Batteries assessing health related fitness in the elderly: a brief review
European Review of Aging and Physical Activity volume 5, pages 97–105 (2008)
Evaluation of physical functioning is a key issue in clinical geriatrics and in aging research. In recent years, different physical performance batteries in which individuals are asked to perform several tasks and are evaluated using different criteria have been designed and used in elderly populations. These batteries include different types of test which range from basic motor abilities to relevant everyday activities, depending on the construct area in the domain of physical function that must be measured. This paper reviews and classifies the main physical functioning batteries that can be found in the scientific field of aging research in order to provide knowledge on selection, administration, and interpretation of this indispensable assessment tools.
During the past three decades, physical clinicians and researchers have struggled to determine the most appropriate methods to assess the ability of elder individuals to maintain their independence in activities of daily living (ADLs)  in order to get an objective measure of their functional status. Given that this level of autonomy relies on the effective combination of several physical capacities (mainly endurance, strength, and flexibility) and selected motor abilities (such as balance, coordination, or agility) , standardized methods for the assessment of physical performance and functional ability have been developed, and their reliability and validity have been demonstrated . Moreover, in an attempt to enhance the ability to quantify the functional status of the elderly, direct physical performance measures (defined as a series of tasks that the individual must perform in a standardized manner and are assessed using a priori criteria)  have been developed and gathered under the structure of performance batteries.
This paper reviews the most relevant performance batteries that have been specifically designed to assess the functional status of the elderly in order to provide knowledge on selection, administration, and interpretation of this indispensable assessment tools.
Functional fitness batteries
Functional fitness has been designed as having the physiologic capacity to perform normal everyday activities safely and independently without undue fatigue, so batteries must asses the physiologic attributes that support the behavioral functions necessary to perform activities of daily living . Functional fitness is typically assessed using batteries that include a combination of health- and performance-related test (Table 1), including measurements of aerobic capacity, muscular strength and endurance, body weight and composition, flexibility, balance, and coordination  (Table 2).
American Alliance for Health, Physical Education, Recreation and Dance
One of the first attempts to create a specific battery to measure the physical fitness of the elderly was carried out by the American Alliance for Health, Physical Education, Recreation and Dance (AAHPERD) . This battery, also known as Functional Fitness Assessment Battery , having been subjected to several reliability and validity examinations  and once established the pertinent normative parameters , has become one of the most popular batteries and one of the most useful databank tools. However, certain weak points have been detected, such as the absence of some lower body muscle function tests or the fact that some of the exercises (flexibility and aerobic endurance) may be difficult to perform for many elderly people, as well as the verification of a learning effect . Besides, it is worth mentioning that the protocol in two of the exercises (coordination and strength) should undergo some modifications in order to improve its reproducibility .
All in all, the AAHPERD is a battery which can be easily administered due to its low cost and its minimal space and equipment requirements, and it also includes a large number of reference parameters and a user’s manual to apply it. Only the learning effect needs to be controlled, especially as far as the agility, flexibility, and coordination exercises are concerned. This fact makes of it a useful instrument to evaluate the underlying physical parameters associated with daily activities.
Short physical performance battery
This battery, known as SPPB or Nacional Institute on Aging (NIA battery) was derived from the adaptation of different functional tests created during the 1980s with the objective of being administered by one single person, in any home, regardless of any spatial constraints. The resulting battery was focused on assessing the lower extremity function and was able to classify a large number of elderly people across a broad spectrum of functional status, predicting mortality in an efficient way . That may be the reason why this is one of the most widely used batteries in longitudinal studies seeking to evaluate elderly people (whether they are sedentary  or affected by certain pathologies ) or to assess the effects of training in these populations (the physical exercise programmes ). The SPPB battery is characterized by the short period of time involved in its performance (10–15 min) and by the fact that it predicts mobility disability and activities of daily living disability independently, mainly through the assessment of strength, balance, and gait speed. Nevertheless, significant ceiling or floor effects on some of the items limit their ability to provide measurement data on a continuous scale across a wide range of ability levels . Probably due to this fact, some researchers have included a 0 level (performance level between 0 and 5) which refers to people who cannot perform the exercises, to those individuals who are not able to walk, or to those situations in which it is self-evident that there is a risk of injury if the candidates take the test . Some other tests are generally added to this battery (such as the ability to walk 400 m or the 6-min walking test) in order to make a more thorough assessment.
