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Showing papers in "Journal of the American Geriatrics Society in 2005"


Journal ArticleDOI
TL;DR: A 10‐minute cognitive screening tool (Montreal Cognitive Assessment, MoCA) to assist first‐line physicians in detection of mild cognitive impairment (MCI), a clinical state that often progresses to dementia.
Abstract: Objectives: To develop a 10-minute cognitive screening tool (Montreal Cognitive Assessment, MoCA) to assist first-line physicians in detection of mild cognitive impairment (MCI), a clinical state that often progresses to dementia. Design: Validation study. Setting: A community clinic and an academic center. Participants: Ninety-four patients meeting MCI clinical criteria supported by psychometric measures, 93 patients with mild Alzheimer's disease (AD) (Mini-Mental State Examination (MMSE) score≥17), and 90 healthy elderly controls (NC). Measurements: The MoCA and MMSE were administered to all participants, and sensitivity and specificity of both measures were assessed for detection of MCI and mild AD. Results: Using a cutoff score 26, the MMSE had a sensitivity of 18% to detect MCI, whereas the MoCA detected 90% of MCI subjects. In the mild AD group, the MMSE had a sensitivity of 78%, whereas the MoCA detected 100%. Specificity was excellent for both MMSE and MoCA (100% and 87%, respectively). Conclusion: MCI as an entity is evolving and somewhat controversial. The MoCA is a brief cognitive screening tool with high sensitivity and specificity for detecting MCI as currently conceptualized in patients performing in the normal range on the MMSE.

16,037 citations


Journal ArticleDOI
TL;DR: It is possible that fall‐prevention strategies have limited effect on falls that result in injuries or are ineffective in populations who are at a higher risk of injury.
Abstract: The prevention of injury associated with falls in older people is a public health target in many countries around the world. Although there is good evidence that interventions such as multifactorial fall prevention and individually prescribed exercise are effective in reducing falls, the effect on serious injury rates is unclear. Historically, trials have not been adequately powered to detect injury endpoints, and variations in case definition across trials have hindered meta-analysis. It is possible that fall-prevention strategies have limited effect on falls that result in injuries or are ineffective in populations who are at a higher risk of injury. Further research is required to determine whether fall-prevention interventions can reduce serious injuries. Prevention of Falls Network Europe (ProFaNE) is a collaborative project to reduce the burden of fall injury in older people through excellence in research and promotion of best practice (www.profane.eu.org). The European Commission funds the network, which links clinicians, members of the public, and researchers worldwide. The aims are to identify major gaps in knowledge in fall injury prevention and to facilitate the collaboration necessary for large-scale clinical research activity, including clinical trials, comparative research, and prospective meta-analysis. Work is being undertaken in a 4-year program. As a first step, the development of a common set of outcome definitions and measures for future trials or meta-analysis was considered.

1,725 citations


Journal ArticleDOI
TL;DR: Clinical relevant cutpoints for usual gait speed are defined and their predictive value for health‐related events in older persons is investigated.
Abstract: OBJECTIVES: To define clinically relevant cutpoints for usual gait speed and to investigate their predictive value for health-related events in older persons. DESIGN: Prospective cohort study. SETTING: Health, Aging and Body Composition Study. PARTICIPANTS: Three thousand forty-seven well-functioning older persons (mean age 74.2). MEASUREMENTS: Usual gait speed on a 6-m course was assessed at baseline. Participants were randomly divided into two groups to identify (Sample A; n = 2,031) and then validate (Sample B; n = 1,016) usual gait-speed cutpoints. Rates of persistent lower extremity limitation events (mean follow-up 4.9 years) were calculated according to gait speed in Sample A. A cutpoint (defining high- (<1 m/s) and low risk (≥1 m/s) groups) was identified based on persistent lower extremity limitation events. The predictive value of the identified cutpoints for major health-related events (persistent severe lower extremity limitation, death, and hospitalization) was evaluated in Sample B using Cox regression analyses. RESULTS: A graded response was seen between risk groups and health-related outcomes. Participants in the high-risk group had a higher risk of persistent lower extremity limitation (rate ratio (RR) = 2.20, 95% confidence interval (CI) = 1.76-2.74), persistent severe lower extremity limitation (RR = 2.29, 95% CI = 1.63-3.20), death (RR = 1.64, 95% CI = 1.14-2.37), and hospitalization (RR = 1.48, 95% CI = 1.02-2.13) than those in the low-risk group. CONCLUSION: Usual gait speed of less than 1 m/s identifies persons at high risk of health-related outcomes in well-functioning older people. Provision of a clinically meaningful cutpoint for usual gait speed may facilitate its use in clinical and research settings.

1,025 citations


Journal ArticleDOI
TL;DR: This work defines frailty using simple indicators and investigates the predictive validity of this frailty classification for death, hospitalization, hip fracture, and activity of daily living disability.
Abstract: Author(s): Woods, Nancy Fugate; LaCroix, Andrea Z; Gray, Shelly L; Aragaki, Aaron; Cochrane, Barbara B; Brunner, Robert L; Masaki, Kamal; Murray, Anne; Newman, Anne B; Women's Health Initiative | Abstract: ObjectivesTo define frailty using simple indicators; to identify risk factors for frailty as targets for prevention; and to investigate the predictive validity of this frailty classification for death, hospitalization, hip fracture, and activity of daily living (ADL) disabilityDesignProspective study, the Women's Health Initiative Observational StudySettingForty US clinical centersParticipantsForty thousand six hundred fifty-seven women aged 65 to 79 at baselineMeasurementsComponents of frailty included self-reported muscle weakness/impaired walking, exhaustion, low physical activity, and unintended weight loss between baseline and 3 years of follow-up Death, hip fractures, ADL disability, and hospitalizations were ascertained during an average of 59 years of follow-upResultsBaseline frailty was classified in 163% of participants, and incident frailty at 3-years was 148% Older age, chronic conditions, smoking, and depressive symptom score were positively associated with incident frailty, whereas income, moderate alcohol use, living alone, and self-reported health were inversely associated Being underweight, overweight, or obese all carried significantly higher risk of frailty than normal weight Baseline frailty independently predicted risk of death (hazard ratio (HR)=171, 95% confidence interval (CI)=148-197), hip fracture (HR=157, 95% CI=111-220), ADL disability (odds ratio (OR)=315, 95% CI=247-402), and hospitalizations (OR=195, 95% CI=172-222) after adjustment for demographic characteristics, health behaviors, disability, and comorbid conditionsConclusionThese results support the robustness of the concept of frailty as a geriatric syndrome that predicts several poor outcomes in older women Underweight, obesity, smoking, and depressive symptoms are strongly associated with the development of frailty and represent important targets for prevention

