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1.  A pilot study of exercise in men with prostate cancer receiving androgen deprivation therapy 
BMC Cancer  2012;12:103.
Androgen deprivation therapy (ADT) is the mainstay therapy for men with prostate cancer. However, there are musculoskeletal side effects from ADT that increase the risk for osteoporosis and fracture, and can compromise the quality of life of these individuals. The objectives of this study are to determine the efficacy of a home-based walking exercise program in promoting bone health, physical function and quality of life in men with prostate cancer receiving ADT.
A 12-month prospective, single-blinded, randomized controlled trial will be conducted to compare the Exercise Group with the Control Group. Sixty men with prostate cancer who will be starting ADT will be recruited and randomly assigned to one of the two groups: the Exercise Group will receive instructions in setting up an individualized 12-month home-based walking exercise program, while the Control Group will receive standard medical advice from the attending physician. A number of outcome measures will be used to assess bone health, physical function, and health-related quality of life. At baseline and 12 months, bone health will be assessed using dual-energy X-ray absorptiometry. At baseline and every 3 months up to 12 months, physical function will be evaluated using the Functional Assessment of Chronic Illness Therapy - Fatigue Scale, Activities-specific Balance Confidence Scale, Short Physical Performance Battery, and Six-Minute Walk Test; and health-related quality of life will be assessed using the Functional Assessment of Cancer Therapy Prostate Module and the Medical Outcomes Study 12-item Short Form Health Survey Version 2. A mixed multiple analysis of variance will be used to analyze the data.
Musculoskeletal health management remains a challenge in men with prostate cancer receiving ADT. This study addresses this issue by designing a simple and accessible home-based walking exercise program that will potentially have significant impact on reducing the risk of fracture, promoting physical function, and ultimately improving the health-related quality of life in men with prostate cancer receiving ADT.
Trial registration NCT00834392.
PMCID: PMC3352294  PMID: 22436542
Prostate cancer; Androgen deprivation therapy; Walking; Home-based exercise; Bone health; Physical function; Quality of life
2.  Obese frailty, physical performance deficits, and falls in older men with biochemical recurrence of prostate cancer on androgen deprivation therapy: a case-control study 
Urology  2011;77(4):934-940.
Early androgen deprivation therapy (ADT) has no proven survival advantage in older men with biochemical recurrence (BCR) of prostate cancer (PCa), and it may contribute to geriatric frailty; we tested this hypothesis.
We conducted a case-control study of men aged 60+ with BCR on ADT (n=63) versus PCa survivors without recurrence (n=71). Frailty prevalence, “obese” frailty, Short Physical Performance Battery (SPPB) scores and falls were compared. An exploratory analysis of frailty biomarkers (CRP, ESR, hemoglobin, albumin, and total cholesterol) was performed. Summary statistics, univariate and multivariate regression analyses were conducted.
More patients on ADT were obese (BMI >30; 46.2% vs. 20.6%; p=0.03). There were no statistical differences in SPPB (p=0.41) or frailty (p=0.20). Using a proposed “obese” frailty criteria, 8.7% in ADT group were frail and 56.5% were “prefrail”, compared with 2.9% and 48.8% of controls (p=0.02). Falls in the last year were higher in ADT group (14.3% vs. 2.8%; p=0.02). In analyses controlling for age, clinical characteristics, and comorbidities, the ADT group trended toward significance for “obese” frailty (p = 0.14) and falls (OR = 4.74, p = 0.11). Comorbidity significantly increased the likelihood of “obese” frailty (p=0.01) and falls (OR 2.02, p = 0.01).
Men with BCR on ADT are frailer using proposed modified “obese” frailty criteria. They may have lower performance status and more falls. A larger, prospective trial is necessary to establish a causal link between ADT use and progression of frailty and disability.
PMCID: PMC3074039  PMID: 21269665
prostate cancer; biochemical recurrence; androgen deprivation therapy; frailty; older adults
3.  Evaluating the Utility of Existing Patient-Reported Outcome Scales in Novel Patient Populations with Pancreatic Cancer, Lung Cancer, and Myeloproliferative Neoplasms Using Medicare Current Beneficiary Survey Data 
The Patient  2013;6(3):189-200.
While there are validated patient-reported outcomes (PRO) instruments for use in specific cancer populations, no validated general instruments exist for use in conditions common to multiple cancers, such as muscle wasting and consequent physical disability. The Medicare Current Beneficiary Survey (MCBS), a survey in a nationally representative sample of Medicare beneficiaries, includes items from three well known scales with general applicability to cancer patients: Katz activities of daily living (ADL), Rosow–Breslau instrumental ADL (IADL), and a subset of physical performance items from the Nagi scale.
This study evaluated properties of the Katz ADL, Rosow–Breslau IADL, and a subset of the Nagi scale in patients with pancreatic cancer, lung cancer, and myeloproliferative neoplasms (MPN) using data from MCBS linked with Medicare claims in order to understand the potential utility of the three scales in these populations; understanding patient-perceived significance was not in scope.
The study cohorts included Medicare beneficiaries aged ≥65 years as of 1 January of the year of their first cancer diagnosis with one or more health assessments in a community setting in the MCBS Access to Care data from 1991 to 2009. Beneficiaries had at least two diagnoses in de-identified Medicare claims data linked to the MCBS for one of the following cancers: pancreatic, lung, or MPN. The Katz ADL, Rosow–Breslau IADL, and Nagi scales were calculated to assess physical functioning over time from cancer diagnosis. Psychometric properties for each scale in each cohort were evaluated by testing for internal consistency, test–retest reliability, and responsiveness by comparing differences in mean scale scores over time as cancer progresses, and differences in mean scale scores before and after hospitalization (for lung cancer cohort).