Mac Arthur battery
The MacArthur Study of Successful Aging investigated factors that influence physical and cognitive functioning among relatively highly functional volunteers between the ages of 70 and 79, with the main objective of identifying the key factors that seem to contribute to healthy aging .
The measures included in the battery represent several major domains of physical performance, and the test used derives from previous studies. Because of that, these measures have generally good reliability .
While the battery presents performance measures of functioning as true measures of physical health status in non-disabled old persons, it must be noted that some important domains, such as proximal upper extremity strength and shoulder range of motion, are not included, so further methodological work is needed in order to establish a more comprehensive battery .
The Groningen fitness test for the elderly
The Groningen fitness test for the elderly (GFE) is a field-based motor fitness assessment designed to research the interrelationship between motor fitness, physical activity, health, and daily functioning . This battery includes manual dexterity and reaction time tests, identified as important features of physical aptitude . In addition, it is combined with a questionnaire to assess the subjective self-evaluation of health, and therefore, it has been used in longitudinal studies seeking to analyze the correlation between fitness level perceived through questionnaires and that proved in field tests . The reliability, inter-rater, intra-rater, and internal consistency of the GFE has been demonstrated , which makes of it a very useful tool to measure basic motor abilities such as strength, endurance, and coordination. Although “passing” the GFE does not take long (each test takes 4 min and the endurance test 15) and its items are simple to perform and easily transportable, it does require specific equipment; thus, it might not be easily administered in all situations. In addition to this, it should be noted that the circumduction test lacks objectivity, that including a suitable warming up before the sit and reach test has been suggested, and that some previous practice before the block-transfer exercise would be advisable in order to avoid the learning effect. Furthermore, the endurance exercise (walking test) may not be selective enough, given the fact that some people are able to finish it without reaching their maximum level of effort . Lastly, it must be stressed that because this battery consists of simple exercises and it is easy to administer, it is used to assess the fitness level of sedentary populations and of people affected by different pathologies .
With the aim to develop a field test to assess various components of daily activities, the battery functional fitness was developed . This battery consists of eight subtest components which try to reproduce daily activities, measuring the fitness level at the same time. Three of these components have been taken from the AAHPERD, while the rest are completely new.
This battery does not require special equipment, it is a low-cost battery easy to perform, and it does not involve too much time (50 people can be tested in 3 h). Its strong point is that it is easy to administer and does not need a doctor’s permission. However, it is only useful to assess independent individuals (which is a limitation) and large populations. It might not be a good choice if the purpose is to carry out clinical studies or pre–post over a short period of time.
Fullerton fitness test
With the purpose of developing a series of tests to assess the key physiologic parameters that support functional mobility, the Fullerton fitness test (FFT) was created the , also known as Senior Fitness Test . This battery focuses on the evaluation of those physical abilities which allow the functional independence of the elderly, and it includes the body mass index as well. The FFT is relatively easy to perform, the exercises are safe, it has almost no ceiling and floor effects, and there are “normative scores” for each exercise , which makes of it a very useful battery to assess the functional fitness. Besides, if it is organized as a circuit, it is possible to evaluate up to 24 people in 90 min . It is worth mentioning that in spite of the fact that the construct validity of the FFT has been confirmed, some kind of learning effect has been detected, and therefore, one or two previous practice sessions are advisable prior to the final assessment session . Lastly, it must be taken into consideration that the FFT has been created and validated upon the score of voluntary elderly people, with ambulatory independence and generally active; consequently, the extrapolation of these scores should be done with caution.