931 citations


Journal ArticleDOI
TL;DR: To study the effectiveness of haloperidol prophylaxis on incidence, severity, and duration of postoperative delirium in elderly hip‐surgery patients at risk for Delirium, a large number of them are elderly.
Abstract: OBJECTIVES: To study the effectiveness of haloperidol prophylaxis on incidence, severity, and duration of postoperative delirium in elderly hip-surgery patients at risk for delirium. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Large medical school–affiliated general hospital in Alkmaar, the Netherlands. PARTICIPANTS: A total of 430 hip-surgery patients aged 70 and older at risk for postoperative delirium. INTERVENTION: Haloperidol 1.5 mg/d or placebo was started preoperatively and continued for up to 3 days postoperatively. Proactive geriatric consultation was provided for all randomized patients. MEASUREMENTS: The primary outcome was the incidence of postoperative delirium (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and Confusion Assessment Method criteria). Secondary outcomes were the severity of delirium (Delirium Rating Scale, revised version-98 (DRS-R-98)), the duration of delirium, and the length of hospital stay. RESULTS: The overall incidence of postoperative delirium was 15.8%. The percentage of patients with postoperative delirium in the haloperidol and placebo treatment condition was 15.1% and 16.5%, respectively (relative risk 5 0.91, 95% confidence interval (CI) 5 0.6–1.3); the

600 citations


Journal ArticleDOI
TL;DR: The aim is to gather information about surgical outcomes for patients in their 80s and 90s who have had surgery in the past and to establish a baseline for future research.
Abstract: Objectives: To gather information about surgical outcomes for patients in their 80s and 90s. Design: Prospective cohort study. Setting: Veterans Affairs Medical Centers. Participants: Patients (26,648 aged ≥80; 568,263 aged <80) enrolled in the Veterans Affairs National Surgical Quality Improvement Project (NSQIP) who had noncardiac surgery between 1991 and 1999. Methods: Data were collected prospectively from medical records and healthcare providers. Detailed information was collected about patients' preoperative status, intraoperative experience, and postoperative outcomes. Postoperative outcomes were survival status at 30 days (deaths from any cause occurring during hospitalization and after hospital discharge were captured) and the occurrence of 21 selected surgical complications within 30 days postoperatively: wound complications (3 types), respiratory complications (4), urinary tract complications (3), nervous system complications (3), cardiac complications (3), and other complications (5). Measurements: Mortality and the occurrence of 21 surgical complications within 30 days of surgery. Results: Thirty-day all-cause mortality rates varied widely across operations and were higher for patients aged 80 and older than for younger patients (8% vs 3%, P<.001). Mortality rates for those aged 80 and older were less than 2% for many commonly performed operations (e.g., transurethral prostatectomy, hernia repair, knee replacement, carotid endarterectomy). Of patients aged 80 and older, 20% had one or more postoperative complications, and patients who suffered complications had higher 30-day mortality than those who did not (26% vs 4%, P<.001). For 11 of the 21 complications, mortality for patients aged 80 and older was greater than 33%. The risk factors for poor outcomes were the same for older and younger patients, and the NSQIP Mortality Risk model performed well on patients aged 80 and older (C statistic=0.83). Conclusion: A substantial minority of patients aged 80 and older died or suffered a complication within 30 days of surgery, but for many operations mortality rates were extremely low. Postoperative complications were associated with high 30-day mortality in patients aged 80 and older.

541 citations


Journal ArticleDOI
TL;DR: The relationship between accumulated health‐related problems (deficits), which define a frailty index in older adults, and mortality in population‐based and clinical/institutional‐based samples is investigated.
Abstract: Objectives: To investigate the relationship between accumulated health-related problems (deficits), which define a frailty index in older adults, and mortality in population-based and clinical/institutional-based samples. Design: Cross-sectional and cohort studies. Setting: Seven population-based and four clinical/institutional surveys in four developed countries. Participants: Thirty-six thousand four hundred twenty-four people (58.5% women) aged 65 and older. Measurements: A frailty index was constructed as a proportion of all potential deficits (symptoms, signs, laboratory abnormalities, disabilities) expressed in a given individual. Relative frailty is defined as a proportion of deficits greater than average for age. Measures of deficits differed across the countries but included common elements. Results: In each country, community-dwelling elderly people accumulated deficits at about 3% per year. By contrast, people from clinical/institutional samples showed no relationship between frailty and age. Relative fitness/frailty in both sexes was highly correlated (correlation coefficient >0.95, P<.001) with mortality, although women, at any given age, were frailer and had lower mortality. On average, each unit increase in deficits increased by 4% the hazard rate for mortality (95% confidence interval=0.02–0.06). Conclusion: Relative fitness and frailty can be defined in relation to deficit accumulation. In population studies from developed countries, deficit accumulation is robustly associated with mortality and with age. In samples (e.g., clinical/institutional) in which most people are frail, there is no relationship with age, suggesting that there are maximal values of deficit accumulation beyond which survival is unlikely.

501 citations


Journal ArticleDOI
TL;DR: Whether an early multidisciplinary geriatric intervention in elderly patients with hip fracture reduced length of stay, morbidity, and mortality and improved functional evolution is evaluated.
Abstract: Objectives: To evaluate whether an early multidisciplinary geriatric intervention in elderly patients with hip fracture reduced length of stay, morbidity, and mortality and improved functional evolution. Design: Randomized, controlled intervention trial. Setting: Orthopedic ward in a university hospital. Participants: Three hundred nineteen patients aged 65 and older hospitalized for hip fracture surgery. Intervention: Participants were randomly assigned to a daily multidisciplinary geriatric intervention (n=155) or usual care (n=164) during hospitalization in the acute phase of hip fracture. Measurements: Primary endpoints were in-hospital length of stay and incidence of death or major medical complications. Secondary endpoints were the rate of recovery of previous activities of daily living and ambulation ability at 3, 6, and 12 months. Results: Median length of stay was 16 days in the geriatric intervention group and 18 days in the usual care group (P=.06). Patients assigned to the geriatric intervention showed a lower in-hospital mortality (0.6% vs 5.8%, P=.03) and major medical complications rate (45.2% vs 61.7%, P=.003). After adjustment for confounding variables, geriatric intervention was associated with a 45% lower probability of death or major complications (95% confidence interval=7–68%). More patients in the geriatric intervention group achieved a partial recovery at 3 months (57% vs 44%, P=.03), but there were no differences between the groups at 6 and 12 months. Conclusion: Early multidisciplinary daily geriatric care reduces in-hospital mortality and medical complications in elderly patients with hip fracture, but there is not a significant effect on length of hospital stay or long-term functional recovery.

