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1.  Characteristics, Treatment Practices, and In-Hospital Outcomes of Older Patients Hospitalized With Acute Myocardial Infarction 
Background/Objectives
The objectives of our study were to examine overall, and decade-long trends(1999-2009),patient characteristics, treatment practices, and hospital outcomes among patients≥65 years hospitalized for acute myocardial infarction (AMI) and describe how these factors varied in the youngest, middle, and oldest-old patients.
Design
Retrospective cohort study.
Setting
Population-based Worcester Heart Attack Study.
Measurements
We conducted analyses examining the socio-demographic and clinical characteristics, cardiac treatments, and hospital outcomesof olderpatients in 3age strata (65-74, 75-84, and ≥85 years).
Participants
The study sample consisted of 3,851 patientsaged ≥65 yearshospitalized with AMI during 6 biennial years between 1999and 2009;32% were aged 65-74 years, 43% were aged 75-84 years, and 25% were ≥85 years.
Results
Advancing age was inversely associated with receipt of evidence-based cardiac therapies. After multivariable adjustment, the odds of dying during hospitalization was1.46times higher in patients aged 75-84 years, and 1.78times higher in those aged ≥85 years, compared with those aged 65-74 years. The oldest-old patients had an approximate 25% decreased odds of a prolonged hospital stay (>3 days) compared with those aged 65-74 years. Decade-long trends in our principal study outcomes were also examined.Although the oldest-old patients hospitalized for AMIwere at the greatest risk for dying among olderpatients, we observed persistent age-related differences in hospital treatment practices.Similar results were observed after excluding patients with a DNR order in their medical records.
Conclusion
While there are persistent disparities in care and outcomes of older patients hospitalized with AMI, additional studies are needed to delineate the extent to which less aggressive care reflects patient preferences and appropriate implementation of palliative care approaches.
doi:10.1111/jgs.12941
PMCID: PMC4135447  PMID: 25116983
acute myocardial infarction; elderly; changing trends
2.  Cranberry Capsules Reducing the Incidence of What? 
doi:10.1111/jgs.12950
PMCID: PMC4135525  PMID: 25116998
urinary tract infection; antimicrobial stewardship; clinical trials
4.  Apolipoprotein E, Carbon Dioxide Vasoreactivity, and Cognition in Older Adults: Effect of Hypertension 
Objectives
To investigate the associations between the apolipoprotein E (APOE) ε4 allele, carbon dioxide (CO2) vasoreactivity, and cognitive performance and to explore the effect of CO2 vasoreactivity and hypertension on the associations between APOE and cognition.
Design
Observational.
Setting
Community.
Participants
Older adults (N=625) enrolled in the Maintenance of Balance, Independent Living, Intellect and Zest in the Elderly of Boston Study
Measurements
Change in cerebral blood flow velocity in response to CO2 challenge (CO2 vasoreactivity) measured using transcranial Doppler ultrasonography, Trail-Making Test Part B – A (TMT), Hopkins Verbal Learning Test delayed recall (HVLT).
Results
APOE-ε4 was associated with lower CO2 vasoreactivity (p=.009) and poorer performance on the TMT (p<.001) and HVLT (p<.001). Having hypertension and APOE-ε4 was associated with worse cognitive and CO2 vasoreactivity measures than having neither or either alone (p<.001 for TMT and HVLT, p=.01 for CO2 vasoreactivity). The association between APOE-ε4 and cognition was only significant if it was present concurrent with low CO2 vasoreactivity, defined as below the median of the sample (APOE by CO2 vasoreactivity: p=.04 for TMT, p=.04 for HVLT). In hypertension, the association between APOE-ε4 and executive function was also only significant in participants with lower CO2 vasoreactivity (p=.005 for APOE by CO2 vasoreactivity)
Conclusion
Individuals at risk of Alzheimer’s disease (AD) because they have APOE-ε4 may have lower CO2 vasoreactivity, which in turn may be contributing to the observed lower cognitive performance associated with this allele. The cognitive effect of APOE-ε4 are magnified in hypertension and low CO2 vasoreactivity. This study offers evidence that APOE-ε4 may be associated with microvascular brain injury even in the absence of clinical AD.
doi:10.1111/jgs.13235
PMCID: PMC4375955  PMID: 25688603
hypertension; apolipoprotein E; cognition; CO2 vasoreactivity
5.  Polypharmacy and Potentially Inappropriate Medication Use among Older Adults with Cancer Undergoing Chemotherapy: Impact on Chemotherapy-Related Toxicity and Hospitalization During Treatment 
Polypharmacy and potentially inappropriate medication (PIM) use are understudied among older adults with cancer undergoing chemotherapy. The current study’s aims were to evaluate in this population: 1) the prevalence of polypharmacy and PIM use; and 2) the association between these and chemotherapy-related adverse events.
