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Background: The presence of treatment limitations in patients with frailty at intensive care unit (ICU) admission is unknown. We aimed to evaluate the presence and predictors of treatment limitations in patients with and without COVID‐19 pneumonitis in those admitted to Australian and New Zealand ICUs. Methods: This registry‐based multicenter, retrospective cohort study included all frail adults (≥16 years) with documented clinical frailty scale (CFS) scores, admitted to ICUs with admission diagnostic codes for viral pneumonia or acute respiratory distress syndrome (ARDS) over 2 years between January 01, 2020 and December 31, 2021. Frail patients (CFS ≥5) coded as having viral pneumonitis or ARDS due to COVID‐19 were compared to those with other causes of viral pneumonitis or ARDS for documented treatment limitations. Results: 884 frail patients were included in the final analysis from 129 public and private ICUs. 369 patients (41.7%) had confirmed COVID‐19. There were more male patients in COVID‐19 (55.3% vs 47.0%; p = 0.015). There were no differences in age or APACHE‐III scores between the two groups. Overall, 36.0% (318/884) had treatment limitations, but similar between the two groups (35.8% [132/369] vs 36.1% [186/515]; p = 0.92). After adjusting for confounders, increasing frailty (OR = 1.72; 95%‐CI 1.39–2.14), age (OR = 1.05; 95%‐CI 1.04–1.06), and presence of chronic respiratory condition (OR = 1.58; 95%‐CI 1.10–2.27) increased the likelihood of instituting treatment limitations. However, the presence of COVID‐19 by itself did not influence treatment limitations (odds ratio [OR] = 1.39; 95%‐CI 0.98–1.96). Conclusions: The proportion of treatment limitations was similar in patients with frailty with or without COVID‐19 pneumonitis at ICU admission. [ABSTRACT FROM AUTHOR]

Background: In managing older adults with atrial fibrillation (AF), their symptomatology impacts their well‐being and may inform treatment decision‐making. We examined AF symptom perception, its impact on quality of life (QoL), and its relation to treatment strategies in older adults with AF. Methods: Data were obtained from older adults with AF enrolled in a multicenter study conducted at clinic sites in Massachusetts and Georgia between 2016 and 2018. Participants were stratified into three age groups: 65–74 (youngest–old), 75–84 (middle–old), and ≥85 (oldest). Perception of AF symptoms was assessed by participant self‐report during their clinic visit and at study enrollment by the Atrial Fibrillation Effect on Quality‐of‐Life Questionnaire which assessed cardiac‐specific and non‐specific, non‐cardiac AF symptoms and their impact on QoL. Treatment strategies (rate or rhythm control) utilized were ascertained from electronic medical records. Results: Among the 1184 participants (mean age 75 years, 48% women, 86% Non‐Hispanic White), 51% were aged 65–74 years, 36% were 75–84 years, and 13% were ≥ 85 years. The most commonly reported AF symptoms were non‐specific, non‐cardiac symptoms (fatigue, dyspnea, lightheadedness) with similar prevalence and impact on QoL in all age groups. Cardiac‐specific AF symptoms (palpitations, irregular heartbeat, pause in heart activity) were less prevalent, but most commonly reported by the youngest participants (65–74 years), who endorsed considerable impact of these symptoms on their QoL. Overall, those who reported experiencing any AF symptoms during their clinic visit were more likely to have received rhythm compared with rate control (OR: 1.56; 95% CI: 1.18–2.04) with similar findings for all age groups except those aged ≥85 years. Conclusions: Our findings suggest a high prevalence of non‐specific, non‐cardiac symptoms among older adults with AF and that cardiac‐specific AF symptoms may exert considerable impact on their QoL. The presence of any AF symptoms may drive more rhythm control in a majority of older adults. See related Editorial by Blachman et al. in this issue. [ABSTRACT FROM AUTHOR]