496 citations


Journal ArticleDOI
TL;DR: Three years after implementation, the LTCI system and its needs‐assessment/certification system have been well accepted in Japan and there remain challenges, including area variations, growing demands for services, and the difficulty of keeping the needs certification free of politics.
Abstract: The introduction of Japan's long-term care insurance (LTCI) system in April 2000 has made long-term care an explicit and universal entitlement for every Japanese person aged 65 and older based strictly on physical and mental status. At the start of the program, more than two million seniors were expected to apply for services to approximately 3,000 municipal governments, which are the LTCI insurers. The LTCI implementation required a nationally standardized needs-certification system to determine service eligibility objectively, fairly, and efficiently. The current computer-aided initial needs-assessment instrument was developed based on data collected in a large-scale time study of professional caregivers in long-term care institutions. The instrument was subsequently tested and validated by assessing data of 175,129 seniors involved in the national model programs before the start of LTCI. The computer-aided initial assessment (an 85-item questionnaire) is used to assign each applicant to one of seven need levels. The Care Needs Certification Board, a committee of medical and other professionals, reviews the results. Three years after implementation, the LTCI system and its needs-assessment/certification system have been well accepted in Japan. Despite the overall successes, there remain challenges, including area variations, growing demands for services, and the difficulty of keeping the needs certification free of politics. The LTCI computer network that links municipalities and the central government is instrumental in continuously improving the needs-certification system. Future challenges include promoting evidence-based system improvements and building incentives into the system for various constituencies to promote seniors' functional independence.

495 citations


Journal ArticleDOI
TL;DR: The objectives were to identify fall‐related psychological outcome measures and to undertake a systematic quality assessment of their key measurement properties, and to establish and compare the instruments' measurement properties.
Abstract: The objectives were to identify fall-related psychological outcome measures and to undertake a systematic quality assessment of their key measurement properties. A Cochrane review of fall-prevention interventions in older adults was used to identify fall-related psychological measurements. PubMed, CINAHL, and PsycINFO were systematically searched to identify instruments not used in trials and papers reporting the methodological quality of relevant measures. Reference lists of articles were searched for additional literature, and researchers were contacted. Two reviewers undertook quality extraction relating to content, population, reliability, validity, responsiveness, practicality, and feasibility. Twenty-five relevant papers were identified. Twenty-three measures met the inclusion criteria: six single-item questions, Falls Efficacy Scale (FES), revised FES, modified FES, FES-UK, Activities-specific Balance and Confidence Scale (ABC), ABC-UK, Confidence in maintaining Balance Scale, Mobility Efficacy Scale, adapted FES, amended FES, Survey of Activities and Fear of Falling in the Elderly (SAFFE), University of Illinois at Chicago Fear of Falling Measure, Concern about Falling Scale, Falls Handicap Inventory, modified SAFFE, Consequences of Falling Scale, and Concern about the Consequences of Falling Scale. There is limited evidence about the measurement properties of single-item measures. Several multiitem measures obtained acceptable reliability and validity, but there is less evidence regarding responsiveness, practicality, and feasibility. Researchers should select measures based on the constructs they intend to study. Further research is needed to establish and compare the instruments' measurement properties.

456 citations


Journal ArticleDOI
TL;DR: To determine the effects of an 8‐week progressive lingual resistance exercise program on swallowing in older individuals, the most “at risk” group for dysphagia, an 8-week study is conducted.
Abstract: OBJECTIVES: To determine the effects of an 8-week progressive lingual resistance exercise program on swallowing in older individuals, the most ‘‘at risk’’ group for dysphagia. DESIGN: Prospective cohort intervention study. SETTING: Subjects were recruited from the community at large. PARTICIPANTS: Ten healthy men and women aged 70 to 89. INTERVENTION: Each subject performed an 8-week lingual resistance exercise program consisting of compressing an air-filled bulb between the tongue and hard palate. MEASUREMENTS: At baseline and Week 8, each subject completed a videofluoroscopic swallowing evaluation for kinematic and bolus flow assessment of swallowing. Swallowing pressures and isometric pressures were collected at baseline and Weeks 2, 4, and 6. Four of the subjects also underwent oral magnetic resonance imaging (MRI) to measure lingual volume. RESULTS: All subjects significantly increased their isometric and swallowing pressures. All subjects who had the MRI demonstrated increased lingual volume of an average of 5.1%. CONCLUSION: The findings indicate that lingual resistance exercise is promising not only for preventing dysphagia due to sarcopenia, but also as a treatment strategy for patients with lingual weakness and swallowing disability due to frailty or other age-related conditions. The potential effect of lingual exercise on reducing dysphagiarelated comorbidities (pneumonia, malnutrition, and dehydration) and healthcare costs while improving quality of life is encouraging. J Am Geriatr Soc 53:1483–1489, 2005.

