JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 9 2010
[See editorial comments by Dr. Soo Borson, pp 1797-1798]
OBJECTIVES: To explore the association between posttraumatic stress disorder (PTSD) and dementia in older veterans. DESIGN: Administrative database study of individuals seen within one regional division of the Veterans Affairs healthcare network. SETTING: Veterans Integrated Service Network 16. PARTICIPANTS: Veterans aged 65 and older who had a diagnosis of PTSD or who were recipients of a Purple Heart (PH) and a comparison group of the same age with no PTSD diagnosis or PH were divided into four groups: those with PTSD and no PH (PTSD+/PH,, n=3,660), those with PH and no PTSD (PTSD,/PH+, n=1,503), those with PTSD and a PH (PTSD+/PH+, n=153), and those without PTSD or a PH (PTSD,/PH,, n=5,165). MEASUREMENTS: Incidence and prevalence of dementia after controlling for confounding factors in multivariate logistic regression. RESULTS: The PTSD+/PH, group had a significantly higher incidence and prevalence of dementia than the groups without PTSD with or without a PH. The prevalence and incidence of a dementia diagnosis remained two times as high in the PTSD+/PH, group as in the PTSD,/PH+ or PTSD,/PH, group after adjusting for the confounding factors. There were no statistically significant differences between the other groups. CONCLUSION: The incidence and prevalence of dementia is greater in veterans with PTSD. It is unclear whether this is due to a common risk factor underlying PTSD and dementia or to PTSD being a risk factor for dementia. Regardless, this study suggests that veterans with PTSD should be screened more closely for dementia. Because PTSD is so common in veterans, this association has important implications for veteran care. [source]

Length of Stay for Older Adults Residing in Nursing Homes at the End of Life

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 9 2010
Anne Kelly MSW
OBJECTIVES: To describe lengths of stay of nursing home decedents. DESIGN: Retrospective cohort study. SETTING: The Health and Retirement Study (HRS), a nationally representative survey of U.S. adults aged 50 and older. PARTICIPANTS: One thousand eight hundred seventeen nursing home residents who died between 1992 and 2006. MEASUREMENTS: The primary outcome was length of stay, defined as the number of months between nursing home admission and date of death. Covariates were demographic, social, and clinical factors drawn from the HRS interview conducted closest to the date of nursing home admission. RESULTS: The mean age of decedents was 83.3±9.0; 59.1% were female, and 81.5% were white. Median and mean length of stay before death were 5 months (interquartile range 1,20) and 13.7±18.4 months, respectively. Fifty-three percent died within 6 months of placement. Large differences in median length of stay were observed according to sex (men, 3 months vs women, 8 months) and net worth (highest quartile, 3 months vs lowest quartile, 9 months) (all P<.001). These differences persisted after adjustment for age, sex, marital status, net worth, geographic region, and diagnosed chronic conditions (cancer, hypertension, diabetes mellitus, lung disease, heart disease, and stroke). CONCLUSION: Nursing home lengths of stay are brief for the majority of decedents. Lengths of stay varied markedly according to factors related to social support. [source]

Dehydroepiandrosterone Combined with Exercise Improves Muscle Strength and Physical Function in Frail Older Women

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 9 2010
Anne M. Kenny MD
OBJECTIVES: To investigate the effects of dehydroepiandrosterone (DHEA) combined with exercise on bone mass, strength, and physical function in older, frail women. DESIGN: Double-blind, randomized, placebo-controlled trial. SETTING: A major medical institution. PARTICIPANTS: Ninety-nine women (mean age 76.6 ± 6.0) with low sulfated DHEA (DHEAS) levels, low bone mass, and frailty. INTERVENTION: Participants received 50 mg/d DHEA or placebo for 6 months; all received calcium and cholecalciferol. Women participated in 90-minute twice-weekly exercise regimens. MEASUREMENTS: Hormone levels, bone mineral density (BMD), bone turnover markers, body composition, upper and lower extremity strength, physical performance. RESULTS: Eighty-seven women (88%) completed 6 months. There were no significant changes in BMD or bone turnover markers. DHEA supplementation resulted in gains in lower extremity strength (from 459 ± 121 N to 484 ± 147 N; P=.01). There was also improvement in Short Physical Performance Battery score, a composite score that focuses on lower extremity function, in those taking DHEA (from 10.1 ± 1.8 to 10.7 ± 1.9; P=.02). There were significant changes in all hormone levels, including DHEAS, estradiol, estrone, and testosterone, and a decline in sex hormone-binding globulin levels in those taking DHEA. CONCLUSION: DHEA supplementation improved lower extremity strength and function in older, frail women involved in a gentle exercise program of chair aerobics or yoga. No changes were found in BMD either due to small sample size, short duration of study or no effect. The physical function findings are promising and require further evaluation as frail women are at high risk for falls and fracture. [source]

The Cross-Sectional Relationship Between Body Mass Index, Waist,Hip Ratio, and Cognitive Performance in Postmenopausal Women Enrolled in the Women's Health Initiative

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2010
Diana R. Kerwin MD
OBJECTIVES: To determine whether body mass index (BMI) is independently associated with cognitive function in postmenopausal women and the relationship between body fat distribution as estimated by waist-hip ratio (WHR). DESIGN: Cross-sectional data analysis. SETTING: Baseline data from the Women's Health Initiative (WHI) hormone trials. PARTICIPANTS: Eight thousand seven hundred forty-five postmenopausal women aged 65 to 79 free of clinical evidence of dementia who completed the baseline evaluation in the WHI hormone trials. MEASUREMENTS: Participants completed a Modified Mini-Mental State Examination (3MSE), health and lifestyle questionnaires, and standardized measurements of height, weight, body circumference, and blood pressure. Statistical analysis was performed of associations between 3MSE score, BMI, and WHR after controlling for known confounders. RESULTS: With the exception of smoking and exercise, vascular disease risk factors, including hypertension, waist measurement, heart disease, and diabetes mellitus, were significantly associated with 3MSE score and were included as covariables in subsequent analyses. BMI was inversely related to 3MSE score; for every 1-unit increase in BMI, 3MSE score decreased 0.988 points (P<.001) after adjusting for age, education, and vascular disease risk factors. BMI had the most pronounced association with poorer cognitive functioning scores in women with smaller waist measurements. In women with the highest WHR, cognitive scores increased with BMI. CONCLUSION: Higher BMI was associated with poorer cognitive function in women with smaller WHR. Higher WHR, estimating central fat mass, was associated with higher cognitive function in this cross-sectional study. Further research is needed to clarify the mechanism for this association. [source]

