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Objective: The challenges posed by people living with multiple chronic conditions are unique for people with dementia and other significant cognitive impairment. There have been recent calls to action to review the existing literature on co-occurring chronic conditions and dementia in order to better understand the effect of cognitive impairment on disease management, mobility, and mortality., Methods: This systematic literature review searched PubMed databases through 2011 (updated in 2016) using key constructs of older adults, moderate-to-severe cognitive impairment (both diagnosed and undiagnosed dementia), and chronic conditions. Reviewers assessed papers for eligibility and extracted key data from each included manuscript. An independent expert panel rated the strength and quality of evidence and prioritized gaps for future study., Results: Four thousand thirty-three articles were identified, of which 147 met criteria for review. We found that moderate-to-severe cognitive impairment increased risks of mortality, was associated with prolonged institutional stays, and decreased function in persons with multiple chronic conditions. There was no relationship between significant cognitive impairment and use of cardiovascular or hypertensive medications for persons with these comorbidities. Prioritized areas for future research include hospitalizations, disease-specific outcomes, diabetes, chronic pain, cardiovascular disease, depression, falls, stroke, and multiple chronic conditions., Conclusions: This review summarizes that living with significant cognitive impairment or dementia negatively impacts mortality, institutionalization, and functional outcomes for people living with multiple chronic conditions. Our findings suggest that chronic-disease management interventions will need to address co-occurring cognitive impairment. Copyright © 2017 John Wiley & Sons, Ltd., (Copyright © 2017 John Wiley & Sons, Ltd.)

Community wayfinding becomes more challenging with age and decrements in functioning. Given the growth in numbers of older adults, we need to understand features that facilitate or inhibit wayfinding in outdoor settings to enhance mobility and community engagement. This exploratory study of 35 short- ( n = 14) and long-term ( n = 21) residents in an ethnically diverse neighborhood identified relevant wayfinding factors. Data collection included an interview, map-drawing task, and walk along a previously audited, prescribed route to identify key wayfinding strategies. Most participants sought information from other people as a primary method of route planning. Street signs and landmarks were overwhelming favorites as helpful wayfinding features. When asked to recall the route following the walk, only half of participants gave completely correct directions. Findings reinforce the importance of landmarks and legible, systematic, and consistently available signage, as well as trustworthy person-to-person information sources. Findings also underscore the need for wayfinding research in diverse environments.

Objective: We investigated the association between the peroxisome proliferator-activated receptor (PPAR)-gamma Pro12Ala polymorphism and cognitive decline in older adults., Methods: Participants from a population-based cohort of older Hispanic and non-Hispanic white adults (n = 492) were administered the Mini Mental State Examination (MMSE), a multi-domain cognitive screening tool, and the Behavioral Dyscontrol Scale (BDS), a measure of executive cognitive function, at baseline and at follow-up, an average of 22 months later. Multiple linear regression was used to investigate the association between the two cognitive test scores and the Pro12Ala polymorphism., Results: At baseline, presence of the Ala12 allele was not significantly associated with MMSE score (P = 0.62) nor with BDS score (P = 0.85). Heterogeneity was present for cognitive decline as measured by the MMSE among ethnic, sex and Ala12 allele status (P = 0.04 for three-way interaction term). Stratification by the cross-classification of sex and ethnicity revealed significantly greater declines in MMSE score among male Hispanic carriers of the Ala12 allele compared to male Hispanic non-carriers (decline = 4.0 versus 1.6 points; P = 0.02). A significant difference in decline between Ala12 carriers and non-carriers was not present among the other sex/ethnic groups., Conclusions: Carriers of the PPAR-γ Ala12 allele showed greater cognitive decline compared to non-carriers as detected by the MMSE but the risk varied across sex and ethnic groups. Male Ala12 carriers of Hispanic origin may be a high-risk group for cognitive decline., (© The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

The purpose of this paper is to examine factors that are associated with tooth loss in older adults living in the San Luis Valley (SLV), Colorado, which is a rural and large geographical area (roughly the size of Connecticut) that has a large population age 60 years or older. Data used in this manuscript were collected as a part of the SLV Community Health Survey. The analyzed sample included 308 adults over the age of 65 years who completed the survey. Basic descriptive statistics and a series of step-wise binary logistic regression analyses were conducted; the dependent variable was the number of permanent teeth removed because of tooth decay or gum disease. Fifty-two percent of the participants were male, Hispanic participants made up 40 % of the sample and 76 % of the participants had at least a high school education. Tooth loss was significantly associated with older age (OR = 1.09; p = 0.02), lower income (OR = 0.01; p = 0.00), less than high school education (OR = 0.32; p = 0.01), being Hispanic (OR = 2.15; p = 0.05), self-reported fair-poor health status (OR 2.94; p = 0.02), consumption of one or more than one sweet beverage per day (OR = 4.52; p = 0.00), no dental insurance (OR = 4.70; p = 0.01) and length of time since last dental visit (OR = 0.21; p = 0.01). The findings of the present study suggest possible causes for tooth loss in rural adults and underscore the need for in-depth research to study the overall oral health of rural older adults living in SLV.

This study examined the psychometric properties of the Sense of Coherence (SOC) scale in the context of an oral health-related clinical trial conducted in an American Indian population-specifically, people of the Navajo Nation. Data were derived from baseline evaluations of parents (or caregivers) of Navajo children aged 3-5 from 52 Head Start classes enrolled in a trial of an intervention to prevent early childhood caries (ECC). A 190-item Basic Research Factors Questionnaire, which included the SOC, was administered to 1,016 parents/caregivers. Assessment of internal reliability and convergent validity, and confirmatory factor analyses were conducted. Multiple linear regression analysis was used to examine associations between parents' SOC and other potentially convergent measures. Confirmatory factor analysis was used to examine 1- and 3-factor solutions of the SOC scale. Higher SOC was significantly related to higher parental education and income, employment status, and higher scores for social support, internal Oral Health Locus of Control (OHLOC), self-efficacy, importance of oral health, oral health knowledge and behavior, and children's oral health quality of life. Higher SOC also was related to lower reported distress and lower external OHLOC. Cronbach's α was 0.84 for all SOC items, but lower for each of the 3 SOC subscales. Confirmatory factor analyses suggested a 3-factor solution was superior to a 1-factor solution. The SOC scale had good internal reliability and convergent validity in this American Indian population., ((c) 2016 APA, all rights reserved.)

