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1.  Racial Similarities and Differences in Predictors of Mobility Change over Eighteen Months 
Journal of General Internal Medicine  2004;19(11):1118-1126.
OBJECTIVES
To define racial similarities and differences in mobility among community-dwelling older adults and to identify predictors of mobility change.
DESIGN
Prospective, observational, cohort study.
PARTICIPANTS
Nine hundred and five community-dwelling older adults.
MEASURES
Baseline in-home assessments were conducted to assess life-space mobility, sociodemographic variables, disease status, geriatric syndromes, neuropsychological factors, and health behaviors. Disease reports were verified by review of medications, physician questionnaires, or hospital discharge summaries. Telephone interviews defined follow-up life-space mobility at 18 months of follow-up.
RESULTS
African Americans had lower baseline life-space (LS-C) than whites (mean 57.0 ± standard deviation [SD] 24.5 vs. 72.7 ± SD 22.6; P < .001). This disparity in mobility was accompanied by significant racial differences in socioeconomic and health status. After 18 months of follow-up, African Americans were less likely to show declines in LS-C than whites. Multivariate analyses showed racial differences in the relative importance and strength of the associations between predictors and LS-C change. Age and diabetes were significant predictors of LS-C decline for both African Americans and whites. Transportation difficulty, kidney disease, dementia, and Parkinson's disease were significant for African Americans, while low education, arthritis/gout, stroke, neuropathy, depression, and poor appetite were significant for whites.
CONCLUSIONS
There are significant disparities in baseline mobility between older African Americans and whites, but declines were more likely in whites. Improving transportation access and diabetes care may be important targets for enhancing mobility and reducing racial disparities in mobility.
doi:10.1111/j.1525-1497.2004.30239.x
PMCID: PMC1494786  PMID: 15566441
aging; mobility; function; African American; minority health; health disparities
2.  Correlates of ADL difficulty in a large hemodialysis cohort 
Needing assistance with activities of daily living (ADL) is an early indicator of functional decline and has important implications for individuals’ quality of life. However, correlates of need for ADL assistance have received limited attention among patients undergoing maintenance hemodialysis (HD). A multi-center cohort of 742 prevalent HD patients was assessed 2009–2011 and classified as frail, pre-frail and non-frail by the Fried frailty index (recent unintentional weight loss, reported exhaustion, low grip strength, slow walk speed, low physical activity). Patients reported need for assistance with four ADL tasks and identified contributing symptoms/conditions (pain, balance, endurance, weakness, other). Nearly one in five patients needed assistance with one or more ADL. Multivariable analysis showed increased odds for needing ADL assistance among frail (odds ratio [OR], 11.35; 95% CI, 5.50–23.41; P < 0.001) and pre-frail (OR, 1.93; (95% CI, 1.01–3.68; P = 0.046) compared with non-frail patients. In addition, the odds for needing ADL assistance were lower among blacks compared with whites and were higher among patients with diabetes, lung disease, and stroke. Balance, weakness, and “other” (frequently dialysis-related) symptoms/conditions were the most frequently named reasons for ADL difficulty. In addition to interventions such as increasing physical activity that might delay or reverse the process of frailty, the immediate symptoms/conditions to which individuals attribute their ADL difficulty may have clinical relevance for developing targeted management and/or treatment approaches.
doi:10.1111/hdi.12098
PMCID: PMC3887518  PMID: 24118865
Activities of daily living; frailty; hemodialysis; symptoms/conditions
3.  Digoxin Use and Lower 30-Day All-Cause Readmission for Medicare Beneficiaries Hospitalized for Heart Failure 
The American journal of medicine  2013;127(1):61-70.
BACKGROUND
Heart failure is the leading cause for hospital readmission, the reduction of which is a priority under the Affordable Care Act. Digoxin reduces 30-day all-cause hospital admission in chronic systolic heart failure. Whether digoxin is effective in reducing readmission after hospitalization for acute decompensation remains unknown.
METHODS
Of the 5153 Medicare beneficiaries hospitalized for acute heart failure and not receiving digoxin, 1054 (20%) received new discharge prescriptions for digoxin. Propensity scores for digoxin use, estimated for each of the 5153 patients, were used to assemble a matched cohort of 1842 (921 pairs) patients (mean age, 76 years; 56% women; 25% African American) receiving and not receiving digoxin, who were balanced on 55 baseline characteristics.
RESULTS
30-day all-cause readmission occurred in 17% and 22% of matched patients receiving and not receiving digoxin, respectively (hazard ratio {HR} for digoxin, 0.77; 95% confidence interval {CI}, 0.63–0.95). This beneficial association was observed only in those with ejection fraction <45% (HR, 0.63; 95% CI, 0.47–0.83), but not in those with ejection fraction ≥45% (HR, 0.91; 95% CI, 0.60–1.37; p for interaction, 0.145), a difference that persisted throughout first 12-month post-discharge (p for interaction, 0.019). HRs (95% CIs) for 12-month heart failure readmission and all-cause mortality were 0.72 (0.61–0.86) and 0.83 (0.70–0.98), respectively.
CONCLUSIONS
In Medicare beneficiaries with systolic heart failure, a discharge prescription of digoxin was associated with lower 30-day all-cause hospital readmission, which was maintained at 12 months, and was not at the expense of higher mortality. Future randomized controlled trials are needed to confirm these findings.
doi:10.1016/j.amjmed.2013.08.027
PMCID: PMC3929967  PMID: 24257326
Digoxin; heart failure; hospital readmission
4.  Prevention of heart failure in older adults may require higher levels of physical activity than needed for other cardiovascular events 
International journal of cardiology  2013;168(3):1905-1909.