Heterogeneity in Serum 25-Hydroxy-Vitamin D Response to Cholecalciferol in Elderly Women with Secondary Hyperparathyroidism and Vitamin D Deficiency

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2010
Andrea Giusti MD
OBJECTIVES: To compare the effects on parathyroid hormone (PTH) and 25-hydroxy-vitamin D (25(OH)D) of two dosing regimens of cholecalciferol in women with secondary hyperparathyroidism (sHPTH) and hypovitaminosis D and to investigate variables affecting 25(OH)D response to cholecalciferol. DESIGN: Randomized-controlled trial with 6-month follow-up. SETTING: Two osteoporosis centers in northern Italy. PARTICIPANTS: Sixty community-dwelling women aged 65 and older with sHPTH and hypovitaminosis D, creatinine clearance greater than 65 mL/min and without diseases or drugs known to influence bone and vitamin D metabolism. INTERVENTION: Cholecalciferol 300,000 IU every 3 months, once at baseline and once at 3 months (intermittent D3 group) or cholecalciferol 1,000 IU/day (daily D3 group). MEASUREMENTS: Serum PTH, 25(OH)D, calcium, bone-specific alkaline phosphatase, ,-C-terminal telopeptide of type I collagen, phosphate, 24-hour urinary calcium excretion. RESULTS: The two groups had similar baseline characteristics. All participants had vitamin D deficiency [25(OH)D<20 ng/mL)], and 36 subjects (60%) had severe deficiency (<10 ng/mL), with no difference between the groups (severe deficiency: intermittent D3 group, n=18; daily D3 group, n=18). After 3 and 6 months, both groups had a significant increase in 25(OH)D and a reduction in PTH. Mean absolute increase±standard deviation of 25(OH)D at 6 months was higher in the intermittent D3 group (22.7±11.8 ng/mL) than in the daily D3 group (13.7±6.7 ng/mL, P<.001), with a higher proportion of participants in the intermittent D3 group reaching desirable serum concentration of 25(OH)D , 30 ng/mL (55% in the intermittent D3 group vs 20% in the daily D3 group, P<.001). Mean percentage decrease of PTH in the two groups was comparable, and at 6 months, a similar proportion of participants reached normal PTH values. 25(OH)D response to cholecalciferol showed a wide variability. In a logistic regression analysis, body mass index and type of treatment appeared to be significantly associated with normalization of 25(OH)D values. CONCLUSION: Cholecalciferol 300,000 IU every 3 months was more effective than 1,000 IU daily in correcting vitamin D deficiency, although the two groups achieved similar effects on PTH at 6 months. Only 55% of the higher-dose intermittent group reached desirable concentrations of 25(OH)D, suggesting that yet-higher doses will be required for adequate vitamin D repletion. [source]

Activating Seniors to Improve Chronic Disease Care: Results from a Pilot Intervention Study

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2010
Dominick L. Frosch PhD
OBJECTIVES: To evaluate the effect of an activation intervention delivered in community senior centers to improve health outcomes for chronic diseases that disproportionately affect older adults. DESIGN: Two-group quasi-experimental study. SETTING: Two Los Angeles community senior centers. PARTICIPANTS: One hundred sixteen senior participants. INTERVENTION: Participants were invited to attend group screenings of video programs intended to inform about and motivate self-management of chronic conditions common in seniors. Moderated discussions reinforcing active patient participation in chronic disease management followed screenings. Screenings were scheduled over the course of 12 weeks. MEASUREMENTS: One center was assigned by coin toss to an encouragement condition in which participants received a $50 gift card if they attended at least three group screenings. Participants in the nonencouraged center received no incentive for attendance. Validated study measures for patient activation, physical activity, and health-related quality of life were completed at baseline and 12 weeks and 6 months after enrollment. RESULTS: Participants attending the encouraged senior center were more likely to attend three or more group screenings (77.8% vs 47.2%, P=.001). At 6-month follow-up, participants from either center who attended three or more group screenings (n=74, 64%) reported significantly greater activation (P<.001), more minutes walking (P<.001) and engaging in vigorous physical activity (P=.006), and better health-related quality of life (Medical Outcomes Study 12-item Short-Form Survey (SF-12) mental component summary, P<.001; SF-12 physical component summary, P=.002). CONCLUSION: Delivering this pilot intervention in community senior centers is a potentially promising approach to activating seniors that warrants further investigation for improving chronic disease outcomes. [source]

Changing Patterns in Medication Use with Increasing Probability of Death for Older Medicare Beneficiaries

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2010
Thomas Shaffer MHS
OBJECTIVES: To determine whether use of symptom relief drugs (e.g., antidepressants, anxiolytics, opioid analgesics, sleep aids) rises and use of two commonly prescribed classes of chronic medications (statins and osteoporosis drugs) falls with greater probability of death for older Medicare beneficiaries. DESIGN: Pooled cross-sectional study. SETTING: Noninstitutionalized older Medicare population in 2000 to 2005. PARTICIPANTS: Community-dwelling Medicare beneficiaries aged 65 and older (N=20,233). MEASUREMENTS: Use of medications measured according to dichotomous flags; intensity of use by annual medication fills. Annual probability of death modeled using logistic regression and stratified into seven groups with predicted probabilities of death that range from less than 5% to greater than 50%. Prevalence of use and intensity (mean prescription fills per month) were computed for each class of medication. RESULTS: For symptom relief medications, there is relatively constant use with increasing probability of death, along with greater intensity of use. For the two chronic medications, there was a monotonic decrease in use but at a relatively constant intensity. Decline in statin use ranged from 34.4% in the lowest mortality stratum to 17.6% for those in the highest (P<.001). Use of osteoporosis drugs fell from 10.4% to 6.6% over the same range (P<.001). CONCLUSION: Greater intensity of use of symptom relief medications with increasing probability of death is consistent with hypothesized use. The different profile for chronic medications suggests that the time to benefit is being considered regarding therapy initiation, which results in lower use. [source]

Association Between Dietary Quality of Rural Older Adults and Self-Reported Food Avoidance and Food Modification Due to Oral Health Problems