Successful interventions require consistent participation by intended recipients. We utilized mixed methods to describe participation of 518 parent-child dyads enrolled in a randomized cluster trial of a 2-year oral health intervention for Head Start (HS) families across Navajo Nation delivered by native Community Oral Health Specialists (COHS). We quantitatively assessed factors that contributed to participation and qualitatively examined barriers and strategies. The intervention offered fluoride varnish (FV) and oral health promotion (OHP) activities for two cohorts (enrolled in 2011, N = 286, or 2012, N = 232) of children in the HS classrooms and OHP for parents outside the classroom. Child participation was good: FV: 79.7 (Cohort 1) and 85.3 % (Cohort 2) received at least 3 of 4 applications; OHP: 74.5 (Cohort 1) and 78.4 % (Cohort 2) attended at least 3 of 5 events. Parent participation was low: 10.5 (Cohort 1) and 29.8 % (Cohort 2) attended at least three of four events. Analysis of survey data found significant effects on parent participation from fewer people in the household, Cohort 2 membership, greater external-locus of control, and a greater perception that barriers existed to following recommended oral health behaviors. Qualitative analysis of reports from native field staff, COHS, community members, and the research team identified barriers (e.g., geographic expanse, constraints of a research trial) and suggested strategies to improve parent participation (e.g., improve communication between COHS and parents/community). Many challenges to participation exist when conducting interventions in rural areas with underserved populations. Working with community partners to inform the development and delivery of interventions is critical.

Background: Research on walking and walkability has yet to focus on wayfinding, the interactive, problem-solving process by which people use environmental information to locate themselves and navigate through various settings., Methods: We reviewed the literature on outdoor pedestrian-oriented wayfinding to examine its relationship to walking and walkability, 2 areas of importance to physical activity promotion., Results: Our findings document that wayfinding is cognitively demanding and can compete with other functions, including walking itself. Moreover, features of the environment can either facilitate or impede wayfinding, just as environmental features can influence walking., Conclusions: Although there is still much to be learned about wayfinding and walking behaviors, our review helps frame the issues and lays out the importance of this area of research and practice.

Purpose: To validate oral health knowledge and behavior measures from the Basic Research Factors Questionnaire, developed to capture specific themes contributing to children's oral health outcomes and the influence of caregivers., Methods: Data were collected as part of a randomized clinical trial (n equals 992) aimed at reducing dental caries in young children. Participants were American Indian/Alaska Native caregivers with a three- to five-year-old child enrolled in a Navajo Nation Head Start Center. Caregivers completed the questionnaire at enrollment with concomitant evaluation of children for decayed, missing, and filled tooth surfaces (dmfs). Oral health knowledge and behavior outcomes were compared with convergent measures (participant sociodemographic characteristics, oral health attitudes, and indicators of oral health status)., Results: Caregiver oral health knowledge was significantly associated with education, income, oral health behavior, and all but one of the oral health attitude measures. Behavior was significantly associated with several measures of oral health attitudes and all but one measure of oral health status. As the behavior score improved, dmfs scores declined, child/caregiver overall oral health status improved, and pediatric oral health quality of life improved., Conclusions: Questionnaire measures were valid for predicting specific caregiver factors potentially contributing to children's oral health status.

Objectives: Depression is an important precursor to dementia, but less is known about the role dementia plays in altering the course of depression. We examined whether depression prevalence, incidence, and severity are higher in those with dementia versus those with mild cognitive impairment (MCI), or normal cognition., Design: Prospective cohort study using the longitudinal Uniform Data Set of the National Alzheimer's Coordinating Center (2005-2013)., Setting: 34 Alzheimer Disease research centers., Participants: 27,776 subjects with dementia, MCI, or normal cognition., Measurements: Depression status was determined by a clinical diagnosis of depression within the prior 2 years and by a Geriatric Depression Scale-Short Form score >5., Results: Rates of depression were significantly higher in subjects with MCI and dementia compared with those with normal cognition at index visit. Controlling for demographics and common chronic conditions, logistic regression analysis revealed elevated depression in those with MCI (OR: 2.40 [95% CI: 2.25, 2.56]) or dementia (OR: 2.64 [95% CI: 2.43, 2.86]) relative to those with normal cognition. In the subjects without depression at the index visit (N = 18,842), those with MCI and dementia had higher probabilities of depression diagnosis 2 years post index visit than those with normal cognition: MCI = 21.7%, dementia = 24.7%, normal cognition = 10.5%., Conclusion: MCI and dementia were associated with significantly higher rates of depression in concurrent as well as prospective analyses. These findings suggest that efforts to effectively engage and treat older adults with dementia will need also to address co-occurring depression., (Copyright © 2015 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Preventing and/or delaying cognitive impairment is a public health priority. To increase awareness of and participation in behaviors that may help maintain cognitive function or reduce risk of impairment, we need to understand public perceptions about risk and protective factors., Methods: We conducted a scoping review of studies examining the public's perceptions about risk and protective factors related to cognitive health and impairment published since the 2007 National Public Health Road Map to Maintaining Cognitive Health., Results: A search of five databases yielded 1,115 documents published between June 2007 and December 2013. Initial review of abstracts identified 90 potentially eligible studies. After full-article review, 30 met inclusion criteria; four additional articles identified in reference lists also met inclusion criteria. Of the 34, 16 studies addressed Alzheimer's disease (AD) specifically, 15 dementia broadly, 5 mild to moderate cognitive impairment, and 8 normal functioning, with some content overlap. Across studies, respondents reported genetics (n = 14 studies), older age (n = 8), stress (n = 7), brain/head injury (n = 6), and mental illness/brain disease (n = 6) as perceived risk factors for AD and dementia. Protective factors most commonly identified for maintaining cognitive health were intellectual/mental stimulation (n = 13), physical activity (n = 12), healthy diet (n = 10), and social/leisure activities (n = 10)., Conclusions: Studies identified genetics and older age as key perceived risk factors more so than behaviors such as smoking. Individuals perceived that numerous lifestyle factors (e.g. intellectual stimulation, physical activity) could protect against cognitive impairment, AD, and/or dementia. Results can inform national and international education efforts about AD and other dementias.

Background: Dementia or other significant cognitive impairment (SCI) are often comorbid with other chronic diseases. To promote collaborative research on the intersection of these conditions, we compiled a systematic inventory of major data resources., Methods: Large data sets measuring dementia and/or cognition and chronic conditions in adults were included in the inventory. Key features of the resources were abstracted including region, participant sociodemographic characteristics, study design, sample size, accessibility, and available measures of dementia and/or cognition and comorbidities., Results: 117 study data sets were identified; 53% included clinical diagnoses of dementia along with valid and reliable measures of cognition. Most (79%) used longitudinal cohort designs and 41% had sample sizes greater than 5000. Approximately 47% were European-based, 40% were US-based, and 11% were based in other countries., Conclusions: Many high-quality data sets exist to support collaborative studies of the effects of dementia or SCI on chronic conditions and to inform the development of evidence-based disease management programs., (Copyright © 2015 The Alzheimer's Association. Published by Elsevier Inc. All rights reserved.)