The study cohorts included 90 patients with pancreatic cancer, 863 with lung cancer, and 135 with MPN. Among each cancer cohort, the Katz ADL, Rosow–Breslau IADL, and Nagi scales had acceptable internal consistency (Cronbach’s alpha generally between 0.70 and 0.90) and test–retest reliability for consecutive surveys before diagnosis and consecutive surveys after diagnosis (when patients’ functioning was more stable). Compared with mean scale scores at the survey 1–2 years before cancer diagnosis (baseline), mean scale scores at the first survey after cancer diagnosis were significantly higher (P < 0.05), indicating worsening, for Katz ADL, Rosow–Breslau IADL, and Nagi scales (items scored 0–1) (0.54 vs. 1.45, 1.15 vs. 2.20, and 2.29 vs. 3.08, respectively, for pancreatic cancer; 0.73 vs. 1.24, 1.29 vs. 2.01, and 2.41 vs. 2.85 for lung cancer; and 0.44 vs. 0.86, 0.87 vs. 1.36, and 1.87 vs. 2.32 for MPN). Among lung cancer patients, scale scores increased significantly following a hospitalization, suggesting a worsening of functional status.
The Katz ADL, Rosow–Breslau IADL, and Nagi scales collected in the MCBS demonstrate acceptable internal consistency and test–retest reliability among patients with pancreatic cancer, lung cancer, and MPN, and are consistent with clinical worsening following diagnosis or hospitalization. These results suggest that using retrospective data may allow researchers to conduct preliminary assessments of existing PRO instruments in new populations of interest and generate useful exploratory disease information before embarking on de novo PRO development.
PMCID: PMC3751268  PMID: 23828691
4.  Characterization of Activities of Daily Living in Individuals With Mild Cognitive Impairment 
To determine whether participants with mild cognitive impairment (MCI) differ from cognitively normal (NC) older adults on traditional and novel informant-based measures of activities of daily living (ADL) and to identify cognitive correlates of ADLs among participants with MCI.
University medical setting.
Seventy-seven participants (NC: N = 39; MCI: N = 38), 60 to 90 years old (73.5 ± 6.6 years; 53% female).
Neuropsychological and ADL measures.
Neuropsychological tests were administered to NC and MCI participants. Informants completed the Lawton and Brody Instrumental Activities of Daily Living and Physical Self-Maintenance Scale, including instrumental (IADL) and basic ADL (BADL) scales, as well as the Functional Capacities for Activities of Daily Living (FC-ADL), an error-based ADL measure.
No statistically or clinically significant between-group differences emerged for the BADL or IADL subscales. However, a robust difference was noted for the FC-ADL scale (MCI errors > NC errors; F(1,75) = 13.6, p <0.001; d = 0.84). Among MCI participants, correlations revealed that a measure of verbal learning was the only neuropsychological correlate of FC-ADL total score (r =-0.39, df = 36, p = 0.007). No neuropsychological measures were significantly associated with the IADL or BADL subscale score.
Traditional measures assessing global ADLs may not be sensitive to early functional changes related to MCI; however, error-based measures may capture the subtle evolving functional decline associated with MCI. Among MCI participants, early functional difficulties are associated with verbal learning performance, possibly secondary to the hallmark cognitive impairment associated with this cohort.
PMCID: PMC2682324  PMID: 18332397
Instrumental activities of daily living; MCI; memory; functional errors; neuropsychology
5.  Muscle function, physical performance and body composition changes in men with prostate cancer undergoing androgen deprivation therapy 
Asian Journal of Andrology  2012;14(2):204-221.
Prostate cancer (PCa) is the most common visceral malignancy in men with androgen deprivation therapy (ADT) the preferred therapy to suppress testosterone production and hence tumor growth. Despite its effectiveness in lowering testosterone, ADT is associated with side effects including loss of muscle mass, diminished muscle strength, decrements in physical performance, earlier fatigue and declining quality of life. This review reports a survey of the literature with a focus on changes in muscle strength, physical function and body composition, due to short-term and long-term ADT. Studies in these areas are sparse, especially well-controlled, prospective randomized trials. Cross-sectional and longitudinal data (up to 2 years) for men with PCa treated with ADT as well as patients with PCa not receiving ADT and age-matched healthy men are presented when available. Based on limited longitudinal data, the adverse effects of ADT on muscle function, physical performance and body composition occur shortly after the onset of ADT and tend to persist and worsen over time. Exercise training is a safe and effective intervention for mitigating these changes and initial guidelines for exercise program design for men with PCa have been published by the American College of Sports Medicine. Disparities in study duration, types of studies and other patient-specific variables such as time since diagnosis, cancer stage and comorbidities may all affect an understanding of the influence of ADT on health, physical performance and mortality.
PMCID: PMC3735097  PMID: 22367184
androgen deprivation therapy; androgen suppression; exercise prescription; exercise training; functional assessment; lean body mass; older men; prostate cancer
6.  Scaling functional status within the interRAI suite of assessment instruments 
BMC Geriatrics  2013;13:128.
As one ages, physical, cognitive, and clinical problems accumulate and the pattern of loss follows a distinct progression. The first areas requiring outside support are the Instrumental Activities of Daily Living and over time there is a need for support in performing the Activities of Daily Living. Two new functional hierarchies are presented, an IADL hierarchical capacity scale and a combination scale integrating both IADL and ADL hierarchies.
A secondary analyses of data from a cross-national sample of community residing persons was conducted using 762,023 interRAI assessments. The development of the new IADL Hierarchy and a new IADL-ADL combined scale proceeded through a series of interrelated steps first examining individual IADL and ADL item scores among persons receiving home care and those living independently without services. A factor analysis demonstrated the overall continuity across the IADL-ADL continuum. Evidence of the validity of the scales was explored with associative analyses of factors such as a cross-country distributional analysis for persons in home care programs, a count of functional problems across the categories of the hierarchy, an assessment of the hours of informal and formal care received each week by persons in the different categories of the hierarchy, and finally, evaluation of the relationship between cognitive status and the hierarchical IADL-ADL assignments.
