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1.  Ficolin-2 inhibitors are present in sera after prolonged storage at −80 °C 
PeerJ  2016;4:e2705.
Ficolins can activate the lectin pathway of the complement system that provides innate immune protection against pathogens, marks host cellular debris for clearance, and promotes inflammation. Baseline inflammation increases with aging in a phenomenon known as “inflammaging.” Although IL-6 and C-reactive protein are known to increase with age, contributions of many complement factors, including ficolins, to inflammaging have been little studied.
Ficolin-2 is abundant in human serum and can recognize many target structures; therefore, ficolin-2 has potential to contribute to inflammaging. We hypothesized that inflammaging would alter ficolin-2 levels among older adults and examined 360 archived sera collected from older individuals. We found that these sera had apparently reduced ficolin-2 levels and that 84.2% of archived sera exhibited ficolin-2 inhibitors, which suppressed apparent amounts of ficolin-2 detected by enzyme-linked immunosorbent assay. Fresh serum samples were obtained from donors whose archived sera showed inhibitors, but the fresh sera did not have ficolin-2 inhibitors. Ficolin-2 inhibitors were present in other long-stored sera from younger persons. Furthermore, noninhibiting samples and fresh sera from older adults had apparently normal amounts of ficolin-2. Thus, ficolin-2 inhibitors may arise as an artifact of long-term storage of serum at −80 °C.
doi:10.7717/peerj.2705
PMCID: PMC5119277  PMID: 27896034
Ficolins; Lectins; Storage artifacts; Lectin pathway; Complement
2.  The Association Between Life-Space and Health Care Utilization in Older Adults with Heart Failure 
Background:
Life-space is associated with adverse health outcomes in older adults, but its role in health care utilization among individuals with heart failure is not well understood. We examined the relationship between life-space and both emergency department (ED) utilization and hospitalization.
Methods:
Participants were community-dwelling older adults with a verified diagnosis of heart failure who completed a baseline in-home assessment and at least one follow-up telephone interview. Life-space was measured at baseline and at follow-up every 6 months for 8.5 years. Poisson models were used to determine the association between life-space, measured at the beginning of each 6-month interval, and health care utilization, defined as ED utilization or hospitalization in the immediate ensuing 6 months, adjusting for sociodemographic and clinical confounders.
Results:
A total of 147 participants contributed 259 total health care utilization events involving an ED visit or a hospital admission. Multivariate analysis demonstrated an inverse association between life-space and health care utilization, where a clinically significant 10-point difference in life-space was independently associated with a 14% higher rate of ED utilization or hospitalization (incidence rate ratio 1.14, 95% CI 1.04–1.26, p = .004).
Conclusions:
Life-space may be a useful identifier of community-dwelling older adults with heart failure at increased risk of ED visits or hospital admissions in the ensuing 6 months. Life-space may therefore be a potentially important component of intervention programs to reduce health care utilization.
doi:10.1093/gerona/glv076
PMCID: PMC4715243  PMID: 26219849
Life-space; Heart failure; Health care utilization.
3.  The Impact of Veteran Status on Life-Space Mobility among Older Black and White Men in the Deep South 
Ethnicity & Disease  null;25(3):255-262.
Objective
To examine life-space mobility over 8.5 years among older Black and White male veterans and non-veterans in the Deep South.
Design
A prospective longitudinal study of community-dwelling Black and White male adults aged >65 years (N=501; mean age=74.9; 50% Black and 50% White) enrolled in the University of Alabama at Birmingham (UAB) Study of Aging. Data from baseline in-home assessments with follow-up telephone assessments of life-space mobility completed every 6 months were used in linear mixed-effects modeling analyses to examine life-space mobility trajectories.
Main Outcome Measures
Life-space mobility.
