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1.  Interleukin-6, C-Reactive Protein, Tumor Necrosis Factor-alpha as Predictors of Mortality in Frail, Community-Living Elderly Individuals 
Aging is characterized by a chronic low-grade inflammation that has been found to be related to mortality risk in older persons.
The aim of the present study was to investigate whether interleukin-6 (IL-6), C-reactive protein (CRP) and Tumor Necrosis Factor-alpha (TNF-α) protein levels predict all-cause mortality in a sample of older persons living in the community.
Design and Setting
Data are from the Aging and Longevity Study in the Sirente Geographic Area (ilSIRENTE Study), a prospective cohort study that collected information on individuals aged 80 years and older living in an Italian mountain community (n=362). The main outcome was the hazard ratio of death after four years of follow-up.
Participants and measurements
Participants were classified according to the median value of the 3 inflammatory markers (IL-6: 2.08 pg/mL; TNF-α: 1.43 pg/mL and CRP: 3.08 mg/L). In addition, a composite summary score of inflammation was created.
A total of 150 deaths occurred during a 4-year follow-up. In the unadjusted model, high levels of each of the 3 markers were associated with increased mortality. After adjusting for potential confounders, high levels of IL-6 and CRP were associated with a significantly increased risk of death (HR, 2.18; 95% CI 1.29–3.69 and 2.58; 95% CI 1.52–4.40, respectively); whereas the association between TNF-α protein levels and mortality lost significance (1.26; 95% CI: 0.74 to 2.15). The composite summary score of inflammation was strongly associated with mortality, with the highest risk estimated for individuals with all three inflammatory markers above the median.
Low levels of inflammatory markers are associated with better survival in elderly, independently of age and other clinical and functional variables.
PMCID: PMC4321727  PMID: 21883115
Interleukin-6; C-Reactive Protein; TNF-alpha; Mortality; Frail Elderly
2.  Burden Among Caregivers of Elders Who Were Cognitively Impaired at the Time of Hospitalization: A Cross-Sectional Analysis 
Caregiver burden is a multidimensional outcome of the chronic stress associated with care giving. We aim to describe the factors associated with burden experienced by caregivers of older adults who were cognitively impaired (i.e. dementia, delirium or both) at the time of hospitalization..
Cross sectional data analyses.
Three hospitals – one academic tertiary hospital and two associated community hospitals
495 caregivers of older adults who were cognitively impaired at the time of hospital admission.
Multivariable linear regression was performed to analyze the effect of the independent variables (caregiver: demographics, presence of depressive symptoms and self-efficacy; patient: neuropsychiatric symptoms, delirium, functional deficits) on caregiver burden.
In this cohort of caregivers, higher burden was associated with younger caregiverage (p=0.02), being a spouse (p=0.03), the presence of depressive symptoms (p<0.001), caregivers’ lower perceived self-efficacy to manage patient symptoms (p=0.002) and limited finances at the end of the month (p=0.01). Additionally, caregiver burden was strongly associated with the following patient factors: distressing neuropsychiatric symptoms (p=0.001), the presence of delirium (p=0.001) and greater functional deficits in basic activities of daily living (p=0.001).
These findings suggest that caregivers of older adults who were cognitively impaired on hospital admission experience burden. Understanding the contributing factors to burden at the time of hospitalization for caregivers of persons with CI can inform the development of interventions targeted throughout the hospitalization that have the potential to decrease burden.
PMCID: PMC3945647  PMID: 24502827
Hospitalization; Dementia; Self-Efficacy; Caregiver Burden
3.  [No title available] 
PMCID: PMC3927159  PMID: 24521364
4.  [No title available] 
PMCID: PMC3929156  PMID: 24521371
5.  [No title available] 
PMCID: PMC3945188  PMID: 24417565
6.  [No title available] 
PMCID: PMC3945231  PMID: 24428306
7.  [No title available] 
PMCID: PMC3945402  PMID: 24438515
8.  [No title available] 
PMCID: PMC3945403  PMID: 24438020
9.  [No title available] 
PMCID: PMC3945439  PMID: 24437990
10.  [No title available] 
PMCID: PMC3947865  PMID: 24417536
11.  [No title available] 
PMCID: PMC4037885  PMID: 24438554
12.  [No title available] 
PMCID: PMC4115075  PMID: 24521363
13.  Differences In Rate Of ADL Loss Between Stroke Patients And Stroke-Free Adults Emerge Years Prior To Stroke Onset 
To compare typical age-related changes in activities of daily living (ADL) independence in stroke-free adults to long-term ADL trajectories before and after stroke.
