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1.  Risk Factors for Restricting Back Pain in Older Persons 
Journal of the American Medical Directors Association  2013;15(1):10.1016/j.jamda.2013.09.013.
Objectives
To identify risk factors for back pain leading to restricted activity (restricting back pain) in older persons.
Design
Prospective cohort study.
Setting
Greater New Haven, Connecticut.
Participants
731 men and women aged 70 years or older, who were community-living and non-disabled in essential activities of daily living at baseline.
Measurements
Candidate risk factors were ascertained every 18 months for 108 months during comprehensive home-based assessments. Restricting back pain was assessed during monthly telephone interviews for up to 126 months. Incident episodes of: (1) short-term (one episode lasting one month) restricting back pain; and (2) persistent (one episode lasting two or more months) or recurrent (two or more episodes of any duration) restricting back pain were determined during each 18-month interval. The associations between the candidate risk factors and short-term and persistent/recurrent restricting back pain, respectively, were evaluated using a multivariable Cox model.
Results
The cumulative incidence was 21.3% (95% confidence interval (CI) 19.6%, 23.1%) for short-term restricting back pain and 20.6% (CI 18.6%, 22.9%) for persistent/recurrent restricting back pain over a median follow-up of 109 months. In a recurrent event multivariable analysis, female sex (HR 1.30; 1.07, 1.58), weak grip strength (HR 1.24; 1.01,1.52), and hip weakness (HR 1.19; 1.07,1.32) were independently associated with an increased likelihood of having short-term restricting back pain, while female sex (HR 1.48; CI 1.13,1.94), depressive symptoms (HR 1.57; 1.23, 2.00), 2 or more chronic conditions (HR 1.38; 1.08, 1.77), and arthritis (HR1.66; 1.31, 2.09) were independently associated with persistent/recurrent restricting back pain.
Conclusion
In this prospective study, several factors were independently associated with restricting back pain, including some that may be modifiable and therefore potential targets for interventions to reduce this common and often recurrent condition in older persons.
doi:10.1016/j.jamda.2013.09.013
PMCID: PMC3872215  PMID: 24239445
Aged; Back Pain; Risk Factors; Cohort Studies
2.  Trends in Fall-Related Traumatic Brain Injury among Older Persons in Connecticut from 2000–2007 
Background
Anecdotal evidence suggests a rising trend in the occurrence of fall-related traumatic brain injuries (FR-TBI) among persons ≥ 70 years. To document this apparent trend on a more substantive basis, this report longitudinally describes overall and age-stratified rates of three outcomes attributed to FR-TBI among persons ≥ 70 years: emergency department visits (ED), hospitalizations, and terminal hospitalizations.
Methods
Eight years (2000–2007) of observational data from emergency departments and acute care hospitals serving a non-randomly selected, densely populated region in southern Connecticut, U.S.
Results
From 2000–2007 among persons 70 years and older, overall rates of FR-TBI visits to emergency departments more than doubled while corresponding rates of hospitalization and terminal hospitalization rose 58% each. The point estimate of growth in the rate of ED in the oldest stratum was nearly triple that of the younger stratum whereas point estimates of growth in rates of hospitalization and terminal hospitalization were nearly four times higher. Total Medicare costs for ED visits increased nearly four-fold while corresponding costs for hospitalizations and terminal hospitalizations rose by 64% and 76%. The most common discharge diagnoses for ED and hospitalization were unspecified head injury and intracranial hemorrhage.
Conclusions
The rapid rise in rates of FR-TBI and associated Medicare costs underscore the urgent need to prevent this burgeoning source of human suffering and health care utilization. We believe the rise in rates is at least partially due to a greater public awareness of the outcome that has been facilitated by increasing use of diagnostic imaging in the ED and hospital.
doi:10.4172/2167-7182.1000168
PMCID: PMC4280829  PMID: 25558438
Connecticut collaboration for fall prevention; Fall-related traumatic brain injury; Hospitalization; Emergency department; Anticoagulation therapy
3.  Association Between Treatment or Usual Care Region and Hospitalization for Fall-Related Traumatic Brain Injury in the Connecticut Collaboration for Fall Prevention 
BACKGROUND
Most traumatic brain injuries among older persons in the U.S. are attributed to falls. Efforts to prevent falls may also plausibly reduce the incidence of TBIs and resultant costs.