Background
Little is known if the levels of physical activity required for the prevention of incident heart failure (HF) and other cardiovascular events vary in community-dwelling older adults.
Methods
We studied 5503 Cardiovascular Health Study (CHS) participants, age ≥65 years, free of baseline HF. Weekly metabolic equivalent task-minutes (MET-minutes), estimated using baseline total leisure-time energy expenditure, were used to categorize participants into four physical activity groups: inactive (0 MET-minutes; n=489; reference), low (1–499; n=1458), medium (500–999; n=1086) and high (≥1000; n=2470).
Results
Participants had a mean (±SD) age of 73 (±6) years, 58% were women, and 15% African American. During 13 years of follow-up, centrally-adjudicated incident HF occurred in 26%, 23%, 20%, and 19% of participants with no, low, medium and high physical activity, respectively (trend p <0.001). Compared with inactive older adults, age-sex-race-adjusted hazard ratios (95% confidence intervals) for incident HF associated with low, medium and high physical activity were 0.87 (0.71–1.06; p=0.170), 0.68 (0.54–0.85; p=0.001) and 0.60 (0.49–0.74; p<0.001), respectively (trend p <0.001). Only high physical activity had significant independent association with lower risk of incident HF (HR, 0.79; 95% CI, 0.64–0.97; p=0.026). All levels of physical activity had significant independent association with lower risk of incident acute myocardial infarction (AMI), stroke and cardiovascular mortality.
Conclusion
In community-dwelling older adults, high level of physical activity was associated with lower risk of incident HF, but all levels of physical activity were associated with lower risk of incident AMI, stroke, and cardiovascular mortality.
doi:10.1016/j.ijcard.2012.12.053
PMCID: PMC4142221  PMID: 23380700
Physical activity; MET-minutes; Incident heart failure; Older adults
5.  Symptom Burden Predicts Nursing Home Admissions Among Older Adults 
Context
Symptom burden has been associated with functional decline in community-dwelling older adults and may be responsive to interventions. Known predictors of nursing home (NH) admission are often nonmodifiable.
Objectives
To determine if symptom burden independently predicted NH admission among community-dwelling older adults over an 8½ year follow-up period.
Methods
A random sample of community-dwelling Medicare beneficiaries in Alabama, stratified by race, gender, and rural/urban residence, had baseline in-home assessments of sociodemographic measurements, Charlson comorbidity count, and symptoms. Symptom burden was derived from a count of 10 patient-reported symptoms. Nursing home admissions were determined from telephone interviews conducted every six months over the 8½ years of the study. Cox proportional hazard modeling was used to examine the significance of symptom burden as a predictor for NH admission after adjusting for other variables.
Results
The mean±SD age of the sample (N=999) was 75.3±6.7 years, and the sample was 51% rural, 50% African American, and 50% male. Thirty-eight percent (n=380) had symptom burden scores ≥ 2. Seventy-five participants (7.5%) had confirmed dates for NH admission during the 8½ years of follow-up. Using Cox proportional hazard modeling, symptom burden remained an independent predictor of time to NH placement (HR=1.11, P=0.02), even after adjustment for comorbidity count, race, sex and age.
Conclusion
Symptom burden is an independent risk factor for NH admission. Aggressive management of symptoms in older adults may reduce or delay NH admission.
doi:10.1016/j.jpainsymman.2012.10.228
PMCID: PMC3748255  PMID: 23218806
symptom burden; nursing home admission; risk factor
6.  Religiosity and Function Among Community-Dwelling Older Adult Survivors of Cancer 
Aspects of religiosity/spirituality are important to health and quality of life of cancer patients. The three components of religiosity of the Duke Religiosity Scale: organizational (religious affiliation and attendance); non-organizational (prayer, meditation, and private study); and intrinsic religiosity (identification with a higher power and integration of spiritual belief into daily life) are used to determine whether religiosity was associated with physical and/or mental functioning among older cancer survivors of the UAB Study of Aging. Church attendance was independently associated with lower ADL and IADL difficulty and fewer depressive symptoms, while intrinsic religiosity was independently associated with lower depression scores.
doi:10.1080/15528030.2013.787575
PMCID: PMC3889668  PMID: 24436690
Aging/Ageing; Bible Study; Church; Religion; Prayer
7.  Functional status, life-space mobility, and quality of life: a longitudinal mediation analysis 
Purpose
Using the Wilson–Cleary model of patient outcomes as a conceptual framework, the impact of functional status on health-related quality of life (HRQoL) among older adults was examined, including tests of the mediation provided by life-space mobility.
Methods
Participants were enrollees in a population-based, longitudinal study of mobility among community-dwelling older adults. Data from four waves of the study equally spaced approximately 18 months apart (baseline, 18, 36, and 54 months) were used for participants who survived at least 1 year beyond the 54-month assessment (n = 677). Autoregressive mediation models using longitudinal data and cross-sectional mediation models using baseline data were evaluated and compared using structural equation modeling.
Results
The longitudinal autoregressive models supported the mediating role of life-space mobility and suggested that this effect is larger for the mental component summary score than the physical component summary score of the SF-12. Evidence for a reciprocal relationship over time between functional status, measured by ADL difficulty, and life-space mobility was suggested by modification indices; these model elaborations did not alter the substantive meaning of the mediation effects. Mediated effect estimates from longitudinal autoregressive models were generally larger than those from cross-sectional models, suggesting that mediating relationships would have been missed or were potentially underestimated in cross-sectional models.