Results
In comparison to veterans, non-veterans were more likely to be Black, single, and live in rural areas. They also reported lower income and education. Veterans had higher baseline life-space (73.7 vs 64.9 for non-veterans; P<.001). Race-veteran subgroup analyses revealed significant differences in demographics, comorbidity, cognition, and physical function. Relative to Black veterans, there were significantly greater declines in life-space trajectories for White non-veterans (P=.009), but not for White veterans (P=.807) nor Black non-veterans (P=.633). Mortality at 8.5 years was 43.5% for veterans and 49.5% for non-veterans (P=.190) with no significant differences by race-veteran status.
Conclusions
Veterans had significantly higher baseline life-space mobility. There were significantly greater declines in life-space trajectories for White non-veterans in comparison to other race-veteran subgroups. Black veterans and non-veterans did not have significantly different trajectories.
doi:10.18865/ed.25.3.255
PMCID: PMC4671410  PMID: 26675739
Life-space Mobility; Older Veterans; Cumulative Inequality
4.  An Examination of Lower Extremity Function and its Correlates in Older African American and White Men 
Ethnicity & Disease  null;25(3):271-278.
Objective
Maintaining functional status and reducing/eliminating health disparities in late life are key priorities. Older African Americans have been found to have worse lower extremity functioning than Whites, but little is known about potential differences in correlates between African American and White men. The goal of this investigation was to examine measures that could explain this racial difference and to identify race-specific correlates of lower extremity function.
Methods
Data were analyzed for a sample of community-dwelling men. Linear regression models examined demographics, medical conditions, health behaviors, and perceived discrimination and mental health as correlates of an objective measure of lower extremity function, the Short Physical Performance Battery (SPPB). Scores on the SPPB have a potential range of 0 to 12 with higher scores corresponding to better functioning.
Results
The mean age of all men was 74.9 years (SD=6.5), and the sample was 50% African American and 53% rural. African American men had scores on the SPPB that were significantly lower than White men after adjusting for age, rural residence, marital status, education, and income difficulty (P<.01). Racial differences in cognitive functioning accounted for approximately 41% of the race effect on physical function. Additional models stratified by race revealed a pattern of similar correlates of the SPPB among African American and White men.
Conclusions
The results of this investigation can be helpful for researchers and clinicians to aid in identifying older men who are at-risk for poor lower extremity function and in planning targeted interventions to help reduce disparities.
doi:10.18865/ed.25.3.271
PMCID: PMC4671416  PMID: 26673095
Health Disparities; African American Men; Lower Extremity Function
5.  Race and Sex Differences in Correlates of Systolic Blood Pressure in Community-Dwelling Older Adults 
Objectives
To describe correlates of measured systolic blood pressure (SBP) among community-dwelling older African American and White Medicare beneficiaries.
Methods
Participants completed an in-home assessment and factors significantly correlated with SBP were tested using multivariable models.
Results
Among the 958 participants (mean age= 75.3 [SD = 6.8]; 49% African American; 49% female; 52% rural) African Americans were more often diagnosed with hypertension, more likely on anti-hypertensives, and on more anti-hypertensive medications. SBP was 2.7 mmHg higher in African Americans than Whites (p=.03). SBP was higher in women than men. Multivariable models revealed differences in the factors associated with SBP by race/sex specific groups. Having a history of smoking and reports of being relaxed and free of tension were associated with higher SBP among African American men.
Discussion
Although more likely prescribed anti-hypertensives, mean SBP was higher for older African Americans than Whites. Results support the hypothesis that behavioral and psychosocial factors are more important correlates of SBP levels among older African Americans than among Whites.
PMCID: PMC4713041  PMID: 26779393
older adults; blood pressure; African-Americans; race/ethnicity
6.  Comparison of In-Person and Telephone Administration of the Mini-Mental State Examination in the University of Alabama at Birmingham Study of Aging 
Objectives
To validate the Mini-Mental State Examination (MMSE) telephone (MMSET) against the MMSE.
Design
Cross-sectional.
Setting
Homes of community-dwelling older adults.
Participants
African-American and non-Hispanic white adults aged 75 and older participating in the University of Alabama at Birmingham Study of Aging II, a longitudinal epidemiological study across the state of Alabama (N=419).