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 7 2010
Margaret R. Savoca PhD
OBJECTIVES: To quantify the association between food avoidance and modification due to oral health problems, to examine the association between food practices and dietary quality, and to determine foods associated with these self-management behaviors. DESIGN: Cross-sectional. SETTING: Rural North Carolina. PARTICIPANTS: Six hundred thirty-five community-dwelling adults aged 60 and older. MEASUREMENTS: Demographic and food frequency data and oral health assessments were obtained during home visits. Avoidance (0, 1,2 foods, 3,14 foods) and modification (0,3 foods, 4,5 foods) due to oral health problems were assessed for foods representing oral health challenges. Food frequency data were converted into Healthy Eating Index-2005 (HEI-2005) scores. Linear regression models tested the significance of associations between HEI-2005 measures and food avoidance and modification. RESULTS: Thirty-five percent of participants avoided three to 14 foods, and 28% modified four to five foods. After adjusting for age, sex, ethnicity, poverty, education, and tooth loss, total HEI-2005 score was lower (P<.001) for persons avoiding more foods and higher for persons modifying more foods (P<.001). Those avoiding three to 14 foods consumed more saturated fat and energy from solid fat and added sugar and less nonhydrogenated fat than those avoiding fewer than three foods. Those who modified four to five foods consumed less saturated fat and solid fat and added sugar but more total grains than those modifying fewer than four foods. CONCLUSION: Food avoidance and modification due to oral health problems are associated with significant differences in dietary quality. Approaches to minimize food avoidance and promote food modification by persons having eating difficulties due to oral health conditions are needed. [source]

Effect of a Disease-Specific Planning Intervention on Surrogate Understanding of Patient Goals for Future Medical Treatment

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 7 2010
Karin T. Kirchhoff PhD
OBJECTIVES: To determine whether a disease-specific planning process can improve surrogate understanding of goals of patients with life-limiting illnesses for future medical treatments. DESIGN: A multisite randomized controlled trial conducted between January 1, 2004 and July 31, 2007. SETTING: Six outpatient clinics of large community or university health systems in three Wisconsin cities. PARTICIPANTS: Competent, English-speaking adults aged 18 and older with chronic congestive heart failure or chronic renal disease and their surrogate decision-makers. INTERVENTION: Trained health professionals conducted a structured, patient-centered interview intended to promote informed decision-making and to result in the completion of a document clarifying the goals of the patient with regard to four disease-specific health outcome situations and the degree of decision-making latitude granted to the surrogate. MEASUREMENTS: Surrogate understanding of patient goals for care with regard to four expected, disease-specific outcomes situations and of the degree of surrogate latitude in decision-making. RESULTS: Three hundred thirteen patient,surrogate pairs completed the study. As measured according to kappa scores and in all four situations and in the degree of latitude, intervention group surrogates demonstrated a significantly higher degree of understanding of patient goals than control group surrogates. Intervention group kappa scores ranged from 0.61 to 0.78, whereas control group kappa scores ranged from 0.07 to 0.28. CONCLUSION: Surrogates in the intervention group had a significantly better understanding of patient goals and preferences than surrogates in the control group. This finding is the first step toward ensuring that patient goals for care are known and honored. [source]

Randomized Trial of a Delirium Abatement Program for Postacute Skilled Nursing Facilities

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 6 2010
0000], [See editorial comments by Dr. Steven A. Levenson on pp 0000
OBJECTIVES: To determine whether a delirium abatement program (DAP) can shorten duration of delirium in new admissions to postacute care (PAC). DESIGN: Cluster randomized controlled trial. SETTING: Eight skilled nursing facilities specializing in PAC within a single metropolitan region. PARTICIPANTS: Four hundred fifty-seven participants with delirium at PAC admission. INTERVENTION: The DAP consisted of four steps: assessment for delirium within 5 days of PAC admission, assessment and correction of common reversible causes of delirium, prevention of complications of delirium, and restoration of function. MEASUREMENTS: Trained researchers screened eligible patients. Those with delirium defined according to the Confusion Assessment Method were eligible for participation using proxy consent. Regardless of location, researchers blind to intervention status re-assessed participants for delirium 2 weeks and 1 month after enrollment. RESULTS: Nurses at DAP sites detected delirium in 41% of participants, versus 12% in usual care sites (P<.001), and completed DAP documentation in most participants in whom delirium was detected, but the DAP intervention had no effect on delirium persistence based on two measurements at 2 weeks (DAP 68% vs usual care 66%) and 1 month (DAP 60% vs usual care 51%) (adjusted P,.20). Adjusting for baseline differences between DAP and usual care participants and restricting analysis to DAP participants in whom delirium was detected did not alter the results. CONCLUSION: Detection of delirium improved at the DAP sites, but the DAP had no effect on the persistence of delirium. This effectiveness trial demonstrated that a nurse-led DAP intervention was not effective in typical PAC facilities. [source]

Are All Commonly Prescribed Antipsychotics Associated with Greater Mortality in Elderly Male Veterans with Dementia?

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 6 2010
Rebecca C. Rossom MD
OBJECTIVES: To estimate mortality risk associated with individual commonly prescribed antipsychotics. DESIGN: Five-year retrospective study. SETTING: Veterans national healthcare data. PARTICIPANTS: Predominantly male, aged 65 and older, with a diagnosis of dementia and no other indication for an antipsychotic. Subjects who received an antipsychotic were compared with randomly selected controls who did not. Exposed and control cohorts were matched according to their date of dementia diagnosis and time elapsed from diagnosis to the start of antipsychotic therapy. MEASUREMENTS: Mortality during incident antipsychotic use. RESULTS: Cohorts who were exposed to haloperidol (n=2,217), olanzapine (n=3,384), quetiapine (n=4,277), or risperidone (n=8,249) had more comorbidities than their control cohorts. During the first 30 days, there was a significant increase in mortality in subgroups prescribed a daily dose of haloperidol greater than 1 mg (hazard ratio (HR)=3.2, 95% confidence interval (CI)=2.2,4.5, P<.001), olanzapine greater than 2.5 mg (HR=1.5, 95% CI=1.1,2.0, P=.01), or risperidone greater than 1 mg (HR=1.6, 95% CI=1.1,2.2, P=.01) adjusted for demographic characteristics, comorbidities, and medication history using Cox regression analyses. Greater mortality was not seen when a daily dose of quetiapine greater than 50 mg (HR=1.2, 95% CI=0.7,1.8, P=.50) was prescribed, and there was no greater mortality associated with a dose less than 50 mg (HR=0.7, 95% CI=0.5,1.0, P=.03). No antipsychotic was associated with greater mortality after the first 30 days. CONCLUSION: Commonly prescribed doses of haloperidol, olanzapine, and risperidone, but not quetiapine, were associated with a short-term increase in mortality. Further investigations are warranted to identify patient characteristics and antipsychotic dosage regimens that are not associated with a greater risk of mortality in elderly patients with dementia. [source]