OBJECTIVES
To evaluate the association between the treatment or usual care region of the Connecticut Collaboration for Fall Prevention (CCFP), a clinical intervention for prevention of falls, and the rate of hospitalization for fall-related traumatic brain injury (FR-TBI) among persons ≥ 70 years. The Medicare charges of FR-TBI hospitalizations are also described.
DESIGN
Using a quasi-experimental design, rates of hospitalization for FR-TBI were recorded over an eight year period (2000–2007) in two distinct geographic regions (treatment and usual care) chosen for their similarity in characteristics associated with occurrence of falls.
SETTING/PARTICIPANTS
Over 200,000 persons, 70 years and older, residing in two geographical regions in Connecticut.
INTERVENTION
Clinicians in the treatment region translated research protocols from Yale FICSIT, a successful fall prevention randomized clinical trial, into discipline- and site-specific fall prevention procedures for integration into their clinical practices.
MEASUREMENTS
The rate of hospitalization for fall-related traumatic brain injury among persons 70 years and older
RESULTS
Relative to the usual care region, CCFP’s treatment region exhibited lower rates of hospitalization for FR-TBI; RR= 0.84 with 95% credible interval (0.72 – 0.99).
CONCLUSION
The significantly lower rate of hospitalization for FR-TBI in CCFP’s treatment region suggests that the engagement of practicing clinicians in the implementation of evidence-based fall-prevention practices may reduce hospitalizations for FR-TBI.
doi:10.1111/jgs.12462
PMCID: PMC3801219  PMID: 24083593
Connecticut Collaboration for Fall Prevention; fall-related traumatic brain injury; hospitalization; Bayesian; spatial model
4.  Integration of Fall Prevention into State Policy in Connecticut 
The Gerontologist  2012;53(3):508-515.
Purpose of Study: To describe the ongoing efforts of the Connecticut Collaboration for Fall Prevention (CCFP) to move evidence regarding fall prevention into clinical practice and state policy. Methods: A university-based team developed methods of networking with existing statewide organizations to influence clinical practice and state policy. Results: We describe steps taken that led to funding and legislation of fall prevention efforts in the state of Connecticut. We summarize CCFP’s direct outreach by tabulating the educational sessions delivered and the numbers and types of clinical care providers that were trained. Community organizations that had sustained clinical practices incorporating evidence-based fall prevention were subsequently funded through mini-grants to develop innovative interventional activities. These mini-grants targeted specific subpopulations of older persons at high risk for falls. Implications: Building collaborative relationships with existing stakeholders and care providers throughout the state, CCFP continues to facilitate the integration of evidence-based fall prevention into clinical practice and state-funded policy using strategies that may be useful to others.
doi:10.1093/geront/gns122
PMCID: PMC3635855  PMID: 23042690
Polypharmacy; Connecticut Collaboration for Fall Prevention; Balance training; Visiting nurse association; Fall prevention
6.  Impact of Comorbidity on Mortality Among Older Persons with Advanced Heart Failure 
BACKGROUND
Care for patients with advanced heart failure (HF) has traditionally focused on managing HF alone; however, little is known about the prevalence and contribution of comorbidity to mortality among this population. We compared the impact of comorbidity on mortality in older adults with HF with high mortality risk and those with lower mortality risk, as defined by presence or absence of a prior hospitalization for HF, respectively.
METHODS
This was a retrospective cohort study (2002–2006) of 18,322 age-matched and gender-matched Medicare beneficiaries. We used the baseline year of 2002 to ascertain HF hospitalization history, in order to identify beneficiaries at either high or low risk of future HF mortality. We calculated the prevalence of 19 comorbidities and overall comorbidity burden, defined as a count of conditions, among both high and low risk beneficiaries, in 2002. Proportional hazards regressions were used to determine the effect of individual comorbidity and comorbidity burden on mortality between 2002 and 2006 among both groups.