Methods
This was a secondary analysis of prospectively collected data of adults age ≥65 years with cancer undergoing chemotherapy. Measures included: the number of daily medications (i.e, polypharmacy); PIM use based on 3 indices [Beers, Zhan, and Drugs to Avoid in the Elderly (DAE) criteria], as well as use of 6 “high-risk” medication classes for adverse drug events (i.e., anticoagulants, antiplatelet agents, opioids, insulin, oral hypoglycemics and antiarrhythmics). Using multivariate logistic regression, the relations were evaluated between these criteria and 1) Grade 3-5 chemotherapy-related toxicity; and 2) hospitalization during chemotherapy.
Results
The patients (N=500; mean age, 73 years, 61% Stage IV disease) took a mean of 5 daily medications (±4; range, 0-23). PIM use among patients was common (up to 29% using Beers criteria). No association was found between the number of daily medications and either toxicity (0-3 medications as reference: 4-9, OR=1.34, 95% CI: 0.92-1.97; ≥10, OR=0.82, 95% CI: 0.45-1.49), or hospitalization (0-3 medications as reference, ≥4, OR=1.34, 95%CI: 0.82-2.18, p=0.24). There was also no association between PIM use and toxicity (p=0.93) or hospitalization (p=0.98). No medication class was associated with either outcome.
Conclusions
Polypharmacy and PIM use were common but werenot associated with chemotherapy-related toxicity or hospitalization in older adults with cancer.
doi:10.1111/jgs.12942
PMCID: PMC4134360  PMID: 25041361
Polypharmacy; Cancer; Elderly; Chemotherapy; Toxicity
6.  “Missing Pieces” – Functional, Social, and Environmental Barriers to Recovery for Vulnerable Older Adults Transitioning From Hospital to Home 
Background
Recent interventions to improve transitions in care for older adults focus on hospital discharge processes. Limited data exists on patient concerns for care at home after discharge, particularly for vulnerable older adults.
Design
We used in-depth, in-person interviews to describe barriers to recovery at home after leaving the hospital for vulnerable, older adults. We purposefully sampled by age, gender, race, and English proficiency to ensure a wide breadth of experiences. Interviews were independently coded by two investigators using the constant comparative method. Thematic analysis was performed by the entire research team with diverse backgrounds in primary care, hospital medicine, geriatrics, and nursing.
Setting and Participants
We interviewed vulnerable older adults (low income/health literacy, and/or Limited English Proficiency) who were enrolled in a larger discharge interventional study within 30 days of discharge from an urban public hospital. All participants were interviewed in their native language (English, Spanish, or Chinese).
Results
We interviewed 24 patients: mean age 63 (55–84), 66% male, 67% Non-white, 16% Spanish-speaking, 16% Chinese-speaking. We identified an overarching theme of “missing pieces” in the plan for post-discharge recovery at home from which three specific sub-themes emerged: (1) functional limitations and difficulty with mobility and self-care tasks; (2) social isolation and lack of support from family and friends; (3) challenges from poverty and the built environment at home. In contrast, patients described mostly supportive experiences with traditional focuses of transition care such as following prescribed medication and diet regimens.
Conclusion
Hospital-based discharge interventions that focus on traditional aspects of care may overlook social and functional gaps in post-discharge care at home for vulnerable older adults. Post-discharge interventions that address these challenges may be necessary to reduce readmissions in this population.
doi:10.1111/jgs.12928
PMCID: PMC4134399  PMID: 24934494
Transitions of care; discharge care; vulnerable seniors; qualitative methods
7.  Weight Change, Body Composition and Risk of Mobility Disability and Mortality in Older Adults:A Population Based Cohort Study 
Objectives
To examine associations between weight change, body composition, risk of mobility disability and mortality in older adults.
Design
Prospective, longitudinal, population-based cohort.
Setting
The Health ABC Study.
Participants
Women (n=1044) and men (n=931) aged 70-79.
Measurements
Weight,lean and fat mass from DXA measured annually over 5 years. Weight was defined as stable (n=664, referent group), loss (n=662), gain (n=321) or cycling (gain and loss, n=328) using change of 5% from year to year or from year 1 to 6. Mobility disability (two consecutive reports of difficulty walking one-quarter mile or climbing 10 steps) and mortality were determined for 8 years subsequent to the weight change period. Associations were analyzed with cox proportional hazards regression adjusted for covariates.