Purpose: Given that emotional health is a critical component of healthy aging, we undertook a systematic literature review to assess whether current interventions can positively affect older adults' emotional health., Methods: A national panel of health services and mental health researchers guided the review. Eligibility criteria included community-dwelling older adult (aged ≥ 50 years) samples, reproducible interventions, and emotional health outcomes, which included multiple domains and both positive (well-being) and illness-related (anxiety) dimensions. This review focused on three types of interventions - physical activity, social support, and skills training - given their public health significance and large number of studies identified. Panel members evaluated the strength of evidence (quality and effectiveness)., Results: In all, 292 articles met inclusion criteria. These included 83 exercise/physical activity, 25 social support, and 40 skills training interventions. For evidence rating, these 148 interventions were categorized into 64 pairings by intervention type and emotional health outcome, e.g., strength training targeting loneliness or social support to address mood. 83% of these pairings were rated at least fair quality. Expert panelists found sufficient evidence of effectiveness only for skills training interventions with health outcomes of decreasing anxiety and improving quality of life and self-efficacy. Due to limitations in reviewed studies, many intervention-outcome pairings yielded insufficient evidence., Conclusion: Skills training interventions improved several aspects of emotional health in community-dwelling older adults, while the effects for other outcomes and interventions lacked clear evidence. We discuss the implications and challenges in moving forward in this important area.

Objective: We aimed to identify salutogenic patterns of parental knowledge, behaviors, attitudes, and beliefs that may support resistance to early childhood caries (ECC) among a high caries population of preschool American Indian (AI) children., Method: Participants were 981 child-parent dyads living on a Southwestern reservation who completed baseline assessments for an ongoing randomized clinical trial. T-tests were used to assess differences between reported knowledge, behaviors, and beliefs of parents whose children were caries-free (10.7 percent) and those whose children had caries (89.3 percent). Chi-square analyses were used for categorical variables., Results: Although there were no socio-demographic differences, parents of caries-free children viewed oral health as more important and reported more oral health knowledge and adherence to caries-preventing behaviors for their children. Parents of caries-free children were more likely to have higher internal locus of control, to perceive their children as less susceptible to caries, and to perceive fewer barriers to prevention. These parents also had higher sense of coherence scores and reported lower levels of personal distress and community-related stress., Conclusions: Effective interventions for ECC prevention in high-caries AI populations may benefit from approaches that support and model naturally salutogenic behaviors., (© 2014 American Association of Public Health Dentistry.)

The literature reports psychosocial, environmental, and cultural factors related to Early Childhood Caries (ECC), but few studies have included American Indian/Alaska Native (AI/AN) populations. AI/AN children have the highest prevalence of ECC among any population group in the United States. This study examined socio-demographic characteristics of children and their parents/caregivers and psychosocial characteristics of parents/caregivers as risk factors for baseline oral health status of preschool children in the Navajo Nation, as part of a 3-year cluster randomized clinical trial to evaluate the effectiveness of trained community workers providing a fluoride varnish and oral health promotion intervention to. The study recruited 1,015 children at 52 Head Start Centers. Baseline ECC data were collected by calibrated dental hygienists for 981 of the children ages of 3-5 years, and a Basic Research Factors Questionnaire (BRFQ) was completed by their parents/caregivers. Bivariable analysis revealed that dmfs was higher in older children; in males; in children with male parents/caregivers; and when the parent/caregiver had less education and income, worse oral health behavior in caring for their children's teeth, and higher scores for external powerful others and external chance locus of control, greater perceived susceptibility and barriers, and lower scores for community risky behavior. In a multiple linear regression model, the variables that remained statistically significant were child's age and gender, and oral health behavior score of the parent/caregiver. Intervening to improve parent/caregiver oral health behavior in caring for the teeth of children potentially could in AI/AN children.

Cardiometabolic risk factors, including hypertension, dyslipidemia, central obesity, insulin resistance and diabetes are linked to cognitive impairment. The Hispanic population appears to be differentially affected by both cardiometabolic risk factors and cognitive impairment. We sought to determine whether ethnic differences in cognitive impairment in long-resident southwestern US elders was explained by the presence of cardiometabolic risk factors, and to explore patterns of cognitive decline over time. We performed a secondary analysis of data collected on 378 Hispanic and 409 non-Hispanic white adult participants in a longitudinal study of community-dwelling elderly in southern Colorado. Measures of cardiometabolic risk included waist circumference, blood pressure, diagnosis of diabetes, and random blood glucose. Cognitive measures included the Mini-Mental State Exam (MMSE) and the behavioral dyscontrol scale (a measure of executive cognitive function), at baseline and after an average of 22 months. Subjects were also administered the Center for Epidemiologic Studies Depression Scale, and the Coronary Artery Risk Development in Young Adults 1-Year Activity Recall. At baseline, Hispanic elders had a greater number of cardiometabolic risk factors and lower MMSE and behavioral dyscontrol scale scores than non-Hispanic whites. Hispanic ethnicity was associated with a greater likelihood of decline in general cognitive function, but not executive cognitive function, after adjusting for age and education. This differential decline was not explained by either individual or total number of baseline cardiometabolic risk factors, depression, or physical activity. A borderline increased risk of decline in general cognitive function was seen in sedentary individuals (P = 0.05).

Introduction: In low-income and underserved populations, financial hardship and multiple competing roles and responsibilities lead to difficulties in lifestyle change for cardiovascular disease (CVD) prevention. To improve CVD prevention behaviors, we adapted, pilot-tested, and evaluated a problem-solving intervention designed to address barriers to lifestyle change., Methods: The sample consisted of 81 participants from 3 underserved populations, including 28 Hispanic or non-Hispanic white women in a western community (site 1), 31 African-American women in a semirural southern community (site 2), and 22 adults in an Appalachian community (site 3). Incorporating focus group findings, we assessed a standardized intervention involving 6-to-8 week group sessions devoted to problem-solving in the fall of 2009., Results: Most sessions were attended by 76.5% of participants, demonstrating participant adoption and engagement. The intervention resulted in significant improvement in problem-solving skills (P < .001) and perceived stress (P < .05). Diet, physical activity, and weight remained stable, although 72% of individuals reported maintenance or increase in daily fruit and vegetable intake, and 67% reported maintenance or increase in daily physical activity., Conclusion: Study results suggest the intervention was acceptable to rural, underserved populations and effective in training them in problem-solving skills and stress management for CVD risk reduction.

Unlabelled: Navajo Nation children have the greatest prevalence of early childhood caries in the United States. This protocol describes an innovative combination of community-based participatory research and clinical trial methods to rigorously test a lay native Community Oral Health Specialists-delivered oral health intervention, with the goal of reducing the progression of disease and improving family knowledge and behaviors., Methods/design: This cluster-randomized trial designed by researchers at the Center for Native Oral Health Research at the University of Colorado in conjunction with members of the Navajo Nation community compares outcomes between the manualized 2-year oral health fluoride varnish-oral health promotion intervention and usual care in the community (child-caregiver dyads from 26 Head Start classrooms in each study arm; total of 1016 dyads). Outcome assessment includes annual dental screening and an annual caregiver survey of knowledge, attitudes and behaviors; collection of cost data will support cost-benefit analyses., Discussion: The study protocol meets all standards required of randomized clinical trials. Aligned with principles of community-based participatory research, extended interaction between members of the Navajo community and researchers preceded study initiation, and collaboration between project staff and a wide variety of community members informed the study design and implementation. We believe that the benefits of adding CBPR methods to those of randomized clinical studies outweigh the barriers and constraints, especially in studies of health disparities and in challenging settings. When done well, this innovative mix of methods will increase the likelihood of valid results that communities can use., (Copyright © 2014 Elsevier Inc. All rights reserved.)