RESULTS
Most comorbidities were significantly more prevalent among hospitalized versus non-hospitalized beneficiaries; myocardial infarction, atrial fibrillation, kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and hip fracture were more than twice as prevalent in the hospitalized group. Among hospitalized beneficiaries, myocardial infarction, diabetes, COPD, CKD, dementia, depression, hip fracture, stroke, colorectal cancer and lung cancer were each significantly associated with increased hazard of dying (hazard ratios [HRs]: 1.16-1.93), adjusting for age, gender and race. The mortality risk associated with most comorbidities was higher among non-hospitalized beneficiaries (HRs: 1.32-3.78).
CONCLUSIONS
Comorbidity confers a significantly increased mortality risk even among older adults with an overall high mortality risk due to HF. Clinicians who routinely care for this population should consider the impact of comorbidity on outcomes in their overall management of HF. Such information may also be useful when considering the risks and benefits of aggressive, high-intensity life-prolonging interventions.
doi:10.1007/s11606-011-1930-3
PMCID: PMC3326095  PMID: 22095572
heart failure; mortality; comorbidity
7.  Effect of Dissemination of Evidence in Reducing Injuries from Falls 
The New England journal of medicine  2008;359(3):252-261.
Background
Falling is a common and morbid condition among elderly persons. Effective strategies to prevent falls have been identified but are underutilized.
Methods
Using a nonrandomized design, we compared rates of injuries from falls in a region of Connecticut where clinicians had been exposed to interventions to change clinical practice (intervention region) and in a region where clinicians had not been exposed to such interventions (usual-care region). The interventions encouraged primary care clinicians and staff members involved in home care, outpatient rehabilitation, and senior centers to adopt effective risk assessments and strategies for the prevention of falls (e.g., medication reduction and balance and gait training). The outcomes were rates of serious fall-related injuries (hip and other fractures, head injuries, and joint dislocations) and fall-related use of medical services per 1000 person-years among persons who were 70 years of age or older. The interventions occurred from 2001 to 2004, and the evaluations took place from 2004 to 2006.
Results
Before the interventions, the adjusted rates of serious fall-related injuries (per 1000 person-years) were 31.2 in the usual-care region and 31.9 in the intervention region. During the evaluation period, the adjusted rates were 31.4 and 28.6, respectively (adjusted rate ratio, 0.91; 95% Bayesian credibility interval, 0.88 to 0.94). Between the preintervention period and the evaluation period, the rate of fall-related use of medical services increased from 68.1 to 83.3 per 1000 person-years in the usual-care region and from 70.7 to 74.2 in the intervention region (adjusted rate ratio, 0.89; 95% credibility interval, 0.86 to 0.92). The percentages of clinicians who received intervention visits ranged from 62% (131 of 212 primary care offices) to 100% (26 of 26 home care agencies).
Conclusions
Dissemination of evidence about fall prevention, coupled with interventions to change clinical practice, may reduce fall-related injuries in elderly persons.
doi:10.1056/NEJMoa0801748
PMCID: PMC3472807  PMID: 18635430
8.  Change in Comorbidity Prevalence with Advancing Age Among Persons with Heart Failure 
Journal of General Internal Medicine  2011;26(10):1145-1151.
Background
Comorbidity—a condition that co-exists with a primary illness—is common among older persons with heart failure and can complicate the overall management of this population.
Objectives
To determine the relationship between advancing age and the prevalence and patterns of comorbidity among older persons with heart failure.
Design
Retrospective longitudinal cohort study
Participants
A total of 201,130 Medicare beneficiaries with heart failure stratified into three age strata in 2001: 66–75, 76–85, and 86+ years, and followed over 5 years.
Measurements
(1) Prevalence of 19 conditions as identified by the Chronic Conditions Warehouse from Medicare claims data, characterized as concordant (related to heart failure) or discordant (unrelated to heart failure), and (2) overall comorbidity burden, defined as count of conditions.
