To evaluate the association between pressure-redistributing support surface (PRSS) use and incident pressure ulcers in older adults with hip fracture.
Secondary analysis of data from prospective cohort with assessments performed as soon as possible after hospital admission and on alternating days for 21 days.
Nine hospitals in the Baltimore Hip Studies network and 105 postacute facilities to which participants were discharged.
Six hundred fifty-eight people aged 65 and older who underwent surgery for hip fracture.
Full-body examination for pressure ulcers; bedbound status; and PRSS use, recorded as none, powered (alternating pressure mattresses, low-air-loss mattresses, and alternating pressure overlays), or nonpowered (high-density foam, static air, or gel-filled mattresses or pressure-redistributing overlays except for alternating pressure overlays).
Incident pressure ulcers (IPUs), Stage 2 or higher, were observed at 4.2% (195/4,638) of visits after no PRSS use, 4.5% (28/623) of visits after powered PRSS use, and 3.6% (54/1,496) of visits after nonpowered PRSS use. The rate of IPU per person-day of follow-up did not differ significantly between participants using powered PRSSs and those not using PRSSs. The rate also did not differ significantly between participants using nonpowered PRSSs and those not using PRSSs, except in the subset of bedbound participants (incidence rate ratio = 0.3, 95% confidence interval = 0.1–0.7).
PRSS use was not associated with a lower IPU rate. Clinical guidelines may need revision for the limited effect of PRSS use, and it may be appropriate to target PRSS use to bedbound patients at risk of pressure ulcers.
pressure ulcers; prevention; mattresses; overlays; guidelines
To explore strategies used by clinical programs to justify operations to decision-makers using the example of the Hospital Elder Life Program (HELP), an evidence-based, cost-effective program to improve care for hospitalized older adults.
Qualitative study design utilizing 62 in-depth, semi-structured interviews conducted with HELP staff members and hospital administrators between September 2008 and August 2009.
19 HELP sites in hospitals across the U.S. and Canada that had been recruiting patients for at least 6 months.
PARTICIPANTS and MEASUREMENTS
HELP staff and hospital administrator experiences sustaining the program in the face of actual or perceived financial threats, with a focus on factors they believe are effective in justifying the program to decision-makers in the hospital or health system.
Using the constant comparative method, a standard qualitative analysis technique, three major themes were identified across interviews. Each focuses on a strategy for successfully justifying the program and securing funds for continued operations: 1) interact meaningfully with decision-makers, including formal presentations that showcase operational successes, and also informal means that highlight the benefits of HELP to the hospital or health system; 2) document day-to-day, operational successes in metrics that resonate with decision-maker priorities; and 3) garner support from influential hospital staff that feed into administrative decision-making, particularly nurses and physicians.
As clinical programs face financially challenging times, it is important to find effective ways to justify their operations to decision-makers. Strategies described here may help clinically-effective and cost-effective programs sustain themselves, and thus may help improve care in their institutions.
Hospital Elder Life Program; cost-effectiveness; sustaining programs; hospital administration; clinical innovations; quality of care; delirium prevention; acute care; geriatrics
The Hospital Elder Life Program (HELP), an effective intervention to prevent delirium among hospitalized elders, has been successfully replicated in a community teaching hospital as a quality improvement project. Now, we report on successfully sustaining the program over 7 years and expanding its scale from 1 to 6 inpatient units at the same hospital. The program currently serves over 7000 older patients annually and is accepted as the standard of care throughout the hospital. Innovations which enhanced scalability and widespread implementation included ensuring dedicated staffing for the program, local adaptations to streamline protocols, continuous recruitment of volunteers, and more efficient data collection. Outcomes include reduced rate of incident delirium, reduced length of stay, increased satisfaction by patients, families, and nursing staff, and significantly reduced costs for the hospital. The financial return of the program, estimated at over $7.3 million per year during 2008, is comprised of cost savings from delirium prevention as well as revenue generated from freeing up hospitals beds (reduced length of stay in delirious and non-delirious HELP patients). Delirium poses a major challenge for hospital quality of care, patient safety, Medicare no-pay conditions, and costs of hospital care for older persons. Faced with rising numbers of elderly patients, hospitals can utilize HELP to improve both the quality and cost-effectiveness of care.
delirium; Hospital Elder Life Program (HELP) ; intervention; prevention; hospital care; sustainability
Cognitive decline and dementia risk have been associated with diet, exercise, social interaction, church attendance, alcohol consumption and smoking.