Hearing Impairment Affects Older People's Ability to Drive in the Presence of Distracters

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 6 2010
Louise Hickson PhD
OBJECTIVES: To investigate the effects of hearing impairment and distractibility on older people's driving ability, assessed under real-world conditions. DESIGN: Experimental cross-sectional study. SETTING: University laboratory setting and an on-road driving test. PARTICIPANTS: One hundred seven community-living adults aged 62 to 88. Fifty-five percent had normal hearing, 26% had a mild hearing impairment, and 19% had a moderate or greater impairment. MEASUREMENTS: Hearing was assessed using objective impairment measures (pure-tone audiometry, speech perception testing) and a self-report measure (Hearing Handicap Inventory for the Elderly). Driving was assessed on a closed road circuit under three conditions: no distracters, auditory distracters, and visual distracters. RESULTS: There was a significant interaction between hearing impairment and distracters, such that people with moderate to severe hearing impairment had significantly poorer driving performance in the presence of distracters than those with normal or mild hearing impairment. CONCLUSION: Older adults with poor hearing have greater difficulty with driving in the presence of distracters than older adults with good hearing. [source]

Old Age and Outcome After Primary Angioplasty for Acute Myocardial Infarction

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 5 2010
Menko-Jan De Boer MD
OBJECTIVES: To assess the influence of age as an independent factor determining the prognosis and outcome of patients with acute myocardial infarction (AMI) treated using primary percutaneous coronary intervention (PCI). DESIGN: A retrospective analysis from a dedicated database. SETTING: A high-volume interventional cardiology center in the Netherlands. PARTICIPANTS: Four thousand nine hundred thirty-three consecutive patients with AMI. MEASUREMENTS: Baseline characteristics and clinical outcomes after 30 days and 1 year were compared according to age categorized in three groups: younger than 65, 65 to 74, and 75 and older. A more-detailed analysis was performed with six age groups, from younger than 40 to 80 and older. RESULTS: Of the 4,933 consecutive patients with AMI treated with PCI between 1992 and 2004, 643 were aged 75 and older. Multivariate analysis revealed that patients aged 65 to 75 had a greater risk of 1-year mortality than those younger than 65 (adjusted odds ratio (AOR)=1.57, 95% confidence interval (CI)=1.15,2.16) and that those aged 75 and older had a greater risk of 1-year mortality than those younger than 65 (AOR=3.03, 95% CI=2.14,4.29). CONCLUSION: In this retrospective analysis, older age was independently associated with greater mortality after PCI for AMI. Patients aged 65 and older had a higher risk of mortality than younger patients, and those aged 75 and older had the highest risk of mortality. [source]

Depressive Symptoms and Cognitive Decline in Community-Dwelling Older Adults

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 5 2010
Sebastian Köhler PhD
OBJECTIVES: To examine the temporal association between depressive symptoms and cognitive functioning and estimate the effect measure modification of the apolipoprotein E (APOE) ,4 allele on this relationship. DESIGN: Prospective cohort study. SETTING: General community. PARTICIPANTS: Population-based sample of 598 cognitively intact older adults aged 60 and older, with re-assessments after 3 (N=479) and 6 years (N=412). MEASUREMENTS: Depressive symptoms (Symptom Checklist) and neurocognitive functioning (memory, Visual Verbal Learning Test; attention, Stroop Color,Word Test; processing speed, Letter Digit Substitution Test; general cognition, Mini-Mental State Examination). Longitudinal associations were assessed using linear mixed models. The risk for cognitive impairment, no dementia (CIND) was examined using logistic regression. RESULTS: Adjusting for age, sex, education, and baseline cognition, the rate of change in memory z -scores was 0.00, ,0.11, ,0.20, and ,0.37 for those in the lowest (reference group), second, third, and highest depressive symptom quartiles at baseline, respectively (P<.001 for highest vs lowest quartile). The odds ratios for developing CIND with amnestic features were 1.00, 0.87, 0.69, and 2.98 for the four severity groups (P=.05 for highest vs lowest quartile). Associations were strongest for those with persistent depressive symptoms, defined as high depressive symptoms at baseline and at least one follow-up visit. Results were similar for processing speed and global cognitive function but were not as strong for attention. No APOE interaction was observed. CONCLUSION: Depression and APOE act independently to increase the risk for cognitive decline and may provide targets for prevention and early treatment. [source]

Daily Variations in Objective Nighttime Sleep and Subjective Morning Pain in Older Adults with Insomnia: Evidence of Covariation over Time

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 5 2010
Joseph M. Dzierzewski MS
OBJECTIVES: To examine the relationship between objectively measured nocturnal sleep and subjective report of morning pain in older adults with insomnia; to examine not only the difference between persons in the association between sleep and pain (mean level over 14 days), but also the within-person, day-to-day association. DESIGN: Cross-sectional. SETTING: North-central Florida. PARTICIPANTS: Fifty community-dwelling older adults (mean age±standard deviation 69.1±7.0, range 60,90) with insomnia. MEASUREMENTS: Daily home-based assessment using nightly actigraphic measurement of sleep and daily self-report of pain over 14 consecutive days. RESULTS: Between persons, average sleep over 14 days was not associated with average levels of rated pain, but after a night in which an older adult with insomnia experienced above-average total sleep time he or she subsequently reported below-average pain ratings. The model explained approximately 24% of the within-person and 8% of the between-person variance in pain ratings. CONCLUSIONS: Sleep and pain show day-to-day associations (i.e., covary over time) in older adults with insomnia. Such associations may suggest that common physiological systems underlie the experience of insomnia and pain. Future research should examine the crossover effects of sleep treatment on pain and of pain treatment on sleep. [source]

Maximum Daily 6 Minutes of Activity: An Index of Functional Capacity Derived from Actigraphy and Its Application to Older Adults with Heart Failure