Results
The median number of comorbidities rose from four (IQR: 2–5) to five (IQR: 4–7) among the young-old, and from 4 (IQR: 3–6) to 6 (IQR: 5–8) among the middle-old and oldest-old between 2001 and 2006. In 2001, the majority of concordant conditions were more prevalent among the youngest than oldest beneficiaries (e.g., diabetes 46.2% vs 26.9%; kidney disease 21.8% vs 18.4%), while the majority of discordant conditions were more prevalent among the oldest-old than youngest-old beneficiaries (e.g., dementia 39.6% vs 9.9%; hip fracture 9.5% vs 1.9%). Discordant conditions increased in prevalence faster among the oldest than youngest beneficiaries (e.g., dementia 13% points versus 9% points).
Conclusion
Among older Medicare beneficiaries with heart failure, there is a higher overall burden of comorbidity and greater prevalence of discordant comorbidity among the oldest old. Comorbidity prevalence increases over time, with discordant comorbidity increasing at the fastest rate among the oldest old. This comorbidity burden highlights the challenge of effectively treating heart failure while simultaneously managing co-existing and unrelated conditions.
doi:10.1007/s11606-011-1725-6
PMCID: PMC3181289  PMID: 21573881
heart failure; comorbidity; prevalence; age groups
9.  Epidemiology of Restricting Back Pain in Community-Living Older Persons 
Objectives
To estimate the incidence of back pain leading to restricted activity (restricting back pain) in community-living older persons and to characterize its descriptive epidemiology.
Design
Prospective cohort study.
Setting
Greater New Haven, Connecticut.
Participants
550 nondisabled, community-living men and women, aged 70+ years, who did not report restricting back pain at baseline.
Measurements
Participants were interviewed monthly for more than 10 years to ascertain the cumulative incidence, time to first episode, incidence rates (including first and repeat episodes), and duration of restricting back pain. Cumulative incidence (proportions) were estimated using the Kaplan-Meier method and incidence rates (per 1000 person-months) were estimated using a Poisson regression model.
Results
During the 10+ years of follow-up (median: 107 months), the cumulative incidence of restricting back pain was 77.3% for men and 81.7% for women. The median time to the first episode was significantly shorter in women (25 months) than men (49 months) (p = 0.01). The incidence rates of restricting back pain per 1000 person-months were 32.9 overall, 24.4 for men, and 37.5 for women (p < 0.001). There were no differences by baseline age group. Of the 1528 total episodes of restricting back pain, the median duration was 1.0 month, and only 6.4% lasted for ≥ three consecutive months.
Conclusion
Restricting back pain among older persons is common, short-lived, and frequently episodic. The burden of restricting back pain is greater among older women than older men.
doi:10.1111/j.1532-5415.2011.03329.x
PMCID: PMC3098613  PMID: 21410444
Aged; Back Pain; Epidemiology; Cohort Studies
10.  Prognostic Significance of Potential Frailty Criteria 
Objectives
To determine the independent prognostic effect of 7 potential frailty criteria, including 5 from the Fried phenotype, on several adverse outcomes.
Design
Prospective cohort study.
Setting
Greater New Haven, Connecticut.
Participants
Seven hundred fifty-four initially non-disabled, community-living persons aged 70 and older.
Measurements
An assessment of 7 potential frailty criteria (slow gait speed, low physical activity, weight loss, exhaustion, weakness, cognitive impairment and depressive symptoms) was completed at baseline and every 18 months for 72 months. Participants were followed with monthly telephone interviews for up to 96 months to determine the occurrence of chronic disability, long-term nursing home (NH) stays, injurious falls, and death.