To identify distinct behavioral patterns, and to examine their association with subsequent dementia risk.
Longitudinal, population-based dementia study.
Rural county in northern Utah, at-home evaluations.
2,491 non-demented participants (51% male) initially reported no problems in activities of daily living and no stroke or head injury within past five years. Average age was 73.01 (SD=5.69) years and average education 13.67 (SD=4.10) years.
Six dichotomized lifestyle behaviors included: Diet: high = above median on the Dietary Approaches to Stop Hypertension scale; Exercise: 5+ hours/week of light activity and at least occasional moderate/vigorous activity; Church attendance: attending church services at least weekly; Social Interaction: spending time with family/friends at least twice weekly; Alcohol: currently drinking alcoholic beverages 2+/week; Non-smoker: no current use (or former if < 100 cigarettes ever). Latent Class Analysis (LCA) identified patterns among these behaviors. Proportional hazards regression modeled time to dementia onset as a function of behavioral class, age, gender, education, APOE status. Follow-up averaged 6.32 (SD=5.31) years, revealing 278 cases of incident dementia (200 AD).
LCA identified four distinct lifestyle classes. “Unhealthy-Religious” (UH-R; 11.5%), “Unhealthy-Non-Religious” (UH-NR; 10.5%), “Healthy-Moderately Religious” (H-MR; 38.5%), and “Healthy-Very Religious” (H-VR; 39.5%). Compared to UH-R class, UH-NR (Hazard Ratio, HR=.54, p=.028), H-MR (HR=.56, p=.003), and H-VR (HR=.58, p=.005) had significantly lower dementia risk. Results were comparable for AD, except that UH-NR was less definitive.
Functionally independent older adults appear to cluster into subpopulations having distinct patterns of lifestyle behaviors with different levels of risk for subsequent dementia and AD.
Lifestyle; health-related behaviors; dementia
To evaluate the relationships between body composition and physical frailty in community-dwelling HIV-infected older adults (HOA).
Academic hospital-based infectious disease clinic in Rochester NY
Community-dwelling HIV-infected adults >50 years of age.
Subjective and objective measures of functional status were evaluated by using the Physical Performance Test (PPT), graded treadmill test, knee strength, gait speed, balance and Functional Status Questionnaires (FSQ). Body composition was evaluated by using Dual Energy X-ray Absorptiometry (DXA) and Magnetic Resonance Imaging (MRI).
We studied 40 HOA on antiretroviral therapy (with mean: age 58 years, BMI 29, CD4 569 cells/ml, duration since HIV diagnosis 17 years; 28% female and 57% Caucasian) who were able to ambulate without assistive devices. Sixty percent (25/40) of the subjects met our standard criteria for physical frailty. Both frail (FR) and non-frail (NF) subjects were comparable in age, gender, CD4 count and viral load. Compared to NF HOA, FR HOA showed impairments in PPT, peak aerobic power (VO2peak), FSQ, walking speed, balance and muscle quality. Importantly, FR HOA had greater body mass index (BMI), fat mass and truncal fat with lipodystrophy. Moreover, PPT score was inversely related to both trunk fat (r=−0.34; p=0.045) and intermuscular fat (IMF) to total fat ratio (r=−60; p=0.02) after adjusting for covariates.
HOA represent an emerging cohort of older adults who frequently experience frailty at a much younger age compared to the general older population. Central obesity and fat redistribution are important predictors of frailty among community-dwelling HOA. These findings suggest that physical frailty in HOA may be amenable to lifestyle interventions, especially exercise and diet therapy.