Using items from interRAI’s suite of assessment instruments, two new functional scales were developed, the interRAI IADL Hierarchy Scale and the interRAI IADL-ADL Functional Hierarchy Scale. The IADL Hierarchy Scale consisted of 5 items, meal preparation, housework, shopping, finances and medications. The interRAI IADL-ADL Functional Hierarchy Scale was created through an amalgamation of the ADL Hierarchy (developed previously) and IADL Hierarchy Scales. These scales cover the spectrum of IADL and ADL challenges faced by persons in the community.
An integrated IADL and ADL functional assessment tool is valuable. The loss in these areas follows a general hierarchical pattern and with the interRAI IADL-ADL Functional Hierarchy Scale, this progression can be reliably and validly assessed. Used across settings within the health continuum, it allows for monitoring of individuals from relative independence through episodes of care.
PMCID: PMC3840685  PMID: 24261417
7.  Activity Restriction Induced by Fear of Falling and Objective and Subjective Measures of Physical Function: A Prospective Cohort Study 
To examine whether activity restriction specifically induced by fear of falling (FF) contributes to greater risk of disability and decline in physical function.
Prospective cohort study.
Population-based older cohort.
Six hundred seventy-three community-living elderly (≥65) participants in the Invecchiare in Chianti Study who reported FF.
FF, fear-induced activity restriction, cognition, depressive symptoms, comorbidities, smoking history, and demographic factors were assessed at baseline. Disability in activities of daily living (ADLs) and instrumental activities of daily living (IADLs) and performance on the Short Performance Physical Battery (SPPB) were evaluated at baseline and at the 3-year follow-up.
One-quarter (25.5%) of participants did not report any activity restriction, 59.6% reported moderate activity restriction (restriction or avoidance of <3 activities), and 14.9% reported severe activity restriction (restriction or avoidance of ≥3 activities). The severe restriction group reported significantly higher IADL disability and worse SPPB scores than the no restriction and moderate restriction groups. Severe activity restriction was a significant independent predictor of worsening ADL disability and accelerated decline in lower extremity performance on SPPB over the 3-year follow-up. Severe and moderate activity restriction were independent predictors of worsening IADL disability. Results were consistent even after adjusting for multiple potential confounders.
In an elderly population, activity restriction associated with FF is an independent predictor of decline in physical function. Future intervention studies in geriatric preventive care should directly address risk factors associated with FF and activity restriction to substantiate long-term effects on physical abilities and autonomy of older persons.
PMCID: PMC2645621  PMID: 18312314
fear of falling; activity restriction; aging; disability; physical function
8.  Efficacy and safety of haloperidol prophylaxis for delirium prevention in older medical and surgical at-risk patients acutely admitted to hospital through the emergency department: study protocol of a multicenter, randomised, double-blind, placebo-controlled clinical trial 
BMC Geriatrics  2014;14:96.
Delirium is associated with substantial morbidity and mortality rates in elderly hospitalised patients, and a growing problem due to increase in life expectancy. Implementation of standardised non-pharmacological delirium prevention strategies is challenging and adherence remains low. Pharmacological delirium prevention with haloperidol, currently the drug of choice for delirium, seems promising. However, the generalisability of randomised controlled trial results is questionable since studies have only been performed in selected postoperative hip-surgery and intensive care unit patient populations. We therefore present the design of the multicenter, randomised, double-blind, placebo-controlled clinical trial on early pharmacological intervention to prevent delirium: haloperidol prophylaxis in older emergency department patients (The HARPOON study).
In six Dutch hospitals, at-risk patients aged 70 years or older acutely admitted through the emergency department for general medicine and surgical specialties are randomised (n = 390) for treatment with prophylactic haloperidol 1 mg or placebo twice daily for a maximum of seven consecutive days. Primary outcome measure is the incidence of in-hospital delirium within seven days of start of the study intervention, diagnosed with the Confusion Assessment Method, and the Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria for delirium. Secondary outcome measures include delirium severity and duration assessed with the Delirium Rating Scale Revised 98; number of delirium-free days; adverse events; hospital length-of-stay; all-cause mortality; new institutionalisation; (Instrumental) Activities of Daily Living assessed with the Katz Index of ADL, and Lawton IADL scale; cognitive function assessed with the Six-item Cognitive Impairment Test, and the Dutch short form Informant Questionnaire on Cognitive Decline in the Elderly. Patients will be contacted by telephone three and six months post-discharge to collect data on cognitive- and physical function, home residency, all-cause hospital admissions, and all-cause mortality.
The HARPOON study will provide relevant information on the efficacy and safety of prophylactic haloperidol treatment for in-hospital delirium and its effects on relevant clinical outcomes in elderly at-risk medical and surgical patients.
Trial registration
EudraCT Number: 201100476215; Identifier: NCT01530308; Dutch Clinical Trial Registry: NTR3207
PMCID: PMC4161272  PMID: 25168927
Haloperidol; Delirium; Prophylactic treatment; Older patients
9.  Efficacy of walking exercise in promoting cognitive-psychosocial functions in men with prostate cancer receiving androgen deprivation therapy 
BMC Cancer  2012;12:324.
Prostate cancer is the most commonly diagnosed non-melanoma cancer among men. Androgen deprivation therapy (ADT) has been the core therapy for men with advanced prostate cancer. It is only in recent years that clinicians began to recognize the cognitive-psychosocial side effects from ADT, which significantly compromise the quality of life of prostate cancer survivors. The objectives of the study are to determine the efficacy of a simple and accessible home-based, walking exercise program in promoting cognitive and psychosocial functions of men with prostate cancer receiving ADT.