Health Aging and Body Composition Study
The Health Aging and Body Composition Study (Health ABC) is “a prospective investigation of interrelationships between health conditions, body composition, social behavioral factors, and change in physical function” . To measure a wider range of function in this population, the SPPB battery was expanded to create the Health ABC performance battery . Because of that, the hold times on the standing balance items were increased to 30 s, and two additional balance tests were added. Besides, walking endurance is usually assessed by means of the 400-m walk test . Although this battery includes a large reference database to compare scores, it is important to point out that the selective criteria for joining the ABC study are being able to walk a quarter of a mile, climbing up ten steps, or performing basic daily life activities. Additionally, the fact that strength, mobility, and flexibility tests are not included leaves this battery somehow incomplete. In spite of this, the Health ABC battery has been described as a set of effective exercises to identify functional limitation in a discriminatory and concise way .
Batteries assessing activities of daily living
The extent to which an individual can live independently depends largely on his or her ability to perform daily functional tasks known as ADLs. ADLs are the tasks that define an individual’s daily functional competence: basic (self-care, hygiene, etc.) and instrumental (household, shopping, etc.) . The batteries reviewed in this section (Table 3) include ADL tests focused on the ability to reproduce complex, real-life tasks rather than on specific physiologic abilities. Thus, these measures are closer to the concept of disability than are the tests of more basic abilities. To avoid repetition data, several classic batteries that assess ADLs are not mentioned here, since they have been fully reviewed elsewhere .
Physical performance and mobility examination
The physical performance and mobility examination (PPME) was developed to fill the need for a performance measure of physical functioning and mobility appropriate for hospitalized and frail elders . Tasks were selected that could be safely and reliably administered at the bedside, office, or home by non-professionals after brief training. The tests have been designed to screen (1) from gross level of function and to detect clinically relevant changes in mobility. The PPME has been proven to be reliable and valid when used with healthy older people especially with those who have suffered a hip fracture .
Physical performance test
The battery physical performance test (PPT) was created with the idea of obtaining an objective quantifiable measure of functional capabilities. The PPT assesses multiple components of the physical function through the performance of different daily life activities of various degrees of difficulty . This test has been confirmed as an independent predictor of death or institutionalization , and it is presented in several shortened versions (nine, eight, or seven items) which enable the completion of the test in less than 10 min. Although this battery constitutes in itself an objective way to assess the functional level, it is normally used together with another tests such as the “Tinetti gait score” or the “6-min walking test”, with which it is perfectly correlated, obtaining a more complete assessment at the same time . Furthermore, it is not unusual (in studies seeking a more thorough physical and functional assessment) to administer this battery in coordination with the SPPB, since they are also perfectly correlated . The PPT seems to be an appropriate way of assessing those daily life activities involving strength, balance, and flexibility, although it has also been used successfully to evaluate the effects of training programs  or the level of autonomy of sick populations .
Timed movement battery
The timed movement battery (TMB) is a battery designed to assess the range of mobility in elderly people (“mobility” meaning their ability to manage their own body in order to face different situations in an autonomous way); therefore, it includes tests related to the basic and instrumental activities of daily living . Unlike most tests, TMB tasks are performed at two speeds (self-selected speed and maximum movement), which facilitate the elimination of the “ceiling effects”. In spite of the fact that its construct validity has been verified, that it is perfectly correlated with other classic elderly fitness tests (such as Up & Go test ), and that it is being used in current clinic research , it is noticeable that some kind of accurate coordination test is missing in order to fully evaluate the mobility upon which daily life autonomy rests. Besides, performing some of the tasks may be difficult for those people suffering from certain mobility problems, hence the need for more research in order to evaluate its sensitivity and specificity.
There are some batteries that include several tests to assess health-related fitness (HRF) as well as to measure functional performance (FP). In this context, HRF refers to the components of fitness (cardiorespiratory, motor, musculoskeletal, morphologic, etc.) that are affected by habitual physical activity and are related to various health outcomes. FP, which is related to the components of HRF, refers to the ability to perform tasks for independent living and overall well-being.
The comprehensive test batteries presented here (Table 4) generally include motor skills (coordination, kinesthetic differentiation, or sense of rhythm) and some performance measures (flexibility, strength or endurance, among others).