HIV; older adults; frailty; function; obesity; lipodystrophy
White matter hyperintensities (WMH) and silent brain infarcts (SBI) have been associated with both vascular factors and cognitive decline. We examined among cognitively normal elderly, whether vascular factors predict cognitive decline and whether these associations are mediated by MRI measures of subclinical vascular brain injury.
Prospective multi-site longitudinal study of subcortical ischemic vascular diseases
Memory and aging centers in California
We studied 74 participants who were cognitively normal at entry and received at least 2 neuropsychological evaluations and 2 MRI exams over an average follow-up of 6.9 years.
Item response theory was used to create composite scores of global, verbal memory, and executive functioning. Volumetric MRI measures included WMH, SBI, hippocampus, and cortical gray matter (CGM). We used linear mixed effects models to examine the associations between vascular factors, MRI measures, and cognitive scores.
History of coronary artery disease (CAD) was associated with greater declines in global, verbal memory, and executive cognition. The CAD associations remained after controlling for changes in WMH, SBI, hippocampal and CGM volumes.
History of CAD may be a surrogate marker for clinically significant atherosclerosis which also affects the brain. Structural MRI measures of WMH and SBI do not fully capture the potential adverse effects of atherosclerosis on the brain. Future longitudinal studies of cognition should incorporate direct measures of atherosclerosis in cerebral arteries, as well as more sensitive neuroimaging measures.
cognitively normal elderly; coronary artery disease; cognitive decline; MRI
In efforts to control costs, Medicare reduced reimbursement for office-based imaging services in 2007, an act projected to save $2.8B over 5 years. Many were concerned that imaging reimbursement reductions would reduce osteoporosis preventive bone mineral density (BMD) screening, which could lead to undiagnosed and untreated osteoporosis. The purpose of this study was to describe BMD testing rates and the proportion of women diagnosed after BMD screening versus an osteoporosis-related fracture before and after the 2007 Medicare reimbursement reductions.
In a retrospective observational analysis of administrative medical claims reimbursement data, BMD screening services between 2005 and 2008 in women age 65+ with employer-sponsored Medicare supplemental coverage were evaluated. BMD testing and the incidence of patients whose first diagnosis for osteoporosis occurred with BMD screening versus as a result of osteoporosis-related fracture were identified by calendar year.
A cohort of 405,093 women (average age 74.1 ±6.7 years) was identified of which 37.9% of study women received ≥1 BMD test during the study period. The proportion of women who received a BMD test was 12.9% in 2005, 11.4% in 2006, 11.8% in 2007, and 11.6% in 2008. Although testing rates varied, results were consistent with testing guidelines and did not decrease at a rate relative to reimbursement reductions as anticipated.
In an analysis of data from a medical claims dataset, BMD screening rates did not substantially decline during the 2 years after reimbursements reductions in Medicare-eligible women. Meanwhile, the proportion of women diagnosed after a fracture increased, although the nature of this increase is unclear.
osteoporosis; bone mineral density; Medicare reimbursement
Limitation in the activities of daily living (ADLs) is strongly prognostic for mortality. Current ADL assessments based on numbers of limitations (counts) obscure the particular activities limited, thus lacking clinical interpretability.
To examine the independent association of 5 stages of ADL with mortality after accounting for known diagnostic and sociodemographic risk factors.
For five stages (ADL 0 to IV), describing both the severity and pattern of ADLs limited, we estimated unadjusted life expectancies and adjusted associations with mortality using a Cox proportional hazards regression model.
Included were 9,447 persons 70 years of age and older from the second Longitudinal Study of Aging.
1-, 5-, and 10-year survival and time to death.