Conclusions
These results support a mediating role for life-space mobility in the relationship between functional status and HRQoL. Functional status limitations might cause diminished HRQoL in part by limiting mobility. Mobility limitations may precede functional status limitations in addition to being a consequence thereof.
doi:10.1007/s11136-012-0315-3
PMCID: PMC3618999  PMID: 23161329
Wilson; Cleary model; Activities of daily living; Mobility; SF-12; Longitudinal mediation; Autoregressive mediation modeling
8.  Life-Space Mobility Predicts Nursing Home Admission Over Six Years 
Journal of aging and health  2013;25(6):907-920.
Objective
To explore the association between baseline life-space mobility and nursing home (NH) admission among community-dwelling older adults over six years.
Methods
Using data from a prospective, observational cohort study consisting of a random sample of 1000 Medicare beneficiaries ≥ 65 years of age stratified by race (African American and non-Hispanic White), sex, and rural/urban residence. Baseline life-space mobility was assessed during in-home interviews. Participants were contacted by telephone every six months to ascertain NH admissions, Life-Space Assessment (LSA) scores and vital status (living or deceased). Using multivariate logistic regression, the significance and independence of the relationship of life-space mobility with NH admission was examined.
Results
Over six years, the odds of NH admission increased 2% for every one point lower baseline life-space score independent of previously recognized risk factors.
Discussion
The LSA may be a useful tool to identify older adults at risk for NH admission.
doi:10.1177/0898264313497507
PMCID: PMC4071297  PMID: 23965310
Geriatric Assessment; Risk Factors; Nursing Homes
9.  Physical Impairment Is Associated With Nursing Home Admission for Older Adults in Disadvantaged But Not Other Neighborhoods: Results From the UAB Study of Aging 
The Gerontologist  2012;53(4):641-653.
Objectives: Aging adults face an increased risk of adverse health events as well as risk for a decrease in personal competencies across multiple domains. These factors may inhibit the ability of an older adult to age in place and may result in a nursing home admission (NHA). This study combines insights from Lawton’s environmental press theory with the neighborhood disadvantage (ND) literature to examine the interaction of the neighborhood environment and individual characteristics on NHA. Methods: Characteristics associated with the likelihood of NHA for community-dwelling older adults were examined using data collected for 8.5 years from the UAB Study of Aging. Logistic regression models were used to test direct effects of ND on NHA for all participants. The sample was then stratified into 3 tiers of ND to examine differences in individual-level factors by level of ND. Results: There was no direct link between living in a disadvantaged neighborhood environment and likelihood of NHA, but physical impairment was associated with NHA for older adults living highly disadvantaged neighborhood environments in contrast to older adults living in less disadvantaged neighborhood environments, where no association was observed. Discussion: These outcomes highlight (a) the usefulness of linking Lawton’s theories of the environment with the ND literature to assess health-related outcomes and (b) the importance of neighborhood environment for older adults’ ability to age in place.
doi:10.1093/geront/gns118
PMCID: PMC3709842  PMID: 23034471
Long-term care; Sociology of aging/social gerontology; Home- and community-based care and services; Neighborhoods; Theory
10.  Digoxin Reduces 30-Day All-Cause Hospital Admission in Older Patients with Chronic Systolic Heart Failure 
The American journal of medicine  2013;126(8):701-708.
BACKGROUND
Heart failure is a leading cause of hospital admission and readmission in older adults. The new United States healthcare reform law has created provisions for financial penalties for hospitals with higher-than-expected 30-day all-cause readmission rates for hospitalized Medicare beneficiaries ≥65 years with heart failure. We examined the effect of digoxin on 30-day all-cause hospital admission in older patients with heart failure and reduced ejection fraction.
METHODS
In the main Digitalis Investigation Group (DIG) trial, 6800 ambulatory patients with chronic heart failure (ejection fraction ≤45%) were randomly assigned to digoxin or placebo. Of these, 3405 were ≥65 years (mean age, 72 years, 25% women, 11% non-whites). The main outcome in the current analysis was 30-day all-cause hospital admission.
RESULTS
In the first 30 days after randomization, all-cause hospitalization occurred in 5.4% (92/1693) and 8.1% (139/1712) of patients in the digoxin and placebo groups, respectively, (hazard ratio {HR} when digoxin was compared with placebo, 0.66; 95% confidence interval {CI}, 0.51–0.86; p=0.002). Digoxin also reduced both 30-day cardiovascular (3.5% vs. 6.5%; HR, 0.53; 95% CI, 0.38–0.72; p<0.001) and heart failure (1.7 vs. 4.2%; HR, 0.40; 95% CI, 0.26–0.62; p<0.001) hospitalizations, with similar trends for 30-day all-cause mortality (0.7% vs. 1.3%; HR, 0.55; 95% CI, 0.27–1.11; p=0.096). Younger patients were at lower risk of events but obtained similar benefits from digoxin.
CONCLUSIONS
Digoxin reduces 30-day all-cause hospital admission in ambulatory older patients with chronic systolic heart failure. Future studies need to examine its effect on 30-day all-cause hospital readmission in hospitalized patients with acute heart failure.
doi:10.1016/j.amjmed.2013.02.001
PMCID: PMC3926199  PMID: 23490060
Digoxin; heart failure; 30-day all-cause hospital admission
11.  Effects of enalapril in systolic heart failure patients with and without chronic kidney disease: Insights from the SOLVD Treatment trial 
International journal of cardiology  2012;167(1):151-156.