Measurements
Cognition, measured using the MMSE, MMSET, and Six-Item Screener (SIS), and function, based on self-reported difficulty performing instrumental activities of daily living (IADLs). Correlation and agreement coefficients were used to examine concordance of the MMSE and MMSET; linear and logistic regressions were used to test associations with clinical outcomes of IADL difficulty and verified diagnoses of dementia.
Results
The MMSET showed good internal consistency (Cronbach α=0.845), similar to the full MMSE, and strong correlation with the latter (Spearman ρ=0.694, p<.001). The MMSET explained a similar proportion of IADL difficulty as the full MMSE (coefficient of variation=0.201 and 0.189, respectively). The MMSET was also associated with verified dementia diagnoses (area under the receiver operating characteristic curve=0.73), which was similar to the full MMSE.
Conclusion
The MMSET is a brief, valid measure of cognition in older adults with psychometric properties similar to that of the full MMSE. Because it can be administered over the telephone, further use in epidemiological studies is promising.
doi:10.1111/jgs.13027
PMCID: PMC4311874  PMID: 25283801
Mini-Mental State Examination; telephone administration; epidemiological studies; cognitive assessment
7.  Nutritional Risk and Body Mass Index Predict Hospitalization, Nursing Home Admissions, and Mortality in Community-Dwelling Older Adults: Results From the UAB Study of Aging With 8.5 Years of Follow-Up 
Background.
Nutritional risk and low BMI are common among community-dwelling older adults, but it is unclear what associations these factors have with health services utilization and mortality over long-term follow-up. The aim of this study was to assess prospective associations of nutritional risk and BMI with all-cause, nonsurgical, and surgical hospitalization; nursing home admission; and mortality over 8.5 years.
Methods.
Data are from 1,000 participants in the University of Alabama at Birmingham Study of Aging, a longitudinal, observational study of older black and white residents of Alabama aged 65 and older. Nutritional risk was assessed using questions associated with the DETERMINE checklist. BMI was categorized as underweight (<18.5), normal weight (18.5–24.9), overweight (25.0–29.9), class I obese (30.0–34.9), and classes II and III obese (≥35.0). Cox proportional hazards models were fit to assess risk of all-cause, nonsurgical, and surgical hospitalization; nursing home admission; and mortality. Covariates included social support, social isolation, comorbidities, and demographic measures.
Results.
In adjusted models, persons with high nutritional risk had 51% greater risk of all-cause hospitalization (95% confidence interval: 1.14–2.00) and 50% greater risk of nonsurgical hospitalizations (95% confidence interval: 1.11–2.01; referent: low nutritional risk). Persons with moderate nutritional risk had 54% greater risk of death (95% confidence interval: 1.19–1.99). BMI was not associated with any outcomes in adjusted models.
Conclusions.
Nutritional risk was associated with all-cause hospitalizations, nonsurgical hospitalizations, and mortality. Nutritional risk may affect the disablement process that leads to health services utilization and death. These findings point to the need for more attention on nutritional assessment, interventions, and services for community-dwelling older adults.
doi:10.1093/gerona/glu024
PMCID: PMC4158410  PMID: 24589863
Nutritional risk; BMI; Health services utilization; Mortality.
