Research Report

Companion Confidence in the Balance

of Community-Dwelling Older Adults:
Implications for Physical Activity Promotion
James T. Cavanaugh, PT, PhD1; Julia C. Dunfey, PT, DPT2;
Megan K. Wyand, PT, DPT3

ABSTRACT significantly yet moderately associated (intraclass correlation

Background and Purpose: Positive social relationships may coefficient (1,1) = 0.56; 95% CI = 0.31-0.74; P < 0.01). The
increase the intention of older adults to be physically active. In association between ABCCompanion and PASE scores was stron-
the presence of balance impairments, however, the potential ger (r = 0.51; 95% CI = 0.23-0.79; P < 0.01) than the asso-
influence of a familiar companion on an older adult’s physical ciation between ABCOlder Adult and PASE scores (r = 0.33; 95%
activity is not well understood. The purpose of this preliminary CI = 0.02-0.64; P = 0.04) and increased in cases for which
investigation was to explore companion confidence in the bal- companions were markedly less confident than older adults.
ance capability of an older adult as a potential determinant of Discussion and Conclusions: Older adults and their compan-
older adult physical activity. ions did not necessarily share similar confidence in the older
Methods: The study employed a cross-sectional design, in adult’s balance capability. Companion confidence, especially
which 40 dyads formed by a community-dwelling older adult when markedly less than older adult confidence, showed
and his or her close companion (eg, family member, friend, promise as a predictor of older adult physical activity. Study
and caregiver) were recruited as a sample of convenience. findings provided a foundation for future investigations that
Older adults completed the Activities-Specific Balance Con- examine the effect of social relationships on the physical
fidence (ABC) scale and the Physical Activity Survey for the activity self-efficacy of older adults with balance impairments.
Elderly (PASE). Companions completed a modified version of Key Words: aging, balance, physical activity, self-efficacy,
the ABC scale, in which they were asked to rate their confi- social relationships
dence in the older adult’s balance. The agreement between
and correspondence of paired ABC scores were analyzed (J Geriatr Phys Ther 2014;37:121-126.)
using mean difference (95% confidence interval [CI]), depen-
dent samples t test (α = 0.05), and the intraclass correlation
coefficient 1-way random effects model. The Pearson prod- INTRODUCTION
uct-moment correlation coefficient was used to characterize The promotion of physical activity is an important non-
the relationship between companion confidence and older
adult physical activity. pharmaceutical strategy in chronic disease management.1
Results: Older adults were more confident in their balance Physical activity interventions, whether targeting older
capability (mean ABCOlder Adult = 70.0; 95% CI = 62.8-77.2) adults2,3 or the general population,4 are thought to be
than their companions (mean ABCCompanion = 60.2; 95% vitally important for attenuating the risks for and amelio-
CI = 50.6-69.8). The difference between group mean scores rating the consequences of many health conditions (eg, car-
was significant (mean difference = 9.8; 95% CI = 2.3-17.3,
t (39) = 2.38; P = 0.02). Discordance increased as the diovascular disease, obesity, diabetes, cancer, arthritis, and
mean of paired ABC scores diminished. ABC scores were also depression).5,6 Despite these efforts, older adults generally
remain among the least physically active of any adult age
1Department of Physical Therapy, University of New group,6-8 with more than half not attaining the amount of
England, Portland, Maine. physical activity recommended for their age.9
2Coastal Rehab, LLC, Cape Elizabeth, Maine. Numerous determinants of older adult physical activ-
3Spaulding Nursing and Therapy Center North End, ity have been identified, including many characteristics of
Boston, Maine. the individual, social environment, physical environment,
This work was sponsored by the Department of Physical and cultural environment.10-12 For some older adults
Therapy, University of New England, Portland, Maine. with balance impairments, however, self-imposed activity
The authors declare no conflicts of interest. avoidance represents an additional determinant, given its
Address correspondence to: James T. Cavanaugh, PT, association with falls, fear of falling, and low fall-related
PhD, Department of Physical Therapy, University of New self-efficacy.13-18 Activity avoidance, in turn, has been asso-
England, 716 Stevens Ave., Portland, ME 04103 (jcavana- ciated with depression and social isolation.19-22 Strategies
[email protected]). for addressing the unique barriers to physical activity
Robert Wellmon was the Decision Editor. among individuals with balance impairments are important
DOI: 10.1519/JPT.0b013e3182abe7c0 considerations for health promotion and rehabilitation.
Journal of GERIATRIC Physical Therapy 121
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Research Report