Continuous scale physical functional performance test
This battery, known as continuous scale physical functional performance (CS-PFP), was created with the intention of producing a measuring tool which avoided the ceiling and floor effects and which identified the causes of poor physical functional performance. As a result, it was obtained an instrument which uses a continuous scale to quantify the physical function performance of the whole body as well as across several physical domains . Therefore, the CS-PFP is based on the performance of very common and simple daily life tasks, which minimizes the “learning effect” and assesses the levels of strength, balance, coordination, and endurance upon which these tasks rest. The fact that the battery is applicable to elderly people with different functional levels should be emphasized, although it was not designed to assess those individuals who need assistance in order to perform some of their daily tasks. Nevertheless, the battery has been used to assess people with specific disorders, such as cardiovascular disease, pot-born injury, or Parkinson’s disease . There are several versions of this battery worth mentioning. The German version modifies the size of the furniture where the tests are carried out and substitutes the “vertical reach task” with the “functional reach test”. Thus, the flexibility is evaluated by a combination of a forward standing reach and sit and reach task (putting a Velcro-closed strip across the shoe). It was estimated that the battery had changed in more than 30%, so a new one was defined, the daily activity performance . Besides, in order to overcome the difficulties in the application of the CS-PFP (a fixed laboratory space and approximately 1 h were necessary to administer the test), a shortened version, “physical function performance 10 test” (PFP-10), was created, which requires less room and equipment and which is applied in 30 min . Lastly, the CS-PFP has also been adapted to elderly wheelchair users .
Health-related fitness and functional performance test
The health-related functional test battery (HR-FTB) is a battery comprising several motor and musculoskeletal fitness tests which has been widely used in adults. Due to its success, it was decided to test its efficiency in assessing the level of fitness in people over 60, and as a result, a battery including six HRF tests and three FP tests was originated . This battery has a great correlation with the perceived level of health, although two of the tests (dynamic back extension and one-leg extension) may cause safety problems. However, this battery was validated with people who do not show mobility problems, so more research should be done in order to determine the possible applicability of the HR-FTB to a wider range of elderly populations.
Instrumental activities of daily living
With the objective of creating an index to correlate chronological age with the level of functional decline, the instrumental activities of daily living (IADL) was designed, which consists of 17 tests related to instrumental daily life activities . This battery can be completed in 40 min, and it only requires an examiner and minimum equipment. Although the IADL includes different exercises which have been developed and validated in different studies , it must be taken into account that the capability of the exercise “functional reach” to assess the dynamic balance has been questioned  and that this battery has only been used in Japanese populations . Therefore, more studies confirming its reliability in different geographical contexts would be necessary.
Women’s Health and Aging Study
The Women’s Health and Aging Study (WHAS) is a longitudinal study designed to identify the factors related to progressive physical disability in impaired elderly women over 65 . The WHAS battery consists of fitness exercises and other tests which assess the efficiency of the performance of certain daily life tasks; therefore, it has been pointed out as a very effective method to predict and calculate the risk of developing progressive disabilities . Besides, a remarkable feature of the WHAS battery is that it can be safely performed in home setting . Although the use of the battery in a longitudinal study has provided a significant amount of reference data, we have to bear in mind that the women who were selected to participate in WHAS had to show some kind of difficulty in performing certain tasks which assess the functional autonomy; consequently, this results are not applicable to healthy populations, nor to men, of course .
The batteries which have been designed to assess the healthy physical condition of the elderly and which are used nowadays in clinical relevant studies present some inclusion and exclusion criteria as well as some normative values which are clear enough and which enable a good replicability of the tests. However, new applications of these batteries need to be carried out for the current level of health of elderly people to become clear. On the other hand, a better explanation of the performance protocols on which those batteries which asses daily life activities are based is necessary in order to facilitate their application in different contexts as well as the comparison of the obtained data.
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Varela, S., Ayán, C. & Cancela, J.M. Batteries assessing health related fitness in the elderly: a brief review. Eur Rev Aging Phys Act 5, 97–105 (2008). https://doi.org/10.1007/s11556-008-0037-2