8.  Benzodiazepine Use in Community-Dwelling Older Adults: Longitudinal Associations with Mobility, Functioning, and Pain 
The aim of the study was to determine the prospective association between baseline benzodiazepine use and mobility, functioning, and pain among urban and rural African-American and non-Hispanic white community-dwelling older adults. From 1999 to 2001, a cohort of 1,000 community-dwelling adults, aged ≥65 years, representing a random sample of Medicare beneficiaries, stratified by ethnicity, sex, and urban/rural residence were recruited. Benzodiazepine use was assessed at an in-home visit. Every six months thereafter, study outcomes were assessed via telephone for 8.5-years. Mobility was assessed with the Life-Space Assessment. Functioning was quantified with level of difficulty in five basic activities of daily living (ADL: bathing, dressing, transferring, toileting, eating), and six instrumental activities of daily living (shopping, managing money, preparing meals, light and heavy housework, telephone use). Pain was measured by frequency per week and the magnitude of interference with daily tasks. All analytic models were adjusted for relevant covariates and mental health symptoms. After multivariable adjustment, baseline benzodiazepine use was significantly associated with greater difficulty with basic ADL (Estimate = 0.39, 95%CI: 0.04–0.74), and more frequent pain (Estimate = 0.41, 95%CI: 0.09–0.74) in the total sample and declines in mobility among rural residents (Estimate = −0.67, t(5,902)= −1.98, p= .048), over 8.5 years. Benzodiazepine use was prospectively associated with greater risk for basic ADL difficulties and frequent pain among African-American and non-Hispanic white community-dwelling older adults, and life-space mobility declines among rural-dwellers, independently of relevant covariates. These findings highlight the potential long-term negative impact of benzodiazepine use among community-dwelling older adults.
doi:10.1016/j.archger.2014.04.017
PMCID: PMC4130769  PMID: 24880195
benzodiazepines; mobility; pain; older adults; activities of daily living
9.  Life-Space Mobility Declines Associated with Incident Falls and Fractures 
OBJECTIVES
To determine the impact of falls and fractures on life-space mobility in a cohort of community-dwelling older adults.
DESIGN
Prospective, observational study with a baseline in-home assessment and 6-month telephone follow-up interviews over 4 years.
SETTING
Central Alabama, U.S.A.
PARTICIPANTS
Nine hundred seventy community-dwelling adults age ≥ 65 years, recruited from a random sample of Medicare beneficiaries were stratified by sex, race, and urban/rural residence.
MEASUREMENTS
Sociodemographic factors, medical history, depressive symptoms (using the Geriatric Depression Scale), cognitive function (using the Mini-Mental State Examination), mobility-related symptoms, transportation difficulty, and healthcare utilization were assessed during a baseline in-home interview of participants. Life-space mobility, as well as any falls or injuries (including fractures) were assessed both at the baseline interview and at six-month intervals by follow-up telephone calls.
RESULTS
Four hundred and fifty-four (47%) participants reported at least one fall during the 4-year follow-up. The life-space score decreased 3.2 points from the beginning to the end of the six-month interval during which a fall occurred, adjusting for other known predictors of decline in life-space mobility. The decrease in interval life-space score was progressively greater for a fall and an injury (−4.7 points), a fall and a fracture (−14.2 points), and was highest for a fall and a hip fracture (−23.6 points).
CONCLUSION
Falls, whether associated with an injury or not, were independently associated with a decrease in life-space mobility in the ensuing six months. Further studies are needed to determine reasons for life-space mobility decline among community-dwelling older adults with incident falls without any injuries.
doi:10.1111/jgs.12787
PMCID: PMC4049071  PMID: 24731095
Falls; injury; mobility; life-space
10.  Community Mobility Among Older Adults With Reduced Kidney Function: A Study of Life-Space 
Background
Life-space Assessment (LSA) captures community mobility and social participation and quantifies the distance, frequency and independence obtained as an older adult moves through their environment. Reduced estimated glomerular filtration rate (eGFR) is associated with decline in activities of daily living among older adults, but less is known about the association of eGFR with restrictions in mobility.
Study Design
Prospective, observational cohort study.
Setting & Participants
Community-dwelling Medicare beneficiaries from the University of Alabama at Birmingham Study of Aging who had serum creatinine measured during a baseline in-home study visit and completed at least one telephone follow-up (N=390).
Predictor
eGFR ≥ 60, 45-59 and <45 ml/min/1.73 m2.
Outcome
Life-space mobility trajectory.
Measurements
Life-space mobility was evaluated by telephone every six months for up to 4.5 years using the previously validated LSA. Scores using this tool range from 0-120 (higher scores indicate greater mobility).