Background
Angiotensin-converting enzyme inhibitors improve outcomes in systolic heart failure (SHF). However, doubts linger about their effect in SHF patients with chronic kidney disease (CKD).
Methods
In the Studies of Left Ventricular Dysfunction (SOLVD) Treatment trial, 2569 ambulatory chronic HF patients with left ventricular ejection fraction ≤35% and serum creatinine level ≤2.5 mg/dL were randomized to receive either placebo (n=1284) or enalapril (n=1285). Of the 2502 patients with baseline serum creatinine data, 1036 had CKD (estimated glomerular filtration rate <60 ml/min/1.73 m2).
Results
Overall, during 35 months of median follow-up, all-cause mortality occurred in 40% (502/1252) and 35% (440/1250) of placebo and enalapril patients, respectively (hazard ratio {HR}, 0.84; 95% confidence interval {CI}, 0.74–0.95; p=0.007). All-cause mortality occurred in 45% and 42% of patients with CKD (HR, 0.88; 95% CI, 0.73–1.06; p=0.164), and 36% and 31% of non-CKD patients (HR, 0.82; 95% CI, 0.69–0.98; p=0.028) in the placebo and enalapril groups, respectively (p for interaction=0.615). Enalapril reduced cardiovascular hospitalization in those with CKD (HR, 0.77; 95% CI, 0.66–0.90; p<0.001) and without CKD (HR, 0.80; 95% CI, 0.70–0.91; p<0.001). Among patients in the enalapril group, serum creatinine elevation was significantly higher in those without CKD (0.09 versus 0.04 mg/dL in CKD; p=0.003) during first year of follow-up, but there was no differences in changes in systolic blood pressure (mean drop, 7 mmHg, both) and serum potassium (mean increase, 0.2 mEq/L, both).
Conclusions
Enalapril reduces mortality and hospitalization in SHF patients without significant heterogeneity between those with and without CKD.
doi:10.1016/j.ijcard.2011.12.056
PMCID: PMC3395757  PMID: 22257685
enalapril; heart failure; chronic kidney disease
12.  Design and rationale of studies of neurohormonal blockade and outcomes in diastolic heart failure using OPTIMIZE-HF registry linked to Medicare data 
International journal of cardiology  2011;166(1):230-235.
Background
Heart failure (HF) is the leading cause of hospitalization for Medicare beneficiaries. Nearly half of all HF patients have diastolic HF or HF with preserved ejection fraction (HF-PEF). Because these patients were excluded from major randomized clinical trials of neurohormonal blockade in HF there is little evidence about their role in HF-PEF.
Methods
The aims of the American Recovery & Reinvestment Act-funded National Heart, Lung, and Blood Institute-sponsored “Neurohormonal Blockade and Outcomes in Diastolic Heart Failure” are to study the long-term effects of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and aldosterone antagonists in four separate propensity-matched populations of HF-PEF patients in the OPTIMIZE-HF (Organized Program to Initiate Life-Saving Treatment in Hospitalized Patients with Heart Failure) registry. Of the 48,612 OPTIMIZE-HF hospitalizations occurring during 2003–2004 in 259 U.S. hospitals, 20,839 were due to HF-PEF (EF ≥40%). For mortality and hospitalization we used Medicare national claims data through December 31, 2008.
Results
Using a two-step (hospital-level and hospitalization-level) probabilistic linking approach, we assembled a cohort of 11,997 HF-PEF patients from 238 OPTIMIZE-HF hospitals. These patients had a mean age of 75 years, mean EF of 55%, were 62% women, 15% African American, and were comparable with community-based HF-PEF cohorts in key baseline characteristics.
Conclusions
The assembled Medicare-linked OPTIMIZE-HF cohort of Medicare beneficiaries with HF-PEF with long-term outcomes data will provide unique opportunities to study clinical effectiveness of various neurohormonal antagonists with outcomes in HF-PEF using propensity-matched designs that allow outcome-blinded assembly of balanced cohorts, a key feature of randomized clinical trials.
doi:10.1016/j.ijcard.2011.10.089
PMCID: PMC3465528  PMID: 22119116
Diastolic heart failure; neurohormonal antagonists; OPTIMIZE-HF; Medicare
13.  Low Hemoglobin and Recurrent Falls in U.S. Men and Women: Prospective findings from the REasons for Geographic and Racial Differences in Stroke (REGARDS) Cohort 
Background
There are few data available on low hemoglobin levels and incident falls in the general U.S. population.
Methods
Of 30,239 Black and white U.S. adults ≥ 45 years old in the population-based REasons for Geographic and Racial Differences in Stroke (REGARDS) study, 16,782 had hemoglobin measured at baseline and follow-up data on falls. Hemoglobin was categorized by 1.0 g/dL increments relative to the World Health Organization cut-point for anemia (13.0 g/dL for men, 12.0 g/dL for women). Recurrent falls, defined as ≥2 falls in the 6 months following baseline were assessed during a telephone interview.
Results
Recurrent falls occurred in 3.9% of men and 4.8% of women. Compared to those with a hemoglobin 1 to 2 g/dL above the anemia cut-point the multivariable adjusted odds ratios (OR; 95% confidence interval [CI]) for recurrent falls associated with hemoglobin levels ≥ 3g/dL, 2 to <3 g/dL, and 0 to 1 g/dL above the cut-point, and 0 to <1 g/dL and ≥1 g/dL below the cut-point were 0.73 (0.45–1.19), 0.84 (0.57–1.24), 1.29 (0.88–1.90), 1.32 (0.0.80–1.2.18) and 2.12 (1.23–3.63), respectively, among men (linear trend p<0.001) and 1.59 (1.10–2.3), 1.24 (0.95–1.62), 1.42(1.11–1.81), 1.28 (0.91–1.80) and 1.76 (1.13–2.74), respectively, among women (linear trend p=0.45; quadratic trend p=0.016).