Results
During follow-up, 313 women and 375 men developed mobility disability,322 women and 378 men were deceased. There was no risk of mobility disability or mortality with weight gain. Weight loss and weight cycling were associated with mobility disability in women:hazard ratio (HR)=1.88 (95% confidence interval (CI)=1.40-2.53),HR=1.59 (95% CI=1.11-2.29) and weight loss was associated in men:HR=1.30 (95% CI=1.01-1.69).Weight loss and weight cycling were associated with mortality risk in women:HR=1.47 (95% CI=1.07-2.01), HR=1.62 (95% CI=1.15-2.30) and in men:HR=1.41 (95% CI=1.09-1.83),HR=1.50 (95% CI=1.08-2.08). Adjustment for lean and fat mass and change in lean and fat mass from year 1 to 6 attenuated relationships between weight loss and mobility disability in men, and weight loss and mortality in men and women.
Conclusion
Weight cycling and weight loss predict impendingmobility disability and mortality in old age, underscoring the prognostic importance of weight history.
doi:10.1111/jgs.12954
PMCID: PMC4134405  PMID: 25039391
Aging; obesity; physical function; body composition; muscle loss
8.  Depression, Antidepressants and Bone Health in Older Adults: A Systematic Review 
Objectives
Some studies have reportedan association between depression or serotonin reuptake inhibitor (SRI) antidepressant use and osteoporosis. This association raises concern about the widespread use of antidepressants in older adults and suggests the need to reevaluate this practice. This review examines the association of both depression and antidepressant use with bone health in older adults and the implications for treatment.
Design
A systematic review of studies of the association between depression or antidepressants and bone health in older adults.
Setting
All studies that measured depression or antidepressant exposure and bone mineral density (BMD).
Participants
Adults aged 60 and above.
Measurements
Age, site of BMD measurement by dual-energy x-ray absorptiometry (DXA), measure of depression or depressive symptoms, association between BMD changes and depression or antidepressant use.
Results
Nineteen observational studies met the final inclusion criteria; no experimental studies were found. Several cross-sectional and longitudinal studies found that depression or depressive symptoms were associated with decreased BMD. Few studies and only two longitudinal studies addressed the association between SRI antidepressant use and a decrease in BMD and they had conflicting results.
Conclusion
Depression and depressive symptoms are associated with decreased bone mass and accelerated bone loss in older adults; putative mechanisms underlying this relationship are discussed. There is insufficient evidence that SRI antidepressants adversely affect bone health.Thus, a change in current recommendations for the use of antidepressants in older adults is not justified at the present time. Given the high public health significance of this question, more studies are required to determine whether (and in whom) antidepressants may be deleterious for bone health.
doi:10.1111/jgs.12945
PMCID: PMC4134423  PMID: 25039259
depression; antidepressants; BMD; older adults
9.  Does Walking Speed Mediate The Association Between Visual Impairment and Self-Report of Mobility Disability? The Salisbury Eye Evaluation Study 
Objectives
To determine if performance speeds mediate the association between visual impairment and self-reported mobility disability over an eight-year period.
Design
Longitudinal analysis
Setting
Salisbury, MD
Participants
2,520 Salisbury Eye Evaluation Study participants, age 65 years or older.
Measurements
Visual impairment was defined as best-corrected visual acuity worse than 20/40 in the better-seeing eye, or visual field less than 20°. Self-reported mobility disability on three tasks was assessed: walking up stairs, walking down stairs, and walking 150 feet. Performance speed on three similar tasks was measured: walking up steps (steps/second), walking down steps (steps/second), and walking 4 meters (meters/second).
Results
For each year of observation, the odds of reporting mobility disability was significantly greater for visually impaired than the non-visually impaired (OR difficulty walking up steps = 1.58, 95% CI: 1.32–1.89; OR difficulty walking down steps = 1.90, 95% CI: 1.59–2.28; OR difficulty walking 150 feet = 2.11, 95% CI: 1.77–2.51). Once performance speed on a similar mobility task was included in the models, the visually impaired were no longer more likely to report mobility disability than the non-visually impaired (OR difficulty walking up steps = 0.84, 95% CI: 0.65–1.11; OR difficulty walking down steps = 0.96, 95% CI: 0.74–1.24; OR difficulty walking 150 feet = 1.22, 95% CI: 0.98–1.50).
Conclusion
The difference in the odds of reporting mobility disability by visual impairment status is largely accounted for by slower performance speeds among the visually impaired. This suggests that visually impaired older adults walk slower and are therefore more likely to report mobility disability than the non-visually impaired. Improving mobility performance in older adults with visual impairment may minimize the perception of mobility disability.
doi:10.1111/jgs.12937
PMCID: PMC4134428  PMID: 25040870
Visual Impairment; Mobility; Disability; Aging
10.  Abbreviated Care-Process Quality Indicator Sets Linked with Survival and Functional Status Benefit in Older Ambulatory-Care Patients 
Objectives
Better quality-of-care measured by 140 care-process quality indicators (QIs) from the Assessing Care of Vulnerable Elders Study (ACOVE-1) predicts better survival. A subsequent study (ACOVE-2) reduced the measures to 69 ambulatory-care QIs. We identified further need to prioritize and reduce the QIs to facilitate future quality improvement efforts. We aimed to identify subsets of ambulatory QIs associated with better survival and physical function outcomes.
