and the “Kommunalverband für Jugend und Soziales Baden-Württemberg” (Municipal Association for Youth and Social Affairs in Baden-Württemberg, Germany) (grant no: 80221-208-009-01-01). Funders had no role in study concept and design, data collection, analysis and interpretation, and preparation of the manuscript. Conflict of interest None reported. References Al Snih, S., Peek, K. M., Sawyer, P., Markides, K. S., Allman, R. M., & Ottenbacher, K. J. ( 2012). Life-space mobility in Mexican Americans aged 75 and older. Journal of the American Geriatrics Society , 60( 3), 532– 537. doi: 10.1111/j.1532-5415.2011.03822.x Google Scholar CrossRef Search ADS PubMed  Auger, C., Demers, L., Gélinas, I., Routhier, F., Jutai, J., Guérette, C., & Deruyter, F. ( 2009). 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Published: Jan 31, 2018

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