For those with no ADL limitations, the median life expectancy was 10.6 years compared to 6.5, 5.1, 3.8, and 1.6 years for those at ADL I, II, III, and IV, respectively. The sociodemographic and diagnostic-adjusted hazard of death at 1 year was 5-fold greater at stage IV compared to stage 0 (hazard ratio=5.6; 95% confidence interval, 3.8–8.3). The associations of ADL stage with mortality declined over time, but remained statistically significant at 5 and 10 years.
ADL stage continued to explain mortality risk after adjusting for known risk factors including advanced age, stroke, and cancer. ADL stages might aid clinical care planning and policy as a powerful prognostic indicator particularly of short-term mortality, improving on current ADL measures by profiling activity limitations of relevance to determining community support needs.
Activities of Daily Living; Staging; Mortality; Risk factors
To compare characteristics of indoor and outdoor recurrent fallers and explore some implications for clinical practice, in which a fall risk assessment for all recurrent fallers has been recommended.
Prospective cohort study.
MOBILIZE Boston, a study of falls etiology among community-dwelling older individuals from randomly sampled households in the Boston MA area.
713 women and men, mainly of age 70 years and older, with at least one year of follow-up.
Data at baseline and an 18-month follow-up examination were collected by questionnaire and comprehensive clinic examination. During follow-up participants recorded falls on daily calendars. A telephone interview queried location and circumstances of each fall.
145 participants reported recurrent falls (≥ 2 falls) during the first year. Those who had fallen only outdoors had good health characteristics, whereas those who had fallen only indoors were generally in poor health. For instance, 25.5% of indoor-only recurrent fallers had gait speeds < 0.6 meters/second compared to 2.9% among outdoor-only recurrent fallers; the respective percentages were 44.7% and 8.8% for Berg balance score < 48. Recurrent indoor fallers generally had poor health characteristics regardless of their activity at the time of their falls, whereas recurrent outdoor fallers who fell during vigorous activity or walking were especially healthy. A report of any recurrent falls in the first year did not predict number of positive findings on either a comprehensive or abbreviated fall risk assessment at the 18-month follow-up examination.
Characteristics of community-dwelling older people with recurrent indoor and outdoor falls are very different. If confirmed, these results suggest that different types of fall risk assessment are needed for specific categories of recurrent fallers.
recurrent falls; risk factors; aging research; fall risk assessment
Describe prevalence of diabetes mellitus among centenarians.
44 counties in northern Georgia.
244 centenarians (aged 98-108, 15.8% men, 20.5% African-American, 38.0% community-dwelling) from the Georgia Centenarian Study (2001-2009).
Nonfasting blood samples assessed HbA1c and relevant clinical parameters. Demographic, diagnosis, and diabetes complications covariates were assessed.
12.5% of centenarians were known to have diabetes. Diabetes was more prevalent among African-Americans (27.7%) than Whites (8.6%, p=.0002). There were no differences between men (16.7%) and women (11.7%, p=.414), centenarians living in the community (10.2%) or facilities (13.9%, p=.540). Diabetes was more prevalent among overweight/obese (23.1%) than non-overweight (7.1%, p=.002) centenarians. Anemia (78.6% versus 48.3%, p=.004) and hypertension (79.3% versus 58.6%, p=.041) were more prevalent among centenarians with diabetes than without and centenarians with diabetes took more nonhypoglycemic medications(8.6 versus 7.0, p=.023). No centenarians with hemoglobin A1c < 6.5% had random serum glucose levels above 200 mg/dl. Diabetes was not associated with 12 month all-cause mortality, visual impairment, amputations, cardiovascular disease or neuropathy. 37% of centenarians reported onset before age 80 (survivors), 47% between 80 and 97 years (delayers) and 15% age 98 or older (escapers).
Diabetes is a risk factor for cardiovascular disease and mortality, but is seen in persons who live into very old age. Aside from higher rates of anemia and use of more medications, few clinical correlates of diabetes were observed in centenarians.