Design
Observational cohort study
Setting and participants
1015 older ambulatory-care patients in ACOVE-1 and ACOVE-2
Measurements
To develop the QI subsets, we first convened an expert panel to rate each of 69 ambulatory-care QIs for strength of process-benefit link, defined as: (1) direct trial evidence on older patients, or(2) high expectation of benefit if a trial were conducted in older patients. This resulted in three reduced QI sets, reflecting their intended benefit: 17 QIs for survival (ACOVE-Quality-for-Survival, AQS-17), 5 QIs to preserve function (AQF-5), and 16 QIs to improve quality-of-life related to physical health and symptoms(AQQ-16). We first tested whether AQS-17 would predict3-year survival in 1015 pooled ACOVE-1 and ACOVE-2 patients. Second, we tested whether AQF-5(n=74) and AQQ-16(n=359) would predict change in the physical component score (PCS) ofShort-Form-12 at one-year in the ACOVE-2cohort. Controls: age, function-based vulnerability, co-morbidity.
Results
Each20 percentage-point increment inAQS-17 was associated with survival (HR .83, p=.014)up to 500 days, but not thereafter. AQF-5, but not AQQ-16, predicted 1-year improvement in PCS (1.13-points per 20 percentage-point increment in AQF-5, p=.021).
Conclusion
Subsets of care processes can be linked with outcomes important to older patients.AQS-17 and AQF-5 are potential tools for improving ambulatory care for older adults.
doi:10.1111/jgs.12943
PMCID: PMC4137322  PMID: 25041473
Quality indicators; geriatric; mortality; physical function
11.  Achieving Effective Antidepressant Pharmacotherapy in Primary Care: The Role of Depression Care Management in Treating Late-Life Depression 
OBJECTIVES
To estimate the effect of an evidence-based depression care management (DCM) intervention on the initiation and appropriate use of antidepressant in primary care patients with late-life depression.
DESIGN
Secondary analysis of data from a randomized trial.
SETTING
Community, primary care.
PARTICIPANTS
Randomly selected individuals aged 60 and older with routine appointments at 20 primary care clinics randomized to provide a systematic DCM intervention or care as usual.
METHODS
Rates of antidepressant use and dose adequacy of patients in the two study arms were compared at each patient assessment (baseline, 4, 8, and 12 months). For patients without any antidepressant treatment at baseline, a longitudinal analysis was conducted using multilevel logistic models to compare the rate of antidepressant treatment initiation, dose adequacy when initiation was first recorded, and continued therapy for at least 4 months after initiation between study arms. All analyses were conducted for the entire sample and then repeated for the subsample with major or clinically significant minor depression at baseline.
RESULTS
Rates of antidepressant use and dose adequacy increased over the first year in patients assigned to the DCM intervention, whereas the same rates held constant in usual care patients. In longitudinal analyses, the DCM intervention had a significant effect on initiation of antide-pressant treatment (adjusted odds ratio (OR) = 5.63, P<.001) and continuation of antidepressant medication for at least 4 months (OR = 6.57, P = .04) for patients who were depressed at baseline.
CONCLUSIONS
Evidence-based DCM models are highly effective at improving antidepressant treatment in older primary care patients.
PMCID: PMC4520214  PMID: 19484846
depression care management; collaborative care models; antidepressant treatment; process outcomes
12.  A Comparison of Four Frailty Models 
OBJECTIVES
To determine how well the interview-based, clinic-friendly International Academy of Nutrition and Aging (FRAIL) frailty scale predicts future disability and mortality in the African American Health (AAH) cohort compared with the clinic-friendly Study of Osteoporotic Fractures (SOF) frailty scale, the phenotype-based Cardiovascular Health Study (CHS) frailty scale, and the comprehensive Frailty Index (FI).
DESIGN
Longitudinal cohort study.
SETTING
Metropolitan St. Louis, Missouri.
PARTICIPANTS
African American Health is a population-based panel study of African Americans (baseline age 49–65) from St. Louis, Missouri. Participants completed in-home assessments at baseline (N = 998) and 3- (n = 853) and 9- (n = 582) year follow-up.
MEASUREMENTS
Outcomes included activity of daily living (ADL) and instrumental ADL difficulties at 3 and 9 years and 9-year mortality. Frailty measures included the FRAIL, SOF, and CHS scales and the FI.
RESULTS
The FRAIL, SOF, CHS, and FI measures predicted new 3- and 9-year disability, and the FRAIL and FI scales predicted 9-year mortality. Receiver operating characteristic (ROC) contrasts showed that the FRAIL scale performed as well as (9-year disability and mortality) or better than (3-year disability) the CHS and SOF scales and the FI better than the FRAIL, CHS, and SOF scales for all outcomes except the FRAIL and CHS scales for 9-year ADL difficulties. The CHS and SOF scales were equivalent for all outcomes in ROC contrasts.