There is an urgent need to translate science into practice and help enhance the capacity of professionals to deliver evidence-based programming. We describe contributions of the Healthy Aging Research Network in building professional capacity through online modules, issue briefs, monographs, and tools focused on health promotion practice, physical activity, mental health, and environment and policy. We also describe practice partnerships and research activities that helped inform product development and ways these products have been incorporated into real-world practice to illustrate possibilities for future applications. Our work aims to bridge the research-to-practice gap to meet the demands of an aging population.

Background: Palliative care services are lacking in rural hospitals. Implementing palliative care services in rural and remote areas requires knowledge of available resources, specific barriers, and a commitment from the hospital and community., Objective: The purpose of the study was to determine awareness, knowledge, barriers, and resources regarding palliative care services in rural hospitals., Methods: A descriptive survey design used an investigator-developed needs assessment to survey 374 (40% response rate) health care providers (chief executive officers, chiefs of medical staff, chief nursing officers, and social worker directors) at 236 rural hospitals (<100 beds) in seven Rocky Mountain states., Results: Significant barriers to integrating palliative care exist: lack of administrative support, mentorship, and access to palliative care resources; inadequate basic knowledge about palliative care strategies; and limited training/skills in palliative care. Having contractual relationships with local hospices is a key facilitator. Respondents (56%) want to learn more about palliative care, specifically focusing on pain management, communication techniques, and end-of-life care issues. Webinar and online courses were suggested as strategies to promote long distance learning., Conclusions: It is imperative for quality of care that rural hospitals have practitioners who are up to date on current evidence and practice within a palliative care framework. Unique challenges exist to implementing palliative care services in rural hospitals. Opportunities for informing rural areas focus around utilizing existing hospice resources and relationships, and favoring Web-based classes and online courses. The development of a multifaceted intervention to facilitate education about palliative care and cultivate palliative care services in rural settings is indicated.

Introduction: Limited research has examined primary care providers' communication with patients about maintaining cognitive functioning. Our study's objective was to compare the perceptions of consumers and primary care providers related to beliefs and communication practices about lifestyle behaviors beneficial for overall health and for maintaining cognitive functioning., Methods: In 2009, we submitted 10 questions to Porter Novelli's HealthStyles survey and 6 questions to their DocStyles survey. We compared consumers' (n = 4,728) and providers' (n = 1,250) beliefs, practices, and information sources related to maintaining health and cognitive functioning. We made comparisons using nonparametric statistics., Results: Approximately 76% of consumers considered their health to be good or very good; 73.4% were concerned or very concerned about the possibility that their memory may worsen with age. Women were significantly more concerned than men, and white consumers were more concerned than black and Hispanic consumers. Consumers reported they believed that intellectual stimulation (86.6%), physical activity (82.6%), and healthful diet (82.5%) prevented or delayed cognitive impairment. Providers reported advising patients to reduce cognitive impairment risk through physical activity (85.9%), intellectual stimulation (80.3%), and social involvement (67.4%). Few consumers (7.8%) reported receiving this information from providers but reported learning about strategies to maintain memory, primarily from television (50.1%), magazines (44.1%), and newspapers (33.7%)., Conclusion: Providers reported advising patients about how to reduce risks of cognitive impairment. Consumers reported receiving this information from other sources. Findings suggest a need to examine and assess media messages and to better understand patient-provider communication about cognitive functioning.

Introduction: To facilitate national efforts to maintain cognitive health through public health practice, the Healthy Brain Initiative recommended examining diverse groups to identify stakeholder perspectives on cognitive health. In response, the Healthy Aging Research Network (HAN), funded by the Centers for Disease Control and Prevention (CDC), coordinated projects to document the perspectives of older adults, caregivers of people with dementia, and primary care providers (PCPs) on maintaining cognitive health. Our objective was to describe PCPs' perceptions and practices regarding cognitive health., Methods: HAN researchers conducted 10 focus groups and 3 interviews with physicians (N = 28) and advanced practice providers (N = 21) in Colorado, Texas, and North Carolina from June 2007 to November 2008. Data were transcribed and coded axially., Results: PCPs reported addressing cognitive health with patients only indirectly in the context of physical health or in response to observed functional changes and patient or family requests. Some providers felt evidence on the efficacy of preventive strategies for cognitive health was insufficient, but many reported suggesting activities such as games and social interaction when queried by patients. PCPs identified barriers to talking with patients about cognitive health such as lack of time and patient reactions to recommendations., Conclusion: Communicating new evidence on cognitive health and engaging older adults in making lasting lifestyle changes recommended by PCPs and others may be practical ways in which public health practitioners can partner with PCPs to address cognitive health in health care settings.

Objective: To characterize Latino families' experiences with family-centered rounds at an academic children's hospital to identify areas for improvement., Methods: Five focus groups of families of Latino children hospitalized on a general medical ward were conducted in Spanish by a single bilingual facilitator. Participants were recruited from a convenience sample of Spanish-speaking Latino family members present at the patients' bedside. Data were transcribed verbatim, content coded, and analyzed in Spanish for emergent themes., Results: Twenty-eight Latino family members of 21 hospitalized children participated in the 5 focus groups. Most spoke only Spanish (75%), and Spanish was the preferred language of all focus group participants. Qualitative data analysis indicated that families reported positive experiences with rounds involving a Spanish-speaking provider. Thematic issues focused on family-physician communication problems, lack of family empowerment, family and provider participants for family-centered rounds, and cultural needs. Parents were dissatisfied with telephonic interpretation services and preferred a live interpreter in the absence of a fluent, bilingual physician. Many families did not feel empowered to request interpretation assistance or health information; parents often felt embarrassed as a result of their inability to understand the primary language (English) of the care providers. Some parents felt inhibited to express themselves in the presence of other family members. Addressing cultural needs (e.g., chaplain support) was appreciated by families., Conclusions: Spanish-speaking Latino families are not consistently receiving optimal family-centered rounds. Different strategies are needed to fully engage and empower Latino families., (Copyright © 2011 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Potentially inappropriate medication (PIM) prescribing in older adults is quite prevalent and is associated with an increased risk for adverse drug events, morbidity, and utilization of health care resources. In the acute care setting, PIM prescribing can be even more problematic due to multiple physicians and specialists who may be prescribing for a single patient as well as difficulty with medication reconciliation at transitions and limitations imposed by hospital formularies. This article highlights critical issues surrounding PIM prescribing in the acute care setting such as risk factors, screening tools, and potential strategies to minimize this significant public health problem.