A 6-month prospective, single-blinded, randomized controlled trial will be conducted to compare the Exercise Group with the Control Group. Twenty men with prostate cancer starting ADT will be recruited and randomly assigned to one of the two groups: the Exercise Group will receive instructions in setting up an individualized 6-month home-based, walking exercise program, while the Control Group will receive standard medical advice from the attending physician. The primary outcomes will be psychosocial and cognitive functions. Cognitive functions including memory, attention, working memory, and executive function will be assessed using a battery of neurocognitive tests at baseline and 6 months. Psychosocial functions including depression, anxiety and self-esteem will be assessed at baseline, 3 and 6 months using the Center for Epidemiological Studies Depression Scale, Spielberger State-Trait Anxiety Inventory, and Rosenberg Self-Esteem Scale.
The significance of the cognitive-psychosocial side effects of ADT in men with prostate cancer has only been recently recognized, and the management remains unclear. This study addresses this issue by designing a simple and accessible home-based, exercise program that may potentially have significant impact on reducing the cognitive and psychosocial side effects of ADT, and ultimately improving the health-related quality of life in men with prostate cancer receiving ADT.
Trial registration
PMCID: PMC3517385  PMID: 22846379
Prostate cancer; Androgen deprivation therapy; Walking; Home-based exercise; Cognitive function; Psychosocial function
10.  Factors associated with functional incapacity in elders living in long stay institutions in Brazil: a cross-sectional study 
BMC Geriatrics  2014;14:47.
The increase of the elderly population and the high prevalence of chronic diseases have contributed to the increasing importance of functional ability as a global public health problem. This study aimed to assess functional capacity in institutionalized elders, as well as undertake an exploratory analysis of its associated factors.
This is a cross-sectional study with institutionalized Brazilian elders. Functional capacity was assessed using the Katz Index for Activities of Daily Living (ADL) and the Lawton Scale for Instrumental Activities of Daily Living (IADL). The characteristics of dependent individuals were described and logistic regression models were developed for both scales. Multiple models that included all selected variables were developed using a hierarchical approach. We considered the results from the Wald test (p < 0.05) as a rule for progressing to the next level.
A population of 760 elders was considered. The prevalence of dependence was 50.3% for ADL and 81.2% for IADL. We observed associations between ADL dependence and the following factors: self-report of stroke, difficulty of walking 400 meters, lower total scores in questions related to the temporal orientation section of the cognition test, and self-reports of frequently feeling upset. IADL dependence was associated with educational level, self-report of cancer, difficulty of walking 400 meters, use of glasses, and self-reported memory problems.
Sociodemographic and health conditions were associated with functional incapacity in institutionalized elders. Based on these findings, we emphasize the importance of both prevention and treatment of chronic conditions as well as social support in the maintenance of individuals’ autonomy.
PMCID: PMC3991891  PMID: 24731189
Functional dependency; Prevalence; Determinants; Elders; Long-stay institutions for elders
11.  Contemporary Role of Androgen Deprivation Therapy for Prostate Cancer 
European urology  2011;61(1):11-25.
Androgen deprivation therapy (ADT) for prostate cancer (PCa) represents one of the most effective systemic palliative treatments known for solid tumors. Although clinical trials have assessed the role of ADT in patients with metastatic and advanced locoregional disease, the risk–benefit ratio, especially in earlier stages, remains poorly defined. Given the mounting evidence for potentially life-threatening adverse effects with short- and long-term ADT, it is important to redefine the role of ADT for this disease.
Review the published experience with currently available ADT approaches in various contemporary clinical settings of PCa and reported serious treatment-related adverse events. This review addresses the level of evidence associated with the use of ADT in PCa, focusing upon survival outcome measures. Furthermore, this paper discusses evolving approaches targeting androgen receptor signaling pathways and emerging evidence from clinical trials with newer compounds.
Evidence acquisition
A comprehensive review of the literature was performed, focusing on data from the last 10 yr (January 2000 to July 2011) and using the terms androgen deprivation, hormone treatment, prostate cancer and adverse effects. Abstracts from trials reported at international conferences held in 2010 and 2011 were also evaluated.
Evidence synthesis
Data from randomized controlled trials and population-based studies were analyzed in different clinical paradigms. Specifically, the role of ADT was evaluated in patients with nonmetastatic disease as the primary and sole treatment, in combination with radiation therapy (RT) or after surgery, and in patients with metastatic disease. The data suggest that in men with nonmetastatic disease, the use of primary ADT as monotherapy has not shown a benefit and is not recommended, while ADT combined with conventional-dose RT (<72 Gy) for patients with high-risk disease may delay progression and prolong survival. The postoperative use of ADT remains poorly evaluated in prospective studies. Likewise, there are no trials evaluating the role of ADT in patients with biochemical relapses after surgery or RT. In patients with metastatic disease, there is a clear benefit in terms of quality of life, reduction of disease-associated morbidity, and possibly survival. Treatment with bilateral orchiectomy, luteinizing hormone–releasing hormone agonist therapy, with and without antiandrogens has been associated with various serious adverse events, including cardiovascular disease, diabetes, and skeletal complications that may also affect mortality.
Although ADT is an effective treatment of PCa, consistent long-term benefits in terms of quality and quantity of life are predominantly evident in patients with advanced/metastatic disease or when ADT is used in combination with RT (<72 Gy) in patients with high-risk tumors. Implementation of ADT should be evidence based, with special consideration to adverse events and the risk–benefit ratio.
PMCID: PMC3483081  PMID: 21871711
Prostate cancer; Androgen deprivation; Hormone treatment; Adverse effects
12.  Management of complications of androgen deprivation therapy in the older man☆ 
Prostate cancer is the most common malignancy in older men. With the aging of the population, the number of older men with prostate cancer will grow rapidly. Androgen deprivation therapy (ADT) is the mainstay of treatment for men with systemic disease and is increasingly utilized as primary therapy or in combination with other therapies for localized disease. Side effects of therapy are multifold and include hot flashes, osteoporosis, and adverse psychological and metabolic effects. Recent research has illustrated that ADT can negatively impact the functional, cognitive, and physical performance of older men. Patients with prostate cancer, despite recurrence of the disease, have a long life expectancy and may be subjected to the side effects of ADT for many years. This review highlights the complications of ADT and approaches to management. We also provide recommendations for assessment and management of ADT complications among the most vulnerable and frail older male patients.