Positive social relationships with close companions surveys, or (3) if the targeted older adult participant was
(eg, spouse, partner, family member, or caregiver) seem nonambulatory. The Institutional Review Board for the
to have a protective effect on physical function and Protection of Human Subjects at the University of New
physical disability23 and may increase the intention to be England approved the study. Data were collected from July
physically active and adherence to exercise classes.24,25 A through November 2011.
possible explanation for this effect is that structure and
function of social connections contribute to individual self- Measures
efficacy.26,27 The extent to which positive social relation-
ships might influence the physical activity of older adults Descriptive Measures
with balance impairments, especially those impairments We recorded the age and sex of each participant, whether
that challenge fall-related self-efficacy and lead to physical dyad members shared a residence, the nature of the rela-
activity restriction,17,28 has not been studied. tionship (eg, spouse, friend, family member, and caregiver),
To begin examining this issue, our first aim was to the approximate number of hours per week spent together
explore how confidence in an older adult’s balance capa- during the previous month, and the number of times the
bility might differ between 2 perspectives: that of the older adult participant had fallen in the previous year. To
older adult and that of his or her close companion. Our characterize older adult ambulatory mobility, we collected
second aim was to explore how companion confidence in 2 trials of self-selected gait speed over a 3-m distance;
the balance capability of an older adult might serve as a assistive devices were allowed as needed.31
potential determinant of older adult physical activity. To
conduct the study, we recruited older adult-–companion Activities-Specific Balance Confidence Scale
dyads and administered 2 versions of the Activities-Specific The ABC is a 16-item survey that examines balance con-
Balance Confidence (ABC) scale.29 Older adults completed fidence during a series of progressively more challenging
the traditional version, whereas companions completed a balance tasks, from ambulatory activities inside the home
modified version that we created specifically for this study. to walking in various community environments.29 Modeled
Older adults also completed the Physical Activities Scale after Bandura’s self-efficacy framework,27 respondents rate
for the Elderly (PASE).30 We hypothesized that percep- their confidence in response to the root question, “How
tions of confidence in the older adult’s balance capability confident are you that you will not lose your balance or
would be relatively similar, especially for pairs who spent become unsteady when you…?” Each item is rated from 0
substantial time together each week. We also hypothesized (no confidence) to 100 (complete confidence). A total score
that companions with relatively higher confidence in the is calculated as the mean of the individual item scores. In
older adult’s balance capability would be associated with the original report of its development, the ABC scale dem-
physically active older adults, whereas companions with onstrated high internal consistency (Cronbach α = 0.96),
relatively lower confidence would be paired with less physi- test-retest reliability (r = 0.92), convergent and discrimi-
cally active older adults. native validity in comparison to scales of self-perceived
physical ability and emotionality, and the ability to dis-
METHODS criminate between seniors reporting high or low mobility.29
Additional evidence of its validity and reliability was later
Design and Participants summarized.32
The study employed a cross-sectional design in which We administered the traditional ABC scale to older
dyads formed by a community-dwelling older adult and adult participants and generated a total score (ie, ABCOlder
his or her close companion were recruited as a sample of Adult). For companion participants, we modified the root
convenience. Older adult participants were at least 60 years question of the ABC scale to read, “How confident are you
of age and identified their companion as “someone with that [insert older adult name] will not lose [his / her] bal-
whom they have spent at least 7 hours per week during ance or become unsteady when [he/she]…?” The item list
the last month.” Dyads were recruited via word of mouth and scoring of the modified version remained unchanged,
and posted flyers from the Greater Portland, Maine, area. so as to produce a comparable score (ABCCompanion). To
Many were recruited at local independent living facilities. our knowledge, the modified version of the ABC scale was
Every effort was made to recruit a range of companion unique to this study and had not been validated previously.
types, that is, those who shared a residence with the older
adult participant (eg, spouse, partner, and sibling) and Physical Activity Scale for the Elderly
those who did not (eg, extended family and friend). Dyads The PASE is a brief survey designed to measure physi-
were excluded if either individual (1) was unable to speak cal activity in persons 65 years and older during leisure,
English, (2) reported cognitive, memory, or communica- household, and occupational activities occurring over the
tion impairments that limited his or her ability to complete previous 7-day period.30 PASE item scores are calculated
122 Volume 37 • Number 3 • July-September 2014
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Research Report