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 5 2010
Jason Howell BA
OBJECTIVES: To compare the correlation between the maximum 6 minutes of daily activity (M6min) and standard measures of functional capacity in older adults with heart failure (HF) with that in younger subjects and its prognostic utility. DESIGN: Prospective, cohort study. SETTING: Tertiary care, academic HF center. PARTICIPANTS: Sixty, ambulatory, adults, New York Heart Association (NYHA) Class I to III, stratified into young (50.9 ± 9.4) and older cohorts (76.8 ± 8.0). MEASUREMENTS: Correlation between M6min and measures of functional capacity (6-minute walk test; 6MWT) and peak oxygen consumption (VO2) according to cardiopulmonary exercise testing in a subset of subjects. Survival analysis was employed to evaluate the association between M6min and adverse events. RESULTS: Adherence to actigraphy was high (90%) and did not differ according to age. The correlation between M6min and 6MWT was higher in subjects aged 65 and older than in those younger than 65 (correlation coefficient (r=0.702, P<.001 vs r=0.490, P=.002). M6min was also significantly associated with peak VO2 (r=0.612, P=.006). During the study, 26 events occurred (2 deaths, 10 hospitalizations, 8 emergency department visits, and 6 intercurrent illnesses). The M6min was significantly associated with subsequent events (hazard ratio=2.728, 95% confidence interval=1.10,6.77, P=.03), independent of age, sex, ejection fraction, NYHA class, brain natriuretic peptide, and 6MWT. CONCLUSION: The high adherence to actigraphy and association with standard measures of functional capacity and independent association with subsequent morbid events suggest that it may be useful for monitoring older adults with HF. [source]

Potentially Avoidable Hospitalizations of Nursing Home Residents: Frequency, Causes, and Costs

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 4 2010
[See editorial comments by Drs.
OBJECTIVES: To examine the frequency and reasons for potentially avoidable hospitalizations of nursing home (NH) residents. DESIGN: Medical records were reviewed as a component of a project designed to develop and pilot test clinical practice tools for reducing potentially avoidable hospitalization. SETTING: NHs in Georgia. PARTICIPANTS: In 10 NHs with high and 10 with low hospitalization rates, 10 hospitalizations were randomly selected, including long- and short-stay residents. MEASUREMENTS: Ratings using a structured review by expert NH clinicians. RESULTS: Of the 200 hospitalizations, 134 (67.0%) were rated as potentially avoidable. Panel members cited lack of on-site availability of primary care clinicians, inability to obtain timely laboratory tests and intravenous fluids, problems with quality of care in assessing acute changes, and uncertain benefits of hospitalization as causes of these potentially avoidable hospitalizations. CONCLUSION: In this sample of NH residents, experienced long-term care clinicians commonly rated hospitalizations as potentially avoidable. Support for NH infrastructure, clinical practice and communication tools for health professionals, increased attention to reducing the frequency of medically futile care, and financial and other incentives for NHs and their affiliated hospitals are needed to improve care, reduce avoidable hospitalizations, and avoid unnecessary healthcare expenditures in this population. [source]

Cardiovascular Disease Is Associated with Greater Incident Dehydroepiandrosterone Sulfate Decline in the Oldest Old: The Cardiovascular Health Study All Stars Study

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 3 2010
Jason L. Sanders BA
OBJECTIVES: To describe cross-sectional and longitudinal associations with dehydroepiandrosterone sulfate (DHEAS) and change in DHEAS with age. DESIGN: Longitudinal cohort study. SETTING: Pittsburgh, Pennsylvania. PARTICIPANTS: Cardiovascular Health Study All Stars study participants assessed in 2005/06 (N=989, mean age 85.2, 63.5% women, 16.5% African American). MEASUREMENTS: Health characteristics were assessed in 2005/06 according to DHEAS level, mean DHEAS and DHEAS change across age categories were tested, and linear and logistic regression was used to identify factors present in 1996/97 associated with continuous and categorical DHEAS change. RESULTS: Mean ± standard deviation DHEAS was 0.555 ± 0.414 ,g/mL in 1996/97 and 0.482 ± 0.449 ,g/mL in 2005/06 for women and 0.845 ± 0.520 ,g/mL in 1996/97 and 0.658 ± 0.516 ,g/mL in 2005/06 for men. In 2005/06, DHEAS was lower in women and subjects with cardiovascular disease (CVD) and chronic pulmonary disease and higher for African Americans and subjects with hypertension and high cholesterol. Mean DHEAS change was greater in men (,0.200 ,g/mL) than in women (,0.078 ,g/mL) (P<.001). Each 1-year increase in age attenuated the effect of male sex by 0.01 ,g/mL (P=.009), abolishing the sex difference in DHEAS change by age 79. Presence of CVD before the study period was associated with greater absolute DHEAS change (,=,0.04 ,g/mL, P=.04) and with the fourth quartile of DHEAS change versus the first to third quartiles (odds ratio=1.46, 95% confidence interval=1.03,2.05). CONCLUSION: DHEAS change continues into very old age, is not homogenous, is affected by sex, and is associated with prevalent CVD. Future studies should investigate factors that might accelerate DHEAS decline. [source]

Screening for Abuse and Neglect of People with Dementia

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 3 2010
Aileen Wiglesworth PhD
OBJECTIVE: To investigate characteristics of people with dementia and their caregivers (CGs) that are associated with mistreatment in order to inform clinicians about screening for mistreatment. DESIGN: A convenience sample of CG,care recipient (CR) dyads were assessed for literature-supported factors associated with mistreatment, and evidence of mistreatment for the prior year was collected. An expert panel considered the evidence and decided on occurrences of psychological abuse, physical abuse, and neglect based on criteria adopted before data collection. SETTING: Participants' homes. PARTICIPANTS: One hundred twenty-nine persons with dementia and their CGs. MEASUREMENTS: CG and CR characteristics (demographic, health, and psychosocial variables), relationship characteristics, and three elder abuse and neglect detection instruments. RESULTS: Mistreatment was detected in 47.3%. Variables associated with different kinds and combinations of mistreatment types included the CG's anxiety, depressive symptoms, social contacts, perceived burden, emotional status, and role limitations due to emotional problems and the CR's psychological aggression and physical assault behaviors. The combination of CR's physical assault and psychological aggression provided the best sensitivity (75.4%) and specificity (70.6%) for elder mistreatment as defined by the expert panel. This finding has potential to be useful as a clinical screen for detecting mistreatment. CONCLUSIONS: The findings suggest important characteristics of older adults with dementia and their CGs that have potential for use in a clinical screening tool for elder mistreatment. Potential screening questions to be asked of CGs of people with dementia are suggested. [source]

