Showing papers in "Journal of the American Geriatrics Society in 2013"

Operationalization of Frailty Using Eight Commonly Used Scales and Comparison of Their Ability to Predict All‐Cause Mortality

Abstract: Objectives: To operationalize frailty using eight scales and to compare their content validity, feasibility, prevalence estimates of frailty, and ability to predict all-cause mortality. Design: Secondary analysis of the Survey of Health, Ageing and Retirement in Europe (SHARE). Setting: Eleven European countries. Participants: Individuals aged 50 to 104 (mean age 65.3 ± 10.5, 54.8% female, N = 27,527). Measurements: Frailty was operationalized using SHARE data based on the Groningen Frailty Indicator, the Tilburg Frailty Indicator, a 70-item Frailty Index (FI), a 44-item FI based on a Comprehensive Geriatric Assessment (FI-CGA), the Clinical Frailty Scale, frailty phenotype (weighted and unweighted versions), the Edmonton Frail Scale, and the FRAIL scale. Results: All scales had fewer than 6% of cases with at least one missing item, except the SHARE-frailty phenotype (11.1%) and the SHARE-Tilburg (12.2%). In the SHARE-Groningen, SHARE-Tilburg, SHARE-frailty phenotype, and SHARE-FRAIL scales, death rates were 3 to 5 times as high in excluded cases as in included ones. Frailty prevalence estimates ranged from 6% (SHARE-FRAIL) to 44% (SHARE-Groningen). All scales categorized 2.4% of participants as frail. Of unweighted scales, the SHARE-FI and SHARE-Edmonton scales most accurately predicted mortality at 2 (SHARE-FI area under the receiver operating characteristic curve (AUC) = 0.77, 95% confidence interval (CI) = 0.75�0.79); SHARE-Edmonton AUC = 0.76, 95% CI = 0.74�0.79) and 5 (both AUC = 0.75, 95% CI = 0.74�0.77) years. The continuous score of the weighted SHARE-frailty phenotype (AUC = 0.77, 95% CI = 0.75�0.78) predicted 5-year mortality better than the unweighted SHARE-frailty phenotype (AUC = 0.70, 95% CI = 0.68�0.71), but the categorical score of the weighted SHARE-frailty phenotype did not (AUC = 0.70, 95% CI = 0.68�0.72). Conclusion: Substantive differences exist between scales in their content validity, feasibility, and ability to predict all-cause mortality. These frailty scales capture related but distinct groups. Weighting items in frailty scales can improve their predictive ability, but the trade-off between specificity, predictive power, and generalizability requires additional evaluation.

Discriminative Ability and Predictive Validity of the Timed Up and Go Test in Identifying Older People Who Fall: Systematic Review and Meta‐Analysis

Abstract: OBJECTIVES: To investigate the discriminative ability and diagnostic accuracy of the Timed Up and Go Test (TUG) as a clinical screening instrument for identifying older people at risk of falling. DESIGN: Systematic literature review and meta-analysis. SETTING AND PARTICIPANTS: People aged 60 and older living independently or in institutional settings. MEASUREMENTS: Studies were identified with searches of the PubMed, EMBASE, CINAHL, and Cochrane CENTRAL data bases. Retrospective and prospective cohort studies comparing times to complete any version of the TUG of fallers and non-fallers were included. RESULTS: Fifty-three studies with 12,832 participants met the inclusion criteria. The pooled mean difference between fallers and non-fallers depended on the functional status of the cohort investigated: 0.63 seconds (95% confidence (CI) = 0.14-1.12 seconds) for high-functioning to 3.59 seconds (95% CI = 2.18-4.99 seconds) for those in institutional settings. The majority of studies did not retain TUG scores in multivariate analysis. Derived cut-points varied greatly between studies, and with the exception of a few small studies, diagnostic accuracy was poor to moderate. CONCLUSION: The findings suggest that the TUG is not useful for discriminating fallers from non-fallers in healthy, high-functioning older people but is of more value in less-healthy, lower-functioning older people. Overall, the predictive ability and diagnostic accuracy of the TUG are at best moderate. No cut-point can be recommended. Quick, multifactorial fall risk screens should be considered to provide additional information for identifying older people at risk of falls. Language: en

Advance Care Planning and the Quality of End-of-Life Care in Older Adults

Abstract: Objectives: To determine whether advance care planning influences quality of end-of-life care. Design: In this observational cohort study, Medicare data and survey data from the Health and Retirement Study (HRS) were combined to determine whether advance care planning was associated with quality metrics. Setting: The nationally representative HRS. Participants: Four thousand three hundred ninety-nine decedent subjects (mean age 82.6 at death, 55% women). Measurements: Advance care planning (ACP) was defined as having an advance directive (AD), durable power of attorney (DPOA) or having discussed preferences for end-of-life care with a next of kin. Outcomes included previously reported quality metrics observed during the last month of life (rates of hospital admission, in-hospital death, >14 days in the hospital, intensive care unit admission, >1 emergency department visit, hospice admission, and length of hospice ?3 days). Results: Seventy-six percent of subjects engaged in ACP. Ninety-two percent of ADs stated a preference to prioritize comfort. After adjustment, subjects who engaged in ACP were less likely to die in a hospital (adjusted relative risk (aRR) = 0.87, 95% confidence interval (CI) = 0.80�0.94), more likely to be enrolled in hospice (aRR = 1.68, 95% CI = 1.43�1.97), and less likely to receive hospice for 3 days or less before death (aRR = 0.88, 95% CI = 0.85�0.91). Having an AD, a DPOA or an ACP discussion were each independently associated with a significant increase in hospice use (P < .01 for all). Conclusion: ACP was associated with improved quality of care at the end of life, including less in-hospital death and increased use of hospice. Having an AD, assigning a DPOA and conducting ACP discussions are all important elements of ACP.