by multiplying either time spent (hours per week) or par- The sample contained 33 female and 7 male compan-
ticipation in (yes/no) each activity with empirically derived ions, who had a mean age ± SD of 69.2 ± 14.4 years. Two
item weights. The total PASE score, which represents the companions did not report their age. Twenty-five compan-
sum of individual item scores, ranges from 0 to more than ions reported living with the older adult. Mean time spent
400. In early publications, the PASE demonstrated good per week together ± SD was 90.7 ± 62.3 hours, with 19
test-retest reliability (r = 0.75) and construct validity in dyads reporting spending more than 100 hours per week
relation to physical measures and self-perceptions of health together. Companions included 21 spouses, 11 children,
status in samples of community-dwelling older adults.30,33 6 friends, and 2 unrelated caregivers.
Additional evidence of its validity and reliability was sum- Older adults as a group were more confident in their
marized more recently.34 balance capability (mean ABCOlder Adult= 70.0; 95% CI =
62.8-77.2; SD = 22.4; minimum = 14.4; maximum =
Procedures 100.0) than the group of companions (mean ABCCompanion=
Trained research personnel collected descriptive data and 60.2; 95% CI = 50.6-69.8; SD = 30.0; minimum = 2.2;
administered the ABC scale to each older adult and com- maximum = 99.7). The difference between group mean
panion dyad in a place convenient to them (eg the older scores was significant (mean difference = 9.8; 95% CI =
adult’s home). Participants were sequestered from one 2.3-17.3, t (39) = 2.38; P = 0.02). The 2 sets of scores
another when completing the surveys to avoid influencing were significantly yet moderately associated (intraclass
each other’s responses. Older adults also completed the correlation coefficient (1,1) = 0.56; 95% CI = 0.31-0.74;
PASE and underwent gait speed testing. P < 0.001). Time spent together was not associated with
the difference in ABC scores (ρ = 0.19; P = 0.25).
Data Analysis Figure 1 features a Bland–Altman plot35 in which mean
Data were analyzed using SPSS version 20 (SPSS Inc, of paired scores (x-axis) was plotted against difference in
Chicago, IL). Descriptive statistics (ie, mean, standard paired ABC scores (y-axis). Positive differences (n = 25)
deviation [SD], and frequency) were used to character- indicated cases in which older adults were more confident
ize the sample. Gait speed was calculated as the mean of in their balance capability than their companion (mean
2 trials. Time spent together and the number of falls in difference = 21.9; 95% CI = 13.5-30.3). Negative differ-
the previous year were characterized using the average ences (n = 15) indicated cases in which companions were
reported value, to account for the possibility of recall error more confident in their older adult’s balance capability than
by either participant. For our first aim, we characterized the
agreement between and correspondence of ABCOlder Adult 80
and ABCCompanion scores using mean difference (95%
60
confidence interval [CI]), dependent samples t test (α =
Difference in paired ABC scores