Serum Lipid Levels and Cognitive Change in Late Life

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 3 2010
Chandra A. Reynolds PhD
OBJECTIVES: To assess the effect of lipids and lipoproteins on longitudinal cognitive performance and cognitive health in late life and to consider moderating factors such as age and sex that may clarify conflicting prior evidence. DESIGN: Prospective cohort study. SETTING: A 16-year longitudinal study of health and cognitive aging. PARTICIPANTS: Eight hundred nineteen adults from the Swedish Adoption Twin Study of Aging aged 50 and older at first cognitive testing, including 21 twin pairs discordant for dementia. MEASUREMENTS: Up to five occasions of cognitive measurements encompassing verbal, spatial, memory, and perceptual speed domains across a 16-year span; baseline serum lipids and lipoproteins including high-density lipoprotein cholesterol (HDL-C), apolipoprotein (apo)A1, apoB, total serum cholesterol, and triglycerides. RESULTS: The effect of lipids on cognitive change was most evident before age 65. In women, higher HDL-C and lower apoB and triglycerides predicted better maintenance of cognitive abilities, particularly verbal ability and perceptual speed, than age. Lipid values were less predictive of cognitive trajectories in men and, where observed, were in the contrary direction (i.e., higher total cholesterol and apoB values predicted better perceptual speed performance though faster rates of decline). In twin pairs discordant for dementia, higher total cholesterol and apoB levels were observed in the twin who subsequently developed dementia. CONCLUSION: High lipid levels may constitute a more important risk factor for cognitive health before age 65 than after. Findings for women are consistent with clinical recommendations, whereas for men, the findings correspond with earlier age-associated shifts in lipid profiles and the importance of lipid homeostasis to cognitive health. [source]

Depressive Symptoms in Middle Age and the Development of Later-Life Functional Limitations: The Long-Term Effect of Depressive Symptoms

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 3 2010
Kenneth E. Covinsky MD
OBJECTIVES: To determine whether middle-aged persons with depressive symptoms are at higher risk for developing activity of daily living (ADL) and mobility limitations as they advance into older age than those without. DESIGN: Prospective cohort study. SETTING: The Health and Retirement Study (HRS), a nationally representative sample of people aged 50 to 61. PARTICIPANTS: Seven thousand two hundred seven community living participants in the 1992 wave of the HRS. MEASUREMENTS: Depressive symptoms were measured using the 11-item Center for Epidemiologic Studies Depression Scale (CES-D 11), with scores of 9 or more (out of 33) classified as significant depressive symptoms. Difficulty with five ADLs and basic mobility tasks (walking several blocks or up one flight of stairs) was measured every 2 years through 2006. The primary outcome was persistent difficulty with ADLs or mobility, defined as difficulty in two consecutive waves. RESULTS: Eight hundred eighty-seven (12%) subjects scored 9 or higher on the CES-D 11 and were classified as having significant depressive symptoms. Over 12 years of follow-up, subjects with depressive symptoms were more likely to reach the primary outcome measure of persistent difficulty with mobility or difficulty with ADL function (45% vs 23%, Cox hazard ratio (HR)=2.33, 95% confidence interval (CI)=2.06,2.63). After adjusting for age, sex, measures of socioeconomic status, comorbid conditions, high body mass index, smoking, exercise, difficulty jogging 1 mile, and difficulty climbing several flights of stairs, the risk was attenuated but still statistically significant (Cox HR=1.44, 95% CI=1.25,1.66). CONCLUSION: Depressive symptoms independently predict the development of persistent limitations in ADLs and mobility as middle-aged persons advance into later life. Middle-aged persons with depressive symptoms may be at greater risk for losing their functional independence as they age. [source]

Development and Validation of Quality Indicators for Dementia Diagnosis and Management in a Primary Care Setting

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 3 2010
Marieke Perry MD
OBJECTIVES: To construct a set of quality indicators (QIs) for dementia diagnosis and management in a primary care setting. DESIGN: RAND modified Delphi method, including a postal survey, a stakeholders consensus meeting, a scientific expert consensus meeting, and a demonstration project. SETTING: Primary care. PARTICIPANTS: General practitioners (GPs), primary care nurses (PCNs), and informal caregivers (ICs) in postal survey and stakeholders consensus meeting. Eight national dementia experts in scientific consensus meeting. Thirteen GPs in the demonstration project. MEASUREMENTS: Mean face validity and feasibility scores. Compliance rates using GPs' electronic medical record data. RESULTS: The initial set consisted of 31 QIs. Most indicators showed moderate or good face validity and feasibility scores. Consensus panels reduced the preliminary set used in the demonstration project to 24 QIs. The overall compliance to the QIs was 45.3%. Discriminative validity of the set was good; significant differences in adherence were found between GPs with high and low levels of patients aged 65 and older in their practice, with and without PCNs, and with positive and negative attitudes toward dementia (all P<.05). Based on the demonstration project, one QI was excluded. The final set consisted of 23 QIs; 15 QIs contained innovative quality criteria on collaboration between GPs and PCNs, referral criteria, and assessment of caregivers' needs. CONCLUSION: This new set of dementia QIs is feasible, reliable, and valid and can be used to improve primary dementia care. Because of the innovative quality criteria, the set is complementary to the existing dementia QIs. [source]

Association Between Fitness and Changes in Body Composition and Muscle Strength

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 2 2010
George A. Kuchel, [see editorial comments by Drs. Gustavo Duque, pp 37
OBJECTIVES: To examine the association between physical fitness, assessed according to ability and time to complete a 400-m walk, on changes in body composition and muscle strength over a 7-year period. DESIGN: Prospective observational cohort study. SETTING: Memphis, Tennessee, and Pittsburgh, Pennsylvania. PARTICIPANTS: Two thousand nine hundred forty-nine black and white men and women aged 70 to 79 participating in the Health, Aging and Body Composition Study. MEASUREMENTS: Body composition (fat and bone-free lean mass) was assessed using dual-energy X-ray absorptiometry in Years 1 to 6 and 8. Knee extension strength was measured using isokinetic dynamometry and grip strength using isometric dynamometry in Years 1, 2, 4, 6, and 8. RESULTS: Less fit people weighed more and had a higher total percentage of fat and a lower total percentage of lean mass than very fit men and women at baseline (P<.001). Additionally, the least fit lost significantly more weight, fat mass, and lean mass over time than the very fit (all P<.01). Very fit people had the highest grip strength and knee extensor strength at baseline and follow-up; decline in muscle strength was similar in every fitness group. CONCLUSION: Low fitness in old age was associated with greater weight loss and loss of lean mass than with high fitness. Despite having lower muscle strength, the rate of decline in the least fit persons was similar to that in the most fit. In clinical practice, a long-distance walk test as a measure of fitness might be useful to identify people at risk for these adverse health outcomes. [source]