Background: Physician Orders for Life‐Sustaining Treatment (POLST) facilitates documentation and transition of patients' life‐sustaining treatment orders across care settings. Little is known about patient and facility factors related to care preferences within POLST across a large, diverse nursing home population. We describe the orders within POLST among all nursing home (NH) residents in California from 2011 to 2016. Methods: California requires NHs to document in the Minimum Data Set whether residents complete a POLST and orders within POLST. Using a serial cross‐sectional design for each year, we describe POLST completion and orders for all California NH residents from 2011 to 2016 (N = 1,112,668). We used logistic mixed‐effects regression models to estimate POLST completion and resuscitation orders to understand the relationship with resident and facility characteristics, including Centers for Medicare and Medicaid Services (CMS) Nursing Home Compare overall five‐star quality rating. Results: POLST completion significantly increased from 2011 to 2016 with most residents having a POLST in 2016 (short‐stay:68%; long‐stay:81%). Among those with a POLST in 2016, 54% of long‐stay and 41% of short‐stay residents had a DNR order. Among residents with DNR, >90% had orders for limited medical interventions or comfort measures. Few residents (<6%) had a POLST with contradictory orders. In regression analyses, POLST completion was greater among residents with more functional dependence, but was lower among those with more cognitive impairment. Greater functional and cognitive impairment were associated with DNR orders. Racial and ethnic minorities indicated more aggressive care preferences. Higher CMS five‐star facility quality rating was associated with greater POLST completion. Conclusions: Six years after a state mandate to document POLST completion in NHs, most California NH residents have a POLST, and about half of long‐stay residents have orders to limit life‐sustaining treatment. Future work should focus on determining the quality of care preference decisions documented in POLST. This article comments on the editorial by Lam et al. and the letter by Zingmond et al. in this issue. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Depressive Symptoms Increase the Risk of Mortality in Older Mexican Community-Dwelling Adults" by S. D. Piña-Escuerdo, A. P. Navarrete-Reyes and J. A. Ávila-Funes.

Background/Objectives Off-label use of antipsychotics is common in hospitals, most often for delirium management. Antipsychotics have been associated with aspiration pneumonia in community and nursing home settings, but the association in hospitalized individuals is unexplored. We aimed to investigate the association between antipsychotic exposure and aspiration pneumonia during hospitalization. Design Retrospective cohort study. Setting Large academic medical center. Participants All adult hospitalizations between January 2007 and July 2013. We excluded outside hospital transfers, hospitalizations shorter than 48 hours, and psychiatric hospitalizations. Measurements Antipsychotic use defined as any pharmacy charge for an antipsychotic medication. Aspiration pneumonia was defined according to a discharge diagnosis code for aspiration pneumonia not present on admission and validated using chart review. A generalized estimating equation was used to control for 43 potential confounders. Results Our cohort included 146,552 hospitalizations (median age 56; 39% male). Antipsychotics were used in 10,377 (7.1%) hospitalizations (80% atypical, 35% typical, 15% both). Aspiration pneumonia occurred in 557 (0.4%) hospitalizations. The incidence of aspiration pneumonia was 0.3% in unexposed individuals and 1.2% in those with antipsychotic exposure (odds ratio ( OR) = 3.9, 95% confidence interval ( CI) = 3.2-4.8). After adjustment, antipsychotic exposure was significantly associated with aspiration pneumonia (adjusted OR = ( aOR) = 1.5, 95% CI = 1.2-1.9). Similar results were demonstrated in a propensity-matched analysis and in an analysis restricted to those with delirium or dementia. The magnitude of the association was similar for typical ( aOR = 1.4, 95% CI = 0.94-2.2) and atypical ( aOR = 1.5, 95% CI = 1.1-2.0) antipsychotics. Conclusion Antipsychotics were associated with greater odds of aspiration pneumonia after extensive adjustment for participant characteristics. This risk should be considered when prescribing antipsychotics in the hospital. [ABSTRACT FROM AUTHOR]