Conclusions
Among men, lower hemoglobin was associated with an increased risk for recurrent falls. While our findings suggest an increased risk for recurrent falls at both lower and higher hemoglobin levels among women, these findings should be confirmed in subsequent studies.
doi:10.1097/MAJ.0b013e3182638364
PMCID: PMC3640699  PMID: 23328832
falls; hemoglobin; gender
14.  Angiotensin-Converting Enzyme Inhibitors and Outcomes in Heart Failure and Preserved Ejection Fraction 
The American journal of medicine  2013;126(5):401-410.
BACKGROUND
The role of angiotensin-converting enzyme (ACE) inhibitors in patients with heart failure and preserved ejection fraction remains unclear.
METHODS
Of the 10,570 patients ≥65 years with heart failure and preserved ejection fraction (≥40%) in OPTIMIZE-HF (2003–2004) linked to Medicare (through December, 2008), 7304 were not receiving angiotensin receptor blockers and had no contraindications to ACE inhibitors. After excluding 3115 patients with pre-admission ACE inhibitor use, the remaining 4189 were eligible for new discharge prescriptions for ACE inhibitors, and 1706 received them. Propensity scores for the receipt of ACE inhibitors, calculated for each of the 4189 patients, were used to assemble a cohort of 1337 pairs of patients, balanced on 114 baseline characteristics.
RESULTS
Matched patients had a mean age of 81 years, mean ejection fraction of 55%, 64% were women and 9% African American. Initiation of ACE inhibitor therapy was associated with lower risk of the primary composite endpoint of all-cause mortality or heart failure hospitalization during 2.4 years of median follow-up (hazard ratio {HR}, 0.91; 95% confidence interval {CI}, 0.84–0.99; p=0.028), but not with individual endpoints of all-cause mortality (HR, 0.96; 95% CI, 0.88–1.05; p=0.373) or heart failure hospitalization (HR, 0.93; 95% CI, 0.83–1.05; p=0.257).
CONCLUSION
In hospitalized older patients with heart failure and preserved ejection fraction not receiving angiotensin receptor blockers, discharge initiation of ACE inhibitor therapy was associated with a modest improvement in the composite endpoint of total mortality or heart failure hospitalization, but had no association with individual endpoint components.
doi:10.1016/j.amjmed.2013.01.004
PMCID: PMC3656660  PMID: 23510948
ACE inhibitors; Heart Failure; Preserved Ejection Fraction
15.  Nondisease-Specific Problems and All-Cause Mortality in the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study 
Background/Objectives
Problems that cross multiple domains of health are frequently assessed in older adults. We evaluated the association between six of these nondisease-specific problems and mortality among middle-aged and older adults.
Design
Prospective, observational cohort
Setting
U.S. population sample
Participants
Participants included 23,669 black and white US adults ≥ 45 years of age enrolled in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study.
Measurements
Nondisease-specific problems included cognitive impairment, depressive symptoms, falls, polypharmacy, impaired mobility and exhaustion. Age-stratified (<65, 65-74, and ≥ 75 years) hazard ratios for all-cause mortality were calculated for each problem individually and by number of problems.
Results
Among participants < 65, 65-74, ≥ 75 years old, one or more nondisease-specific problems occurred in 40%, 45% and 55% of participants, respectively. Compared to those with none of these problems the multivariable adjusted hazard ratios and 95% confidence intervals for all-cause mortality associated with each additional nondisease-specific problem was 1.34 (1.23–1.46), 1.24 (1.15–1.35) and 1.30 (1.21–1.39), among participants < 65, 65 – 74 years, ≥ 75 years of age, respectively.
Conclusion
Nondisease-specific problems were associated with mortality across a wide age spectrum. Future studies should determine if treating these problems will improve survival and identify innovative healthcare models to address multiple nondisease-specific problems simultaneously.
doi:10.1111/jgs.12214
PMCID: PMC3656135  PMID: 23617688
nondisease-specific problems; geriatrics; mortality
16.  Life-Space Mobility Among Mexican Americans Aged 75 Years and Older 
OBJECTIVE
To examine the factors associated with life-space mobility in older Mexican Americans.
DESIGN
Cross-sectional study involving a population-based survey.
SETTING
Hispanic Established Population for the Epidemiologic Study of the Elderly survey conducted in the southwestern of United States (Texas, Colorado, Arizona, New Mexico, and California).
PARTICIPANTS
728 Mexican American men and women aged 75 years and older.
MEASUREMENTS
In-home interviews assessed socio-demographic factors, self-reported physician-diagnoses of medical conditions (arthritis, diabetes, heart attack, stroke, hip fracture, and cancer), depressive symptoms, cognitive function, body mass index (BMI), upper and lower extremity muscle strength, short physical performance battery (SPPB), activities of daily living (ADLs), instrumental activities of daily living (IADLs), and the life-space assessment (LSA).
RESULTS
Mean age of participants was 84.2 years (SD, 4.2). Sixty-five percent were female. Mean score of LSA was 41.7 (SD, 20.9). Multiple regression analysis showed that older age, being female, limitation in ADLs, stroke, high depressive symptoms and BMI ≥35 kg/m2 were significantly associated with lower scores in LSA. Education and high performances in lower extremity function and in muscle strength were factors significantly associated with higher scores in LSA.