Study Design, Setting, and Participants
Prospective, observational cohort of 18,441 Health and Retirement Study participants who were stroke-free in 1998 and followed through 2008 (average follow-up=7.9 years).
Strokes were assessed with self- or proxy-report of a doctor’s diagnosis and month/year of event. We used logistic regression to compare within-person changes in odds of self-reported independence in 5 ADLs among those who remained stroke free throughout follow-up (n=16,816); those who survived a stroke (n=1,208); and those who had a stroke and did not survive to participate in another interview (n=417). Models were adjusted for demographic and socioeconomic covariates.
Even prior to stroke, those who later developed stroke had significantly lower ADL independence and were experiencing faster independence losses, compared to similar aged individuals who remained stroke free. Of those who developed a stroke, survivors experienced slower loss of ADL independence compared to those who died. ADL independence declined at the time of stroke and decline continued afterwards.
Among adults at risk of stroke, disproportionate ADL limitations emerge well before stroke onset. Excess disability among stroke survivors should not be entirely attributed to effects of acute stroke or quality of acute stroke care. Although there are many possible causal pathways between ADL and stroke, the association may alternatively be non-causal. For example, ADL limitations may be a consequence of stroke risk factors (e.g., diabetes) or early cerebrovascular ischemia.
PMCID: PMC4312665  PMID: 23668393
stroke; activities of daily living; older adults; disability; mortality; longitudinal
15.  The Johns Hopkins Delirium Consortium: One Model for Collaborating Across Disciplines and Departments for Delirium Prevention and Treatment 
Delirium is an important syndrome affecting inpatients in various hospital settings. This article focuses on multidisciplinary and interdepartmental collaboration for advancing efforts in delirium clinical care and research. One model for such collaboration is represented by the Johns Hopkins Delirium Consortium, which includes members from the disciplines of Nursing, Medicine, Rehabilitation Therapy, Psychology, and Pharmacy within the Departments/Divisions of Anesthesiology, Geriatrics, Oncology, Orthopedic Surgery, Psychiatry, Critical Care Medicine, and Physical Medicine and Rehabilitation at both the Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center. This paper describes the process involved in developing functional collaboration around delirium, and highlights projects, opportunities, and challenges resulting from them.
PMCID: PMC4305431  PMID: 22091568
Delirium care and prevention; inpatient care; interdisciplinary; collaboration
16.  Decreased Daytime Sleeping is Associated with Improved Cognition Following Hospital Discharge in Older Adults 
The longitudinal association between sleep and cognitive functioning is not well understood in late-life. Examination of the association between a potentially modifiable risk factor such as sleep, and cognitive change in at-risk older adults is of both theoretical and practical importance. We examined the relationship between changes in objectively-assessed sleep and global cognitive functioning from inpatient post-acute rehabilitation to 6-months follow-up.
Secondary analysis of two prospective, longitudinal studies.
Inpatient rehabilitation units at a VA Medical Center.
192 older patients (mean age=73.8±9.4 years) undergoing inpatient rehabilitation.
All participants completed 7 nights/days of ambulatory sleep monitoring via wrist actigraphy (yielding an estimate of nighttime wakefulness and daytime sleep) and the Mini-Mental State Examination (MMSE; global cognitive functioning) during a post-acute inpatient rehabilitation stay and 6-months following discharge. The 5-item Geriatric Depression Scale (GDS5), Geriatric Pain Measure (GPM), and Cumulative Illness Rating Scale for Geriatrics were completed during inpatient rehabilitation.
Growth curve modeling (controlling for baseline age, education, gender, BMI, depression, pain, and comorbidity burden) revealed that individuals whose amount of daytime sleep decreased from inpatient post-acute rehabilitation to 6-month follow-up also experienced improvements in MMSE (β = −0.01, t(80) = β3.22, p<0.01). Change in nighttime wakefulness was not a significant predictor of change in MMSE.
Older adults whose daytime sleeping decreased following hospital discharge also experienced improvements in cognitive functioning at 6-months follow-up. As such, daytime sleep may represent a promising candidate for targeted interventions aimed at promoting cognitive recovery following hospital discharge.