Background: Poor lower-body capacity is associated with reduced mobility in older populations., Purpose: This study sought to determine whether neighborhood environments (e.g., land-use patterns and safety) moderate that association., Methods: The study is based on a cross-sectional sample of 884 people aged > or =65 years identified through service organizations in Alameda County CA, Cook County IL, Allegheny County PA, and Wake and Durham counties NC. In-person interviews focused on neighborhood characteristics, physical and cognitive function, and physical activity and walking. Functional capacity was tested using measures of lower-body strength, balance, and walking speed. The main outcome was time spent walking in a typical week (<150 vs > or =150 minutes per week). Objective environmental measures were also included. Estimates of main and interaction effects were derived from regression models., Results: Living in a residential area, compared to a mixed-use or commercial area, was associated with less time spent walking (<150 minutes per week; OR=1.57, 95% CI=1.04, 2.38). Living in a less-compact area (greater median block length) is also significantly associated with less walking for seniors, but only among those with excellent lower-body strength., Conclusions: Neighborhood type is associated with walking among older people, as it is among the general adult population. In individuals with poor lower-body function, no association was found between residence in a less-compact area and walking. For those people, the relationship between neighborhood characteristics and walking requires further study., (2010 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Cardiovascular disease is the leading cause of deaths and illnesses in US adults, and the prevalence is disproportionately high in underserved populations. In this study, we assessed respondents' understanding of context-specific differences in knowledge and perceptions of disease, risk, and prevention in 6 underserved communities, with the longer-term goal of developing appropriate interventions., Methods: Thirty-nine small-group sessions and 14 interviews yielded data from 318 adults. Each site's researchers coded, analyzed, and extracted key themes from local data. Investigators from all sites synthesized results and identified common themes and differences., Results: Themes clustered in 3 areas (barriers to cardiovascular health, constraints related to multiple roles, and suggestions for effective communications and programs). Barriers spanned individual, social and cultural, and environmental levels; women in particular cited multiple roles (eg, competing demands, lack of self-care). Programmatic suggestions included the following: personal, interactive, social context; information in language that people use; activities built around cultural values and interests; and community orientation. In addition, respondents preferred health-related information from trusted groups (eg, AARP), health care providers (but with noticeable differences of opinion), family and friends, and printed materials., Conclusion: Interventions to decrease barriers to cardiovascular health are needed; these strategies should include family and community context, small groups, interactive methods, culturally sensitive materials, and trusted information sources. New-immigrant communities need culturally and linguistically tailored education before receiving more substantive interventions.

Objective: To conduct a systematic review of the literature to examine the influence of the built environment (BE) on the physical activity (PA) of adults in rural settings., Data Source: Key word searches of Academic Search Premier, PubMed, CINAHL, Web of Science, and Sport Discus were conducted., Study Inclusion and Exclusion Criteria: Studies published prior to June 2008 were included if they assessed one or more elements of the BE, examined relationships between the BE and PA, and focused on rural locales. Studies only reporting descriptive statistics or assessing the reliability of measures were excluded., Data Extraction: Objective(s), sample size, sampling technique, geographic location, and definition of rural were extracted from each study. Methods of assessment and outcomes were extracted from the quantitative literature, and overarching themes were identified from the qualitative literature., Data Synthesis: Key characteristics and findings from the data are summarized in Tables 1 through 3., Results: Twenty studies met inclusion and exclusion criteria. Positive associations were found among pleasant aesthetics, trails, safety/crime, parks, and walkable destinations., Conclusions: Research in this area is limited. Associations among elements of the BE and PA among adults appear to differ between rural and urban areas. Considerations for future studies include identifying parameters used to define rural, longitudinal research, and more diverse geographic sampling. Development and refinement of BE assessment tools specific to rural locations are also warranted.

Objective: To assess the relationship between mortality and impairment and decline in a specific executive cognitive function, the capacity for behavioral self-regulation., Study Design and Setting: This study examined the association between mortality and baseline and 22-month decline in the capacity for behavioral self-regulation, as measured by the Behavioral Dyscontrol Scale, among 1,293 participants of the San Luis Valley Health and Aging Study (SLVHAS), a population-based longitudinal study. The Behavioral Dyscontrol Scale and a measure of overall mental status, the Mini-Mental State Examination, were administered at baseline and follow-up interviews. Cox regression was used to examine baseline and decline in capacity for behavioral self-regulation as possible predictors of mortality., Results: Baseline Behavioral Dyscontrol Scale score was predictive of mortality, independent of demographics and comorbidity count (hazard ratio [HR]=1.07; 95% confidence interval [CI]: 1.04, 1.09). It remained a significant predictor with further adjustment for Mini-Mental State Examination score. Decline in this specific executive cognitive function was associated with mortality after adjustment for covariates and baseline cognitive scores (HR=1.09; 95% CI: 1.04, 1.13)., Conclusion: Thus, both baseline capacity for behavioral self-regulation and its decline over time predicted mortality in the SLVHAS cohort. These associations may partly be attributed to maintaining the ability for self-care. Understanding how specific forms of impairment contribute to mortality may help identify patients who could benefit from early intervention.

Purpose: Description of study participants and documentation of the desired diversity in the Prevention Research Centers Healthy Aging Research Network's Workgroup on Promoting Cognitive Health large multisite study designed to examine attitudes about brain health, behaviors associated with its maintenance, and information-receiving preferences among a diverse group of older Americans, to provide a foundation for developing health promotion interventions., Design and Methods: Four hundred fifty older adults in 55 focus groups at 9 sites completed a common participant survey. Using descriptive statistics, the analysis compares participant characteristics (age, sex, and race/ethnicity; rural-urban location; income and education; social activity; physical activity, nutrition, and body mass index; and self-reported measures of cognitive function) across sites and with national data., Results: Comparisons across sites document the rich diversity of the sample., Implications: The substantial representation of a variety of demographic groups suggests that the qualitative data obtained in the focus group research provide a useful basis for developing well-targeted communication interventions for promoting brain health in diverse populations.

Purpose: Most individuals with Alzheimer's are cared for in their homes by unpaid family members. Research on caregiving focuses disproportionally on costs of care, service utilization, and negative psychosocial outcomes. Few narrative accounts of Alzheimer's exist; those that do suffer similar pejorative framings and narrow foci. No studies that we are aware of examine the health beliefs of diagnosed individuals and support persons, or their attitudes about brain health. This research reports perceptions of "aging well" held by those most intimately acquainted with Alzheimer's., Design and Methods: Diagnosed individuals and their support persons (N = 85) were enrolled into 14 focus groups. Grounded theory methods were used to collect, code, and analyze textual interview data into overarching themes., Results: Respondents found physical and mental health, social activity, independence, and happiness integral to aging well. An acceptance of various limitations was also deemed crucial. Support persons placed more emphasis on lifestyle factors and memory loss as potential obstacles. Diagnosed respondents defined memory loss in less medicalized terms, whereas support persons labeled it Alzheimer's and negatively characterized those affected. Both groups warned against discussing "prevention" of dementia: Diagnosed individuals noted the implication of "aging poorly" and support persons cautioned against blaming diagnosed individuals., Implications: These findings can be used to encourage positive health beliefs and behaviors tailored to the needs of diagnosed seniors and their families, to help practitioners and researchers identify and become sensitive to differences between and among older adults, and to further advance the utility of narrative accounts for informing health interventions and education efforts.