Results
The mean age of the 390 participants was 77.6 ± 5.8 (SD) years, 41% were African American, and 50.5% were women; 30.0% had an eGFR of 45-59 ml/min/1.73 m2, and 20.2% had an eGFR < 45 ml/min/1.73 m2. Age, race, and sex adjusted mean baseline life-space mobility scores were 64.8 (95% CI, 62.0-67.6), 63.8 (95% CI, 60.3-67.4), and 58.3 (95% CI, 53.8-62.7) among those with eGFR categories ≥ 60, 45-59, and < 45 ml/min/1.73 m2, respectively. Compared to those with eGFR ≥ 60 ml/min/1.73 m2, a more rapid decline in life-space mobility was found among those with eGFR < 45 ml/min/1.73 m2, though this did not reach statistical significance (p=0.06); a similar effect was not seen among those with eGFR 45-59 ml/min/1.73 m2 (p=0.3).
Limitations
Urinary albumin or longitudinal measures of eGFR were not available.
Conclusions
An eGFR < 45 ml/min/1.73 m2 was associated with a trend towards a more rapid decline in life-space mobility among community-dwelling older adults. Findings should be confirmed in a larger population.
doi:10.1053/j.ajkd.2013.07.022
PMCID: PMC3943884  PMID: 24074823
chronic kidney disease; life-space mobility; elderly
11.  Religiosity After a Diagnosis of Cancer Among Older Adults 
Aspects of religiosity are important to health and quality of life of cancer patients. This analysis examined changes in religiosity among community-dwelling cancer survivors. Previously diagnosed and newly diagnosed cancer survivors age 65+ were interviewed at baseline and four years later to understand how components of religiosity may change. Religiosity was assessed as organizational, non-organizational, and intrinsic using the Duke Religiosity Scale. At four years, 45 persons had a new diagnosis of non-skin cancer in addition to the 94 diagnosed at baseline. In comparison to persons without a cancer diagnosis and participants with a baseline diagnosis, newly diagnosed participants were more likely to decrease church attendance. Although not statistically significant, a larger proportion of recently diagnosed persons increased non-organizational religiosity behaviors and intrinsic religiosity compared to those with cancer at baseline and those without cancer. African Americans were more likely than Caucasians to show increased non-organizational religiosity. Caucasians with a cancer diagnosis showed increased intrinsic religiosity, perhaps because of a ceiling effect among African Americans. Although all groups showed declines and increases in the measures, baseline religiosity was the strongest predictor of religiosity at 48 months, indicating stability in religiosity over time, even in the context of a cancer diagnosis.
doi:10.1080/15528030.2014.928922
PMCID: PMC4242422  PMID: 25431539
aging/ageing; religion; prayer; church; spirituality
12.  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
13.  Measuring Symptoms in Community-dwelling Older Adults: The Psychometric Properties of a Brief Symptom Screen 
Medical care  2013;51(10):949-955.
Background
With aging, the probability of experiencing multiple chronic conditions is increased, along with symptoms associated with these conditions. Symptoms form a central component of illness burden and distress. To date, most symptom measures have focused on a particular disease population.
Objective
We sought to develop and evaluate a simple symptom screen using data obtained from a representative sample of community-dwelling older adults.
Methods
Psychometric analyses were conducted on 10 self-reported dichotomous symptom indicators collected during in-person interviews from a sample of 1000 community-dwelling older adults. Symptoms included shortness of breath, feeling tired or fatigued, problems with balance or dizziness, perceived weakness in legs, constipation, daily pain, stiffness, poor appetite, anxiety, and anhedonia.
Results
Over one-third of the sample (37.4%) had 5 or more concurrent symptoms. Stiffness and feeling tired were the most common symptoms. Confirmatory factor analyses were performed on the 10 symptoms for single factor and bifactor (physical and affective) models of symptom reporting. Goodness of fit indices indicated better fit for the bifactor model (χ2df=10=89.6, p<0.001) but the practical significance of the improvement in fit was negligible. Differential item functioning (DIF) analyses showed some differences of relatively high magnitude in location parameters by race; however, because the DIF was in different directions, the impact on the overall measure was most likely lessened.