CONCLUSION
Older Mexican Americans had restricted life-space with approximately 80% limited to their home or neighborhood. Age, gender, stroke, high depressive symptoms, BMI ≥ 35 Kg/m2, and ADL disability were related to decreased life-space. Future studies are needed to examine the association between life-space and health outcomes and to characterize the trajectory of life-space over time in this population.
doi:10.1111/j.1532-5415.2011.03822.x
PMCID: PMC3996837  PMID: 22283683
mobility; life-space; older adults; Mexican American
17.  Racial and Sex Differences in Associations between Activities of Daily Living and Cognition Among Community-Dwelling Older Adults 
Background/Objectives
Appropriate management of older adults includes assessment of cognition and understanding its relationship to function. The aim of this analysis was to examine the association between function measured by activities of daily living, both basic (BADL) and instrumental (IADL), and cognition assessed by MMSE scores among older African American and non-Hispanic White community-dwelling men and women.
Design
Cross-sectional study assessing associations between self-reported BADL and IADL difficulty and MMSE scores for race/sex specific groups.
Setting
Homes of community-dwelling older adults.
Participants
A random sample of 974 African American and non-Hispanic White Medicare beneficiaries age 65 years and older living in west-central Alabama, participating in the University of Alabama at Birmingham (UAB) Study of Aging, but excluding those with reported diagnoses of dementia or with missing data.
Measurements
Function, based on self-reported difficulty in performing Basic and Instrumental Activities of Daily Living (BADL and IADL); Cognition, using the Mini-Mental State Exam (MMSE); Multivariable, linear regression models were used to test the association of function and cognition by race and sex-specific groups after adjusting for covariates.
Results
MMSE scores were modestly correlated with BADL and IADL in all four race/sex-specific group with Pearson r values ranging from −0.189 for non-Hispanic white women and −0.429 for African American men. Correlations of MMSE with BADL or IADL difficulty in any of the race/sex-specific groups were no longer significant after controlling for socio-demographic factors and comorbidities.
Conclusion
MMSE was not significantly associated with functional difficulty among older African American and non-Hispanic white men and women in the Deep South after adjusting for socio-demographic factors and comorbidities, suggesting a mediating role in the relationship between cognition and function.
PMCID: PMC3909884  PMID: 24479147
function; basic and instrumental activities of daily living; cognitive screening; MMSE; race, ethnicity, sex, and gender differences
18.  Renin-Angiotensin Inhibition in Diastolic Heart Failure and Chronic Kidney Disease 
The American journal of medicine  2013;126(2):150-161.
BACKGROUND
The role of renin-angiotensin inhibition in older patients with diastolic heart failure and chronic kidney disease remains unclear.
METHODS
Of the 1340 patients (age ≥65 years), with diastolic heart failure (ejection fraction ≥45%) and chronic kidney disease (estimated glomerular filtration rate <60 ml/min/1.73 m2), 717 received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Propensity scores for the use of these drugs, estimated for each of the 1340 patients, were used to assemble a cohort of 421 pairs of patients, receiving and not receiving these drugs, who were balanced on 56 baseline characteristics.
RESULTS
During more than 8 years of follow-up, all-cause mortality occurred in 63% and 69% of matched patients with chronic kidney disease receiving and not receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, respectively (hazard ratio {HR}, 0.82; 95% confidence interval {CI}, 0.70–0.97; p=0.021). There was no association with heart failure hospitalization (HR, 0.98; 95% CI, 0.82–1.18; p=0.816). Similar mortality reduction (HR, 0.81; 95% CI, 0.66–0.995; p=0.045) occurred in a subgroup of matched patients with an estimated glomerular filtration rate <45 ml/min/1.73 m2. Among 207 pairs of propensity-matched patients without chronic kidney disease, the use of these drugs was not associated with mortality (HR, 1.03; 95% CI, 0.80–1.33; p=0.826) or heart failure hospitalization (HR, 0.99; 95% CI, 0.76–1.30; p=0.946).
CONCLUSIONS
A discharge prescription for angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was associated with a significant reduction in all-cause mortality in older patients with diastolic heart failure and chronic kidney disease including those with more advanced chronic kidney disease.
doi:10.1016/j.amjmed.2012.06.031
PMCID: PMC3575519  PMID: 23331442
Angiotensin-converting enzyme inhibitors; Angiotensin receptor blockers; Chronic kidney disease; Diastolic heart failure
19.  Indicators of Childhood Quality of Education in Relation to Cognitive Function in Older Adulthood 
Background.
The association between years of education and cognitive function in older adults has been studied extensively, but the role of quality of education is unknown. We examined indicators of childhood educational quality as predictors of cognitive performance and decline in later life.
Methods.
Participants included 433 older adults (52% African American) who reported living in Alabama during childhood and completed in-home assessments of cognitive function at baseline and 4 years later. Reports of residence during school years were matched to county-level data from the 1935 Alabama Department of Education report for school funding (per student), student–teacher ratio, and school year length. A composite measure of global cognitive function was utilized in analyses. Multilevel mixed effects models accounted for clustering of educational data within counties in examining the association between cognitive function and the educational quality indices.
Results.
Higher student–teacher ratio was associated with worse cognitive function and greater school year length was associated with better cognitive function. These associations remained statistically significant in models adjusted for education level, age, race, gender, income, reading ability, vascular risk factors, and health behaviors. The observed associations were stronger in those with lower levels of education (≤12 years), but none of the education quality measures were related to 4-year change in cognitive function.
Conclusions.