Purpose: Evidence suggests that healthy lifestyles may help maintain cognitive health. The Prevention Research Centers Healthy Aging Research Network, 9 universities collaborating with their communities and the Centers for Disease Control and Prevention, is conducting a multiyear research project, begun in 2005, to understand how to translate this knowledge into public health interventions., Design and Methods: This article provides an overview of the study purpose, design, methods, and processes. We examined the literature on promoting cognitive health, convened a meeting of experts in cognitive health and public health interventions, identified research questions, developed a common focus group protocol and survey, established quality control and quality assurance processes, conducted focus groups, and analyzed the resulting data., Results: We conducted 55 focus groups with 450 participants in 2005-2007, and an additional 20 focus groups and in-depth interviews in 2007-2008. Focus groups were in English, Spanish, Mandarin, Cantonese, and Vietnamese, with African Americans, American Indians, Asian Americans, Hispanics, non-Hispanic Whites, physicians and other health practitioners, rural and urban residents, individuals caring for family or friends with cognitive impairment, and cognitively impaired individuals., Implications: The data provide a wealth of opportunities for designing public health interventions to promote cognitive health in diverse populations.

There is very little information in the literature to prepare massage therapists for what they might expect when they provide treatment to people with advanced cancer in hospice or palliative care. We report an analysis of a subset of data collected from a large multi-site clinical trial of the efficacy of massage therapy for people with advanced cancer. This is the first analysis of empirical data of patient presentation, massage treatment environment, and the characteristics of massage provided for this population.

Background: Small studies of variable quality suggest that massage therapy may relieve pain and other symptoms., Objective: To evaluate the efficacy of massage for decreasing pain and symptom distress and improving quality of life among persons with advanced cancer., Design: Multisite, randomized clinical trial., Setting: Population-based Palliative Care Research Network., Patients: 380 adults with advanced cancer who were experiencing moderate-to-severe pain; 90% were enrolled in hospice., Intervention: Six 30-minute massage or simple-touch sessions over 2 weeks., Measurements: Primary outcomes were immediate (Memorial Pain Assessment Card, 0- to 10-point scale) and sustained (Brief Pain Inventory [BPI], 0- to 10-point scale) change in pain. Secondary outcomes were immediate change in mood (Memorial Pain Assessment Card) and 60-second heart and respiratory rates and sustained change in quality of life (McGill Quality of Life Questionnaire, 0- to 10-point scale), symptom distress (Memorial Symptom Assessment Scale, 0- to 4-point scale), and analgesic medication use (parenteral morphine equivalents [mg/d]). Immediate outcomes were obtained just before and after each treatment session. Sustained outcomes were obtained at baseline and weekly for 3 weeks., Results: 298 persons were included in the immediate outcome analysis and 348 in the sustained outcome analysis. A total of 82 persons did not receive any allocated study treatments (37 massage patients, 45 control participants). Both groups demonstrated immediate improvement in pain (massage, -1.87 points [95% CI, -2.07 to -1.67 points]; control, -0.97 point [CI, -1.18 to -0.76 points]) and mood (massage, 1.58 points [CI, 1.40 to 1.76 points]; control, 0.97 point [CI, 0.78 to 1.16 points]). Massage was superior for both immediate pain and mood (mean difference, 0.90 and 0.61 points, respectively; P < 0.001). No between-group mean differences occurred over time in sustained pain (BPI mean pain, 0.07 point [CI, -0.23 to 0.37 points]; BPI worst pain, -0.14 point [CI, -0.59 to 0.31 points]), quality of life (McGill Quality of Life Questionnaire overall, 0.08 point [CI, -0.37 to 0.53 points]), symptom distress (Memorial Symptom Assessment Scale global distress index, -0.002 point [CI, -0.12 to 0.12 points]), or analgesic medication use (parenteral morphine equivalents, -0.10 mg/d [CI, -0.25 to 0.05 mg/d])., Limitations: The immediate outcome measures were obtained by unblinded study therapists, possibly leading to reporting bias and the overestimation of a beneficial effect. The generalizability to all patients with advanced cancer is uncertain. The differential beneficial effect of massage therapy over simple touch is not conclusive without a usual care control group., Conclusion: Massage may have immediately beneficial effects on pain and mood among patients with advanced cancer. Given the lack of sustained effects and the observed improvements in both study groups, the potential benefits of attention and simple touch should also be considered in this patient population.

The Centers for Disease Control and Prevention's Division for Heart Disease and Stroke Prevention created the Prevention Research Centers (PRCs) Cardiovascular Health Intervention Research and Translation Network (CHIRTN) in 2005 to develop partnerships and create a research agenda that addresses cardiovascular health promotion. Six participating universities with expertise in heart disease and stroke prevention research collaborate with their PRC partner communities and other partners to (a) conduct demonstration research projects and (b) identify gaps in knowledge and make recommendations for future research to address those gaps. This report describes the structure and current efforts of the CHIRTN. The goal of these efforts is to promote cardiovascular health for Americans, particularly underserved, at-risk populations.

Background: Pain often accompanies chronic disease in older adults and may exacerbate physical limitations, which the Disablement Model suggests may increase disability and decrease independence. This study tests the hypothesis that chronic pain and change in levels of pain over time have associations with worsening physical performance independent of disease conditions., Methods: We studied the effects of initial and changing levels of pain on observed physical performance over approximately 22 months in 925 community-dwelling Hispanic and non-Hispanic white participants in the San Luis Valley Health and Aging Study. Logistic regression models controlled for demographic variables, baseline performance, and comorbidities., Results: We found that chronic pain has an independent association with worsening physical performance, regardless of ethnicity. The intensity of the pain appears to have no independent effect. Although the presence of multiple comorbidities (or vascular disease or diabetes singly) also increases the risk of a worsened physical performance outcome, an independent effect of chronic pain remains after adjusting for these disease conditions. Furthermore, ongoing chronic pain increases the risk of worsening performance; obversely, recovery from chronic pain has a significant and substantial protective effect., Conclusions: Pain in and of itself appears to increase physical impairment. These results strongly suggest that controlling chronic pain may interrupt the negative disease-impairment-disability trajectory by significantly reducing impaired physical performance, no matter the disease conditions that may underlie the pain.