0.05), and the intraclass correlation coefficient 1-way 40

random effects model. Because of a skewed distribution in
the amount of time spent together, we used the relatively 20
conservative, nonparametric Spearman ρ correlation coef-
0
ficient to analyze its relationship to the differences in the
ABC scores. We constructed a Bland–Altman plot35 and
–20
calculated the 95% limits of agreement to identify system-
atic bias in and outlier cases of marked difference in paired –40
ABC scores. For our second aim, we analyzed the relation-
ship between each ABC score and the PASE score of the –60

older adult using the Pearson product-moment correlation

–80
coefficient (α = 0.05). 0 10 20 30 40 50 60 70 80 90 100
Mean of paired ABC scores
RESULTS Figure 1. Bland–Altman plot of the agreement between
paired Activities-Specific Balance Confidence (ABC) scale
The sample contained 22 female and 18 male older scores as a function of their mean (n = 40). Positive
adult participants, who had a mean age ± SD of 80.7 ± differences indicate cases in which older adults were more
7.5 years. Mean gait speed ± SD was 0.82 ± 0.26 m/s. confident in their balance capability than their companions.
One dyad did not provide falls data; another dyad reported Negative differences indicate cases in which companions
were more confident in their older adult’s balance capability
multiple daily falls; 22 dyads reported 0 falls. The median than the older adult himself or herself. Dashed lines indicate
value of the resulting highly skewed distribution of older 95% limits of agreement (a difference of ±46.9 in paired
adult falls was 0.5. ABC scores).