Frailty as a novel predictor of mortality and hospitalization in individuals of all ages undergoing hemodialysis.

Abstract: Objectives: To quantify the prevalence of frailty in adults of all ages undergoing chronic hemodialysis, its relationship to comorbidity and disability, and its association with adverse outcomes of mortality and hospitalization. Design: Prospective cohort study. Setting: Single hemodialysis center in Baltimore, Maryland. Participants: One hundred forty-six individuals undergoing hemodialysis enrolled between January 2009 and March 2010 and followed through August 2012. Measurements: Frailty, comorbidity, and disability on enrollment in the study and subsequent mortality and hospitalizations. Results: At enrollment, 50.0% of older (≥ 65) and 35.4% of younger (<65) individuals undergoing hemodialysis were frail; 35.9% and 29.3%, respectively, were intermediately frail. Three-year mortality was 16.2% for nonfrail, 34.4% for intermediately frail, and 40.2% for frail participants. Intermediate frailty and frailty were associated with a 2.7 times (95% confidence interval (CI) = 1.02-7.07, P = .046) and 2.6 times (95% CI = 1.04-6.49, P = .04) greater risk of death independent of age, sex, comorbidity, and disability. In the year after enrollment, median number of hospitalizations was 1 (interquartile range 0-3). The proportion with two or more hospitalizations was 28.2% for nonfrail, 25.5% for intermediately frail, and 42.6% for frail participants. Although intermediate frailty was not associated with number of hospitalizations (relative risk = 0.76, 95% CI = 0.49-1.16, P = .21), frailty was associated with 1.4 times (95% CI = 1.00-2.03, P = .049) more hospitalizations independent of age, sex, comorbidity, and disability. The association between frailty and mortality (interaction P = .64) and hospitalizations (P = .14) did not differ between older and younger participants. Conclusions: Adults of all ages undergoing hemodialysis have a high prevalence of frailty, more than five times as high as community-dwelling older adults. In this population, regardless of age, frailty is a strong, independent predictor of mortality and number of hospitalizations.

Unmet Needs of Community‐Residing Persons with Dementia and Their Informal Caregivers: Findings from the Maximizing Independence at Home Study

Abstract: Objectives To determine the prevalence and correlates of unmet needs in a sample of community-residing persons with dementia (PWD) and their informal caregivers. Design Analysis of cross-sectional, baseline participant characteristics before randomization in a care coordination intervention trial. Setting Baltimore, Maryland. Participants Community-residing PWD (n = 254) and their informal caregivers (n = 246). Measurements In-home assessments of dementia-related needs based on the Johns Hopkins Dementia Care Needs Assessment. Bivariate and multivariate regression analyses were conducted to identify demographic, socioeconomic, clinical, functional, and quality-of-life correlates of unmet needs. Results The mean number of unmet needs was 7.7 ± 4.8 in PWD and 4.6 ± 2.3 in caregivers, with almost all PWD (99%) and caregivers (97%) having one or more unmet needs. Unmet needs in PWD were significantly greater in those with higher cognitive function. Ninety percent of PWD had unmet safety needs, more than half had unmet needs for meaningful activities, and almost one-third had not received a prior evaluation or diagnosis. Higher unmet needs in PWD was significantly associated with nonwhite race, lower income, less impairment in activities of daily living, and more symptoms of depression. For caregivers, more than 85% had unmet needs for resource referrals and caregiver education. Higher unmet caregiver needs was significantly associated with nonwhite race, less education, and more symptoms of depression. Conclusion Many community-residing PWD and their caregivers have unmet dementia-related needs for care, services, and support. Providers should be aware that unmet needs may be higher in minority and low-income community residents, caregivers with lower education, and individuals with early-stage dementia. Identifying and treating symptoms of depression in PWD and caregivers may enable them to address their other unmet needs.

Guidelines abstracted from the American Geriatrics Society Guidelines for Improving the Care of Older Adults with Diabetes Mellitus: 2013 update

Abstract: Author(s): American Geriatrics Society Expert Panel on Care of Older Adults with Diabetes Mellitus; Moreno, Gerardo; Mangione, Carol M; Kimbro, Lindsay; Vaisberg, Ekaterina

National Trends in Emergency Department Use, Care Patterns, and Quality of Care of Older Adults in the United States

Abstract: Objectives To describe trends in use of emergency departments (EDs) of older adults, reasons for visits, resource use, and quality of care. Design Analysis of the National Hospital Ambulatory Medical Care Survey. Setting U.S. emergency departments from 2001 to 2009. Participants Individuals aged 65 and older visiting U.S. EDs. Measurements Emergency departments (ED) visits by patients aged 65 and older were identified, and demographic, clinical, and resource use characteristics and outcomes were assessed. Results From 2001 to 2009, annual visits increased from 15.9 to 19.8 million, a 24.5% increase. Numbers of outpatients grew less than hospital admissions (20.2% vs 33.1%); intensive care unit admissions increased 131.3%. Reasons for visits were unchanged during the study; the top complaints were chest pain, dyspnea, and abdominal pain. Resource intensity grew dramatically: computed tomography 167.0%, urinalyses 87.1%, cardiac monitoring 79.3%, intravenous fluid administration 59.8%, blood tests 44.1%, electrocardiogram use 43.4%, procedures 38.3%, and radiographic imaging 36.4%. From 2005 to 2009, magnetic resonance imaging use grew 84.6%. The proportion receiving a potentially inappropriate medication decreased from 9.6% in 2001 to 4.9% in 2009, whereas the proportion seen in the ED, discharged, and subsequently readmitted to the hospital rose from 2.0% to 4.2%. Conclusion Older adults accounted for 156 million ED visits in the United States from 2001 to 2009, with steady increases in visits and resource use across the study period. Hospital admissions grew faster than outpatient visits. If changes in primary care do not affect these trends, facilities will need to plan to accommodate increasingly greater demands for ED and hospital services.