Centenarians; Type 2 diabetes mellitus; Hemoglobin A1c
Background and Objectives
Nearly one-third of nursing home residents in the US receive antipsychotic medications, yet important questions remain concerning their safety. We sought to compare the risk of major medical events in residents newly initiated on conventional or atypical antipsychotics.
Cohort study, using linked Medicaid, Medicare, Minimum Data Set and Online Survey Certification and Reporting data. Propensity score-adjusted proportional hazards models were used to compare risks for medical events at a class and individual drug level.
Nursing homes in 45 US states.
83,959 Medicaid eligible residents ≥65 who initiated antipsychotic treatment following nursing home admission in 2001-2005.
Conventional and atypical antipsychotics.
Hospitalization for myocardial infarction, cerebrovascular events, serious bacterial infections and hip fracture within 180 days of treatment initiation.
Risks of bacterial infections (HR = 1.25, 95%CI 1.05-1.49) and possibly myocardial infarction (1.23, 95%CI 0.81-1.86) and hip fracture (1.29, 95%CI 0.95-1.76) were higher and risks of cerebrovascular events (0.82, 95%CI 0.65-1.02) were lower among patients initiating conventional compared to atypical agents. Little variation existed among individual atypical agents, except for a somewhat lower risk of cerebrovascular events with olanzapine (0.91, 95%CI 0.81-1.02) and quetiapine (0.89, 95%CI 0.79-1.02); a lower risk of bacterial infections (0.83, 95%CI 0.73-0.94) and possibly a higher risk of hip fracture (1.17, 95%CI 0.96-1.43) with quetiapine, all compared with risperidone. Dose-response relations were observed for all events (1.12, 95%CI 1.05-1.19 for high- vs low-dose for all events combined).
These associations underscore the importance of carefully selecting the specific antipsychotic agent and dose, and monitoring their safety, especially in nursing home residents who have an array of medical illnesses and receive complex medication regimens.
Antipsychotics; nursing homes; safety; dementia
The effect of dietary protein intake on muscle strength in older persons is unknown. The objective of this study was to examine whether protein intake is associated with change in muscle strength in older persons. Because systemic inflammation has been associated with protein catabolism, we also evaluated whethera synergistic effect exists between protein intake and inflammatory markers on change in muscle strength using a longitudinal study of community-dwelling persons aged 65 years or older.
The InCHIANTI Study.
Five hundred and ninety-eight persons.
Knee extension strength was measured at baseline (1998–2000) and during 3-year follow-up (2001–2003) using a hand-held dynamometer. Protein intake was assessed using a very detailed food frequency questionnaire. The inflammatory markers included in this study were C-reactive protein (CRP), Interleukin-6 (IL-6), and Tumor Necrosis Factor-α (TNF-α).
The main effect of protein intake on change in muscle strength was not significant, but we found a significant interaction between protein intake and CRP, IL-6 and TNF-α (p=0.003, p=0.049 and p=0.019, respectively), indicating thata lower protein intake was associated with a greater decline in muscle strength in persons with high levels of inflammatory markers.
Selectively in older persons with a pro-inflammatory state, low protein intake was associated with accelerated decline in muscle strength. These results may help to understand the factors contributing to decline in muscle strength and to identify the target population of older persons who may benefit from nutritional interventions aimed at preventing or reducing age-associated muscle impairments and its detrimental consequences.
Muscle Strength; Protein Intake; Inflammatory markers
The objective of this study is to quantify the relation between reported elder self-neglect and rate of hospitalization in a community population of older adults.
Prospective population-based study
Geographically-defined community in Chicago.
Community-dwelling older adults who participated in the Chicago Health and Aging Project. Of the 6,864 participants in the Chicago Health and Aging Project, a subset of 1,165 participants was reported to social services agency for suspected elder self-neglect.
The primary predictor was elder self-neglect reported to social services agency. Outcome of interest was the annual rate of hospitalization obtained from the Center for Medicare and Medicaid System. Poisson regression models were used to assess these longitudinal relationships.