Objectives: To present findings from an expert panel-informed literature review on community-based treatment of late-life depression., Methods: A systematic literature review was conducted to appraise publications on community-based interventions for depression in older adults. The search was conducted between March and October 2005. An expert panel of mental health, aging, health services, and epidemiology researchers guided the review and voted on quality and effectiveness of these interventions., Results: A total of 3,543 articles were found with publication dates from 1967 to October 2005; of these, 116 were eligible for inclusion. Adequate data existed to determine effectiveness for the following interventions: depression care management, group and individual psychotherapy for depression, psychotherapy targeting mental health, psychotherapy for caregivers, education and skills training (to manage health problems besides depression; and for caregivers), geriatric health evaluation and management, exercise, and physical rehabilitation and occupational therapy. After reviewing the data, panelists rated the depression care management interventions as effective. Education and skills training, geriatric health evaluation and management, and physical rehabilitation and occupational therapy received ineffective ratings. Other interventions received mixed effectiveness ratings. Insufficient data availability and poor study quality prevented the panelists from rating several reviewed interventions., Conclusions: While several well-described interventions were found to treat depression effectively in community-dwelling older adults, significant gaps still exist. Interventions that did not target depression specifically may be of benefit to older adults, but they should not be presumed to treat depression by themselves. Treating depressed elders may require a multifaceted approach to ensure effectiveness. More research in this area is needed.

This study sought to describe the characteristics and correlates of symptom distress and quality of life (QOL) among persons receiving hospice/palliative care. English-speaking adults (n=86), their nurses (n=86), and family caregivers (n=49) from 11 hospice/palliative care organizations completed the Memorial Symptom Assessment Scale (MSAS) and McGill Quality of Life Questionnaire (MQOL) at hospice/palliative care enrollment, at one week, two weeks, then monthly until death or discharge. Mixed effects modeling using proxy reports to impute missing patient-reported data were used to describe predictors of symptom distress and QOL. Given study population attrition due to death, analyses are limited to the first 17 days following hospice/palliative care admission. While lack of energy and pain were the most prevalent and distressing symptoms (prevalence 92% and 82%, respectively; mean MSAS scores 3.27 and 2.71, respectively), pain was identified as the most distressing symptom based on its contribution to MSAS summary scores and responses to a single-item "most distressing symptom" question. Pain, nonpain symptom distress, and MQOL scores remained fairly stable throughout the study period. Distress from all other physical symptoms was significantly associated with distress due to pain. There were no significant associations between patient characteristics and distress due to pain. While greater psychological symptom distress had a negative association with QOL, neither pain nor other physical symptom distress was associated with QOL. The persistence of significant symptom distress, particularly due to pain, argues for the need for enhanced evidence to guide care provided in the last days and weeks of life.

This study sought to advance understanding of the relationships among proxy and patient reports of symptom distress and quality of life (QOL). English-speaking adults (n=86), their nurses (n=86), and family caregivers (n=49) from 11 hospice/palliative care organizations completed the Memorial Symptom Assessment Scale (MSAS) and McGill Quality of Life Questionnaire (MQOL) at hospice/palliative care enrollment, at 1 week, 2 weeks, then monthly until death or discharge. Patients and proxies provided similar average reports of symptom distress, both physical and psychological, but MSAS correlations were generally poor. MQOL correlations were higher for nurse-patient than for patient-caregiver dyads. Based on small differences between ratings but only moderate levels of correlation, proxy response appears to be a fair substitute for patient response, suggesting that symptom and QOL reports should be obtained from all available respondents throughout the course of clinical care or research in the hospice/palliative care setting.

Community-based health care agencies are facing demands for improved outcomes, cost-effective programming, and higher customer satisfaction. Implementing evidence-based health interventions and programs can help to address these challenges. This article provides an overview of evidence-based health practice, including the definition and advantages of this approach, other key terms and concepts inherent to evidence-based practice, and the tasks and steps necessary to its implementation. The article concludes with a list of resources to help health care providers learn about, plan, and implement evidence-based health interventions and programs.

Background: The Prevention Research Centers Healthy Aging Research Network (PRC-HAN), funded by the Centers for Disease Control and Prevention's (CDC's) Healthy Aging program, was created in 2001 to help develop partnerships and create a research agenda that promotes healthy aging. The nine universities that participate in the network use their expertise in aging research to collaborate with their communities and other partners to develop and implement health promotion interventions for older adults at the individual, organizational, environmental, and policy levels., Context: The population of older adults in the United States is growing rapidly; approximately 20% of Americans will be aged 65 years or older by 2030. The health and economic impact of an aging society compel the CDC and the public health community to place increased emphasis on preventing unnecessary disease, disability, and injury among older Americans., Methods: The PRC-HAN has a broad research agenda that addresses health-promoting skills and behaviors, disease and syndrome topics, and knowledge domains. The network chose physical activity for older adults as its initial focus for research and has initiated two networkwide projects: a comprehensive, multisite survey that collected information on the capacity, content, and accessibility of physical activity programs for older adults and a peer-reviewed publication that describes the role of public health in promoting physical activity among older adults. In addition to participating in the core research area, each network member works independently with its community committee on PRC-HAN activities., Consequences: As a result, the network is 1) expanding prevention research for older adults and their communities; 2) promoting the translation and dissemination of findings to key stakeholders; 3) strengthening PRC-HAN capacity through partnerships and expanded funding; and 4) stimulating the adoption of policies and programs by engaging policymakers, planners, and practitioners. In 2003, the PRC-HAN initiated an internal evaluation to better define the network's contributions to healthy aging, formalize internal processes, and better equip itself to serve as a model for other PRC thematic networks. The PRC-HAN is conducting a pilot evaluation for eventual inclusion in the PRC national evaluation., Interpretation: The PRC-HAN has established itself as an effective research network to promote healthy aging. It has developed trust and mutual respect among participants, forged strong ties to local communities, and shown the ability to combine its expertise in healthy aging with that of partners in national, state, and local organizations.

Purpose: Although increased participation in physical activity by older adults is a major public health goal, little is known about the supply and use of physical activity programs in the United States., Design and Methods: Seven academic centers in diverse geographic areas surveyed physical activity programs for older adults. Five sites conducted surveys by mail with telephone follow-up, and two administered surveys primarily by telephone. Reported program attendance rates were compared with local census data to assess unmet needs., Results: Of the 2,110 targeted facilities, 77% responded. Aerobic programs were offered by 73%, flexibility by 47%, and strength training by 26%. Commercial gyms or YMCAs, senior centers, park or recreation centers, and senior-housing facilities offered 90% of available programs. The 2000 Census enumerated 1,123,401 total older adults across the seven sites. Facilities reported 69,634 individuals as current weekly program participants, equaling 6% of the sites' total older-adult population. This percentage varied from 3% in Pittsburgh to 28% in Colorado., Implications: Based on conservative estimates of demand, the number of physical activity programs would have to increase substantially (by 78%) to meet the needs of older adults. The data also indicate the need to develop more strength-training programs and to engage a higher percentage of older adults in these programs. There is a clear need to stimulate demand for programs through health promotion.