Educational factors other than years of schooling may influence cognitive performance in later life. Understanding the role of education in cognitive aging has substantial implications for prevention efforts as well as accurate identification of older adults with cognitive impairment.
doi:10.1093/gerona/gls122
PMCID: PMC3598357  PMID: 22546959
Cognitive aging; Education; Health disparities
20.  Aldosterone Antagonists and Outcomes in Real-World Older Patients with Heart Failure and Preserved Ejection Fraction 
JACC. Heart failure  2013;1(1):40-47.
Objectives
The purpose of this study was to examine the clinical effectiveness of aldosterone antagonists in older patients with heart failure and preserved ejection fraction (HF-PEF).
Background
Aldosterone antagonists improve outcomes in HF and reduced EF. However, their role in HF-PEF remains unclear.
Methods
Of the 10,570 hospitalized older (age ≥65 years) HF-PEF (EF ≥40%) patients in Medicare-linked OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) trial, 8013 had no prior aldosterone antagonist use and no current contraindications, of whom 492 (6% of 8013) received new prescriptions for aldosterone antagonists. We assembled a matched cohort of 487 pairs of patients receiving and not receiving aldosterone antagonists, who had similar propensity to receive these drugs, and were balanced on 116 baseline characteristics.
Results
Patients had a mean age of 80 years, a mean EF of 54%, 59% were women, and 8% were African American. During 2.4 year of mean follow-up (through December, 2008), the primary composite endpoint of all-cause mortality or HF hospitalization occurred in 392 (81%) and 393 (81%) patients receiving and not receiving aldosterone antagonists, respectively (hazard ratio {HR}, 0.97; 95% confidence interval {CI}, 0.84–1.11; p=0.628). Aldosterone antagonists had no association with all-cause mortality (HR, 1.03; 95% CI, 0.89–1.20; p=0.693) or HF hospitalization (HR, 0.88; 95% CI, 0.73–1.07; p=0.188). Among 8013 pre-match patients, multivariable-adjusted HR for primary composite endpoint associated with aldosterone antagonist use was 0.93 (95% CI, 0.83–1.03; p=0.144).
Conclusions
In older HF-PEF patients, aldosterone antagonists had no association with clinical outcomes. Findings from the ongoing randomized controlled TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) trial will provide further insights into their effect in HF-PEF.
doi:10.1016/j.jchf.2012.08.001
PMCID: PMC3694622  PMID: 23814702
Aldosterone antagonists; Heart failure; Preserved ejection fraction
21.  Baseline Characteristics, Quality of Care, and Outcomes of Younger and Older Medicare Beneficiaries Hospitalized with Heart Failure: Findings from the Alabama Heart Failure Project 
Background
Most studies of heart failure (HF) in Medicare beneficiaries have excluded patients age <65 years. We examined baseline characteristics, quality of care, and outcomes among younger and older Medicare beneficiaries hospitalized with HF in the Alabama Heart Failure Project.
Methods
Of the 8049 Medicare beneficiaries discharged alive with a primary discharge diagnosis of HF in 1998–2001 from 106 Alabama hospitals, 991 (12%) were younger (age <65 years). After excluding 171 patients discharge to hospice care, 7867 patients were considered eligible for left ventricular systolic function (LVSF) evaluation and 2211 patients with left ventricular ejection fraction <45% and without contraindications were eligible for angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy.
Results
Nearly half of the younger HF patients (45% versus 22% for ≥65 years; p<0.001) were African American. LVSF was evaluated in 72%, 72%, 70% and 60% (overall p<0.001) and discharge prescriptions of ACE inhibitors or ARBs were given to 83%, 77%, 75% and 75% of eligible patients (overall p=0.013) among those <65, 65–74, 75–84 and ≥85 years, respectively. During 9 years of follow-up, all-cause mortality occurred in 54%, 61%, 71% and 80% (overall p<0.001) and hospital readmission due to worsening HF occurred in 65%, 60%, 55% and 48% (overall p<0.001) of those <65, 65–74, 75–84 and ≥85 years, respectively.
Conclusion
Medicare beneficiaries <65 years with HF, nearly half of whom were African American, generally received better quality of care, had lower mortality, but had higher re-hospitalizations due to HF.
doi:10.1016/j.ijcard.2011.05.003
PMCID: PMC3395759  PMID: 21621285
heart failure; age; Medicare; quality of care; outcomes
22.  Predictors of 4-Year Retention Among African American and White Community-Dwelling Participants in the UAB Study of Aging 
The Gerontologist  2011;51(Suppl 1):S46-S58.
Purpose: To identify racial/ethnic differences in retention of older adults at 3 levels of participation in a prospective observational study: telephone, in-home assessments, and home visits followed by blood draws. Design and Methods: A prospective study of 1,000 community-dwelling Medicare beneficiaries aged 65 years and older included a baseline in-home assessment and telephone follow-up calls at 6-month intervals; at 4 years, participants were asked to complete an additional in-home assessment and have blood drawn. Results: After 4 years, 21.7% died and 0.7% withdrew, leaving 776 participants eligible for follow-up (49% African American; 46% male; 51% rural). Retention for telephone follow-up was 94.5% (N = 733/776); 624/733 (85.1%) had home interviews, and 408/624 (65.4%) had a nurse come to the home for the blood draw. African American race was an independent predictor of participation in in-home assessments, but African American race and rural residence were independent predictors of not participating in a blood draw. Implications: Recruitment efforts designed to demonstrate respect for all research participants, home visits, and telephone follow-up interviews facilitate high retention rates for both African American and White older adults; however, additional efforts are required to enhance participation of African American and rural participants in research requiring blood draws.
doi:10.1093/geront/gnr024
PMCID: PMC3092976  PMID: 21565818
Minority aging; Urban/rural elders; Prospective study; In-home assessments; Observational study; Telephone follow-up
23.  Predicting the Trajectories of Perceived Pain Intensity in Southern Community-Dwelling Older Adults: The Role of Religiousness 
Research on aging  2012;35(6):10.1177/0164027512456402.