Journal ArticleDOI
TL;DR: The objective is to determine whether coronary artery disease, peripheral arterial disease, or noninvasive markers of cardiovascular disease (CVD) predict the onset of dementia and Alzheimer's disease (AD).
Abstract: Objectives: To determine whether coronary artery disease, peripheral arterial disease (PAD), or noninvasive markers of cardiovascular disease (CVD) predict the onset of dementia and Alzheimer's disease (AD). Design: Longitudinal cohort study. Setting: Four U.S. communities. Participants: Men and women (N=3,602) with a brain magnetic resonance imaging (MRI) scan but no dementia were followed for 5.4 years. Participants with stroke were excluded. Measurements: Neurologists and psychiatrists classified incident cases of dementia and subtype using neuropsychological tests, examination, medical records and informant interviews. CVD was defined at the time of the MRI scan. Noninvasive tests of CVD were assessed within 1 year of the MRI. Apolipoprotein E allele status, age, race, sex, education, Mini-Mental State Examination score, and income were assessed as potential confounders. Results: The incidence of dementia was higher in those with prevalent CVD, particularly in the subgroup with PAD. The rate of AD was 34.4 per 1,000 person-years for those with a history of CVD, versus 22.2 per 1,000 person-years without a history of CVD (adjusted hazard ratio (HR)=1.3, 95% confidence interval (CI)=1.0–1.7). Rates of AD were highest in those with PAD (57.4 vs 23.7 per 100 person-years, adjusted HR=2.4, 95% CI=1.4–4.2). Results were similar with further exclusion of those with vascular dementia from the AD group. A gradient of increasing risk was noted with the extent of vascular disease. Conclusion: Older adults with CVD other than stroke had a higher risk of dementia and AD than did those without CVD. The risk was highest in people with PAD, suggesting that extensive peripheral atherosclerosis is a risk factor for AD.

Journal ArticleDOI
TL;DR: To determine whether the interval over which patients are asked to remember their falls affects fall reporting, a large number of patients say they do not remember the interval at all.
Abstract: OBJECTIVES: To determine whether the interval over which patients are asked to remember their falls affects fall reporting. DESIGN: Systematic literature review. SETTING: Community. PARTICIPANTS: Individuals being monitored for falls in prospective studies that asked participants to recall falls over varying intervals. MEASUREMENTS: Sensitivity and specificity of retrospective recall compared with a criterion-standard prospective assessment using some form of ongoing fall monitoring. RESULTS: Six studies met the inclusion criteria. Recall of falls in the previous year was specific (specificity 91-95%) but less sensitive (sensitivity 80-89%) than the criterion standard of ongoing prospective collection of fall data using fall calendars or postcards. Patients with injurious falls were more likely to recall their falls. Lower Mini-Mental State Examination score was associated with poorer recall of falls in the one study addressing this issue. CONCLUSION: Whenever accurate data on all falls are critical, such as with interventions to decrease the rate of falls, researchers should gather information on falls every week or every month from study participants. The optimal method of fall monitoring-postcard, calendar, diary, telephone, or some combination of these-remains unknown.

Journal ArticleDOI
TL;DR: Whether obesity is associated with the frailty phenotype and, if so, whether comorbid conditions or inflammatory markers explain this association is investigated.
Abstract: MEASUREMENTS: The dependent variables were the frailty syndrome, including prefrailty, defined as presence of one or two of five frailty indicators (weakness, slowness, weight loss, low physical activity, exhaustion), and frailty, defined as three or more indicators. Independent variables included BMI, categorized using World Health Organization criteria as normal (18.5 to o25kg/m 2 ), overweight (25 to o30kg/m 2 ), and obese ( � 30kg/m 2 ); chronic diseases; C-reactive protein; and serum carotenoids. RESULTS: Being overweight was significantly associated with prefrailty, and obesity was associated with prefrailty and frailty. In all frail women, regardless of BMI group, a similar pattern of three defining frailty indicators was found: slowness, weakness, and low activity (with the addition of weight loss in the normal weight group.) In multinomial regression models, obesity was significantly associated with prefrailty (odds ratio (OR) 52.23, 95% confidence interval (CI) 51.29‐3.84) and frailty (OR 5 3.52, 95% CI 51.34‐9.13), even when controlling for covariates. CONCLUSION: Obesity is associated with the frailty syndrome in older women in cross-sectional data. This association remains significant even when multiple conditions associated with frailty are considered. Prospective studies are needed to confirm this finding. J Am Geriatr Soc 53:927–934, 2005.

Journal ArticleDOI
TL;DR: A chart‐based method for identification of delirium and compare it with direct interviewer assessment using the Confusion Assessment Method (CAM) is validated.
Abstract: Objectives To validate a chart-based method for identification of delirium and compare it with direct interviewer assessment using the Confusion Assessment Method (CAM). Design Prospective validation study. Setting Teaching hospital. Participants Nine hundred nineteen older hospitalized patients. Measurements A chart-based instrument for identification of delirium was created and compared with the reference standard interviewer ratings, which used direct cognitive assessment to complete the CAM for delirium. Trained nurse chart abstractors were blinded to all interview data, including cognitive and CAM ratings. Factors influencing the correct identification of delirium in the chart were examined. Results Delirium was present in 115 (12.5%) patients according to the CAM. Sensitivity of the chart-based instrument was 74%, specificity was 83%, and likelihood ratio for a positive result was 4.4. Overall agreement between chart and interviewer ratings was 82%, kappa=0.41. By contrast, using International Classification of Diseases, Ninth Revision, Clinical Modification, administrative codes, the sensitivity for delirium was 3%, and specificity was 99%. Independent factors associated with incorrect chart identification of delirium were dementia, severe illness, and high baseline delirium risk. With all three factors present, the chart instrument was three times more likely to identify patients incorrectly than with none of the factors present. Conclusion A chart-based instrument for delirium, which should be useful for patient safety and quality-improvement programs in older persons, was validated. Because of potential misclassification, the chart-based instrument is not recommended for individual patient care or diagnostic purposes.

Journal ArticleDOI
TL;DR: To study the association between performance on psychological tests of executive function and performance on lower extremity tasks with different attentional demands in a large sample of nondemented, older adults.
Abstract: Objectives: To study the association between performance on psychological tests of executive function and performance on lower extremity tasks with different attentional demands in a large sample of nondemented, older adults. Design: Cross-sectional study. Setting: Community-based. Participants: Nine hundred twenty-six persons aged 65 and older, without dementia, stroke, parkinsonism, visual impairment, or current treatment with neuroleptics, enrolled in a large epidemiological study. Measurements: Trail Making Test (TMT) parts A and B and two performance-based measures of lower extremity function that require different executive/attentional-demanding skills: walking speed on a 4-m course at usual pace and walking speed on a 7-m obstacle course at fast pace. A difference score (Delta TMT), obtained by subtracting time to perform part A from time to perform part B of the TMT, was used as an indicator of executive function. Based on Delta TMT, subjects were divided into poor performance, intermediate performance, and good performance. Results: After adjustment, no association between Delta TMT and 4-m course usual-pace walking speed was found. Participants with poor Delta TMT and with intermediate Delta TMT performance were more likely to be in the lowest tertile for 7-m obstacle course walking speed. Conclusion: In nondemented older persons, executive function is independently associated with tasks of lower extremity function that require high attentional demand.

