Research Article| Volume 58, P139-143, March 2023

Exploring the factors associated with decreased dynamic balance ability in older patients with heart failure

Published:December 10, 2022DOI:


      • The prevalence of frailty among study participants was 61.7%.
      • Age, frailty, sex, muscle strength, circumference, and MMSE–J score were significantly correlated with TUG score.
      • Age, frailty, muscle strength, and MMSE–J score were independent predictors of TUG scores.



      Older patients with heart failure (HF) have a higher prevalence of frailty and poorer dynamic balance ability than other community-dwelling older adults. However, the association of frailty and other clinical characteristics with dynamic balance ability in these patients remains unclear.


      We aimed to determine the clinical characteristics associated with decreased dynamic balance ability in older patients with HF.


      This observational study included patients aged ≥65 years who could walk independently and were admitted to our university hospitals to undergo a cardiac rehabilitation. The timed up and go test (TUG) was used to evaluate dynamic balance ability. Pearson's and Spearman's correlation analyses were performed to determine the relationships between TUG scores and clinical characteristics. A multiple regression model based on the forced entry method was used to determine independent predictors of TUG scores.


      Of the 183 participants in this study (94 women; mean age, 82.5 ± 8.1 years), 116 (61.7%) had frailty. Pearson's and Spearman's correlation analyses revealed that age, frailty, sex, knee extensor muscle strength, maximum calf circumference, and Mini-Mental State Examination–Japanese version (MMSE–J) score were significantly correlated with TUG score (p < 0.001). Further, multiple regression analysis showed that age (p < 0.001), frailty (p = 0.041), knee extensor muscle strength (p = 0.002), and MMSE–J score (p = 0.048) were independent predictors of TUG scores.


      Multiple factors, including age, frailty, knee extensor muscle weakness, and cognitive function impairment are independently associated with decreased dynamic balance ability in older patients with HF.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Heart & Lung: The Journal of Cardiopulmonary and Acute Care
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Horak F.B.
        Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls?.
        Age Ageing. 2006; 35: ii7-ii11
        • Kwan M.M.
        • Lin S.I.
        • Chen C.H.
        • Close J.C.
        • Lord S.R.
        Sensorimotor function, balance abilities and pain influence Timed Up and Go performance in older community-living people.
        Aging Clin Exp Res. 2011; 23: 196-201
        • Nikaido M.
        • Abiko T.
        • Anami K.
        • et al.
        Effects of grip strength and foot-gripping strength on motor functions in community-dwelling young-old women and old-old women.
        Jpn J Health Promot Phys Ther. 2016; 6 (in Japanese with English abstract): 53-57
        • Iwase H.
        • Murata S.
        • Miyazaki J.
        • Otao H.
        • Horie J.
        Relationship between time to rise from the floor and physical function in elderly females. Comparison of young-old and old-old.
        J Jpn Acad Home Health Nurs. 2013; 16 (in Japanese with English abstract): 31-36
        • Isles R.C.
        • Choy N.L.
        • Steer M.
        • Nitz J.C.
        Normal values of balance tests in women aged 20-80.
        J Am Geriatr Soc. 2004; 52: 1367-1372
        • Muir S.W.
        • Berg K.
        • Chesworth B.
        • Klar N.
        • Speechley M.
        Quantifying the magnitude of risk for balance impairment on falls in community-dwelling older adults: a systematic review and meta-analysis.
        J Clin Epidemiol. 2010; 63: 389-406
      1. Ministry of Internal Affairs and Communications. Older People in Japan from the Viewpoint of Statistics- “Respect-for-the-Aged Day”. (in Japanese); vol 20; 2020.