CONCLUSION
Overall the FI and the FRAIL scale exhibited the strongest predictive validity for disability and mortality in AAH. The best prediction tool to identify frail individuals at risk of disability and mortality may be one that includes a comorbidity measure. The FRAIL scale includes a comorbidity item and is a brief interview-based measure that is easy to administer, score, and interpret. The FRAIL scale has demonstrated validity and may prove to be a valuable scale for use by clinicians.
doi:10.1111/jgs.12735
PMCID: PMC4519085  PMID: 24635726
frailty; ADLs; IADLs; mortality; African American
13.  Urinary and Fecal Incontinence and Quality of Life in African Americans 
Objectives
To investigate associations between quality of life (QoL) and incontinence in a population-based African-American sample.
Design
Cross-sectional survey.
Setting
Metropolitan St. Louis, Missouri.
Participants
Eight hundred fifty-three non-institutionalized African Americans aged 52 to 68 in the African American Health study.
Measurements
Respondents who reported having involuntarily lost urine over the previous month were classified as having urinary incontinence (UI), and respondents who reported having lost control of their bowels or stool over the past year were classified as having fecal incontinence (FI). QoL was measured using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and the 11-item Center for Epidemiologic Studies Depression Scale (CES-D).
Results
Prevalences of UI and FI were 12.1% (weighted n = 102/841) and 5.0% (weighted n = 42/841). Participants with UI and those with FI had worse SF-36 scores than their referent groups (physical function − 15.5 and − 38.1 points, respectively; role physical −13.2 and −26.5 points; bodily pain −15.7 and −24.5 points; general health perceptions −15.5 and −27.6 points; vitality −15.0 and −16.5 points; social functioning −18.4 and −25.6 points; role emotional −13.2 and −22.1 points; mental health −12.2 and −17.5 points; all Ps< .001), adjusting for age, sex, body mass index, and chronic conditions. Proportions with clinically relevant levels of depressive symptoms were also higher in both groups (UI+17.9% P<.001) and FI (+37.2% P<.001) than in their referent groups.
Conclusion
UI and FI were strongly associated with worse health-related QoL as well as symptoms of depression in this population-based sample of African Americans.
doi:10.1111/j.1532-5415.2010.03057.x
PMCID: PMC4519086  PMID: 20831721
African Americans; quality of life; health-related quality of life; depressive symptoms; incontinence
15.  Incident Physical Disability in People with Lower Extremity Peripheral Arterial Disease: The Role of Cardiovascular Disease 
Objective
To evaluate the risk of incident physical disability and the decline in gait speed over a six year follow-up associated with a low ankle-arm index (AAI) in older adults.
Design
Observational cohort study.
Setting
Forsyth County, North Carolina; Sacramento County, California; Washington County, Maryland; or Allegheny County, Pennsylvania.
Participants
4705 older adults, 58% women and 17.6% black, participating in the Cardiovascular Health Study were included.
Measurements
The AAI was measured in 1992–93 (baseline). Self-reported mobility disability, activities of daily living (ADL) and instrumental activities of daily living (IADL) disability and gait speed were recorded at baseline and at 1 year intervals over 6 years of follow-up. Mobility disability was defined as any difficulty walking ½ mile and ADL/IADL disability was defined as any difficulty with 11 specific ADL/IADL tasks. Individuals with mobility and/or ADL/IADL disability at baseline were excluded from the respective incident disability analyses.
Results
Lower baseline AAI values were associated with increased risk of mobility disability and ADL/IADL disability. These associations were partially explained by clinical cardiovascular disease (CVD), diabetes and interim CVD events for mobility disability and by clinical CVD and diabetes for ADL/IADL disability. Individuals with AAI < 0.90 had on average a mean decrease in gait speed of 0.02 m/s/year or a decline of 0.12 m/s over the 6 year follow-up. This decrease was partly explained by prevalent CVD but not further attenuated by interim CVD events.
Conclusions
Low AAI serves as marker of future disability risk. Reduction of disability risk in patients with a low AAI should consider cardiovascular comorbidity and the prevention of additional disabling CVD events.
doi:10.1111/j.1532-5415.2008.01719.x
PMCID: PMC4509641  PMID: 18384579
Peripheral arterial disease; disability; cardiovascular disease
16.  When Being Thin Is Not a Virtue 
doi:10.1111/j.1532-5415.2008.02047.x
PMCID: PMC4501482  PMID: 19093935
17.  Diet soda intake is associated with long-term increases in waist circumference in a bi-ethnic cohort of older adults: The San Antonio Longitudinal Study of Aging 
BACKGROUND/OBJECTIVES
Diet soda (DS) intake (DSI) has been associated with increased cardiometabolic risk, but its specific impact in older adults has not been addressed. Because central obesity increases cardiovascular risk, we examined the relationship between DSI and long-term waist circumference (WC) change (ΔWC) in the bi-ethnic San Antonio Longitudinal Study of Aging (SALSA).