Journal ArticleDOI
TL;DR: Whether an education program and a reorganization of nursing and medical care improved the outcome for older delirious patients is investigated.
Abstract: A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients.

Journal ArticleDOI
TL;DR: The effects of a community‐based group exercise program for older individuals with chronic stroke and a placebo-controlled study to examine the effects of this program are studied.
Abstract: The consequences of physical inactivity are particularly detrimental in older individuals with chronic disease. Impairments resulting from chronic disease (e.g., reduced mobility, pain), in addition to the lack of accessible and appropriate community-based exercise programs could lead to further sedentary lifestyle, and additional declines in functional status.1 Physical inactivity could also contribute to secondary debilitating or life-threatening diseases. A recent study has found that approximately one third of cardiac disease and osteoporosis cases are attributable to lack of physical activity and have posed tremendous burden on the health care system.2 Stroke is one of the most common chronic conditions seen in older adults, with an incidence approximately doubling each decade after the age of 55.3 Most stroke survivors continue to live with residual physical impairments, which may promote a sedentary lifestyle and resultant secondary complications.4 One of the secondary complications commonly observed following stroke is poor cardiorespiratory fitness.5,6 Low cardiorespiratory fitness is related to poor functional performance7 and increased risk of stroke and cardiovascular disease.8,9 Indeed, cardiac events and recurrent stroke are major occurrences in stroke survivors.10,11 Other common stroke impairments are poor balance and muscle weakness,12–14 which may contribute to the higher incidence of falls in older adults with stroke than the age-matched population.15 In addition, poor mobility and decreased loading of the hemiparetic leg may also result in decline of hip bone mineral density (BMD).16,17 The increased falls and reduced bone health may in part explain the two to four time greater hip fracture risk among stroke survivors.18 These secondary conditions seen in stroke survivors are compounded by the fact that the number of older individuals with chronic stroke in the community is on the rise. Studies have shown that the incidence of stroke is increasing, particularly in older people.3 The mortality rate of stroke, however, has been declining3 and more stroke survivors are returning home instead of going into an inpatient rehabilitation program.19 These factors may translate into an increasing number of older adults living with a chronic stroke in the community, who have not attained optimal functional recovery and are at risk of developing secondary complications due to physical inactivity. There has been an increasing recognition of the importance of health promotion for people with disabilities.20 One of the key components of health promotion for people with disabilities is “the prevention of health complications (medical secondary conditions) and further disabling conditions”.20 According to the conceptual model of health promotion proposed by Rimmer20, community-based fitness programs play one important role in achieving this objective. Considering that physical inactivity in older adults with chronic stroke could lead to devastating secondary health complications, an accessible and multidimensional fitness program is urgently needed.21 Most exercise programs proposed for chronic stroke, however, are not community-based and have addressed only one or two of the impaired domains.5,6,22–24 Moreover, although it is known that stroke is a major risk factor for hip fracture,18 no study has examined the effects of exercise on hip BMD in stroke. This study aims to assess the efficacy of a multidimensional community-based fitness and mobility exercise (FAME) program for individuals with chronic stroke. This is the first study to examine the effects of exercise on hip BMD in this population. It was hypothesized that the individuals who underwent the FAME program would have significantly more improvement in cardiorespiratory fitness, mobility, leg muscle strength, balance, activity and participation, and hip BMD than those in the control group.

Journal ArticleDOI
TL;DR: Risk factors for negative caregiver outcomes have been studied extensively, but little attention has been given to care recipient and caregiver health as risk factors for potentially harmful behavior by informal caregivers.
Abstract: Objectives: Caring for a sick or disabled relative has been linked to compromised caregiver health, and risk factors for negative caregiver outcomes have been studied extensively, but little attention has been given to care recipient and caregiver health as risk factors for potentially harmful behavior by informal caregivers. This article explores such risk factors. Design: Structured interviews from baseline assessment of the Family Relationships in Late Life Study. Setting: Three U.S. communities. Participants: Referred, volunteer sample of 265 caregiver/care recipient dyads. Caregivers were primarily responsible for care of an impaired, community-residing family member aged 60 and older and providing help with at least one activity of daily living (ADL) or two instrumental activities of daily living (IADLs). Measurements: Self-reported care recipient demographics, cognitive status, need for care, and self-rated health; self-reported caregiver demographics, cognitive status, amount of care provided, self-rated health, physical symptoms, and depression. Care recipient reports of potentially harmful caregiver behavior, including screaming and yelling, insulting or swearing, threatening to send to a nursing home, and withholding food, were the main outcome variable. Results: The following were significant risk factors for potentially harmful caregiver behavior: greater care recipient ADL/IADL needs (odds ratio (OR)=1.12, 95% confidence interval (CI)=1.03–1.22), spouse caregivers (vs others; OR=8.00, 95% CI=1.71–37.47), greater caregiver cognitive impairment (OR=1.20, 95% CI=1.04–1.38), more caregiver physical symptoms (OR=1.07, 95% CI=1.01–1.13), and caregivers at risk for clinical depression (OR=3.47, 95% CI=1.58–7.62). Conclusion: Potentially harmful caregiver behavior is more likely in spouse caregiving situations and when care recipients have greater needs for care and caregivers are more cognitively impaired, have more physical symptoms, and are at risk for clinical depression. This risk profile is similar to that for negative caregiver outcomes.