PMCID: PMC4123221  PMID: 25093233
Sleep; Cognition; Longitudinal Change; Inpatient Hospitalization; Older Adults
18.  Racial/Ethnic Differences in Obesity and Overweight as Predictors of the Onset of Functional Impairment 
To examine racial/ethnic differences in the effects of body mass index (BMI) on the onset of functional impairment over 10 years of follow-up.
Longitudinal analyses of a cohort from a nationally representative survey of community-dwelling American adults.
Six waves (1996-2006) of US Health and Retirement Study (HRS).
Two groups of HRS participants aged ≥50 without functional impairment at baseline (1996): 5,884 with no mobility difficulty, and 8,484 with no Activities of Daily Living (ADLs) difficulty.
Mobility difficulty was a composite measure of difficulty in walking several blocks, walking one block, climbing several flights of stairs, and climbing one floor of stairs. ADL difficulty was measured by difficulty in dressing, bathing or showing, eating, and getting in or out of bed without help. The association between the baseline BMI categories and risk to develop functional impairment was estimated using generalized estimating equations (GEE) models.
Overweight and obesity were significant predictors for functional impairment. Compared to the Whites in the same overweight and obese categories, Hispanics were 41% and 91% more likely to develop ADL disability. Blacks in the overweight and severely obese categories were also more likely than their White counterparts to develop ADL disability. Risk of developing ADL difficulty was higher for Hispanics than for Blacks in the obese category. For onset of mobility difficulty, no significant differences were found across racial/ethnic groups within any BMI Category.
Blacks and Hispanics were at higher risk than Whites for ADL but not mobility impairment. In addition to weight control, prevention efforts should promote exercise to reduce functional impairment, especially for Blacks and Hispanics, who are at higher risk.
PMCID: PMC4296972  PMID: 24384026
obesity; overweight; mobility difficulty; ADL difficulty; racial/ethnic difference
19.  [No title available] 
PMCID: PMC4292910  PMID: 24828925
20.  E-Learning Module on Chronic Low Back Pain in Older Adults: Evidence of Effect on Medical Student Objective Structured Clinical Examination Performance 
The Institute of Medicine has highlighted the urgent need to close undergraduate and graduate educational gaps in treating pain. Chronic low back pain (CLBP) is one of the most common pain conditions, and older adults are particularly vulnerable to potential morbidities associated with misinformed treatment. An e-learning case-based interactive module was developed at the University of Pittsburgh Center of Excellence in Pain Education, one of 12 National Institutes of Health–designated centers, to teach students important principles for evaluating and managing CLBP in older adults. A team of six experts in education, information technology, pain management, and geriatrics developed the module. Teaching focused on common errors, interactivity, and expert modeling and feedback. The module mimicked a patient encounter using a standardized patient (the older adult with CLBP) and a pain expert (the patient provider). Twenty-eight medical students were not exposed to the module (Group 1) and 27 were exposed (Group 2). Their clinical skills in evaluating CLBP were assessed using an objective structured clinical examination (OSCE). Mean scores were 62.0 ± 8.6 for Group 1 and 79.5 ± 10.4 for Group 2 (P < .001). Using an OSCE pass–fail cutoff score of 60%, 17 of 28 Group 1 students (60.7%) and 26 of 27 Group 2 students (96.3%) passed. The CLBP OSCE was one of 10 OSCE stations in which students were tested at the end of a Combined Ambulatory Medicine and Pediatrics Clerkship. There were no between-group differences in performance on eight of the other nine OSCE stations. This module significantly improved medical student clinical skills in evaluating CLBP. Additional research is needed to ascertain the effect of e-learning modules on more-advanced learners and on improving the care of older adults with CLBP.
PMCID: PMC4288568  PMID: 24833496
medical student education; older adults; low back pain; objective structured clinical examination
21.  Mild Cognitive Dysfunction Does Not Affect Diabetes Mellitus Control in Minority Elderly Adults 
To determine whether older adults with type 2 diabetes mellitus and cognitive dysfunction have poorer metabolic control of glycosylated hemoglobin, systolic blood pressure, and low-density lipoprotein cholesterol than those without cognitive dysfunction.
Prospective cohort study.
A minority cohort in New York City previously recruited for a trial of telemedicine.