DESIGN
Prospective cohort study.
SETTING
San Antonio, Texas, neighborhoods
PARTICIPANTS
SALSA examined 749 Mexican-American and European-American individuals ≥ 65 years old at baseline (BL: 1992-1996); 79.1% of survivors completed follow-up 1 (FU1) (2000-2001, n=474); 73.4%, FU2 (2001-2003, n=413); and 71.0%, FU3 (2003-2004, n=375). Participants completed a mean of 2.64 follow-up intervals, for 9.41 total follow-up years.
MEASUREMENTS
DSI, WC, height and weight were measured at outset and conclusion of each interval: BL-FU1, FU1-FU2, and FU2-FU3.
RESULTS
Adjusted for initial WC, demographics, physical activity, diabetes, and smoking, mean interval ΔWC (95% confidence interval) for all DS users was almost triple that among non-users: 2.11 (1.45-2.76) vs. 0.77 (0.29-1.23) cm, respectively (p < 0.001). For non-, occasional, and daily DS users, adjusted interval ΔWCs were 0.77 (0.29-1.23), 1.76 (0.96-2.57), and 3.04 (1.82-4.26) cm, respectively (p=0.002 for trend). This translates to ΔWCs of 0.80, 1.83, and 3.16 inches, respectively, for these groups, over the total SALSA follow-up. In sub-analyses stratified separately by key covariates, ΔWC point estimates were consistently higher among DS users.
CONCLUSION
In a striking dose-response relationship, increasing diet soda intake was associated with escalating abdominal obesity, a potential pathway for heightened cardiometabolic risk in this aging population.
doi:10.1111/jgs.13376
PMCID: PMC4498394  PMID: 25780952
diet soda; waist circumference; abdominal obesity; non-nutritive sweeteners; artificial sweeteners
18.  Functional Status After Colon Cancer Surgery In Elder Nursing Home Residents 
Objectives
To determine functional status and mortality rates after colon cancer surgery in older nursing home residents.
Design
Retrospective cohort study.
Setting and Participants
6822 nursing home residents age 65 and older who underwent surgery for colon cancer in the United States between 1999 and 2005.
Measurements
Changes in functional status were assessed before and after surgery using the Minimum Data Set-Activities of Daily Living (MDS-ADL) summary scale, a 28-point scale in which score increases as functional dependence increases.
Methods
Using the Medicare Inpatient File and the Minimum Data Set for Nursing Homes, we identified the 6822 nursing home residents age 65 and older who underwent surgery for colon cancer. We used regression techniques to identify patient characteristics associated with mortality and functional decline at 1 year after surgery.
Results
On average, residents who underwent colectomy experienced a 3.9 point worsening in MDS-ADL score at one year. One year after surgery, the rates of mortality and sustained functional decline were 53% and 24%, respectively. In multivariate analysis, older age (age 80+ v. age 65–69, adjusted relative risk (ARR 1.53), 95%CI 1.15–2.04, p<0.001), readmission after surgical hospitalization (ARR 1.15), 95%CI 1.03–1.29, p<0.01), surgical complications (ARR 1.11), 95%CI 1.02–1.21, p<0.02), and functional decline before surgery (ARR 1.21, 95%CI 1.11–1.32, p<0.0001) were associated with functional decline at one year.
Conclusion
Mortality and sustained functional decline are very common after colon cancer surgery in nursing home residents. Initiatives aimed at improving surgical outcomes are needed in this vulnerable population.
doi:10.1111/j.1532-5415.2012.03915.x
PMCID: PMC4497557  PMID: 22428583
surgery; functional decline; nursing home residents
19.  Association of Experience with Illness and End-of-life Care with Advance Care Planning in Older Adults 
Objectives
To examine whether experiences with illness and end-of-life care are associated with increased readiness to participate in advance care planning (ACP).
Design
Observational cohort study.
Setting
Community.
Participants
Persons age ≥ 60 recruited from physician offices and a senior center.
Measurements
Participants were asked about personal experience with major illness or surgery and experience with others’ end-of-life care, including whether they had made a medical decision for someone dying, knew someone who had a bad death due to too much/too little medical care, or experienced the death of a loved one who made end-of-life wishes known. Stages of change were assessed for specific ACP behaviors: completion of living will and healthcare proxy, communication with loved ones regarding life-sustaining treatments and quantity versus quality of life, and communication with physicians about these same topics. Stages of change included precontemplation, contemplation, preparation and action/maintenance corresponding to whether the participant was not ready to complete the behavior, was considering participation in the next six months, was planning participation within thirty days, or had already participated.