Results
In analyses that were adjusted for age, sex, race, education, number of chronic conditions, and the presence of the other potential frailty criteria, 3 of the 5 Fried criteria (slow gait speed, low physical activity, and weight loss) were independently associated with chronic disability, long-term NH stays, and death. Slow gait speed was the strongest predictor of chronic disability (Hazard ratio [HR] 2.97, 95% confidence interval [CI], 2.32–3.80), and long-term NH stays (HR 3.86, 95% CI, 2.23–6.67), and was the only significant predictor of injurious falls (HR 2.19, 95% CI, 1.33–3.60). Cognitive impairment was also associated with chronic disability (HR 1.82, 95% CI, 1.40–2.38), long-term NH stays (HR 2.64, 95% CI, 1.75–3.99), and death (HR 1.54, 95% CI, 1.13–2.10), and the magnitude of these associations was comparable to that of weight loss.
Conclusions
The results of our study provide strong evidence to support the use of slow gait speed, low physical activity, weight loss and cognitive impairment as key indicators of frailty, while raising concerns about the value of self-reported exhaustion and muscle weakness.
doi:10.1111/j.1532-5415.2008.02008.x
PMCID: PMC2782664  PMID: 19093920
frailty; disability; cohort study; prognosis
11.  Differential Impact of Involuntary Job Loss on Physical Disability Among Older Workers Does Predisposition Matter? 
Research on aging  2009;31(3):345-360.
Older workers' share of involuntary job losses in the United States has grown fairly consistently in recent decades, prompting greater interest in the health consequences of involuntary unemployment among individuals nearing retirement. In this study, the authors applied the multifactorial model of geriatric health to investigate whether late-career involuntary job loss was associated with subsequent physical disability and whether the effect of involuntary job loss on physical disability varied by predisposition. Using data from the first four waves (1992 to 1998) of the Health and Retirement Survey, the authors measured predisposition with individual risk factors for functional disability and indices of aggregate risk. The results of gender-specific models fit with generalized estimating equations revealed that unmarried women and those with low predisplacement incomes had heightened risk for subsequent functional disability. No differential effects of job loss were found for men.
doi:10.1177/0164027508330722
PMCID: PMC2778317  PMID: 19924265
job loss; older workers; disability; Health and Retirement Survey
12.  Recoverable Cognitive Dysfunction at Hospital Admission in Older Persons During Acute Illness 
Journal of General Internal Medicine  2006;21(12):1276-1281.
BACKGROUND
While acute illness and hospitalization represent pivotal events for older persons, their contribution to recoverable cognitive dysfunction (RCD) has not been well examined.
OBJECTIVE
Our goals were to estimate the frequency and degree of RCD in an older hospitalized cohort; to examine the relationship of RCD with delirium and dementia; and to determine 1-year cognitive outcomes.
DESIGN
Prospective cohort study.
PARTICIPANTS
Four hundred and sixty patients aged ≥70 years drawn from consecutive admissions to an academic hospital.
MEASUREMENTS
Patients underwent interviews daily during hospitalization and at 1 year. The primary outcome was RCD, defined as an admission Mini-Mental State Examination (MMSE) score that improved by 3 or more points by discharge.
RESULTS
Recoverable cognitive dysfunction occurred in 179 of 460 (39%) patients, with MMSE impairment at baseline ranging from 3 to 13 points (median=5.0 points). The majority of cases were not characteristic of either delirium or dementia, as 144 of 179 (80%) cases did not meet criteria for delirium, and 133 of 164 (81%) cases did not meet criteria for dementia at baseline. In multivariable analysis controlling for baseline MMSE level, 3 factors were predictive of RCD: higher educational level, preadmission functional impairment, and higher illness severity. At 1 year, further improvement in MMSE score occurred in 38 of 92 (41%) patients with RCD. Recoverable cognitive dysfunction was independently predictive of 1-year mortality with an adjusted odds ratio of 1.82 (95% confidence interval [95% CI] 1.03 to 3.20).
CONCLUSIONS
Acute illness is accompanied by a high rate of RCD that is neither characteristic of delirium or dementia. Our observations underscore the reversible nature of this cognitive dysfunction with continued improvement over the ensuing year, and highlight the potential clinical implications of this under-recognized phenomenon.
doi:10.1111/j.1525-1497.2006.00613.x
PMCID: PMC1924736  PMID: 16965558
delirium; dementia; cognitive impairment; hospitalization; geriatrics

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