Objectives To determine whether potentially inappropriate medications ( PIMs) or potentially inappropriate associations ( PIAs) prescribed knowingly are associated with patient monitoring. Design Prospective observational study. Setting Geriatric units (n = 56) in 28 hospitals. Participants Inpatients aged 75 and older (N = 1,327). Measurements Potentially inappropriate prescriptions ( PIP) were defined as a PIM or a PIA selected by an expert board from lists of explicit criteria (Beers, Priscus, Laroche, French Health Agency) using a Delphi process. They were considered to be prescribed knowingly if they were maintained after reassessment by the geriatrician and the clinical pharmacist. Primary outcome was the rate of PIPs maintained (prescribed knowingly) and for which a geriatrician declared that specific monitoring was performed. Secondary outcomes were the parameters monitored and the rate of participants receiving knowingly a PIP. Results One thousand sixty-three PIPs were detected in 607 participants (46%). After reassessment, 826 (78%) PIPs were maintained in 490 participants (37%), the main reasons being participant's regular treatment and lack of alternative. Psychotropic (36%), cardiovascular (including antithrombotics) (29%), and laxative or antiemetic drugs (16%) were the most-frequent classes prescribed knowingly. The geriatricians declared to perform clinical or biological monitoring for 69% (n = 570) of PIMs or PIAs prescribed knowingly. Three types of specific monitoring were identified: clinical, biological, and follow-up with a specialist. Conclusion Approximately three-quarters of PIMs or PIAs were prescribed knowingly, of which 69% were monitored, with wide variations in occurrence and in quality according to drug classes. This underlines the need for accurate guidelines on PIP monitoring. [ABSTRACT FROM AUTHOR]

Objectives Epidemiologic data suggest older adults receiving serotonergic antidepressants may have accelerated bone loss. We examined bone turnover marker changes and patient-level variables associated with these changes in older adults receiving protocolized antidepressant treatment. Design Open-label, protocolized treatment study. Setting Medical centers in Pittsburgh, St Louis, and Toronto. Participants Older adults with major depression (N = 168). Measurements Serum levels of the bone resorption marker C-terminal cross-linking telopeptide of type 1 collagen ( CTX) and the bone formation marker procollagen type 1 N propeptide (P1 NP) were assayed before and after 12 weeks of treatment with venlafaxine. Whether CTX and P1 NP changes were associated with depression remission and duration of depression and genetic polymorphisms in the serotonin transporter (5 HTTLPR) and 1B receptor ( HTR1B) were also examined. Results CTX increased and P1 NP decreased during venlafaxine treatment, a profile consistent with accelerated bone loss. Two individual-level clinical variables were correlated with bone turnover; participants whose depression did not go into remission had higher CTX levels, and those with chronic depression had lower P1 NP levels. HTR1B genotype predicted P1 NP change, whereas 5 HTTLPR genotype was unrelated to either biomarker. Conclusion Bone turnover markers change with antidepressant treatment in a pattern that suggests accelerated bone loss, although the clinical significance of these changes is unclear. These data are preliminary and argue for a larger, controlled study to confirm whether antidepressants are harmful to bone metabolism and whether certain individuals might be at increased risk. [ABSTRACT FROM AUTHOR]