Persons aged 73.0 ± 3.0 (N = 613; 69.5% female; 82.5% Hispanic, 15.5% non-Hispanic black).
Participants were classified with executive or memory dysfunction based on standardized score cutoffs (<16th percentile) for the Color Trails Test and Selective Reminding Test. Linear mixed models were used to compare repeated measures of the metabolic measures and evaluate the rates of change in individuals with and without dysfunction.
Of the 613 participants, 331 (54%) had executive dysfunction, 202 (33%) had memory dysfunction, and 96 (16%) had both. Over a median of 2 years, participants with executive or memory dysfunction did not exhibit significantly poorer metabolic control than those without executive function or memory type cognitive dysfunction.
Cognitive dysfunction in the mild range did not seem to affect diabetes mellitus control parameters in this multiethnic cohort of older adults with diabetes mellitus, although it cannot be excluded that cognitive impairment was overcome through assistance from formal or informal caregivers. It is possible that more-severe cognitive dysfunction could affect control.
PMCID: PMC4288580  PMID: 25439094
cognition; diabetes mellitus; control; elderly
22.  Associations Between Bone Mineral Density, Grip Strength, and Lead Body Burden Among Older Men 
To study the association of blood lead concentration (BPb) to bone mineral density (BMD), physical, and cognitive function in non-institutionalized community dwelling older men.
Cross sectional study.
University of Pittsburgh clinic, Pittsburgh, PA.
Non-Hispanic Caucasian men aged 65 or older (N=445) recruited as a subset of a prospective cohort Osteoporotic Fractures in Men (MrOS) study.
BPb was measured in 2007-2008. From 2007-2009 BMD (g/cm2) was measured using dual energy x-ray absorptiometry (DXA). At the same time physical performance was measured with five tests: grip strength, leg extension power, walking speed, narrow-walk pace, and chair stands. Cognitive performance was assessed using the Modified Mini-Mental State Examination and the Trail Making Test Part B. Participants were categorized into quartiles of BPb. Multivariate regression analysis was used to evaluate independent relationship between BPb, BMD, cognitive and physical function.
Mean ±sd BPb was 2.25±1.20 μg/dL (median =2 μg/dL, range 1-10). In multivariable adjusted models, men in higher BPb quartiles had lower BMD at femoral neck, and total hip (p-trend =<0.001 for both). Men with higher BPb had lower age adjusted score for grip strength (p-trend<0.001). However, this association was not significant in multivariate adjusted models (p-trend <0.148). BPb was not associated with lumbar spine BMD, cognition, leg extension power, walking speed, narrow-walk pace, and chair stands.
Environmental lead exposure may adversely affect bone health in older men. These findings support consideration of environmental exposures in age associated bone fragility.
PMCID: PMC4055501  PMID: 24383935
lead; elderly; men; bone; grip strength; cognition; physical function
23.  The Impact of Tai Chi on Cognitive Performance in Older Adults: A Systematic Review and Meta-Analysis 
Summarize and critically evaluate research on the effects of Tai Chi on cognitive function in older adults.
Systematic review with meta-analysis.
Community and residential care.
Individuals aged 60 and over (with the exception of one study) with and without cognitive impairment.
Cognitive ability using a variety of neuropsychological testing.
Twenty eligible studies with a total of 2,553 participants were identified that met inclusion criteria for the systematic review: 11 of the 20 eligible studies were randomized controlled trials (RCTs), 1 was a prospective non-randomized controlled study, 4 were prospective non-controlled observational studies, and 4 were cross-sectional studies. Overall quality of RCTs was modest, with 3 of 11 trials categorized as high risk of bias. Meta-analyses of outcomes related to executive function in RCTs of cognitively healthy adults indicated a large effect size when Tai Chi was compared to non-intervention controls (Hedge’s g=0.90; p=0.043) and moderate effect size when compared to exercise controls (Hedge’s g=0.51; p=0.003). Meta-analyses of outcomes related to global cognitive function in RCTs of cognitively impaired adults, ranging from mild cognitive impairment to dementia, showed smaller but statistically significant effects when Tai Chi was compared to both non-intervention controls (Hedge’s g=0.35; p=0.004) and other active interventions (Hedge’s g=0.30; p=0.002). Findings from non-randomized studies add further evidence that Tai Chi may positively impact these and other domains of cognitive function.