Results
Of 304 participants, 84% had one or more personal experiences or experience with others. Personal experiences were not associated with increased readiness for most ACP behaviors. In contrast, having one or more experiences with others was associated with increased readiness to complete a living will and healthcare proxy, discuss life-sustaining treatment with loved ones and discuss quantity versus quality of life with loved ones and with physicians.
Conclusion
Older individuals who have experience with end-of-life care for others demonstrate increased readiness to participate in ACP. Discussions with older patients regarding these experiences may be a useful tool in promoting ACP.
doi:10.1111/jgs.12894
PMCID: PMC4107022  PMID: 24934237
advance care planning; end-of-life care
20.  Pandemic Influenza Plans in Residential Care Facilities 
Objectives
Elderly in long-term facilities are vulnerable to a pandemic influenza. We aimed to identify characteristics of residential care facilities (RCFs) associated with having a pandemic influenza plan.
Design
Nationally representative, cross-sectional survey.
Setting
RCFs in the United States.
Participants
Participating facilities in the 2010 National Survey of RCFs (n=2,294), representing 31,030 assisted living facilities and personal care homes.
Measurements
Facility-level characteristics associated with a pandemic influenza plan, including general organization descriptors, staffing, resident services, and immunization practices.
Results
Overall, 45% (95%CI, 43–47) had a pandemic plan, 14% (95%CI, 13–16) had a plan in preparation, and 41% (95%CI, 38–43) had no plan. In the multivariable model, organization characteristics, staffing, and immunization practices were independently associated with the presence of a pandemic preparedness plan. The organization characteristics were larger size (extra-large, OR 3.27 [95%CI, 1.96–5.46], large, OR 2.60 [95%CI, 1.81–3.75], or medium, OR 1.66 [95%CI, 1.21–2.27], vs. small), not-for-profit status (OR 1.65 [95%CI, 1.31–2.09] vs. for-profit), and chain-affiliation (OR 1.65 [95%CI, 1.31–2.09] vs. non-affiliated). Staffing characteristics included the amount of RN hours (Less than 15 minutes, OR 1.36 [95%CI, 1.07–1.74] vs. no hours), any LPN hours (OR 1.47 [95%CI,1.08–1.99] vs. no hours), and at least 75 hours of required training for aides (OR 1.34 [95%CI, 1.05–1.71] vs. less than 75 hours). RCFs with high staff influenza vaccination rates (81–100%, OR 2.12 [95%CI, 1.27–3.53] vs. 0% vaccinated) were also more likely to have a pandemic plan.
Conclusion
A majority of RCFs lacked a pandemic influenza plan. These facilities were smaller, for-profit, non-chain-affiliated RCFs and had lower staff vaccination rates. These characteristics may help target facilities that need to develop plans to handle a pandemic, or other disasters.
doi:10.1111/jgs.12879
PMCID: PMC4107066  PMID: 24852422
Residential facility; Assisted Living Facility; Geriatric; Pandemic; Influenza
21.  Emergency Department and Outpatient Treatment of Acute Injuries Among Older Adults in the United States, 2009–2010 
OBJECTIVES
Studies of injury among older adults have primarily focused on hospitalizations, especially at trauma centers, which may result in a skewed understanding and underestimation of the burden of injury. We sought to describe epidemiologic patterns of acute injuries treated in both ED and outpatient primary care settings in the United States.
DESIGN
Retrospective cross-sectional analysis of data from the 2009 and 2010 National Health Care Surveys.
SETTING
EDs and outpatient primary care clinics.
PARTICIPANTS
Older adults (age ≥65) with initial visits for acute injuries.
MEASUREMENTS
Frequencies and incidence rates of medically-attended injury by patient characteristics and care setting.
RESULTS
Of the 19.7 million medically-attended acute injuries among older adults in 2009–2010, 50% were treated at EDs and 50% at outpatient primary care clinics. The annual incidence rate of medically-attended injuries rose with age, from 20.8 (95% Confidence Interval [CI]=17.0–24.6) per 100 among those aged 65 to 74 years up to 41.5 (95%CI=33.5–49.4) per 100 for those ≥85 years. Of injury-related ED visits, 60% occurred outside standard business hours, 36% were triaged as “low acuity,” and 25% resulted in admission. Only 9% of injury-related primary care visits had injury prevention counseling documented.