Journal ArticleDOI
TL;DR: To describe where older Americans with dementia die and to compare the state health system factors related to the location of dementia‐related deaths with those of cancer and all other conditions in this population.
Abstract: OBJECTIVES: To describe where older Americans with dementia die and to compare the state health system factors related to the location of dementia-related deaths with those of cancer and all other conditions in this population. DESIGN: Cross-sectional study. SETTING: United States in 2001. PARTICIPANTS: All persons aged 65 and older who died from nontraumatic causes in the United States during 2001. The underlying cause of death, as determined by the National Center for Health Statistics from death certificate data, was used to categorize subjects into three decedent groups: dementia (n 588,523, 5.1%), cancer (n 5389,754, 22.4%), and all other conditions (n 51,256,873, 72.5%). MEASUREMENTS: Site of death was identified as the hospital, home, nursing home, or another location as recorded on the death certificate. In each state, the proportion of hospital deaths in the three decedent groups was categorized as high, medium, and low based on terciles of the national distribution. Using multivariate analyses, associations between state-level variables and the proportion of deathsoccurringinthehospitalineachstatewereexamined. RESULTS: The majority of dementia-related deaths in the United States occurred in nursing homes (66.9%). In contrast, most older persons with cancer died at home (37.8%) or in the hospital (35.4%). The hospital was the most common site of death for all other conditions (52.2%). The state-specific proportion of dementia-related deaths occurring in hospitals varied from 5.0% to 37.0% across the nation and was in the highest tercile in 18 states. Hospital death rates related to cancer and all other conditions were in the highest tercile in 14 of these 18 states. After multivariate adjustment, states with a greater number of hospital beds per 1,000 persons and a lower percentage of decedents aged 85 and older were more likely to have a higher proportion of hospital deaths in all three decedent groups. Additionally, in the dementia cohort, states with fewer nursing home beds had a greater proportion of hospital deaths. CONCLUSION: The majority of older Americans whose underlying cause of death is attributable to dementia on their death certificate die in nursing homes. State-level factors, including the availability of hospital and nursing home beds and the age of decedents in the population, explain, in part, the wide state-to-state variability in the proportion of dementia-related deaths occurring in the hospital. JA m Geriatr Soc 53:299–305, 2005.

Journal ArticleDOI
TL;DR: This paper reviews the literature on spiritual beliefs that may influence the treatment decisions of African Americans and concludes that spirituality should be considered as a factor in the selection of patients for treatment at the end of life.
Abstract: Spirituality is an important part of African-American culture and is often cited as an explanation for the more-aggressive treatment preferences of some African Americans at the end of life. This paper reviews the literature on spiritual beliefs that may influence the treatment decisions of African Americans. Medline 1966 to February 2003, Psych Info 1872 to February 2003, and CINAHL 1982 to February 2003 were searched for studies exploring spiritual beliefs that may influence the treatment preferences of African Americans. All candidate papers were examined for quality, and data were extracted on study population, design, analysis, and results to identify recurrent themes. Forty studies met inclusion criteria. Recurrent themes describing spiritual beliefs that may influence the treatment preferences of African Americans throughout the course of illness include the following: spiritual beliefs and practices are a source of comfort, coping, and support and are the most effective way to influence healing; God is responsible for physical and spiritual health; and the doctor is God's instrument. Spiritual beliefs specifically addressing treatment preferences at the end of life include: only God has power to decide life and death, there are religious prohibitions against physician-assisted death or advance directives limiting life-sustaining treatments, and divine intervention and miracles occur. For some African Americans, spiritual beliefs are important in understanding and coping with illness and may provide a framework within which treatment decisions are made. Given the growing ethnic diversity of the United States, some understanding of the complexities of culture and spirituality is essential for healthcare providers.

Journal ArticleDOI
TL;DR: To examine the psychometric properties of the 15‐item Geriatric Depression Scale (GDS‐15), a brief depression screening measure, the aim was to establish a baseline level of depression in adults over the age of 65.
Abstract: OBJECTIVES: To examine the psychometric properties of the 15-item Geriatric Depression Scale (GDS-15), a brief depression screening measure. DESIGN: Cross-sectional. SETTING: Nineteen counties in western New York, West Virginia, and Ohio. PARTICIPANTS: Nine hundred sixty functionally impaired, cognitively intact, community-dwelling primary care patients aged 65 and older. MEASUREMENTS: The GDS-15, major depression as measured using the Mini-International Neuropsychiatric Interview, depressed mood, life satisfaction, suicidal ideation, and reported suicide attempts. RESULTS: Exploratory factor analyses suggested a two-factor structure for the GDS-15 in this category of patients, with component subscales assessing depression and positive affect. Cronbach alpha coefficients provide evidence for moderate, although acceptable, internal consistency reliability. Significant associations between the GDS-15 and measures of depressed mood, life satisfaction, and suicidal ideation demonstrated construct validity, whereas acceptable sensitivity and specificity to discriminate between depressed and nondepressed patients demonstrated criterion validity. Internal consistency reliability and construct validity did not differ significantly between patients with low and high functional impairment. A significant weakness of the scale is its low correlation with suicide attempt status. CONCLUSION: In general, this study provides evidence of impressive psychometric properties of the GDS-15 when administered to a sample of functionally impaired, cognitively intact, community-dwelling primary care patients.

Journal ArticleDOI
TL;DR: The longitudinal relationship between sensory functioning and a broad range of cognitive functions after 6 years follow‐up is examined and whether cataract surgery or first‐time hearing aid use affected cognition is examined.
Abstract: OBJECTIVES: To examine the longitudinal relationship between sensory functioning and a broad range of cognitive functions after 6 years follow-up and whether cataract surgery or first-time hearing aid use affected cognition. DESIGN: Hierarchical regression procedures were employed to determine whether sensory functioning was predictive of cognitive performance. SETTING: Maastricht University and the University Hospital Maastricht, the Netherlands. PARTICIPANTS: Older Dutch adults (greater than or equal to55) enrolled in the Maastricht Aging Study (N=418). MEASUREMENTS: Visual and auditory acuity, the Visual Verbal Learning Test (VVLT), the Stroop Color Word Test (SCWT), the Concept Shifting Task (CST), the Verbal Fluency Test, and the Letter-Digit Substitution Test (LDST). RESULTS: A change in visual acuity was associated with change in most cognitive measures, including the total and recall scores of the VVLT, the mean score of the first two SCWT cards, the mean score of the first two CST cards and the LDST. In addition, a change in auditory acuity predicted change in memory performance (VVLT total and recall scores), and auditory acuity measured at baseline predicted change in the mean score of the first two SCWT cards and the LDST. CONCLUSION: The findings support the notion of a strong connection between sensory acuity in auditory and visual domains and cognitive performance measures, both from a cross-sectional and a longitudinal perspective. They also suggest that it is essential to screen older individuals in a clinical context for sensory functioning so that changes in visual or auditory acuity are not interpreted as changes in cognitive performance.