PMCID: PMC3074615  PMID: 18952456
Disability; Geriatric assessment; Prostate cancer; Vulnerable elders; Functional impairment; Androgen deprivation; Quality of life; Complications
13.  The relation between age and androgen deprivation therapy use among men in the Medicare population receiving radiation therapy for prostate cancer 
Neoadjuvant and concurrent androgen deprivation therapy (ncADT) is recommended for men with high-risk prostate cancer, but not low-risk cancer or short life expectancy. It is unclear whether the use of ncADT among older men in the community setting is aligned with the potential for clinical benefit.
Materials and methods
We used the Surveillance, Epidemiology, and End Results-Medicare database to assess patterns of ncADT use among men diagnosed with prostate cancer during 2004–2007 who received radiation therapy. Men were stratified according to tumor risk groups and life expectancy. We used logistic regression to identify factors associated with ncADT use within each risk group.
There were 10,686 men in the sample (mean age 74.2 years; 83.4% white). The use of ncADT was 80.7%, 54.1%, and 27.8% in the high-, intermediate-, and low-risk groups, respectively. Men with life expectancy <5 years had higher rates of ncADT use than men with life expectancy ≥10 years in all risk groups. Within each risk group, advancing age was associated with higher likelihood of receiving of ncADT (odds ratio for men aged 80–84 compared to 67–69 = 1.93 (95% CI 1.37–2.70); 1.51 (95% CI 1.22–1.87); and 1.71 (95% CI 1.14–2.57) for high-, intermediate-, and low-risk groups, respectively).
ncADT use is not consistent with guideline recommendations and is more frequent among men who are older, have shorter life expectancy, and are less likely to benefit from therapy.
PMCID: PMC3591488  PMID: 23482846
Prostate cancer; androgen deprivation therapy; elderly; life expectancy; guidelines
14.  Life-Space Mobility Among Mexican Americans Aged 75 Years and Older 
To examine the factors associated with life-space mobility in older Mexican Americans.
Cross-sectional study involving a population-based survey.
Hispanic Established Population for the Epidemiologic Study of the Elderly survey conducted in the southwestern of United States (Texas, Colorado, Arizona, New Mexico, and California).
728 Mexican American men and women aged 75 years and older.
In-home interviews assessed socio-demographic factors, self-reported physician-diagnoses of medical conditions (arthritis, diabetes, heart attack, stroke, hip fracture, and cancer), depressive symptoms, cognitive function, body mass index (BMI), upper and lower extremity muscle strength, short physical performance battery (SPPB), activities of daily living (ADLs), instrumental activities of daily living (IADLs), and the life-space assessment (LSA).
Mean age of participants was 84.2 years (SD, 4.2). Sixty-five percent were female. Mean score of LSA was 41.7 (SD, 20.9). Multiple regression analysis showed that older age, being female, limitation in ADLs, stroke, high depressive symptoms and BMI ≥35 kg/m2 were significantly associated with lower scores in LSA. Education and high performances in lower extremity function and in muscle strength were factors significantly associated with higher scores in LSA.
Older Mexican Americans had restricted life-space with approximately 80% limited to their home or neighborhood. Age, gender, stroke, high depressive symptoms, BMI ≥ 35 Kg/m2, and ADL disability were related to decreased life-space. Future studies are needed to examine the association between life-space and health outcomes and to characterize the trajectory of life-space over time in this population.
PMCID: PMC3996837  PMID: 22283683
mobility; life-space; older adults; Mexican American
15.  Impact of thyroid status and age on comprehensive geriatric assessment 
Endocrine  2013;47(1):255-265.
This study aimed to evaluate the prevalence of thyroid dysfunction in elderly subjects attending an outpatient clinic at a tertiary hospital and to assess whether subclinical hypothyroidism (SCH) or aging affected activities of daily living (ADLs), instrumental activities of daily living (IADLs), cognitive status, or depressive symptoms. This crosssectional study included 411 patients recruited in the outpatient geriatric setting. 48 subjects reported levothyroxine use and were evaluated separately. After excluding subjects with diseases or drugs which could influence thyroid status, the 284 subjects remaining were classified as having euthyroidism (n = 235, 82.8 %), subclinical hypothyroidism (n = 43, 15.1 %), subclinical hyperthyroidism (n = 4, 1.4 %), or overt hyperthyroidism (n = 2, 0.7 %). ADLs and IADLs were assessed using the Katz Index (ranging from 0 [independence] to 6 [dependence in all activities]) and Health Assessment Questionnaire (ranging from 0 to 3 [severely disabled]), respectively. Cognition was assessed using the mini mental state depressive symptoms that were assessed using the Geriatric depression scale or cornell scale for depression in dementia. SCH did not reduce performance in ADLs or IADLs in elderly subjects as a whole, but was an independent protective factor against dependence in ADLs (OR = 0.196 [0.045–0.853]; p = 0.003) and IADLs (OR = 0.060 [0.010–0.361]; p = 0.002) in subjects aged ≥85 years. Very old subjects with SCH showed better performance in ADLs than did those with euthyroidism (Katz Index: 0.9 ± 1.6 [median: 0.5] vs. 1.7 ± 1.7 [1.0], p = 0.024; HAQ: 1.2 ± 0.8 [0.9] vs. 1.8 ± 1.0 [1.9], p = 0.015). This putative protective effect of SCH was not found in subjects aged <85 years. The number of falls, number of medications used, depressive symptoms, and cognitive impairment did not differ among thyroid status groups, regardless of age. In conclusion, SCH does not have impact functional performance in the elderly population as a whole, but was associated with better functional status in subjects aged ≥85 years.