The average annual rate of hospitalization for those without elder self-neglect was 0.6 (1.3) and for those with reported elder self-neglect was 1.8 (3.2). After adjusting for sociodemographic, socioeconomic, medical commorbidities, cognitive function and physical function, elders who self-neglect had significantly higher rate of hospital utilization (RR, 1.47, 95% CI, 1.39–1.55). Greater self-neglect severity (Mild: PE=0.24, SE=0.05, p<0.001; Moderate: PE=0.45, SE=0.03, p<0.001; Severe: PE=0.54, SE=0.11, p<0.001) were associated with increased annual rates of hospital utilization, after considering same confounders. Interaction term analyses suggest that the significant relationship between self-neglect and hospitalization was not mediated through medical conditions, cognitive impairment and physical disability.
Reported elder self-neglect was associated with increased rates of hospitalization in this community population. Greater self-neglect severity was associated with a greater increase in the rate of hospitalization.
elder self-neglect; health services utilization; population-based study
A better understanding is needed about the role of depression and chronic pain, two related chronic conditions, as predictors of falls in older persons.
To examine whether overall depressive symptoms and symptom clusters are associated with fall risk, and to determine whether chronic pain mediates the relationship between depression and fall risk in aging.
Prospective cohort study.
City of Boston and surrounding communities.
Older community-dwelling adults (n=722,mean age 78.3y).
Depressive symptomatology was assessed at baseline by the CESDR as overall depression and two separate domains, cognitive or somatic symptoms. Chronic pain was examined at baseline as: number of pain sites (none, single site, or multisite/widespread), pain severity, and pain interference with daily life activities. Participants recorded falls on monthly postcards during a subsequent 18-month period.
By using negative binomial regression, the rate of incident falls was highest among those with highest burden of depressive symptoms (indicated by total CESDR, Cognitive or Somatic CESDR domains). After adjustment for multiple confounders and fall risk factors, fall rate ratios comparing the highest CESDR three quartiles to the lowest quartile were 1.91, 1.26, 1.11, respectively. Similarly graded associations were observed according to CESDR domains. Although pain location and interference were mediators of the relationship between depression and falls, adjustment for pain reduced fall risk estimates only modestly. There was no interaction between depression and pain in relation to fall risk.
Depressive symptoms are associated with fall risk in older adults and are mediated in part by chronic pain. Research is needed to determine effective strategies for reducing fall risk and related injuries in older people who have pain and depressive symptoms.
Depression; Falls; Pain; Aging
Trauma exposure and posttraumatic stress disorder (PTSD) may increase risk for medical conditions in older adults. We present findings on past-year medical conditions associated with lifetime trauma exposure, and full and partial PTSD, in a nationally representative sample of U.S. older adults.
Design, Setting, Participants, and Measurements
Face-to-face diagnostic interviews were conducted with 9,463 adults aged 60 and older in the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Logistic regression analyses adjusting for sociodemographics and psychiatric comorbidity evaluated associations between PTSD status and past-year medical disorders; linear regression models evaluated associations with past-month physical functioning.
After adjustment for sociodemographic characteristics and comorbid lifetime mood, anxiety, substance use, attention-deficit/hyperactivity, and personality disorders, respondents with lifetime PTSD were more likely than trauma controls to report being diagnosed by a healthcare professional with hypertension, angina pectoris, tachycardia, other heart disease, stomach ulcer, gastritis, and arthritis (odds ratios [ORs]=1.3–1.8); they also scored lower on a measure of physical functioning than controls and respondents with partial PTSD. Respondents with lifetime partial PTSD were more likely than controls to report past-year diagnoses of gastritis (OR=1.7), angina pectoris (OR=1.5), and arthritis (OR=1.4), and reported worse physical functioning. Number of lifetime traumatic event types was associated with most of the medical conditions assessed; adjustment for these events reduced the magnitudes of and rendered non-significant most associations between PTSD status and medical conditions.