Design and methodology of the Irish Longitudinal Study on Ageing.

Abstract: Objectives: To provide comprehensive data on older people in Ireland and new insights into the causal processes underlying the aging transformation. Design: The Irish Longitudinal Study on Ageing (TILDA) is a population-representative prospective cohort study with baseline assessment conducted between October 2009 and Febraury 2011 and follow-up waves planned every 2 years. Participants were sampled in geographic clusters, with each member of the Irish population aged 50 and older having an equal probability of being invited to participate in the study. Setting: Community-living population of the Republic of Ireland aged 50 and older. Participants: Eight thousand one hundred seventy-five participants aged 50 and older at time of interview participated in the study, along with 329 spouses or partners younger than 50. Measurements: The Irish Longitudinal Study on Ageing includes detailed assessments of the mental and physical health and social and financial circumstances of participants, which are assessed in a home interview, a self-completion questionnaire, and a detailed health assessment that takes place at a dedicated health center or in the respondent's home. Results: The response rate was 62.0%, with response rate varying according to educational attainment. Data from the first wave of data collection are available for researchers at the Irish Social Sciences Data Archive. Conclusion: The Irish Longitudinal Study on Ageing provides an opportunity to study the interactions between the health and social and economic circumstances of the older population in a nationally representative sample.

Variation in the prevalence of sarcopenia and sarcopenic obesity in older adults associated with different research definitions: dual-energy X-ray absorptiometry data from the National Health and Nutrition Examination Survey 1999-2004.

Abstract: Objectives To determine the prevalence range for sarcopenic obesity and its relationship with sex, age, and ethnicity. Design Cross-sectional analysis of a population-based sample. Setting Noninstitutionalized persons in the United States participating in the National Health and Nutrition Examination Surveys 1999–2004. Participants Subsample of 4,984 subjects aged 60 and older with dual-energy X-ray absorptiometry body composition data. Measurements Eight definitions of sarcopenic obesity identified from six studies found using a systematic literature review (Baumgartner, Bouchard, Davison, Zoico, Levine, Kim-1,2,3) were applied to the sample. Results were stratified according to sex, age, and ethnicity. Results Prevalence of sarcopenic obesity ranged from 4.4% to 84.0% in men and from 3.6% to 94.0% in women. Prevalence was higher in men using definitions from Baumgartner (17.9% vs 13.3%, P < .001), Levine (14.2% vs 6.6%, P < .001), and Kim-1 (30.0% vs 9.3%, P < .001); lower for men using the Davison (4.4% vs 11.1%, P < .001) and Kim-2 (83.7% vs 94.0%) definitions; and the same for men and women using the Bouchard (45.3% vs 44.3%, P = .32) and Kim-3 (75.6% vs 77.0%, P = .51) definitions. For all but one definition, sarcopenic obesity increased with each decade and was lower in non-Hispanic blacks than whites. Conclusion Prevalence of sarcopenic obesity in older adults varies up to 26-fold depending on current research definitions. Such a high degree of variability suggests the need to establish consensus criteria that can be reliably applied across clinical and research settings.

A Randomized Controlled Trial of an Automated Exercise Coach for Older Adults

Abstract: Objectives: To compare the efficacy of a computer-based physical activity program (Embodied Conversational Agent�ECA) with that of a pedometer control condition in sedentary older adults. Design: Single-blind block-randomized controlled trial stratified according to clinic site and health literacy status. Setting: Three urban ambulatory care practices at Boston Medical Center between April 2009 and September 2011. Participants: Older adults (N = 263; mean age 71.3; 61% female; 63% African American; 51% high school diploma or less). Intervention: ECA participants were provided with portable tablet computers with touch screens to use for 2 months and were directed to connect their pedometers to the computer using a data cable and interact with a computer-animated virtual exercise coach daily to discuss walking and to set walking goals. Intervention participants were then given the opportunity to interact with the ECA in a kiosk in their clinic waiting room for the following 10 months. Control participants were given a control pedometer intervention that only tracked step counts for an equivalent period of time. Intervention participants were also provided with pedometers. Measurements: The primary outcome was average daily step count for the 30 days before the 12-month interview. Secondary outcomes were average daily step count for the 30 days before the 2-month interview. Outcomes were also stratified according to health literacy level. Results: ECA participants walked significantly more steps than control participants at 2 months (adjusted mean 4,041 vs 3,499 steps/day, P = .01), but this effect waned by 12 months (3,861 vs 3,383, P = .09). For participants with adequate health literacy, those in the ECA group walked significantly more than controls at both 2 months (P = .03) and 12 months (P = .02), while those with inadequate health literacy failed to show significant differences between treatment groups at either time point. Intervention participants were highly satisfied with the program. Conclusion: An automated exercise promotion system deployed from outpatient clinics increased walking among older adults over the short-term. Effective methods for long-term maintenance of behavior change are needed.

Hearing loss and depression in older adults.

Abstract: TO THE EDITOR Hearing loss (HL) is a common, but underappreciated health issue affecting older adults. The functional consequences of HL for older adults are now surfacing in epidemiological studies demonstrating that HL may be independently associated with depression1 and loneliness.2 Compared to other medical co-morbidities, HL is more strongly associated with the development of depression in older adults.1 Whether hearing rehabilitative treatment may mitigate the possible effects of HL on depression remains unclear. We investigated the association of HL and hearing aid use with major depressive disorder (MDD)in a nationally representative study of older patients.

The consequences of poor communication during transitions from hospital to skilled nursing facility: a qualitative study.