PMCID: PMC4145217  PMID: 24178891
Activities of daily living; Thyroid function; Subclinical hypothyroidism; Katz Index; HAQ
16.  Patterns of Bone Mineral Density Testing in Men Receiving Androgen Deprivation for Prostate Cancer 
Journal of General Internal Medicine  2013;28(11):1440-1446.
Practice guidelines recommend bone mineral density (BMD) monitoring for men on androgen deprivation therapy (ADT) for prostate cancer, but single center studies suggest this is underutilized.
We examined determinants of BMD testing in men receiving ADT in a large population-based cohort of men with prostate cancer.
Retrospective cohort study.
We used the Surveillance, Epidemiology and End-Results (SEER)-Medicare database to identify 84,036 men with prostate cancer initiating ADT from 1996 through 2008.
Rates of BMD testing within the period 12 months prior to 3 months after initiation of ADT were assessed and compared to matched controls without cancer and to men with prostate cancer not receiving ADT. A logistic regression model was performed predicting use of BMD testing, adjusted for patient demographics, indications for ADT use, year of diagnosis and specialty of the physician involved in the care of the patient.
Rates of BMD testing increased steadily over time in men receiving ADT, diverging from the control groups such that by 2008, 11.5 % of men were receiving BMD testing versus 4.4 % in men with prostate cancer not on ADT and 3.8 % in the non-cancer controls. In the logistic regression model, year of diagnosis, race/ethnicity, indications for ADT use and geographic region were significant predictors of BMD testing. Patients with only a urologist involved in their care were significantly less likely to receive BMD testing as compared to those with both a urologist and a primary care physician (PCP) (odds ratio 0.71, 95 % confidence interval 0.64–0.80).
There has been a sharp increase in rates of BMD testing among men receiving ADT for prostate cancer over time, beyond rates noted in contemporaneous controls. Absolute rates of BMD testing remain low, however, but are higher in men who have a PCP involved in their care.
PMCID: PMC3797344  PMID: 23670565
prostate cancer; osteoporosis; androgen deprivation therapy; bone mineral density
17.  Effects of comorbidities and functional living activities on survival in geriatric breast cancer patients 
Contemporary Oncology  2014;18(3):204-210.
Aim of the study
We evaluated the possible effects of comorbid diseases and functional capacity on the survival of elderly female patients with breast cancer.
Material and methods
The study included 159 breast cancer patients aged 65 years or older. Functional status of the patients was evaluated using Katz's index of activities of daily living (ADL) and Lawton and Brody's Instrumental ADL (IADL) scale.
ADL-based evaluation revealed 121 patients (76.1%) were independent, 34 (21.4%) semi-dependent and 4 (2.5%) dependent whereas IADL-based evaluation showed 69 patients (43.4%) were independent, 67 patients (42.1%) semi-dependent and 23 patients (14.5%) dependent. Among the patients, 69 (43.4%) had one comorbid disease, 62 (39.0%) had two and 26 (16.4%) had three or more. Of the entire cohort, 60.4% received adjuvant chemotherapy. Based on ADL index, overall survival (OS) was significantly better in semi-dependent and independent patients than in dependent patients (p = 0.001). In the upfront non-metastatic patient subgroup, disease-free survival (DFS) was favourable in the independent patients according to ADL index (p = 0.001). Having more than one comorbid disease had an unfavourable effect on OS. In the multiple regression analysis of non-metastatic patients, stage, triple-negative histology and ADL index remained significant in terms of OS (p = 0.008, HR: 3.17, CI: 1.35–7.44; p = 0.027, HR: 2.78, CI: 1.172–6.91; and p = 0.006, HR: 0.29, CI: 0.12–0.70, respectively).
In elderly patients with breast cancer, evaluation of daily living activities and comorbid diseases are as important as staging and subclassification of breast cancer in the determination of prognosis and survival.
PMCID: PMC4268993  PMID: 25520582
geriatric; breast; cancer
18.  Bone Density Testing Among Prostate Cancer Survivors Treated with Androgen Deprivation Therapy 
Cancer  2012;119(4):863-870.
Androgen deprivation therapy (ADT) causes bone loss and fractures. Guidelines recommend bone density testing before and during ADT to characterize fracture risk. We assessed bone density testing among men receiving ADT for at least 1 year.
Materials and Methods
Using Surveillance, Epidemiology, and End Results-Medicare data, we identified 28,960 men aged >65 with local/regional prostate cancer diagnosed during 2001–2007 and followed through 2009 who received ≥1 year of continuous ADT. We documented bone density testing in the 18-month period beginning 6 months before ADT initiation. We used logistic regression to identify factors associated with bone density testing.
Among men receiving ≥1 year of ADT, 10.2% had a bone density assessment from 6 months before starting ADT through 1 year after. Bone density testing increased over time (14.5% of men initiating ADT in 2007–2009 vs 6.0% in 2001–2002, OR=2.29, 95% CI=1.83–2.85). Less bone density testing was observed for men aged ≥85 (vs. 66–69, OR=0.76, 95% CI=0.65–0.89), black vs. white men (OR=0.72, 95% CI=0.61–0.86), and men in areas with lower educational attainment (P<.001). Men seeing a medical oncologist and/or a primary care provider in addition to a urologist had higher odds of testing than men seeing only a urologist (P<.001).
Few men receiving ADT for prostate cancer undergo bone density testing, particularly older men, black men, and those living in areas with low educational attainment. Visits with a medical oncologist were associated with increased odds of testing. Interventions are needed to increase bone density testing among men receiving long-term ADT.
PMCID: PMC3671351  PMID: 23065626
prostate cancer; caner survivorship; male osteoporosis; androgen deprivation therapy; side effects of treatment
19.  Fatigue in a Representative Population of Older Persons and Its Association With Functional Impairment, Functional Limitation, and Disability 
Older persons often complain of fatigue, but the functional consequences of this symptom are unclear. The aim of the present study was to evaluate fatigue and its association with measures of physical function and disability in a representative sample of the older population.