Older adults with lifetime PTSD have elevated rates of several physical health conditions, many of which are chronic disorders of aging, and poorer physical functioning. Older adults with lifetime partial PTSD have elevated rates of gastritis, angina pectoris, and arthritis, and poorer physical functioning.
posttraumatic stress disorder; medical; comorbidity; epidemiology; older adults
To utilize the Medicare Files of Service Use (MFSU) to evaluate patterns in the incidence of aging-related diseases in the U.S. elderly population.
Age-specific incidence rates of nineteen aging-related diseases were evaluated with the National Long Term Care Survey (NLTCS) and the Surveillance, Epidemiology, and End Results (SEER) Registry data both linked to MSUF (NLTCS-M and SEER-M, respectively), using a developed algorithm for individual date at onset evaluation.
A random sample from the entire U.S. elderly population (Medicare beneficiaries) was used in NLTCS, and 26% of U.S. population is covered by the SEER Registry data.
34,077 individuals from NLTCS-M and 2,154,598 from SEER-M.
Individual medical histories were reconstructed using information on diagnoses coded in MFSU, dates of medical services/procedures, and Medicare enrollment/disenrollment.
The majority of diseases (e.g., prostate cancer, asthma, diabetes) had a monotonic decline (or decline following short period of increase) in incidence with age. A monotonic increase of incidence with age with a subsequent leveling off and decline was observed for myocardial infarction, stroke, heart failure, ulcer, and Alzheimer’s disease. An inverted U-shaped age pattern was detected for lung and colon carcinomas, Parkinson’s disease, and renal failure. The results obtained from the NLTCS-M and SEER-M were in agreement (excluding an excess for circulatory diseases in the NLTCS-M). A sensitivity analysis proved the stability of the evaluated incidence rates.
The developed computational approaches applied to the nationally representative Medicare-based datasets allows reconstruction of age patterns of disease incidence in the U.S. elderly population at the national level with unprecedented statistical accuracy and stability with respect to systematic biases.
Medicare; chronic disease onset; comorbidity
To investigate whether demographic (age and education) adjustments for the Mini-Mental State Examination (MMSE) attenuate mean score discrepancies between African American and Caucasian adults, and to determine whether demographically-adjusted MMSE scores improve the diagnostic classification accuracy of dementia in African American adults when compared to unadjusted MMSE scores.
Community-dwelling adults participating in the Mayo Clinic Alzheimer’s Disease Patient Registry (ADPR) and Alzheimer’s Disease Research Center (ADRC).
Three thousand two hundred fifty-four adults (2819 Caucasian, 435 African American) aged 60 and older.
MMSE at study entry.
African American adults obtained significantly lower unadjusted MMSE scores (23.0 ± 7.4) compared to Caucasian adults (25.3 ± 5.4). This discrepancy persisted despite adjustment of MMSE scores for age and years of education using established regression weights or newly-derived weights. However, controlling for dementia severity at baseline and adjusting MMSE scores for age and quality of education attenuated this discrepancy. Among African American adults, an age- and education-adjusted MMSE cut score of 23/24 provided optimal dementia classification accuracy, but this represented only a modest improvement over an unadjusted MMSE cut score of 22/23. The posterior probability of dementia in African American adults is presented for various unadjusted MMSE cut scores and prevalence rates of dementia.
Age, dementia severity at study entry, and quality of educational experience are important explanatory factors to understand the existing discrepancies in MMSE performance between Caucasian and African American adults. Our findings support the use of unadjusted MMSE scores when screening African American elders for dementia, with an unadjusted MMSE cut score of 22/23 yielding optimal classification accuracy.
MMSE; African American; ethnicity; dementia; cognition
Depressive symptoms are often reported to be higher in very old populations when compared to younger age groups. However, it is unclear whether the differences are due to age differences in dysphoria or in other components of depression.
The purpose of this study was to examine age differences for specific items and subscales of the Geriatric Depression Scale (GDS).
The current study compared specific items, subscales, and the total score from the GDS among three age groups.
Community-dwelling older adults were tested.