Results are reported from a large (n = 3,402) four-group randomized trial to increase fruit and vegetable consumption among callers to the National Cancer Institute's (NCI's) Cancer Information Service (CIS) using tailored print materials. Following a baseline telephone interview, which included a brief educational message (BEM), participants were assigned randomly within CIS offices to one of four groups: single untailored (SU) group-one untailored set of materials; single tailored (ST) group-one tailored booklet; multiple tailored (MT) group-four tailored materials; and multiple retailored (MRT) group-four tailored materials with retailoring based on new information obtained at 5 months follow-up. Follow-up telephone interviews were conducted at 5 (n = 2,233) and 12 months (n = 1,927) after baseline. The main outcome measure was self-reported fruit and vegetable consumption using a seven-item food frequency questionnaire. At 12 months follow-up, there was a significant linear trend across groups of 0.21 servings (p = 0.0002). Specific nested hypotheses then were tested and revealed significant mean serving differences between SU (5.07) vs. MT (5.64) (p = 0.002) and SU vs. MRT (5.71; p < 0.001). Although the mean for ST (5.40) was greater than that for SU (5.07), the difference was not statistically significant (p = 0.07), and no difference was found between MT vs. MRT (p = 0.69). A higher proportion of recipients of tailored materials reported reading all of the materials and believing that they were written especially for them. No differences by experimental condition were found for the perceived usefulness or motivational impact of the print materials. In this trial, MT print materials were more effective at increasing fruit and vegetable (FV) consumption than were SU materials. The intervention mechanisms responsible for this effect merit further research. Retailoring did not produce a significant difference when compared with longitudinal baseline tailoring.

Post-acute care (PAC) occurs in a variety of settings-skilled nursing facilities (nursing homes), rehabilitation facilities, and home health agencies. To evaluate the impact of care processes on clinical outcomes and implement changes designed to improve outcomes, one must begin by measuring outcomes in a valid, reliable manner that allows for comparisons to reference or benchmarking data. Currently, several data sets exist in PAC settings for the purpose of outcome measurement. However, there is a need for comparable information across settings to ensure the quality and continuity of care. This article reviews various existing data sets used in PAC settings, examines ongoing projects to create a single set of measures, and suggests some directions for future research.

Objectives: To compare the effectiveness of Cooperative Health Care Clinic ((CHCC) group outpatient model for chronically ill, older health maintenance organization (HMO) patients) with usual care., Design: Two-year, randomized, controlled trial conducted with recruitment from February 1995 through July of 1996., Setting: Nonprofit group model HMO., Participants: Two hundred ninety-four adults (145 intervention and 149 usual care), aged 60 and older (mean age 74.1) with 11 or more outpatient visits in the prior 18 months, one or more self-reported chronic conditions, and expressed interest in participating in a group clinic., Intervention: Monthly group meetings held by patients' primary care physicians., Measurement: Differences in clinic visits, inpatient admissions, emergency room visits, hospital outpatient services, professional services, home health, and skilled nursing facility admissions; measures of patient satisfaction, quality of life, self-efficacy, and activities of daily living (ADLs)., Results: Outpatient, pharmacy services, home health, and skilled nursing facility use did not differ between groups, but CHCC patients had fewer hospital admissions (P=.012), emergency visits (P=.008), and professional services (P=.005). CHCC patients' costs were $41.80 per member per month less than those of control patients. CHCC patients reported higher satisfaction with their primary care physician (P=.022), better quality of life (P=.002), and greater self-efficacy (P=.03). Health status and ADLs did not differ between groups., Conclusion: The CHCC model resulted in fewer hospitalizations and emergency visits, increased patient satisfaction, and self-efficacy, but no effect on outpatient use, health, or functional status., (Copyright 2004 American Geriatrics Society)

Objective: The purpose of this study was to describe quality of life (QOL) and psychosocial and spiritual issues among patients receiving hospice care., Methods: A questionnaire addressing QOL, spirituality, optimism, loss, fears about the terminal process and death anxiety was administered to 66 adults receiving care from 14 hospices. The physical components of QOL (physical symptoms and physical well-being) were rated lower than the psychosocial and spiritual aspects (support, existential well-being, psychological symptoms)., Results: Respondents had a strong spiritual connection and a strong sense of hope. Although these individuals did not express anxiety or fear about death, there were concerns about the dying process itself. Also, although most felt at ease with their current situation, respondents were concerned about how their illness was affecting their family. Financial and legal issues did not concern most of these individuals., Significance of Results: There were few significant associations between patient characteristics and the QOL or other psychosocial or spiritual issues addressed. Among this older terminally ill population receiving hospice care, whose functional status was fair and for whom physical symptoms were troublesome, QOL persisted and a positive outlook prevailed.

Purpose: This study identified modifiable risks associated with incident functional dependence, compared their effects, and estimated the percent risk attributable to each factor, by ethnicity., Design and Methods: The prospective study cohort comprised 751 rural Hispanic and non-Hispanic White elders from southern Colorado who reported no dependence in basic and instrumental activities of daily living (ADLs and IADLs) at baseline. Logistic regression modeled the effects of physical inactivity, nutritional risk, smoking, and falls on incident disability 22 months later, with and without adjustment for baseline ADL and IADL difficulty. Population attributable risk percentages assessed these modifiable risks by ethnicity., Results: Each risk factor multiplied the likelihood of incident dependence by 1.4 or more, adjusted for covariates. Attributable risk percentages ranged from 8% to 32% depending on risk factor, ethnicity, and baseline ADL and IADL difficulty status. Attributable risk was generally greater among Hispanic elders, the result of higher prevalence of most of the risk factors., Implications: Interventions targeted at inadequate nutrition, inactivity, smoking, and preventable falls offer opportunities to reduce incident functional disability, especially among Hispanic elders.

The San Luis Valley Health and Aging Study, was designed to examine Hispanic versus non-Hispanic White differences in prevalence and incidence of aging-related outcomes in a rural population (1,358 community dwellers and 75 nursing home residents). Data presented here were gathered between 1993 and 1997. Previously reported analyses identified greater prevalence of functional dependence in daily living activities among Hispanic elderly, especially females, than among non-Hispanic White elderly. This analysis explored the degree to which incident changes explain these patterns. Comparisons of incidence, recovery, and mortality rates after 22 months revealed no significant ethnic differences, although trends were as hypothesized: greater Hispanic incidence, lower Hispanic recovery rates, and less Hispanic mortality. Overall age-adjusted incidence (activities of daily living = 9.5; instrumental activities of daily living = 15.1 per 100 person-years) exceeded reports from most other studies, while rates of recovery (activities of daily living = 14.5; instrumental activities of daily living = 9.9) and mortality (4.8 among community dwellers; 6.7 including nursing home residents) were similar to those of other reports. Patterns of new dependence, recovery, and mortality did not increase the previously observed disparity. Greater prevalent disability in the Hispanic cohort, especially in women, may reflect a reservoir accumulated during younger years and related to culture and socioeconomic status as well as to older age.