CONCLUSION
Medically-attended injuries occur in older adults at high incidence and increase with advancing age. Half of all initial visits for acute injuries among older adults are to primary care clinics. Most injured patients are discharged home but injury prevention counseling is rarely documented. In order to appropriately inform injury prevention efforts and avoid underestimating the burden of injury, future injury studies should include a range of outpatient and inpatient care settings.
doi:10.1111/jgs.12877
PMCID: PMC4107125  PMID: 24890363
Injury; ambulatory clinic; outpatient; older adult; emergency department
22.  Electronic Communication Capabilities of Residential Care Facilities at Times of Transition 
doi:10.1111/jgs.12905
PMCID: PMC4107356  PMID: 25039508
Residential care facilities; information transfer; readmission; transitions of care
23.  Recruitment of Older Drivers From Primary Care Clinics for On-Road Fitness-to-Drive Testing: Results of a Pilot Study 
doi:10.1111/jgs.12913
PMCID: PMC4107363  PMID: 25039512
Older driver; primary care; recruitment; tiered assessment; behind-the-wheel test
24.  Changes in Daily Activity Patterns with Age among US Men and Women: NHANES 2003–2004 and 2005–2006 
Background/Objectives
Men achieve more moderate-to-vigorous physical activity (MPVA) than women, yet with advancing age men become more sedentary than women. No study has comprehensively assessed this change in activity pattern. We compare daily and hourly activity patterns by gender and age.
Design
Cross-sectional; Observational
Setting
Nationally-representative community sample: NHANES 2003–2004; 2005–2006
Participants
Accelerometer data from respondents (n=5,788) aged ≥20 years with 4+ valid days of monitor wear-time, no missing data on valid wear-time minutes, and covariates.
Measurements
Activity was examined as average counts per minute (CPM) during wear-time, percentage of time spent in non-sedentary activity, and time (minutes) spent in sedentary (<100 counts); light (100–759); MVPA (≥760) intensity levels. Analyses accounted for survey design, adjusted for covariates and were gender specific.
Results
In adjusted models, men spent slightly greater time (~1–2%) in non-sedentary activity than women 20–34y, with levels converging at 35–59y, though a non-significant difference. Women age ≥60 spent significantly greater time (~3–4%) in non-sedentary activity than men, despite similarly achieved average CPM. With increasing age, all non-sedentary activity decreased in men; levels of light-activity remained constant among women (~30%). Older men had fewer CPM at night (~20 CPM), more daytime sedentary minutes (~3), fewer daytime light minutes (~4), and more MVPA minutes (~1) until early evening, than older women.
Conclusion
While gender differences in average CPM reduced with age, differences in non-sedentary activity time emerged as men increased sedentary behavior and reduced MVPA time. Maintained levels of light-intensity activity suggest women continue engaging in common daily activities into older-age more often than men. Findings may help inform the development of behavioral interventions to increase intensity and overall activity levels, particularly among older adults.
doi:10.1111/jgs.12893
PMCID: PMC4115191  PMID: 24962323
NHANES 2003–2004, 2005–2006; Physical activity; Sedentary behavior; Accelerometer; Patterns of daily activity
25.  Life-Space Mobility and Mortality in Older Men: A Prospective Cohort Study 
Background
Life-space mobility assesses the extent, frequency, and independence of an individual’s movement. Limited life-space may be an early marker of end-of-life.
Objectives
To evaluate the relation between life-space and mortality in older men.
Design
Prospective cohort study.
Setting
Six U.S. clinical sites.
Participants
Three thousand eight hundred ninety-two men aged 71–98 years, followed from 2007–2011.
Measurements
Life-space during the past month was assessed as 0 (daily restriction to one’s bedroom) to 120 (daily trips outside one’s town without assistance) and categorized into 20-point intervals. Primary outcome: non-cancer mortality. Secondary outcomes: all-cause, cardiovascular, cancer, and non-cardiovascular non-cancer mortality.
Results
Over 2.7 years (2007–2011), 373 (9.6%) men died, 230 from non-cancer causes. Unadjusted risk of non-cancer mortality was 41.2% among men with the lowest level of life-space (0–20 points, n=34) versus 2.4% among men with the highest life-space (101–120 points, n=868), a 17-fold difference. In multivariable-adjusted models, there was a strong linear trend between decreasing life-space and increasing risk of non-cancer mortality (P=0.005). Compared to men with the highest life-space, risk of non-cancer mortality was 3.8-fold higher (95%CI:1.3,11.5) among men with the lowest life-space. Each SD (24 point) decrease in life-space was associated with a 1.3-fold higher risk (1.1–1.5) of non-cancer mortality. Men who did not travel beyond their neighborhood without assistance (n=471) had a 1.5-fold higher risk (1.0–2.3) of non-cancer mortality. Results were similar for all-cause mortality and did not change after control for chronic disease burden.
Conclusion
Life-space predicted a variety of mortality endpoints in older men; scores ≤40 were associated with mortality independent of other risk factors.
doi:10.1111/jgs.12892
PMCID: PMC4251711  PMID: 24934163
aged; mobility limitation; mortality; independence; activities of daily living

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