Circadian Activity Rhythms and Mortality: The Study of Osteoporotic Fractures

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 2 2010
Gregory J. Tranah PhD
OBJECTIVES: To determine whether circadian activity rhythms are associated with mortality in community-dwelling older women. DESIGN: Prospective study of mortality. SETTING: A cohort study of health and aging. PARTICIPANTS: Three thousand twenty-seven community-dwelling women from the Study of Osteoporotic Fractures cohort (mean age 84). MEASUREMENTS: Activity data were collected using wrist actigraphy for a minimum of three 24-hour periods, and circadian activity rhythms were computed. Parameters of interest included height of activity peak (amplitude), midline estimating statistic of rhythm (mesor), strength of activity rhythm (robustness), and time of peak activity (acrophase). Vital status, with cause of death adjudicated through death certificates, was prospectively ascertained. RESULTS: Over an average of 4.1 years of follow-up, there were 444 (14.7%) deaths. There was an inverse association between peak activity height and all-cause mortality rates, with higher mortality rates observed in the lowest activity quartile (hazard ratio (HR)=2.18, 95% confidence interval (CI)=1.63,2.92) than in the highest quartile after adjusting for age, clinic site, race, body mass index, cognitive function, exercise, instrumental activity of daily living impairments, depression, medications, alcohol, smoking, self-reported health status, married status, and comorbidities. A greater risk of mortality from all causes was observed for those in the lowest quartiles of mesor (HR=1.71, 95% CI=1.29,2.27) and rhythm robustness (HR=1.97, 95% CI=1.50,2.60) than for those in the highest quartiles. Greater mortality from cancer (HR=2.09, 95% CI=1.04,4.22) and stroke (HR=2.64, 95% CI=1.11,6.30) was observed for later peak activity (after 4:33 p.m.; >1.5 SD from mean) than for the mean peak range (2:50,4:33 p.m.). CONCLUSION: Older women with weak circadian activity rhythms have higher mortality risk. If confirmed in other cohorts, studies will be needed to test whether interventions (e.g., physical activity, bright light exposure) that regulate circadian activity rhythms will improve health outcomes in older adults. [source]

Efficacy and Safety of a Once-Yearly Intravenous Zoledronic Acid 5 mg for Fracture Prevention in Elderly Postmenopausal Women with Osteoporosis Aged 75 and Older

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 2 2010
Steven Boonen MD
OBJECTIVES: To determine the efficacy of once-yearly intravenous zoledronic acid (ZOL) 5 mg in reducing risk of clinical vertebral, nonvertebral, and any clinical fractures in elderly osteoporotic postmenopausal women. DESIGN: A post hoc subgroup analysis of pooled data from the Health Outcome and Reduced Incidence with Zoledronic Acid One Yearly (HORIZON) Pivotal Fracture Trial and the HORIZON Recurrent Fracture Trial. SETTING: Multicenter, randomized, double-blind, placebo-controlled trials. PARTICIPANTS: Postmenopausal women (aged ,75) with documented osteoporosis (T -score ,,2.5 at femoral neck or ,1 prevalent vertebral or hip fracture) or a recent hip fracture. INTERVENTION: Patients were randomized to receive an intravenous infusion of ZOL 5 mg (n=1,961) or placebo (n=1,926) at baseline and 12 and 24 months. MEASUREMENTS: Primary endpoints were incidence of clinical vertebral and nonvertebral and any clinical fracture after treatment. RESULTS: At 3 years, incidence of any clinical, clinical vertebral, and nonvertebral fracture were significantly lower in the ZOL group than in the placebo group (10.8% vs 16.6%, 1.1% vs 3.7%, and 9.9% vs 13.7%, respectively) (hazard ratio (HR)=0.65, 95% confidence interval (CI)=0.54,0.78, P<.001; HR=0.34, 95% CI=0.21,0.55, P<.001; and HR=0.73, 95% CI=0.60,0.90, P=.002, respectively). The incidence of hip fracture was lower with ZOL but did not reach statistical significance. The incidence rate of postdose adverse events were higher with ZOL, although the rate of serious adverse events and deaths was comparable between the two groups. CONCLUSION: Once-yearly intravenous ZOL 5 mg was associated with a significant reduction in the risk of new clinical fractures (vertebral and nonvertebral) in elderly postmenopausal women with osteroporosis. [source]

Chronic Kidney Disease and Cognitive Function in Older Adults: Findings from the Chronic Renal Insufficiency Cohort Cognitive Study

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 2 2010
Kristine Yaffe MD
OBJECTIVES: To investigate cognitive impairment in older, ethnically diverse individuals with a broad range of kidney function, to evaluate a spectrum of cognitive domains, and to determine whether the relationship between chronic kidney disease (CKD) and cognitive function is independent of demographic and clinical factors. DESIGN: Cross-sectional. SETTING: Chronic Renal Insufficiency Cohort Study. PARTICIPANTS: Eight hundred twenty-five adults aged 55 and older with CKD. MEASUREMENTS: Estimated glomerular filtration rate (eGFR, mL/min per 1.73 m2) was estimated using the four-variable Modification of Diet in Renal Disease equation. Cognitive scores on six cognitive tests were compared across eGFR strata using linear regression; multivariable logistic regression was used to examine level of CKD and clinically significant cognitive impairment (score ,1 standard deviations from the mean). RESULTS: Mean age of the participants was 64.9, 50.4% were male, and 44.5% were black. After multivariable adjustment, participants with lower eGFR had lower cognitive scores on most cognitive domains (P<.05). In addition, participants with advanced CKD (eGFR<30) were more likely to have clinically significant cognitive impairment on global cognition (adjusted odds ratio (AOR) 2.0, 95% CI=1.1,3.9), naming (AOR=1.9, 95% CI=1.0,3.3), attention (AOR=2.4, 95% CI=1.3,4.5), executive function (AOR=2.5, 95% CI=1.9,4.4), and delayed memory (AOR=1.5, 95% CI=0.9,2.6) but not on category fluency (AOR=1.1, 95% CI=0.6,2.0) than those with mild to moderate CKD (eGFR 45,59). CONCLUSION: In older adults with CKD, lower level of kidney function was associated with lower cognitive function on most domains. These results suggest that older patients with advanced CKD should be screened for cognitive impairment. [source]

The Oldest Old in the Last Year of Life: Population-Based Findings from Cambridge City over-75s Cohort Study Participants Aged 85 and Older at Death