Abstract: OBJECTIVES: To examine how skilled nursing facility (SNF) nurses transition the care of individuals admitted from hospitals, the barriers they experience, and the outcomes associated with variation in the quality of transitions. DESIGN: Qualitative study using grounded dimensional analysis, focus groups, and in-depth interviews. SETTING: Five Wisconsin SNFs. PARTICIPANTS: Twenty-seven registered nurses. MEASUREMENTS: Semistructured questions guided the focus group and individual interviews. RESULTS: SNF nurses rely heavily on written hospital discharge communication to transition individuals into the SNF effectively. Nurses cited multiple inadequacies of hospital discharge information, including regular problems with medication orders (including the lack of opioid prescriptions for pain), little psychosocial or functional history, and inaccurate information regarding current health status. These communication inadequacies necessitated repeated telephone clarifications, created care delays (including delays in pain control), increased SNF staff stress, frustrated individuals and family members, contributed directly to negative SNF facility image, and increased risk of rehospitalization. SNF nurses identified a specific list of information and components that they need to facilitate a safe, high-quality transition. CONCLUSION: Nurses note multiple deficiencies in hospital-to-SNF transitions, with poor quality discharge communication being identified as the major barrier to safe and effective transitions. This information should be used to refine and support the dissemination of evidencebased interventions that support transitions of care, including the Interventions to Reduce Acute Care Transfers program. J Am Geriatr Soc 2013.

People's attitudes, beliefs, and experiences regarding polypharmacy and willingness to Deprescribe.

Abstract: Objectives To capture people's attitudes, beliefs, and experiences regarding the number of medications they are taking and their feelings about stopping medications. Design Administration of a validated questionnaire. Setting Multidisciplinary ambulatory consulting service at the Royal Adelaide Hospital. Participants Participants were individuals aged 18 and older (median 71.5) taking at least one regular prescription medication; 100 participants completed all items of the questionnaire, 65 of whom were aged 65 and older. Measurements Participants were administered the 15-item Patients' Attitudes Towards Deprescribing (PATD) questionnaire. Results Participants were taking an average of 10 different prescription and nonprescription (including complementary), regular and as-needed medications. More than 60% felt that they were taking a "large number" of medications, and 92% stated that they would be willing to stop one or more of their current medications if possible. Number of regular medications, age, and number of medical conditions were not found to be correlated with willingness to stop a medication. The findings were similar in older and younger participants. Conclusion This study has shown that a cohort of mostly older adults were largely accepting of a trial of cessation of medication(s) that their prescriber deemed to be no longer required. Because few factors were associated with willingness to cease medications, all patients should be individually evaluated for deprescribing.

Normative Values of Cognitive and Physical Function in Older Adults: Findings from The Irish Longitudinal Study on Ageing

Abstract: Objectives: To provide normative values of tests of cognitive and physical function based on a large sample representative of the population of Ireland aged 50 and older. Design: Data were used from the first wave of The Irish Longitudinal Study on Ageing (TILDA), a prospective cohort study that includes a comprehensive health assessment. Setting: Health assessment was undertaken at one of two dedicated health assessment centers or in the study participant's home if travel was not practicable. Participants: Five thousand eight hundred ninety-seven members of a nationally representative sample of the community-living population of Ireland aged 50 and older. Those with severe cognitive impairment, dementia, or Parkinson's disease were excluded. Measurements: Measurements included height and weight, normal walking speed, Timed Up-and-Go, handgrip strength, Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), Color Trails Test, and bone mineral density. Normative values were estimated using generalized additive models for location shape and scale (GAMLSS) and are presented as percentiles, means, and standard deviations. Results: Generalized additive models for location shape and scale fit the observed data well for each measure, leading to reliable estimates of normative values. Performance on all tasks decreased with age. Educational attainment was a strong determinant of performance on all cognitive tests. Tests of walking speed were dependent on height. Distribution of body mass index did not change with age, owing to simultaneous declines in weight and height. Conclusion: Normative values were found for tests of many aspects of cognitive and physical function based on a representative sample of the general older Irish population.

Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness

Abstract: In-hospital falls are a significant clinical, legal, and regulatory problem, but information on effective fall reduction is lacking. The Centers for Medicare and Medicaid Services no longer reimburses hospitals for in-hospital falls with trauma.1 As the U.S. population ages, fall prevention is more relevant than ever; older, frail individuals are more prone to falls, and the consequences of falls are more severe.2,3 Preventing falls in U.S. acute care hospitals poses particular challenges, given that patients are acutely ill and average only 4.9 days in the hospital.4 This compressed acuity places a greater burden on staff to keep patients safe, so results from fall prevention interventions in long-term care facilities may not apply to acute care settings. Similarly, results from the international literature, where hospital stays are longer, may not generalize to U.S. hospitals. Fall prevention programs are typically complex, involving multiple components that depend on leadership involvement and the cooperation of frontline staff from multiple disciplines. Programs may require potent monitoring strategies to ensure that staff adhere to implemented care protocols. Recent reviews provide limited evidence for acute care settings.3,5–7 It was hypothesized that the confluence of an effective strategy to implement interventions into clinical practice in acute care settings, the intervention components chosen, the type of monitoring strategies used to ensure adherence, and the baseline level of care intensity provided in the comparison group would determine a fall prevention program's success. A systematic review was performed documenting implementation strategies, intervention components and comparators, adherence information, and the effectiveness of published fall prevention approaches in U.S. acute care hospitals.

Disparities in mental health service use of racial and ethnic minority elderly adults.