        • Cabinet Office
        Annual Report on the Aging Society.
        • Okura Y.
        • Ramadan M.M.
        • Ohno Y.
        • et al.
        Impending epidemic: future projection of heart failure in Japan to the year 2055.
        Circ J. 2008; 72: 489-491
        • Lee K.
        • Pressler S.J.
        • Titler M.
        Falls in patients with heart failure: a systematic review.
        J Cardiovasc Nurs. 2016; 31: 555-561
        • Kannus P.
        • Sievänen H.
        • Palvanen M.
        • Järvinen T.
        • Parkkari J.
        Prevention of falls and consequent injuries in elderly people.
        Lancet. 2005; 366: 1885-1893
        • Tanriverdi A.
        • Kahraman B.O.
        • Ozsoy I.
        • et al.
        Balance performance in patients with heart failure.
        Heart Lung. 2020; 49: 458-462
        • Schmidt C.
        • Santos M.
        • Bohn L.
        • et al.
        Dynamic balance and mobility explain quality of life in HFpEF, outperforming all the other physical fitness components.
        Arq Bras Cardiol. 2020; 114: 701-707
        • Satake S.
        • Shimada H.
        • Yamada M.
        • et al.
        Prevalence of frailty among community-dwellers and outpatients in Japan as defined by the Japanese version of the Cardiovascular Health Study criteria.
        Geriatr Gerontol Int. 2017; 17: 2629-2634
        • Fried L.P.
        • Walston J.
        Frailty and failure to thrive.
        in: Hazzard WR Blass JP Ettinger Jr, WH Halter JB Ouslander J Principles of Geriatric Medicine and Gerontology. 4th ed. McGraw-Hill, New York1998: 1387-1402
        • Clegg A.
        • Rogers L.
        • Young J.
        Diagnostic test accuracy of simple instruments for identifying frailty in community-dwelling older people: a systematic review.
        Age Ageing. 2015; 44: 148-152
        • Ministry of Health, Labour and Welfare
        Research whole concept of public health service for the elderly. Summary. /Shared Research Report.
        in: 2015: Health and Labor Sciences Research Grant (Health Labour Sciences Special Research) general report. National Center for Geriatrics and Gerontology, 2016 (in Japanese)
        • Shimada H.
        • Doi T.
        • Lee S.
        • Makizako H.
        • Chen L.K.
        • Arai H.
        Cognitive frailty predicts incident dementia among community-dwelling older people.
        J Clin Med. 2018; 7: E250
        • Denfeld Q.E.
        • Winters-Stone K.
        • Mudd J.O.
        • Hiatt S.O.
        • Chien C.V.
        • Lee C.S.
        Frequency of and significance of physical frailty in patients with heart failure.
        Am J Cardiol. 2017; 119: 1243-1249
        • Izawa H.
        • Yoshida T.
        • Ikegame T.
        • et al.
        Standard cardiac rehabilitation program for heart failure.
        Circ J. 2019; 83: 2394-2398
        • Podsiadlo D.
        • Richardson S.
        The timed “Up and Go”: a test of basic functional mobility for frail elderly persons.
        J Am Geriatr Soc. 1991; 39: 142-148
        • Shumway-Cook A.
        • Brauer S.
        • Woollacott M.
        Predicting the probability for falls in community-dwelling older adults using the Timed Up and Go Test.
        Phys Ther. 2000; 80: 896-903
        • Sugishita M.
        • Hemmi I.
        Validity and reliability of mini mental state examination-japanese (MMSE–J): a preliminary report.
        Jpn. J. Cogn. Neurosci. 2010; 12 (in Japanese): 186-190
        • Shimada H.
        • Furuna T.
        • Obuchi S.
        • et al.
        Timed up and go test is a useful assessment tool for community health in elderly people.
        Jpn Phys Ther Assoc. 2006; 33 (in Japanese): 105-111
        • Matsue Y.
        • Kamiya K.
        • Saito H.
        • et al.
        Prevalence and prognostic impact of the coexistence of multiple frailty domains in elderly patients with heart failure: the FRAGILE-HF cohort study.
        Eur J Heart Fail. 2020; 22: 2112-2119
        • Vidán M.T.
        • Sánchez E.
        • Fernández-Avilés F.
        • Serra-Rexach J.A.
        • Ortiz J.
        • Bueno H.
        FRAIL-HF, a study to evaluate the clinical complexity of heart failure in nondependent older patients: rationale, methods and baseline characteristics.
        Clin Cardiol. 2014; 37: 725-732
        • Newton P.J.
        • Davidson P.M.
        • Reid C.M.
        • et al.
        Acute heart failure admissions in New South Wales and the Australian Capital Territory: the NSW HF Snapshot Study.
        Med J Aust. 2016; 204 (113.e1-8)
        • Savva G.M.
        • Donoghue O.A.
        • Horgan F.
        • O'Regan C.
        • Cronin H.
        • Kenny R.A.
        Using timed up-and-go to identify frail members of the older population.
        J Gerontol A. 2013; 68: 441-446
        • Moura T.G.
        • Nagata C.A.
        • Garcia P.A.
        The influence of isokinetic peak torque and muscular power on the functional performance of active and inactive community-dwelling elderly: a cross-sectional study.
        Braz J Phys Ther. 2020; 24: 256-263
        • Kinugawa S.
        • Takada S.
        • Matsushima S.
        • Okita K.
        • Tsutsui H.
        Skeletal muscle abnormalities in heart failure.
        Int Heart J. 2015; 56: 475-484
        • Uemura K.
        • Shimada H.
        • Makizako H.
        • et al.
        Cognitive function affects trainability for physical performance in exercise intervention among older adults with mild cognitive impairment.
        Clin Interv Aging. 2013; 8: 97-102
      2. Japanese Circulation Society. Guidelines for diagnosis and treatment of acute and chronic heart failure (JCS 2017/JHFS 2017).

        • McDonagh T.A.
        • Metra M.
        • Adamo M.
        • et al.
        2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure.
        Eur Heart J. 2021; 42: 3599-3726
        • Heidenreich P.A.
        • Bozkurt B.
        • Aguilar D.
        • et al.
        AHA/ACC/HFSA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines.
        J Am Coll Cardiol. 2022; 79: 1757-1780
        • Kitzman D.W.
        • Whellan D.J.
        • Duncan P.
        • et al.
        Physical rehabilitation for older patients hospitalized for heart failure.
        N Engl J Med. 2021; 385: 203-216
        • Sibley K.M.
        • Beauchamp M.K.
        • Van Ooteghem K.
        • Straus S.E.
        • Jaglal S.B.
        Using the systems framework for postural control to analyze the components of balance evaluated in standardized balance measures: a scoping review.
        Arch Phys Med Rehabil. 2015; 96 (122–132.e29)