One hundred and thirty-nine centenarians were compared to 93 octogenarians and 91 sexagenarians.
The GDS (Brink et al., 1982) was used in this study.
Results indicated age-group differences in the overall depression score and in the withdrawal-apathy-vigor (WAV), mental impairment, and hopelessness subscale scores, as well as on the item level with significant age group differences on 12 of the 30 items. Centenarians rated higher on all subscales, but there was no difference in dysphoria.
It is important to distinguish different dimensions of depression when assessing very old populations because some of the questions on the GDS are associated with fatigue, mild cognitive decline, and decline in physical functioning which increase with aging. Future research should revisit the concept of depression in very late life.
Depression; fatigue; centenarians
Frailty is a dynamic geriatric syndrome characterized by decreased reserve and increased vulnerability. Low serum 25-hydroxyvitamin D [25(OH)D] concentrations in older adults are associated with many physiological changes that portend frailty and its consequences. We aimed to assess whether serum 25(OH)D concentrations relate to transitions between the states of robustness, prefrailty, and frailty, and to mortality.
DESIGN, SETTING, and PARTICIPANTS
Adults aged≥65 years (N=1,155) enrolled in Invecchiare in Chianti (InCHIANTI), a prospective cohort study in Tuscany, Italy.
Serum 25(OH)D concentrations measured at baseline and frailty state (robust, prefrail, frail) assessed at baseline and at three and six years post enrollment. Vital status was also determined at three and six years post enrollment.
The median (interquartile range) 25(OH)D concentration was 16.0 (10.4—25.6) ng/mL (multiply by 2.496 to convert to nmol/L). Prefrail participants with 25(OH)D<20 ng/mL were 8.9% (95% Confidence Interval [CI], 2.5—15.2%) more likely to die, 3.0% (95%CI, −5.6—14.6%) more likely to become frail, and 7.7% (95%CI, −3.5—18.7%) less likely to become robust than prefrail participants with 25(OH)D≥20 ng/mL. Among prefrail participants, each 5 ng/mL decrement of continuous 25(OH)D was associated with 1.46 times higher odds of dying (95%CI, 1.18—2.07) and 1.13 higher odds of incident frailty (95%CI, 0.90—1.39) versus recovery of robustness. Transitions from robustness or frailty were not associated with 25(OH)D.
Results provide evidence that prefrailty is an “at risk” state from which older adults with high 25(OH)D are more likely to recover than to decline. However, high 25(OH)D was not associated with recovery from frailty. Thus, 25(OH)D should be investigated as a potential therapy to treat prefrailty and prevent further decline.
Frailty; Mortality; Vitamin D
Expert communication is essential to high quality care for older patients with serious illness. While the importance of communication skills is widely recognized, formal curricula for teaching communication skills to geriatrics and palliative medicine fellows is often inadequate or unavailable. We drew upon the educational principles and format of an evidence-based, interactive teaching method, to develop an intensive communication skills training course designed specifically to address the common communication challenges faced by geriatrics and palliative medicine fellows. The 2-day retreat, held away from the hospital environment, included large-group overview presentations, small-group communication skills practice, and development of future skills practice commitment. Faculty received in-depth training in small-group facilitation techniques prior to the course. Geriatrics and palliative medicine fellows were recruited to participate in the course and 100% (n=18) enrolled. Overall satisfaction with the course was very high (mean 4.8 on 5-point scale). Compared to before the course, fellows reported an increase in self-assessed preparedness for specific communication challenges (mean increase 1.4 on 5-point scale, p<0.01). Two months after the course, fellows reported a high level of sustained skills practice (mean 4.3 on 5-point scale). In sum, the intensive communication skills program, tailored to the specific needs of geriatrics and palliative medicine fellows, improved fellows’ self-assessed preparedness for challenging communication tasks and provided a model for ongoing deliberate practice of communication skills.
3–5 Medical Education; Communication Skills; Geriatrics; Palliative Care