Abstract: Objectives: To apply the Institute of Medicine definition of healthcare disparities, to measure disparities in different aspects of episodes of mental health care and to identify disparities in types of mental health services used. Design: Four 2-year longitudinal datasets from Panels 9 to 13 (2004�2009) of the Medical Expenditure Panel Surveys were combined. Setting: Large-scale surveys of families and individuals and their medical providers across the United States. Participants: One thousand six hundred fifty-eight participants (981 white, 303 black, and 374 Latino) aged 60 and older with probable mental healthcare needs. Measurements: Mental healthcare need was defined as a Kessler-6 Scale score >12 and a Patient Health Questionnaire-2 score >2. Five aspects of mental healthcare episodes were analyzed: treatment initiation, adequacy of care, duration of care, number of visits, and expenditures. Whether episodes of care included only prescription drug fills, only outpatient visits, or both was assessed. Results: Treatment initiation and adequacy were lower for blacks and Latinos than whites. Latinos experienced episodes of longer duration, more visits, and higher expenditures. Blacks and Latinos had significantly lower rates of episodes that consisted of only medication refills. Blacks had significantly greater rates of episodes with only outpatient care visits. Latinos had significantly higher rates of medication plus outpatient visits. Conclusion: Low mental health treatment initiation and poor adequacy suggest the need for culturally appropriate interventions to engage older blacks and Latinos in mental health care. The surprising findings in blacks (higher rates of outpatient care visits) and Latinos (higher rates of medication plus outpatient visits) highlight the complexities of the older adult population and suggest new avenues for disparities research.

Depressive Symptomatology as a Risk Factor for Falls in Older People: Systematic Review and Meta-Analysis

Abstract: OBJECTIVES: To conduct a systematic literature review and meta-analysis to evaluate studies that have addressed depressive symptoms as a risk factor for falls in older people. DESIGN: Systematic review with meta-analysis. SETTING: Community and residential care. PARTICIPANTS: Individuals aged 60 and older. MEASUREMENTS: Depressive symptoms, incidence of falls. RESULTS: Twenty-five prospective studies with a total of 21,455 participants met inclusion criteria for the systematic review. Twenty studies met criteria for the meta-analyses. Recruitment of participants was conducted randomly or by approaching groups with identified healthcare needs. Eleven measures were used to assess depressive symptoms, and length of follow-up for falls ranged from 90 days to 8 years. Reporting of antidepressant use was variable across studies. The pooled effect of 14 studies reporting odds ratios (ORs) indicated that a higher level of depressive symptoms at baseline resulted in a greater likelihood of falling during follow-up (OR = 1.46, 95% confidence interval (CI) = 1.27-1.67, P Language: en

Challenges in Assessing Nursing Home Residents with Advanced Dementia for Suspected Urinary Tract Infections

Abstract: Objectives To describe the presentation of suspected urinary tract infections (UTIs) in nursing home (NH) residents with advanced dementia and how they align with minimum criteria to justify antimicrobial initiation. Design Twelve-month prospective study. Setting Twenty-five NHs. Participants Two hundred sixty-six NH residents with advanced dementia. Measurements Charts were abstracted monthly for documentation of suspected UTI episodes to determine whether episodes met minimum criteria to initiate antimicrobial therapy according to consensus guidelines. Results Seventy-two residents experienced 131 suspected UTI episodes. Presenting symptoms and signs for these episodes are mental status change (44.3%), fever (20.6%), hematuria (6.9%), dysuria (3.8%), costovertebral tenderness (2.3%), urinary frequency (1.5%), rigor (1.5%), urgency (0%), and suprapubic pain (0%). Only 21 (16.0%) episodes met minimal criteria to initiate antimicrobial therapy based on signs and symptoms. Of the 110 episodes that lacked minimum criteria to justify antimicrobial initiation, 82 (74.5%) were treated with antimicrobial therapy. Urinalyses and urine culture results were available for 101 episodes, of which 80 (79.2%) had positive results on both tests. The proportion of episodes with a positive urinalysis and culture was similar for those that met (83.3%) and did not meet (78.3%) minimum criteria (P = .06). Conclusion The symptoms and signs necessary to meet minimum criteria to support antimicrobial initiation for UTIs are frequently absent in NH residents with advanced dementia. Antimicrobial therapy is prescribed for the majority of suspected UTIs that do not meet these minimum criteria. Urine specimens are frequently positive regardless of symptoms. These observations underscore the need to reconsider the diagnosis and the initiation of treatment for suspected UTIs in advanced dementia.

Cognitive‐Behavioral Treatment for Comorbid Insomnia and Osteoarthritis Pain in Primary Care: The Lifestyles Randomized Controlled Trial

Abstract: Objectives: To assess whether older persons with osteoarthritis (OA) pain and insomnia receiving cognitive�behavioral therapy for pain and insomnia (CBT-PI), a cognitive�behavioral pain coping skills intervention (CBT-P), and an education-only control (EOC) differed in sleep and pain outcomes. Design: Double-blind, cluster-randomized controlled trial with 9-month follow-up. Setting: Group Health and University of Washington, 2009 to 2011. Participants: Three hundred sixty-seven older adults with OA pain and insomnia. Interventions: Six weekly group sessions of CBT-PI, CBT-P, or EOC delivered in participants' primary care clinics. Measurements: Primary outcomes were insomnia severity and pain severity. Secondary outcomes were actigraphically measured sleep efficiency and arthritis symptoms. Results: CBT-PI reduced insomnia severity (score range 0�28) more than EOC (adjusted mean difference = -1.89, 95% confidence interval = -2.83 to -0.96; P < .001) and CBT-P (adjusted mean difference = -2.03, 95% CI = -3.01 to -1.04; P < .001) and improved sleep efficiency (score range 0�100) more than EOC (adjusted mean difference = 2.64, 95% CI = 0.44�4.84; P = .02). CBT-P did not improve insomnia severity more than EOC, but improved sleep efficiency (adjusted mean difference = 2.91, 95% CI = 0.85�4.97; P = .006). Pain severity and arthritis symptoms did not differ between the three arms. A planned analysis in participants with severe baseline pain revealed similar results. Conclusion: Over 9 months, CBT of insomnia was effective for older adults with OA pain and insomnia. The addition of CBT for insomnia to CBT for pain alone improved outcomes.