Cross-sectional data from a population-based sample of 1,055 Italian men and women aged 65 and older were analyzed. Fatigue was defined according to two questions evaluating whether participants felt that “everything was an effort” and/or they “could not get going” on three or more days in the past week. Objective measures of physical function were handgrip strength, the Short Physical Performance Battery (SPPB), and 400-m walking speed. Disability was defined as the inability to complete the 400-m walk test and self-reported difficulty in activities of daily living (ADL) and instrumental activities of daily living (IADL).
The prevalence of fatigue was higher in women (29%) than in men (15%). In age-adjusted analyses, fatigued men and women had weaker handgrip strength, lower SPPB score, slower walking speed, and higher mobility, ADL, and IADL disability than nonfatigued persons. Further adjustment for health behaviors, diseases, inflammatory markers, and thyroid function generally reduced the relationship between fatigue and functional outcomes, but fatigue remained significantly associated with SPPB score, walking speed, and mobility and IADL disability.
Older persons who report fatigue had significantly poorer functional status than those who did not report this symptom. The causal link between fatigue and these outcomes should be further investigated.
PMCID: PMC2691190  PMID: 19176328
Fatigue; Aging; Disability; Physical function
20.  Factors related to functional prognosis in elderly patients after accidental hip fractures: a prospective cohort study 
BMC Geriatrics  2014;14(1):124.
A restriction in functional capacity occurs in all hip fractures and a variety of factors have been shown to influence patient functional outcome. This study sought to provide new and comprehensive insights into the role of factors influencing functional recovery six months after an accidental hip fracture.
A prospective cohort study was conducted of patients aged 65 years or more who attended the Emergency Room (ER) for a hip fracture due to a fall. The following were studied as independent factors: socio-demographic data (age, sex, instruction level, living condition, received help), comorbidities, characteristics of the fracture, treatment performed, destination at discharge, health-related quality of life (12-Item Short Form Health Survey) and hip function (Short Western Ontario and McMaster Universities Osteoarthritis Index). As main outcome functional status was measured (Barthel Index and Lawton Instrumental Activities of Daily Living Scale). Data were collected during the first week after fracture occurrence and after 6 months of follow-up. Patients were considered to have deteriorated if there was worsening in their functional status as measured by Barthel Index and Lawton IADL scores. Factors associated with the outcome were studied via logistic regression analysis.
Six months after the fall, deterioration in function was notable, with mean reductions of 23.7 (25.2) and 1.6 (2.2) in the Barthel Index and Lawton IADL Scale scores respectively. Patients whose status deteriorated were older, had a higher degree of comorbidity and were less educated than those who remained stable or improved. The multivariate model assessing the simultaneous impact of various factors on the functional prognosis showed that older patients, living with a relative or receiving some kind of social support and those with limited hip function before the fall had the highest odds of having losses in function.
In our setting, the functional prognosis of patients is determined by clinical and social factors, already present before the occurrence of the fracture. This could make it necessary to perform comprehensive assessments for patients with hip fractures in order to identify those with a poor functional prognosis to tackle their specific needs and improve their recovery.
PMCID: PMC4280690  PMID: 25425462
Hip fractures; Elderly; Cohort study
21.  Exploring the aggregation of four functional measures in a population of older adults with joint pain and comorbidity 
BMC Geriatrics  2013;13:119.
In clinical settings, it is important for health care providers to measure different aspects of functioning in older adults with joint pain and comorbidity. Besides the use of distinct measures, it could also be attractive to have one general measure of functioning that incorporates several distinct measures, but provides one summary score to quantify overall level of functioning, for example for the identification of older adults at risk of poor functional outcome. Therefore, we selected four measures of functioning: Physical Functioning (PF), Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL) and participation, and tested the possibility to aggregate these measures into one general measure of functioning.
A prospective cohort study of older adults (≥65 years) with joint pain and comorbidity provided baseline data (n = 407) consisting of PF (PF subscale, RAND-36; 10 items), ADL (KATZ index; 6 items), IADL (Lawton index; 7 items) and participation (KAP; 6 items). We tested two models with confirmatory factor analysis: first, a bifactor model with all four measures and second, a bifactor model with PF, ADL and IADL and a correlated but distinct subgroup factor for participation. Several model fit indexes and reliability coefficients, such as explained common variance (ECV) and omegas were computed for both models.
The first model fitted the data well, but the reliability analysis indicated multidimensionality and unique information in the subgroup factor participation. The second model showed similar model fits, but better reliability; ECV = 0.67, omega-t = 0.94, low omega-s = 0.18-0.22 on the subgroup factors and high omega of 0.82 on participation, which all were in favour of the second model.
The results indicate that PF, ADL and IADL could be aggregated into one general measure of functioning, whereas participation should be considered as a distinct measure.
PMCID: PMC3827990  PMID: 24192234
Bifactor model; Functioning; ICF model; Older adults; Pain
22.  Do attitudes toward exercise vary with differences in mobility and disability status? – a study among low-income seniors 
Disability and rehabilitation  2007;29(15):1215-1220.
To examine attitudes toward exercise among a vulnerable aged population characterized by low socioeconomic status, poor functional status and lack, of available therapeutic exercise resources.
This cross-sectional survey among public low-income housing residents (n = 94), aged > 70 years utilizes these assessments: Physician-based Assessment & Counseling for Exercise (PACE) scale, exercise self-efficacy score, Short Physical Performance Battery (SPPB), Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL.) scales.