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Research Report

the older adult himself or herself (mean difference = 10.5; were fortunate to have recruited a sample of older adults
95% CI = 4.6-16.4). Eleven dyads had ABC score differences who reported a range of balance confidence, consistent
more than 20. Four outlier dyads were identified in which with individuals living with chronic health conditions
the difference in paired ABC score was more than 46.9, representing a continuum from low to high functioning.36
the 95% limits of agreement. Each outlier dyad featured an Physical activity levels in the sample also varied, and the
older adult who was markedly more confident than his or sample was relatively inactive in comparison to associated
her companion. normative PASE values.37 Although the median number of
Physical activity levels among older adult participants reported falls among older adults was relatively low, the
were variable and relatively low (mean PASE score = 81.7; mean gait speed value suggested that many of them had
95% CI = 63.4-100.0; SD = 57.2; minimum = 2.25; maxi- an elevated risk of future adverse health events.31 Taken
mum = 271.2). ABCOlder Adult was significantly yet weakly together, these sample characteristics supported both the
related to the PASE score (r = 0.33; 95% CI = 0.02-0.64; internal validity of the correlation analyses (ie, a sufficient
P = 0.04). The association between companion confidence in range of values for each variable) and the generalizability of
older adult balance capability and older adult physical activ- the findings to the broader population of older adults with
ity was relatively stronger (r = 0.51; 95% CI = 0.23-0.79; balance impairments.
P = 0.01). To further explore this relationship, we formed Our hypothesis that older adults and their companions
2 subgroups using older adult–companion dyads with the would similarly perceive the older adults’ balance capabil-
greatest discrepancy in ABC scores. Subgroup A (n = 10) ity was not strongly supported as a general statement. Time
contained the most disparate cases in which older adults were spent together did not seem to be a contributing factor.
more confident in their balance capability than their compan- Although paired ABC scores corresponded moderately
ion. Subgroup B (n = 10) contained the most disparate cases across the sample, the amount of agreement seemed to
in which companions were more confident in the older adult’s depend somewhat on the mean of the paired ABC scores
balance capability than the older adult himself or herself. In (Figure 1). All pairs reporting high confidence (ie, mean
a secondary analysis (Table 1), we determined that for sub- ABC scores >80) agreed relatively closely in their percep-
group A, ABCCompanion was significantly and more strongly tions (ie, ABC score difference <1 SD). In most of these
related to the older adult PASE score (r = 0.70; 95% CI = cases, the difference in ABC scores was less than 10 points.
0.12-1.00; P = 0.02) than ABCOlder Adult (r = 0.42; 95% Among pairs reporting relatively lower confidence (ie,
CI = −0.33-1.00; P = 0.23). In contrast, for subgroup B, mean paired ABC scores <80), there was a greater inci-
the relationships between ABCCompanion and older adult PASE dence of substantial disagreement. Especially for the less
scores, and between ABCOlder Adult and PASE scores, were confident group, older adults tended to be more confident
weak and not statistically significant. in their balance capability than their companions. Taken
together, these findings suggest that high balance confi-
DISCUSSION dence, which previously has been associated with high
levels of older adult physical function,17,28,36 seems to be
The purpose of this study was to explore companion a shared perception among familiar observers. Low bal-
confidence in the balance capability of an older adult as a ance confidence, in contrast, does not necessarily seem to
potential determinant of older adult physical activity. We be similarly perceived. We speculated that such discrepant
perceptions, and their lack of association with less time
Table 1. Secondary Analysis of Balance Confidence and spent together, could have been attributed to companion
Physical Activity Data uncertainty about the impact of chronic health conditions
Subgroup A Subgroup B All
on older adult physical function.
Analysis Item (n = 10) (n = 10) (n = 40) Our results supported the previously articulated premise
that reduced balance confidence and similarly elevated fear
ABCOlder Adult
71.5 ± 22.5 67.3 ± 19.3 70.0 ± 22.4 of falling seem to contribute to reduced physical activity
(mean ± SD)
among community-dwelling older adults.17,38-41 In addition,
ABCCompanion
30.4 ± 20.7 81.4 ± 18.8 60.2 ± 30.0 we confirmed the relatively weak yet significant correlation
(mean ± SD)
between ABCOlder Adult and PASE scores.38,39 Our hypothesis
Corr (ABCOlder Adult, r = 0.42; r = 0.07; r = 0.33;
that companion confidence would be positively associated
PASE) P = 0.23 P = 0.84 P = 0.04a
with older adult physical activity was generally supported
Corr (ABCCompanion, r = 0.70; r = 0.02; r = 0.51; (Table 1). In fact, companion confidence was more strongly
PASE) P = 0.02a P = 0.10 P = 0.001a
associated with older adult physical activity than older
aIndicates statistical significance (α = 0.05).
Abbreviations: ABC, Activities-Specific Balance Confidence; corr, correlation; PASE, Physi-
adult confidence. Moreover, the strength of the association
cal Activity Scale for the Elderly; SD, standard deviation; subgroup A, ABCOlder Adult> > increased when restricting the analysis to dyads containing
ABCCompanion; subgroup B, ABCCompanion> > ABCOlder Adult.
companions who were markedly more conservative in their
124 Volume 37 • Number 3 • July-September 2014
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Research Report

confidence regarding the older adult’s balance capability older adult confidence, showed promise as a predictor of
than the older adult himself or herself. Although it is pos- older adult physical activity. Study findings provided a foun-
sible that these particular older adults may have been over- dation for future investigations that focus on the effect of
confident of their true physical ability, no previous literature social relationships on the self-efficacy of older adults with
existed to support such an interpretation. balance impairments.

Clinical Implications and Future Directions ACKNOWLEDGMENTS

The results of our study have implications for clinical
practice and future research. First, older adults and their The authors thank the study participants, who gave gener-
companions do not necessarily share similar confidence ously of their time and graciously welcomed the research
in the older adult’s balance capability. Especially for older team into their lives. The work was sponsored by the
adult patients presenting with chronic health conditions, Department of Physical Therapy of the University of New
discrepant perceptions between the patient and a familiar England in Portland, Maine.
observer (eg, family member) are not unusual42 and should
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