Greater Number of Narcotic Analgesic Prescriptions for Osteoarthritis Is Associated with Falls and Fractures in Elderly Adults

Abstract: OBJECTIVES: To evaluate the changes in types of medications prescribed for pain before and after withdrawal of certain selective cyclooxygenase 2 (COX-2) inhibitors in 2004 and to determine whether there was an association with fall events in elderly adults with a diagnosis of osteoarthritis (OA). DESIGN: A nested case-control design using electronic medical records compiled between 2001 and 2009. SETTING: Electronic medical records for care provided in an integrated health system in rural Pennsylvania over a 9-year period (2001-09), the midpoint of which rofecoxib and valdecoxib were pulled from the market. PARTICIPANTS: Thirteen thousand three hundred fifty-four individuals aged 65 to 89 with a diagnosis of OA. MEASUREMENTS: The incidence of falls and fractures was examined in relation to analgesics prescribed: narcotics, COX-2 inhibitors, and nonsteroidal anti-inflammatory drugs (NSAIDs). The comparison sample of individuals who did not fall was matched 3:1 with those who fell according to age, sex, and comorbidity. RESULTS: Narcotic analgesic prescriptions were associated with a significantly greater risk of falls and fractures. The likelihood of experiencing a fall/fracture was higher in participants prescribed narcotic analgesics than those prescribed a COX-2 inhibitor (odds ratio (OR) = 3.3, 95% confidence interval (CI) = 2.5-4.3) or NSAID (OR = 4.1, 95% CI = 3.7-4.5). CONCLUSION: Use of narcotic analgesics is associated with risk of falls and fractures in elderly adults with OA, an observation that suggests that the current guidelines for the treatment of pain, which include first-line prescription of narcotics, should be reevaluated. Language: en

Brain Structural Change and Gait Decline: A Longitudinal Population-Based Study

Abstract: Objectives: To investigate longitudinal associations between changes in brain structure and gait decline. Design: Longitudinal. Setting: Population-based Tasmanian Study of Cognition and Gait. Participants: Two hundred twenty-five individuals aged 60 to 86 (mean age 71.4 ± 6.8) randomly selected from the electoral roll with baseline and follow-up data. Measurements: Volumes of gray matter, white matter, hippocampi, and white matter lesions (WML) were estimated using automated segmentation from magnetic resonance imaging (MRI). Gait variables were measured using a computerized walkway. Linear regression was used to estimate the association between change in brain MRI measures and change in gait. Time between measurements, age, sex, BMI, education level, total intracranial volume, baseline infarcts, and medical history were used as baseline covariates. Results: Mean follow-up was 30.6 months. White matter atrophy was associated with a decline in gait speed (P = .001), step length (P = .005), and cadence (P = .001). WML progression was associated with a decline in gait speed (P = .04), and its association with decline in step length was stronger with greater baseline age (P for interaction = .04). Hippocampal atrophy was associated with a decline in gait speed (P = .006) and step length (P = .001). Total gray matter atrophy was associated with decline in cadence in those with cerebral infarcts (P for interaction = .02). Conclusion: These are the first longitudinal data demonstrating the relative contributions of brain atrophy and WML progression to gait decline in older people. Effect modification according to age and infarcts suggests a contribution of reduced physiological and brain reserve. Interventions targeting brain health may be important in preventing mobility decline in older people. © 2013, The American Geriatrics Society.

American Geriatrics Society identifies five things that healthcare providers and patients should question.

Abstract: Given the American Geriatrics Society's (AGS) commitment to improving health care for older adults by, among other means, educating older people and their caregivers about their health and healthcare choices, the AGS was delighted when, in late 2011, the American Board of Internal Medicine Foundation invited the Society to join its "Choosing Wisely(®) " campaign. Choosing Wisely is designed to engage patients, healthcare professionals, and family caregivers in discussions about the safety and appropriateness of medical tests, medications, and procedures. Ideally, these discussions should examine whether the tests and procedures are evidence-based, whether any risks they pose might overshadow their potential benefits, whether they are redundant, and whether they are truly necessary. In addition to improving the quality of care, the initiative aims to rein in unneeded healthcare spending. According to a 2008 Congressional Budget Office report, as much as 30% of healthcare spending in the United States may be unnecessary.

Benefits of Multimodal Exercise Intervention for Postural Control and Frontal Cognitive Functions in Individuals with Alzheimer's Disease: A Controlled Trial

Abstract: Objective: To verify the effects of a systematized multimodal exercise intervention program on frontal cognitive function, postural control, and functional capacity components of individuals with Alzheimer's disease (AD). Design: Nonrandomized controlled trial with pre- and posttraining tests in a training group and a control group. Setting: Kinesiotherapy program for seniors with AD, Sao Paulo State University. Participants: Convenience sample of older adults with AD (n = 30) were assigned to a training (n = 14; aged 78.6 ± 7.1) and a control (n = 16; aged 77.0 ± 6.3) group. Intervention: The intervention program was structured with the aim of simultaneously promoting better balance and frontal cognitive capacity. The participants attended a 1-hour session three times a week for 16 weeks, whereas the control group did not participate in any activity during the same period. Measurements: Frontal cognitive function was evaluated using the Montreal Cognitive Assessment, the Clock Drawing Test, the Frontal Assessment Battery, and the Symbol Search Subtest. Postural control (center of pressure area) was analyzed under four dual-task conditions. Functional capacity components were analyzed using the Timed Up and Go Test, the 30-second sit-to-stand test, the sit-and-reach test, and the Berg Functional Balance Scale. Results: Intervention group participants showed a significant increase in frontal cognitive function (P < .001, partial ?2 = 0.838), with less body sway (P = .04, partial ?2 = 0.04) during the dual tasks, and greater functional capacity (P = .001, partial ?2 = 0.676) after the 16-week period. Conclusion: Intervention participants performed better on dual-task activities and had better postural balance and greater functional capacity than controls.