Readiness to exercise differed significantly (p < 0.001) across physical performance levels and ADL and IADL groups. Exercise self-efficacy also differed significantly (p < 0.001) across performance levels. The highest performance level (score 7–12) had a significantly (p < 0.05) higher Self-efficacy score (x̄ = 7.0 ± 2.8) than the medium performance level (score 4–6) (x̄ = 5.3±2.8) and the lowest performance level (0–3) (x̄= 4.3 ±: 2.5) groups. Exercise self-efficacy also differed significantly (p < 0.001) across ADL and IADL groups, However, interest in home-based or class-based exercise participation was high among all groups. More than 70% of subjects reported interest with no significant difference noted among groups.
Attitudes toward exercise are significantly associated with observed physical function and self-reported disability among vulnerable older adults living in public low-income housing.
PMCID: PMC2577306  PMID: 17653995
Aging; activities of daily living; disability; exercise; attitudes; mobility; self-efficacy; health promotion
23.  Fall predictors in older cancer patients: a multicenter prospective study 
BMC Geriatrics  2014;14:135.
In the older population falls are a common problem and a major cause of morbidity, mortality and functional decline. The etiology is often multifactorial making the identification of fall predictors essential for preventive measures. Despite this knowledge, data on falls within the older cancer population are limited. The objective of this study was to evaluate the occurrence of falls within 2 to 3 months after cancer treatment decision and to identify predictors of falls (≥1 fall) during follow-up.
Older patients (70 years or more) with a cancer treatment decision were included. At baseline, all patients underwent geriatric screening (G8 and Flemish Triage Risk Screening Tool), followed by a geriatric assessment including living situation, activities of daily living (ADL), instrumental activities of daily living (IADL), fall history in the past 12 months, fatigue, cognition, depression, nutrition, comorbidities and polypharmacy. Questionnaires were used to collect follow-up (2–3 months) data. Univariate and multivariate analyses were performed to identify predictors for falls (≥1 fall) during follow-up.
At baseline, 295 (31.5%) of 937 included patients reported at least one fall in the past 12 months with 88 patients (29.5%) sustaining a major injury. During follow-up (2–3 months), 142 (17.6%) patients fell, of whom 51.4% fell recurrently and 17.6% reported a major injury. Baseline fall history in the past 12 months (OR = 3.926), fatigue (OR = 0.380), ADL dependency (OR = 0.492), geriatric risk profile by G8 (OR = 0.471) and living alone (OR = 1.631) were independent predictors of falls (≥1 fall) within 2–3 months after cancer treatment decision.
Falls are a serious problem among older cancer patients. Geriatric screening and assessment data can identify patients at risk for a fall. A patient with risk factors associated with falls should undergo further evaluation and intervention to prevent potentially injurious fall incidents.
PMCID: PMC4320446  PMID: 25511244
Older persons; Cancer; Falls; Geriatric assessment
24.  Effects of Androgen Deprivation on Cerebral Morphometry in Prostate Cancer Patients – An Exploratory Study 
PLoS ONE  2013;8(8):e72032.
Androgen deprivation therapy (ADT) is a common treatment for non-metastatic, low-risk prostate cancer, but a potential side effect of ADT is impaired brain functioning. Previous work with functional magnetic resonance imaging (MRI) demonstrated altered prefrontal cortical activations in cognitive control, with undetectable changes in behavioral performance. Given the utility of brain imaging in identifying the potentially deleterious effects of ADT on brain functions, the current study examined the effects of ADT on cerebral structures using high resolution MRI and voxel-based morphometry (VBM).
High resolution T1 weighted image of the whole brain were acquired at baseline and six months after ADT for 12 prostate cancer patients and 12 demographically matched non-exposed control participants imaged at the same time points. Brain images were segmented into gray matter, white matter and cerebral ventricles using the VBM toolbox as implemented in Statistical Parametric Mapping 8.
Compared to baseline scan, prostate cancer patients undergoing ADT showed decreased gray matter volume in frontopolar cortex, dorsolateral prefrontal cortex and primary motor cortex, whereas the non-exposed control participants did not show such changes. In addition, the decrease in gray matter volume of the primary motor cortex showed a significant correlation with longer reaction time to target detection in a working memory task.
ADT can affect cerebral gray matter volumes in prostate cancer patients. If replicated, these results may facilitate future studies of cognitive function and quality of life in men receiving ADT, and can also help clinicians weigh the benefits and risks of hormonal therapy in the treatment of prostate cancer.
PMCID: PMC3747074  PMID: 23977199
25.  Utilization of bone densitometry for prediction and administration of bisphosphonates to prevent osteoporosis in patients with prostate cancer without bone metastases receiving antiandrogen therapy 
Prostate cancer subjects with prostate-specific antigen (PSA) relapse who are treated with androgen deprivation therapy (ADT) are recommended to have baseline and serial bone densitometry and receive bisphosphonates. The purpose of this community population study was to assess the utilization of bone densitometry and bisphosphonate therapy in men receiving ADT for non-metastatic prostate cancer.
A cohort study of men aged 65 years or older with non-metastatic incident diagnoses of prostate cancer was obtained from the Surveillance Epidemiology End Results (SEER)-linked Medicare claims between 2004 and 2008. Claims were used to assess prescribed treatment of ADT, bone densitometry, and bisphosphonates.
A total of 30,846 incident prostate cancer cases receiving ADT and aged 65 years or older had no bone metastases; 87.3% (n=26,935) on ADT did not receive either bone densitometry or bisphosphonate therapy. Three percent (n=931) of the cases on ADT received bisphosphonate therapy without ever receiving bone densitometry, 8.8% (n=2,702) of the cases on ADT received bone densitometry without receiving intravenous bisphosphonates, while nearly 1% (0.90%, n=278) of the cases on ADT received both bone densitometry and bisphosphonates. Analysis showed treatment differed by patient characteristics.
Contrary to the recommendations, bone densitometry and bisphosphonate therapy are underutilized in men receiving ADT for non-metastatic prostate cancer.
PMCID: PMC4284007  PMID: 25565887
prostatic neoplasms; androgen antagonists; bone densitometry; gonadotropin-releasing hormone; osteoporosis

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