Conclusion
Among community-dwelling older adults, a large proportion experienced multiple co-occurring symptoms. This Brief Symptom Screen can be used to quickly measure overall symptom load in older adult populations, including those with multiple chronic conditions.
doi:10.1097/MLR.0b013e3182a53d1f
PMCID: PMC4084777  PMID: 23969593
symptom experience; measurement; comorbidity
14.  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
15.  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
16.  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
17.  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
18.  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
19.  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
20.  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
21.  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
22.  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
23.  Housing, the Neighborhood Environment, and Physical Activity among Older African Americans 
This study examines the association of neighborhood environment, as measured by housing factors, with physical activity among older African Americans. Context is provided on the effects of structural inequality as an inhibitor of health enhancing neighborhood environments. The study population included African Americans participating in the UAB Study of Aging (n=433). Participants demonstrated the ability to walk during a baseline in-home assessment. The strength and independence of housing factors were assessed using neighborhood walking for exercise as the outcome variable. Sociodemographic data, co-morbid medical conditions, and rural/urban residence were included as independent control factors. Homeownership, occupancy, and length of residency maintained positive associations with neighborhood walking independent of control factors. Housing factors appear to be predictive of resident engagement in neighborhood walking. Housing factors, specifically high rates of homeownership, reflect functional and positive neighborhood environments conducive for physical activity. Future interventions seeking to promote health-enhancing behavior should focus on developing housing and built-environment assets within the neighborhood environment.
PMCID: PMC3672407  PMID: 23745172
Housing; Neighborhood; Neighborhood Disadvantage; African American; Physical Activity
24.  Inflammatory Biomarkers as Predictors of Hospitalization and Death in Community-Dwelling Older Adults 
Individuals with multimorbidity may be at increased risk of hospitalization and death. Comorbidity indexes do not capture severity of illness or healthcare utilization; however, inflammation biomarkers that are not disease-specific may predict hospitalization and death in older adults. We sought to predict hospitalization and mortality of older adults using inflammation biomarkers. From a prospective, observational study, 370 community-dwelling adults 65 years or older from central Alabama participated in an in-home assessment and provided fasting blood samples for inflammation biomarker testing in 2004. We calculated an inflammation summary score (range 0-4), one point each for low albumin, high C-reactive protein, low cholesterol, and high interleukin-6. Utilizing Cox proportional hazards models, inflammation summary scores were used to predicted time to hospitalization and death during a 4-year follow up period. The mean age was 73.7 (+5.9 yrs), and 53 (14%) participants had summary scores of 3 or 4. The rates of dying were significantly increased for participants with inflammation summary scores of 2, 3, or 4 (hazard ratios (HR) 2.22, 2.78, and 7.55, respectively; p<0.05). An inflammation summary score of 4 significantly predicted hospitalization (HR 5.92, p<0.05). Community-dwelling older adults with biomarkers positive for inflammation had increased rates of being hospitalized or dying during the follow up period. Assessment of the individual contribution of particular inflammation biomarkers in the prediction of health outcomes in older populations and the development of validated summary scores to predict morbidity and mortality are needed.
doi:10.1016/j.archger.2012.01.006
PMCID: PMC3331900  PMID: 22305611
inflammation; hospitalization; mortality; community-dwelling older adults
25.  Wearing the Garment of Widowhood: Variations in Time Since Spousal Loss Among Community-Dwelling Older Adults 
Journal of women & aging  2012;24(2):126-139.
We examine how the passage of time since spousal loss varies by social and demographic characteristics, using data from the University of Alabama at Birmingham Study of Aging. In multivariate analyses, African American race, female sex, lower income, and higher risk of social isolation had significant and independent associations with variation in time since spousal loss. African American women were at highest risk for long-term widowhood. Accurate characterizations of widowhood among community-dwelling older adults must consider variation in the length of time individuals are living as widowed persons and socioeconomic concomitants of long-term widowhood.
doi:10.1080/08952841.2012.639660
PMCID: PMC3601770  PMID: 22486476
widow; bereavement; older women; Black women; community-dwelling; social isolation

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