Quadriceps Strength, Quadriceps Power, and Gait Speed in Older U.S. Adults with Diabetes Mellitus: Results from the National Health and Nutrition Examination Survey, 1999–2002

Abstract: Objectives: To examine the independent association between diabetes mellitus (and its duration and severity) and quadriceps strength, quadriceps power, and gait speed in a national population of older adults. Design: Cross-sectional nationally representative survey. Setting: United States. Participants: Two thousand five hundred seventy-three adults aged 50 and older in the National Health and Nutrition Examination Survey 1999�2002 who had assessment of quadriceps strength. Methods: Diabetes mellitus was ascertained according to questionnaire. Measurement of isokinetic knee extensor (quadriceps) strength was performed at 60o/s. Gait speed was assessed using a 20-foot walk test. Multiple linear regression analyses were used to assess the association between diabetes mellitus status and outcomes, adjusting for potential confounders or mediators. Results: Older U.S. adults with diabetes mellitus had significantly slower gait speed (0.96 ± 0.02 m/s) than those without (1.08 ± 0.01 m/s; P < .001). After adjusting for demographic characteristics, weight, and height, diabetes mellitus was also associated with significantly lower quadriceps strength (-4.6 ± 1.9 Nm; P = .02) and power (-4.9 ± 2.0 W; P = .02) and slower gait speed (-0.05 ± 0.02 m/s; P = .002). Associations remained significant after adjusting for physical activity and C-reactive protein. After accounting for comorbidities (cardiovascular disease, peripheral neuropathy, amputation, cancer, arthritis, fracture, chronic obstructive pulmonary disease), diabetes mellitus was independently associated only with gait speed (-0.04 ± 0.02 m/s; P = .02). Diabetes mellitus duration in men and women was negatively associated with age-adjusted quadriceps strength (-5.7 and -3.5 Nm/decade of diabetes mellitus, respectively) and power (-6.1 and -3.8 W/decade of diabetes mellitus, respectively) (all P ? .001, no significant interactions according to sex). Glycosylated hemoglobin was not associated with outcomes after accounting for body weight. Conclusion: Older U.S. adults with diabetes mellitus have lower quadriceps strength and quadriceps power that is related to the presence of comorbidities and walk slower than those without diabetes mellitus. Future studies should investigate the relationship between hyperglycemia and subsequent declines in leg muscle function.

Frailty and fracture, disability, and falls: a multiple country study from the global longitudinal study of osteoporosis in women.

Abstract: OBJECTIVES: To test whether women aged 55 and older with increasing evidence of a frailty phenotype would have greater risk of fractures, disability, and recurrent falls than women who were not frail, across geographic areas (Australia, Europe, and North America) and age groups. DESIGN: Multinational, longitudinal, observational cohort study. SETTING: Global Longitudinal Study of Osteoporosis in Women (GLOW). PARTICIPANTS: Women (N = 48,636) aged 55 and older enrolled at sites in Australia, Europe, and North America. MEASUREMENTS: Components of frailty (slowness and weakness, poor endurance and exhaustion, physical activity, and unintentional weight loss) at baseline and report of fracture, disability, and recurrent falls at 1 year of follow-up were investigated. Women also reported health and demographic characteristics at baseline. RESULTS: Women younger than 75 from the United States were more likely to be prefrail and frail than those from Australia, Canada, and Europe. The distribution of frailty was similar according to region for women aged 75 and older. Odds ratios from multivariable models for frailty versus nonfrailty were 1.23 (95% confidence interval (CI) = 1.07-1.42) for fracture, 2.29 (95% CI = 2.09-2.51) for disability, and 1.68 (95% CI = 1.54-1.83) for recurrent falls. The associations for prefrailty versus nonfrailty were weaker but still indicated statistically significantly greater risk of each outcome. Overall, associations between frailty and each outcome were similar across age and geographic region. CONCLUSION: Greater evidence of a frailty phenotype is associated with greater risk of fracture, disability, and falls in women aged 55 and older in 10 countries, with similar patterns across age and geographic region. Language: en

Criterion and convergent validity of the Montreal cognitive assessment with screening and standardized neuropsychological testing.

Abstract: Objectives: To compare the validity of the Montreal Cognitive Assessment (MoCA) with the criterion standard of standardized neuropsychological testing and to compare the convergent validity of the MoCA with that of existing screening tools and global measures of cognition. Design: Cross-sectional observational study. Setting: Tertiary care hospital-based cognitive neurology subspecialty clinic. Participants: A convenience sample of 107 individuals with mild Alzheimer's disease (AD, n = 75) or mild cognitive impairment (MCI, n = 32) from the Sunnybrook Dementia Study. Measurements: In addition to the MoCA, all participants completed the Mini-Mental State Examination (MMSE), the Mattis Dementia Rating Scale (DRS), and detailed neuropsychological testing. Results: Convergent validity was supported, with MoCA scores correlating well with the MMSE (correlation coefficient (r) = 0.66, P < .001) and the DRS (r = 0.77, P < .001) and the MoCA better associated with the DRS than did the MMSE. Criterion validity was supported, with MoCA subscores according to cognitive domain correlating well with analogous neuropsychological tests and, in the case of memory (area under the receiver operating characteristic curve (AUC) = 0.86), executive (AUC = 0.79), and visuospatial function (AUC = 0.79), being reasonably sensitive to impairment in those domains. Conclusion: The MoCA is a valid assessment of cognition that shows good agreement with existing screening tools and global measures (convergent validity) and was superior to the MMSE in this regard. The MoCA domain-specific subscores align with performance on more-detailed neuropsychological tests, suggesting not only good criterion validity for the MoCA, but also that it may be useful in guiding further neuropsychological testing.