This study focuses on the identification of multiple latent trajectories of pain intensity, and it examines how religiousness is related to different classes of pain trajectory. Participants were 720 community-dwelling older adults who were interviewed at four time points over a 3-year period. Overall, intensity of pain decreased over 3 years. Analysis using latent growth mixture modeling (GMM) identified three classes of pain: (1) increasing (n = 47); (2) consistently unchanging (n = 292); and (3) decreasing (n = 381). Higher levels of intrinsic religiousness (IR) at baseline were associated with higher levels of pain at baseline, although it attenuated the slope of pain trajectories in the increasing pain group. Higher service attendance at baseline was associated with a higher probability of being in the decreasing pain group. The increasing pain group and the consistently unchanging group reported more negative physical and mental health outcomes than the decreasing pain group.
doi:10.1177/0164027512456402
PMCID: PMC3813015  PMID: 24187410
pain trajectory; religiousness; latent growth modeling
24.  Angiotensin receptor blockers and outcomes in real-world older patients with heart failure and preserved ejection fraction: a propensity-matched inception cohort clinical effectiveness study 
European Journal of Heart Failure  2012;14(10):1179-1188.
Aims
To examine the clinical effectiveness of angiotensin receptor blockers (ARBs) in older patients with heart failure and preserved ejection fraction (HF-PEF).
Methods and results
Of the 10 570 hospitalized HF-PEF patients, aged ≥65 years, EF ≥40%, in OPTIMIZE-HF (2003–2004), linked to Medicare data (up to 31 December 2008), 3806 were not receiving angiotensin-converting enzyme inhibitors or prior ARB therapy. Of these, 303 (8%) patients received new discharge prescriptions for ARBs. Propensity scores for the receipt of ARBs, estimated for each of the 3806 patients, were used to assemble a cohort of 296 pairs of patients receiving and not receiving ARBs, who were balanced on 114 baseline characteristics. Patients had a mean age of 80 years, mean EF of 55%, 69% were women, and 12% were African American. During 6 years of follow-up, the primary composite endpoint of all-cause mortality or HF hospitalization occurred in 79% (235/296) and 81% (241/296) of patients receiving and not receiving ARBs, respectively [hazard ratio (HR) associated with ARB use 0.88, 95% confidence interval (CI) 0.74–1.06; P = 0.179]. ARB use had no association with individual endpoints of all-cause mortality (HR 0.93, 95% CI 0.76–1.14; P = 0.509), HF hospitalization (HR 0.90, 95% CI, 0.72–1.14; P = 0.389), or all-cause hospitalization (HR 0.91, 95% CI 0.77–1.08; P = 0.265). These associations remained unchanged when we compared any (prevalent and new prescriptions) ARB use vs. non-use in a separately assembled propensity-matched cohort of 1137 pairs of HF-PEF patients.
Conclusions
In real-world older HF-PEF patients, ARB use was not associated with improved clinical outcomes.
doi:10.1093/eurjhf/hfs101
PMCID: PMC3448391  PMID: 22759445
Angiotensin receptor blockers; Heart failure; Preserved ejection fraction
25.  Symptom Burden Predicts Hospitalization Independent of Comorbidity in Community-Dwelling Older Adults 
OBJECTIVES
To determine if cumulative symptom burden predicted hospitalizations or emergency department (ED) visits in a cohort of older adults.
DESIGN
Prospective, observational study with a baseline in-home assessment of symptom burden.
SETTING
Central Alabama.
PARTICIPANTS
980 community-dwelling adults age 65 years or older recruited from a random sample of Medicare beneficiaries, stratified by sex, race, and urban/rural residence.
MEASUREMENTS
Symptom burden score (range 0–10). One point was added to the score for each symptom reported: shortness of breath, tiredness/fatigue, problems with balance/dizziness, leg weakness, poor appetite, pain, stiffness, constipation, anxiety, and loss of interest in activities. Dependent variables: Hospitalizations and ED visits assessed every 6 months during the 8.5 year follow-up period. Using Cox proportional hazard models, we determined time from the baseline in-home assessment to the first hospitalization and first hospitalization or ED visit.
RESULTS
During the 8.5 year follow up period, 545 (55.6%) participants were hospitalized or had an ED visit. The participants’ mean age was 75.3 years ± 6.7. Compared to those with lower scores, participants with greater symptom burden had higher risk of hospitalization (hazard ratio (HR)=1.09, 95% confidence interval=1.05–1.14) and hospitalization or ED visit (HR=1.10, 95% CI=1.06–1.14). Participants living in rural areas had significantly lower risk of hospitalization (HR=0.83, 95% CI= 0.69–0.99) and hospitalization or ED visit (HR=0.80, 95% CI=0.70–0.95) compared to individuals in urban areas, independent of symptom burden and comorbidity.
CONCLUSION
Greater symptom burden was associated with higher risk of hospitalization and ED visits in community-dwelling older adults. Health care providers treating older adults should consider symptom burden as an additional risk factor for subsequent hospital utilization.
doi:10.1111/j.1532-5415.2012.04121.x
PMCID: PMC3458585  PMID: 22985139
healthcare utilization; symptom; older adults; comorbidity

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