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 1 2010
Jun Zhao MSc
OBJECTIVES: To characterize people of advanced old age in their last year of life and compare those dying in their late 80s with those dying aged 90 and older to inform policy and planning. DESIGN: Retrospective analysis of prospectively collected population-based data from the Cambridge City over-75s Cohort (CC75C) Study, United Kingdom. PARTICIPANTS: Men and women aged 85 and older at death who died less than 1 year after taking part in any CC75C survey (N=321). MEASUREMENTS: Physical health, functional disability, self-rated health, cognitive status. RESULTS: Functional and cognitive impairments were markedly higher for those who died aged 90 and older, predominantly women,than for those who died aged 85 to 89. At least half (49.4,93.6%) of subjects aged 90 and older needed maximum assistance in virtually every daily activity; those aged 85 to 89 needed this only for shopping and laundry. Disability in basic and instrumental activities rose from 59.1% before to 85.4% after the age of 90 and cognitive impairment (Mini-Mental State Examination score ,21) from 41.7% to 69.4%. Despite this and proximity to death, 60.5% and 67.0%, respectively, rated their health positively. Only one in five reported needing more help. CONCLUSION: This study provides new data identifying high levels of physical and cognitive disability in very old people in the year before death. As the very old population rises, so will support needs for people dying in extreme old age. The mismatch between health perceptions and functional limitations suggests that these vulnerable older adults may not seek help from which they could benefit. These findings have major policy and planning implications for end-of-life care for the oldest old. [source]

The Poor Outcome of Ischemic Stroke in Very Old People: A Cohort Study of Its Determinants

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 1 2010
Licia Denti MD
OBJECTIVES: To assess how much of the excess risk of poor outcome from stroke in people aged 80 and older aging per se explains, independent of other prognostic determinants. DESIGN: Cohort, observational. SETTING: University hospital. PARTICIPANTS: One thousand five hundred fifty-five patients with first-ever ischemic stroke consecutively referred to an in-hospital Clinical Pathway program were studied. MEASUREMENTS: The relationship between age and 1-month outcome (death, disability (modified Rankin Scale 3,5), and poor outcome (modified Rankin Scale 3,6)) was assessed, with adjustment for several prognostic factors. RESULTS: Six hundred twelve patients aged 80 and older showed worse outcome after 1 month than those who were younger, in terms of mortality (19% vs 5%, hazard ratio (HR)=3.85, 95% confidence interval (CI)=2.8,5.4) and disability (51% vs 33%, odds ratio (OR)=3.16, 95% CI=2.5,4.0), although in multivariate models, the adjusted HR for mortality decreased to 1.47 (95% CI=1.0,2.16) and the ORs for disability and poor outcome decreased to 1.76 (95% CI=1.32,2.3.) and 1.83 (95% CI=137,2.43), respectively. Stroke severity, the occurrence of at least one medical complication, and premorbid disability explained most of the risk excess in the oldest-old. CONCLUSION: Stroke outcome is definitely worse in very old people, and most of the excess risk of death and disability is attributable to the higher occurrences of the most-severe clinical stroke syndromes and of medical complications in the acute phase. These represent potential targets for preventive and therapeutical strategies specifically for elderly people. [source]

Physical Performance and Subsequent Disability and Survival in Older Adults with Malignancy: Results from the Health, Aging and Body Composition Study

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 1 2010
Heidi D. Klepin MD
OBJECTIVES: To evaluate objective physical performance measures as predictors of survival and subsequent disability in older patients with cancer. DESIGN: Longitudinal cohort study. SETTING: Health, Aging and Body Composition (Health ABC) Study. PARTICIPANTS: Four hundred twenty-nine individuals diagnosed with cancer during the first 6 years of follow-up of the Health ABC Study. MEASUREMENTS: The associations between precancer measures of physical performance (20-m usual gait speed, 400-m long-distance corridor walk (LDCW), and grip strength) and overall survival and a short-term outcome of 2-year progression to disability or death were evaluated. Cox proportional hazards and logistic regression models, stratified for metastatic disease, respectively, were used for outcomes. RESULTS: Mean age was 77.2, 36.1% were women, and 45.7% were black. Faster 20-m usual walking speed was associated with a lower risk of death in the metastatic group (hazard ratio=0.89, 95% confidence interval (CI)=0.79,0.99) and lower 2-year progression to disability or death in the nonmetastatic group (odds ratio (OR)=0.77, 95% CI=0.64,0.94). Ability to complete the 400-m LDCW was associated with lower 2-year progression to disability or death in the nonmetastatic group (OR=0.24, 95% CI=0.10,0.62). There were no associations between grip strength and disability or death. CONCLUSION: Lower extremity physical performance tests (usual gait speed and 400-m LDCW) were associated with survival and 2-year progression to disability or death. Objective physical performance measures may help inform pretreatment evaluations in older adults with cancer. [source]

Evaluating the Cost-Effectiveness of Fall Prevention Programs that Reduce Fall-Related Hip Fractures in Older Adults

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 1 2010
Kevin D. Frick PhD
OBJECTIVES: To model the incremental cost-utility of seven interventions reported as effective for preventing falls in older adults. DESIGN: Mathematical epidemiological model populated by data based on direct clinical experience and a critical review of the literature. SETTING: Model represents population level interventions. PARTICIPANTS: No human subjects were involved in the study. MEASUREMENS: The last Cochrane database review and meta-analyses of randomized controlled trials categorized effective fall-prevention interventions into seven groups: medical management (withdrawal) of psychotropics, group tai chi, vitamin D supplementation, muscle and balance exercises, home modifications, multifactorial individualized programs for all elderly people, and multifactorial individualized treatments for high-risk frail elderly people. Fall-related hip fracture incidence was obtained from the literature. Salary figures for health professionals were based on Bureau of Labor Statistics data. Using an integrated healthcare system perspective, healthcare costs were estimated based on practice and studies on falls in older adults. Base case incremental cost utility ratios were calculated, and probabilistic sensitivity analyses were conducted. RESULTS: Medical management of psychotropics and group tai chi were the least-costly, most-effective options, but they were also the least studied. Excluding these interventions, the least-expensive, most-effective options are vitamin D supplementation and home modifications. Vitamin D supplementation costs less than home modifications, but home modifications cost only $14,794/quality-adjusted life year (QALY) gained more than vitamin D. In probabilistic sensitivity analyses excluding management of psychotropics and tai chi, home modification is most likely to have the highest economic benefit when QALYs are valued at $50,000 or $100,000. CONCLUSION: Of single interventions studied, management of psychotropics and tai chi reduces costs the most. Of more-studied interventions, home modifications provide the best value. These results must be interpreted in the context of the multifactorial nature of falls. [source]