Inappropriate medication prescriptions in elderly adults surviving an intensive care unit hospitalization.

Abstract: Objectives: To determine types of potentially (PIMs) and actually inappropriate medications (AIMs), which PIMs are most likely to be considered AIMs, and risk factors for PIMs and AIMs at hospital discharge in elderly intensive care unit (ICU) survivors. Design: Prospective cohort study. Setting: Tertiary care, academic medical center. Participants: One hundred twenty individuals aged 60 and older who survived an ICU hospitalization. Measurements: Potentially inappropriate medications were defined according to published criteria; a multidisciplinary panel adjudicated AIMs. Medications from before admission, ward admission, ICU admission, ICU discharge, and hospital discharge were abstracted. Poisson regression was used to examine independent risk factors for hospital discharge PIMs and AIMs. Results: Of 250 PIMs prescribed at discharge, the most common were opioids (28%), anticholinergics (24%), antidepressants (12%), and drugs causing orthostasis (8%). The three most common AIMs were anticholinergics (37%), nonbenzodiazepine hypnotics (14%), and opioids (12%). Overall, 36% of discharge PIMs were classified as AIMs, but the percentage varied according to drug type. Whereas only 16% of opioids, 23% of antidepressants, and 10% of drugs causing orthostasis were classified as AIMs, 55% of anticholinergics, 71% of atypical antipyschotics, 67% of nonbenzodiazepine hypnotics and benzodiazepines, and 100% of muscle relaxants were deemed AIMs. The majority of PIMs and AIMs were first prescribed in the ICU. Preadmission PIMs, discharge to somewhere other than home, and discharge from a surgical service predicted number of discharge PIMs, but none of the factors predicted AIMs at discharge. Conclusion: Certain types of PIMs, which are commonly initiated in the ICU, are more frequently considered inappropriate upon clinical review. Efforts to reduce AIMs in elderly ICU survivors should target these specific classes of medications.

Health and Aging: Development of The Irish Longitudinal Study on Ageing Health Assessment

Abstract: Objectives: To assist researchers planning studies similar to The Irish Longitudinal Study on Ageing (TILDA), concerning the development of the health assessment component, to promote use of the archived data set, to inform researchers of the methods employed, and to complement the accompanying article on normative values. Design: Prospective, longitudinal study of older adults. Setting: Republic of Ireland. Participants: Eight thousand five hundred four community-dwelling adults who participated in wave 1 of the TILDA study. Measurements: The main areas of focus for the TILDA health assessments are neurocardiovascular instability, locomotion, and vision. Results: The article describes the scientific rationale for the choice of assessments and seeks to determine the potential advantages of incorporating novel biomeasures and technologies in population-based studies to advance understanding of aging-related disorders. Conclusion: The detailed description of the physical measures will facilitate cross-national comparative research and put into context the normative values outlined in the subsequent article.

Changes in medical student and Doctor attitudes toward older adults after an intervention: a systematic review

Abstract: Research investigating the effects of attitude-focused interventions on doctors' and medical students' attitudes toward older adults has produced mixed results. The objective of this systematic review was to determine whether factors pertaining to study design and quality might provide some explanation of this inconclusive picture. Articles were judged of interest if they reported doctors' or medicals students' attitude scores before and after a geriatric-focused intervention. Articles that did not report the measure used, mean scores, or inferential statistics were excluded. Twenty-seven databases, including Medline, PsychInfo, and Embase, were searched through April 2011 using a systematic search strategy. After assessment and extraction, 27 studies met the eligibility criteria for this review. These studies demonstrated inconsistent results; 14 appeared successful in effecting positive attitude change toward older adults after an intervention, and 13 appeared unsuccessful. Attitude change results differed in line with the content of the intervention. Of the 27 studies, 11 interventions contained solely knowledge-building content. Three of these studies demonstrated positive changes in doctors' or medical students' attitudes toward older adults after the intervention. The remaining 16 interventions incorporated an empathy-building component, such as an aging simulation exercise or contact with a healthy older adult. Of these, 11 successfully demonstrated positive attitude change after the intervention. The inclusion of an empathy-building task in an intervention appears to be associated with positive attitude change in medical students' and doctors' attitudes toward older adults.

Acute care for elders components of acute geriatric unit care: systematic descriptive review.

Abstract: Objectives: To describe the Acute Care for Elders (ACE) model components implemented as part of acute geriatric unit care and explore the association between each ACE component and outcomes of iatrogenic complications, functional decline, length of hospital stay, nursing home discharges, costs, and discharges home. Design: Systematic descriptive review of 32 articles, including 14 trials reporting on the implementation of ACE components or the effectiveness of their implementation in improving outcomes. Mean effect sizes (ESs) were calculated using trial outcome data. Information describing implementation of the ACE components in the trials was analyzed using content analysis. Setting: Acute care geriatric units. Participants: Acutely ill or injured adults (N = 6,839) with an average age of 81. Interventions: Acute geriatric unit care was characterized by the implementation of one or more ACE components: medical review, early rehabilitation, early discharge planning, prepared environment, patient-centered care. Measurements: Falls, pressure ulcers, delirium, functional decline, length of hospital stay, discharge destination (home or nursing home), and costs. Results: Medical review, early rehabilitation, and patient-centered care, characterized by the implementation of standardized and individualized function-focused interventions, had larger standardized mean ESs (all ES = 0.20) averaged across all outcomes, than did early discharge planning (ES = 0.17) or prepared environment (ES = 0.11). Conclusion: Specific ACE component interventions of medical review, early rehabilitation, and patient-centered care appear to be optimal for overall positive outcomes. These findings can help service providers design and evaluate the most-effective ACE model within the contexts of their respective institutions to improve outcomes for acutely ill or injured older adults.