Journal ArticleDOI
TL;DR: To examine the relationship between insomnia, hypnotic use, falls, and hip fractures in older people, a large number of patients are diagnosed with insomnia.
Abstract: OBJECTIVES: To examine the relationship between in-somnia,hypnoticuse,falls,andhipfracturesinolderpeople.DESIGN: Secondary analysis of a large, longitudinal, as-sessment database.SETTING: Four hundred thirty-seven nursing homes inMichigan.PARTICIPANTS: Residents aged 65 and older in 2001withabaselineMinimumDataSetassessmentandafollow-up 150 to 210 days later.MEASUREMENTS: Logistic regression modeled any fol-low-up report of fall or hip fracture. Predictors were base-line reports of insomnia (previous month) and use ofhypnotics (previous week). Potential confounds taken intoaccount included standard measures of functional status,cognitive status, intensity of resource utilization, proximitytodeath,illnessburden,numberofmedications,emergencyroom visits, nursing home new admission, age, and sex.RESULTS: In 34,163 nursing home residents (76% wom-en, mean age standard deviation 84 8), hypnotic usedid not predict falls (adjusted odds ratio (AOR)51.13,95% confidence interval (CI)50.98, 1.30). In contrast, in-somnia did predict future falls (AOR51.52, 95%CI51.38, 1.66). Untreated insomnia (AOR51.55, 95%CI51.41, 1.71) and hypnotic-treated (unresponsive) in-somnia (AOR51.32, 95% CI51.02, 1.70) predictedmore falls than did the absence of insomnia. After adjust-mentforconfoundingvariables,insomniaandhypnoticusewere not associated with subsequent hip fracture.CONCLUSION: Inelderlynursinghomeresidents,insom-nia, but not hypnotic use, is associated with a greater riskof subsequent falls. Future studies will need to confirmthese findings and determine whether appropriate hypnoticuse can protect against future falls. J Am Geriatr Soc53:955–962, 2005.Key words: insomnia; accidental falls; hip fractures;aged; nursing homes; Minimum Data Set; interRAI

Journal ArticleDOI
TL;DR: The objective is to determine whether vitamin D supplementation can reduce the incidence of falls and fractures in older people in residential care who are not classically vitamin D deficient.
Abstract: OBJECTIVES: To determine whether vitamin D supplementation can reduce the incidence of falls and fractures in older people in residential care who are not classically vitamin D deficient. DESIGN: Randomized, placebo-controlled double-blind, trial of 2 years’ duration. SETTING: Multicenter study in 60 hostels (assisted living facilities) and 89 nursing homes across Australia. PARTICIPANTS: Six hundred twenty-five residents (mean age 83.4) with serum 25-hydroxyvitamin D levels between 25 and 90nmol/L. INTERVENTION: Vitamin D supplementation (ergocalciferol, initially 10,000 IU given once weekly and then 1,000 IU daily) or placebo for 2 years. All subjects received 600 mg of elemental calcium daily as calcium carbonate. MEASUREMENTS: Falls and fractures recorded prospectively in study diaries by care staff. RESULTS: The vitamin D and placebo groups had similar baseline characteristics. In intention-to-treat analysis, the incident rate ratio for falling was 0.73 (95% confidence interval (CI) 50.57‐0.95). The odds ratio for ever falling was 0.82 (95% CI 50.59‐1.12) and for ever fracturing was 0.69 (95% CI 50.40‐1.18). An a priori subgroup analysis of subjects who took at least half the prescribed capsules (n 5540), demonstrated an incident rate ratio for falls of 0.63 (95% CI 50.48‐0.82), an odds ratio (OR) for ever falling of 0.70 (95% CI 50.50‐0.99), and an OR for ever fracturing of 0.68 (95% CI 50.38‐1.22). CONCLUSION: Older people in residential care can reduce their incidence of falls if they take a vitamin D supplement for 2 years even if they are not initially classically vitamin D deficient. J Am Geriatr Soc 53:1881–1888, 2005.

Journal ArticleDOI
TL;DR: In this article, the authors evaluated whether a comprehensive sleep education program (Nighttime Insomnia Treatment and Education for Alzheimer's Disease (NITE-AD)) could improve sleep in dementia patients living at home with their family caregivers.
Abstract: OBJECTIVES: To evaluate whether a comprehensive sleep education program (Nighttime Insomnia Treatment and Education for Alzheimer’s Disease (NITE-AD)) could improve sleep in dementia patients living at home with their family caregivers. DESIGN: A randomized, controlled trial. PARTICIPANTS: Thirty-six community-dwelling patients with Alzheimer’s disease (AD) and their family caregivers. INTERVENTION: All participants received written materials describing age- and dementia-related changes in sleep and standard principles of good sleep hygiene. Caregivers in active treatment (n 5 17) received specific recommendations about setting up and implementing a sleep hygiene program for the dementia patient and training in behavior management skills. Patients in active treatment were also instructed to walk daily and increase daytime light exposure with the use of a light box. Control subjects (n 5 19) received general dementia education and caregiver support. MEASUREMENTS: Primary sleep outcomes were derived for patients and caregivers from 1 week of sleep-wake activity measured at baseline, posttest (2 months), and 6month follow-up using an Actillume wrist-movement recorder. Secondary patient outcomes included the Epworth Sleepiness Scale, the Cornell Depression Scale, and the Revised Memory and Behavior Problem Checklist. Caregiver self-reports included the Pittsburgh Sleep Quality Index and the Center for Epidemiological Study of Depression Scale. RESULTS: Patients participating in NITE-AD showed significantly greater (Po.05) posttest reductions in number of nighttime awakenings, total time awake at night, and depression, and increases in weekly exercise days than control subjects. At 6-month follow-up, treatment gains were maintained, and additional significant improvements in duration of night awakenings emerged. When cognitive level was controlled, NITE-AD patients had lower longitudinal ratings of daytime sleepiness than controls. There was a trend for control subjects to spend more time in bed at 6 months than NITE-AD patients. CONCLUSION: This study provides the first evidence that patients with AD who are experiencing sleep problems can benefit from behavioral techniques (specifically, sleep hygiene education, daily walking, and increased light exposure) that are known to improve sleep in nondemented, institutionalized older adults. J Am Geriatr Soc 53:793–802, 2005.