Tai Chi shows potential to enhance cognitive function in older adults, particularly in the realm of executive functioning and in those individuals without significant impairment. Larger and methodologically sound trials with longer follow-up periods are needed before more definitive conclusions can be drawn.
PMCID: PMC4055508  PMID: 24383523
Tai Chi; cognitive function; executive function; mind-body exercise
24.  Individuals with Exceptional Longevity Manifest a Delayed Association between Vitamin D Insufficiency and Cognitive Impairment 
The elderly are at increased risk for vitamin D deficiency and low vitamin D levels have been related to increased risk of cognitive dysfunction. However, this association has never been investigated in centenarians, who exhibit delayed onset of aging and age-related diseases. We aimed to define vitamin D levels and their association with cognition in subjects with exceptional longevity.
A cross-sectional study in Ashkenazi Jewish subjects (n=253) with exceptional longevity, with comparison made to NHANES III participants, age ≥70 years.
25-hydroxyvitamin D levels were measured using liquid chromatography/tandem mass spectrometry analysis. Cognitive function was assessed using the Mini-Mental State Examination (MMSE) and clock drawing test (CDT: command and copy).
Median age (IQR) of the Ashkenazi subjects was 97 years (95–104). Age-associated rise in the prevalence of vitamin D insufficiency, defined as serum vitamin D level <30ng/mL, was noted in NHANES III (p=0.001). In the Ashkenazi group with longevity, the rate of vitamin D insufficiency was comparable to the NHANES III participants, who were up to 25 years younger. In the cohort with exceptional longevity, 49% demonstrated cognitive impairment as assessed by the MMSE (median score (IQR) 9.5 (0–24) vs. 29 (18–30) in the group with impaired vs. normal cognition, p<0.001). Vitamin D insufficiency was more prevalent in those with impaired cognition, defined by the MMSE and the CDT: copy, compared to those with normal cognition (71.8% vs. 57.7%, p=0.02 and 84.6% vs. 50.6%, p=0.02, respectively). This association remained significant after multivariable adjustment in logistic regression models, for cognitive assessments made by the MMSE (OR 3.2, 95% CI 1.1–9.29, p=0.03) and by the CDT: copy (OR 8.96, 95% CI 1.08–74.69, p=0.04).
Higher vitamin D levels may be a marker of delayed aging, as they are associated with better cognitive function in people achieving exceptional longevity.
PMCID: PMC4055513  PMID: 24383816
vitamin D; exceptional longevity; cognitive function
25.  Restarting the Cycle: Incidence and Predictors of First Acute Care Use After Nursing Home Discharge 
The primary objective of this study was to describe the time to first acute-care use (e.g., emergency department use without hospitalization or rehospitalization)for older adults who discharged to home after receiving post-acute care in skilled nursing facilities (SNFs). The secondary objective was to identify predictors of patients' first acute-care use.
Retrospective cohort study using administrative claims data.
SNFs providing post-acute care in North and South Carolina (N=1,474).
A cohort of Medicare beneficiaries aged 65 years and older (N=55,980) who were hospitalized, then transferred to a SNF for post-acute care, and subsequently discharged home (January 1, 2010, to August 31, 2011).
Medicare institutional claims data (Part A and Part B) and Medicare enrollment data were used; facility-level variables were obtained from CMS Nursing Home Compare. Survival from SNF discharge to first acute-care use was explored. Cox proportional hazards regression models were used to describe patient, home care and nursing facility-level predictors.
After SNF-to-home discharge, 22.1% of older adults had an episode of acute-care use within 30 days, including 7.25% with an ED visit without hospitalization and 14.8% with a rehospitalization; 37.5 % of older adults had their first acute-care usewithin 90 days. Male gender, dual eligibility status, higher Charlson co-morbidity score, certain primary diagnoses at the index hospitalization (neoplasms and respiratory disease), and care in SNFs with for-profit ownership or fewer licensed practical nurses hours per patient day were associated with higher risk for acute-care use.
Medicare patients have a high use of acute-care services after discharge from SNFs, and several factors associated with acute-care use are potentially modifiable. Findings suggest the need for interventions to support patients as they transition from SNFs to home.
PMCID: PMC4128392  PMID: 24383890
care transitions; skilled nursing facilities; epidemiology

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