Journal ArticleDOI
TL;DR: To determine the effect of static and dynamic frailty on mortality in older men and women, a large number of subjects were recruited from across Europe and the United States.
Abstract: OBJECTIVES: To determine the effect of static and dynamic frailty on mortality in older men and women. DESIGN: A prospective cohort study with three 3-year measurement cycles. SETTING: Population based. PARTICIPANTS: The sample was derived from the Longitudinal Aging Study Amsterdam and consisted of respondents who participated in two cycles (T1: 1992/1993 and T2: 1995/1996) and for whom there was complete data on disability and chronic diseases (N=2,257). MEASUREMENTS: Nine frailty markers were assessed at T1 and T2. The frailty markers were defined in two ways: low functioning at T2 (static frailty) and change in functioning between T1 and T2 (dynamic frailty). Survival time, calculated in days from T2 to January 1, 2000, was used as the outcome variable. Predictive ability was examined using Cox proportional hazards analyses separately for men and women. RESULTS: Women were frailer than men. Static frailty was significantly associated with mortality in men (relative risk (RR)=2.4) and in women (RR=2.6). Dynamic frailty was also associated with mortality in women (RR=2.6), but it was not significantly associated with mortality in men (RR=1.3). When disability and chronic diseases were included in the model as possible mediators, these RRs dropped to 1.6, 2.0, 2.1, and 1.2, respectively, of which the first three were still significant. CONCLUSION: Frailty was associated with mortality to a greater extent in women than in men, and this effect was independent of disability and chronic disease. In men, the static definition of frailty was more predictive of mortality than the dynamic definition

Journal ArticleDOI
TL;DR: To determine the association between volitional walking behavior and change in walking ability and lower extremity function over 1 year in functionally limited older women, a large number of women will be functionally limited.
Abstract: Objectives: To determine the association between volitional walking behavior and change in walking ability and lower extremity function over 1 year in functionally limited older women. Design: Longitudinal cohort study. Setting: Data were collected in participant's homes in Baltimore, Maryland. Participants: One thousand two cognitively intact community-resident female Medicare beneficiaries aged 65 and older enrolled in the Women's Health and Aging Study. Measurements: Reported walking behavior and change in reported walking difficulty, usual and rapid gait speed, and lower extremity physical performance score over 1 year. Results: Of 800 functionally limited women who could walk unassisted at baseline and were alive and contacted 1 year later, 226 (28%) walked regularly, at least eight blocks per week. These women exhibited better health and functioning than nonwalkers (e.g., lower prevalence of depressive and fatigue symptoms and cardiovascular disease and higher mean ankle-arm index, forced expiratory volume in the first second, and gait speed). One year later, independent of initial functional status, social-psychological and behavioral factors, and health conditions, walkers were 1.8 times (95% confidence interval=1.2–2.7; P=.002) more likely to maintain reported walking ability and showed less decline in customary walking speed (0.009 m/s vs −0.070 m/s; P=.001) and functional performance score (−0.17 vs −0.73; P=.01) than women who walked less than eight blocks. Conclusion: The strength, consistency, and specificity of the association between walking behavior and maintenance of mobility provide strong evidence that even a small amount of regular walking can confer short-term protection from further mobility loss in functionally limited women. The observation that most women capable of walking at least eight blocks per week were not doing so indicates the need to get more women “out the door” and to encourage those who walk a little to walk a little more.

Journal ArticleDOI
TL;DR: The prevalence of and risk factors for hearing loss in a sample of older adults enrolled in the Health, Aging and Body Composition (Health ABC) Study are determined.
Abstract: Objectives: To determine the prevalence of and risk factors for hearing loss in a sample of 2,052 older adults (aged 73–84; 46.9% male, 37.3% black) enrolled in the Health, Aging and Body Composition (Health ABC) Study. Design: Cross-sectional analysis of a longitudinal cohort study. Setting: Pittsburgh, Pennsylvania, and Memphis, Tennessee, areas. Participants: Random sample of Medicare beneficiary subjects enrolled in the Health ABC program from 1997 to 1998. They included 2,052 individuals: 660 white men (32.2%), 631 white women (30.8%), 310 black men (15.1%), and 451 black women (22.0%). Participants ranged in age from 73 to 84, with a mean age of 77.5. Measurements: Hearing sensitivity was measured using pure-tone threshold testing. Hearing loss was defined based on two averages of hearing thresholds: 500, 1,000, and 2,000 Hz greater than 25-decibel (dB) hearing level (HL) (hearing loss); and 2,000, 4,000, and 8,000 Hz greater than 40-dB HL (high-frequency hearing loss). Potential hearing loss correlates, including demographics, medical history, ototoxic medication use, occupational noise exposure, and lifestyle factors, were collected via questionnaire. Results: The prevalence of hearing loss was 59.9%; the prevalence of high-frequency hearing loss was 76.9%. Hearing loss was most common in white men, followed by white women, black men, and black women. Older age, white race, diabetes mellitus, cerebrovascular disease, smoking, poorer cognitive status, occupational noise exposure, and ear surgery were associated with hearing loss after multivariable adjustment. Race- and sex-specific risk factors included higher blood pressure and occupational noise exposure (white men), poorer cognitive status and smoking (black women), and low total hip bone mineral density (black men). Possible protective factors included salicylate use (overall sample, black men) and moderate alcohol intake (black women). Conclusion: Hearing loss was extremely common in this population. Because many of the identified hearing loss risk factors are modifiable, some of the burden associated with hearing loss in older people should be preventable.

Journal ArticleDOI
TL;DR: Clinicians should ask elderly patients about satisfaction with sleep, and any sleep complaints warrant careful evaluation of contributing factors and appropriate treatment.
Abstract: A good night's sleep is often more elusive as we age, because the prevalence of insomnia in older people is high. Insufficient sleep can have important effects on daytime function by increasing the need to nap, reducing cognitive ability including attention and memory, slowing response time, adversely affecting relationships with friends and family, and contributing to a general sense of being unwell. However, rather than aging per se, circadian rhythm shifts, primary sleep disorders, comorbid medical/psychiatric illnesses, and medication use cause sleep difficulties in older people, which psychosocial factors may also affect. Clinicians should ask elderly patients about satisfaction with sleep. Any sleep complaints warrant careful evaluation of contributing factors and appropriate treatment.