Objectives Renal insufficiency is common among older patients and, accordingly, renally excreted drugs may require an adjustment in dosage for them. Rates of non-adherence to renal dosing guidelines range from 19% to 70% across all settings, with the highest rate occurring in outpatient care. However, there is a paucity of research in this field. The main objective of this systematic review is to assess how often drugs are inappropriately prescribed in non-hospitalized patients with renal insufficiency. Design A systematic literature search was performed. Data were identified from three electronic databases: PubMed, CINAHL, and Scopus. Studies were included if they reported quantitative data on inappropriate drug use with respect to renal function in non-hospitalized patients. Results Our search strategy resulted in 2,403 hits, of which 18 articles satisfied the criteria for inclusion. Mean estimated glomerular filtration rate ranged from 36.0 to 60.4 mL/min. Prevalence of renally inappropriate drug use ranged from 1% to 37% in outpatient settings other than nursing homes, and from 6% to 43% in nursing homes. Eight of the studies we included identified predictors for use of drugs inappropriate for kidney function. Most frequently determined risk factors were increasing age and a high number of prescribed drugs. Conclusion Lack of dose adjustment for renal impairment seems to be a common problem, even in outpatients. However, the differences in methodologies used in these studies hampered any direct comparison. Accepted and comparable standards regarding the drugs included in the studies as well as estimation of renal function would be beneficial. [ABSTRACT FROM AUTHOR]

The control of bacterial dental plaque through daily oral hygiene is essential to prevent oral diseases such as caries or periodontal disease, especially in at-risk populations, including the elderly with mild cognitive impairment and dementia. The aim of this study was to determine the association between different levels of cognitive impairment and dementia in an elderly population and their capacity to maintain adequate oral hygiene. A case-control study (elderly with versus without mild cognitive impairment or dementia) was performed in Granada, Spain. Outcome variables were tooth/prosthesis-brushing frequency/day, bacterial plaque index, and gingival bleeding index. Statistical models were adjusted by age, sex, educational level, and tobacco and alcohol habits. The study included 240 cases and 324 controls. The final model, adjusted by age, sex, educational level, and tobacco and alcohol consumption, showed a significant association between degree of cognitive impairment and daily oral hygiene, accumulation of bacterial plaque, and gingival bleeding. In summary, deficient daily oral hygiene, evidenced by greater bacterial dental plaque accumulation and gingival inflammation, is independently associated with cognitive impairment, even at its earliest stage. [ABSTRACT FROM AUTHOR]

Objectives To develop an evaluation instrument to determine to what extent Tai Chi interventions aimed at improving the balance of older adults disclosed their exercise prescription (Ex Rx) and instructional methods and met best-practice exercise recommendations for balance improvement. Design Review. Setting PubMed, Scopus, and CINAHL databases were searched from their inception until August 22, 2014. Participants Adults aged 60 and older without debilitating disease. Measurements Three electronic databases were searched to identify randomized controlled trials ( RCTs) of Tai Chi interventions aimed at improving balance in older adults without severe debilitating diseases. Three Ex Rx (frequency, time, intervention length) and 10 instructional (e.g., style, number of forms) methods of the included RCTs were evaluated. Results Twenty-seven interventions were identified from 26 RCTs. On average, Tai Chi was performed for a mean 56.5 ± 14.4 minutes per session for 2.8 ± 1.4 sessions per week for 19.7 ± 12.7 weeks. Most interventions reported all three Ex Rx methods items, with a mean reporting rate of 92.6 ± 19.2%. For the 10 instructional methods items, the mean reporting rate was 41.1 ± 18.0%, significantly lower than for the Ex Rx methods items ( P < .001). Fewer than half of the interventions reported unsupervised practice (15%), progression (22%), or the use of breathing (30%) and relaxation (15%) techniques. The instructional methods items most important for targeting Tai Chi practice to improve balance were not routinely disclosed, with only 15% reporting names of forms and 52% reporting movement principles. Conclusion Most Tai Chi interventions disclosed their Ex Rx methods yet routinely failed to report instructional methods. To increase the effectiveness of Tai Chi to improve balance in older adults, future RCTs should disclose their Ex Rx and instructional methods, especially methods that target balance. [ABSTRACT FROM AUTHOR]

Older African Americans who experience pain are especially at high risk of underassessment and undertreatment. This study examined patterns and correlates of pain medication use: severity of pain, medical conditions, and access to care. African Americans aged 65 and older were recruited from 16 churches located in south Los Angeles (N = 400). Structured face-to-face interviews and visual inspection of each participant's medications were conducted. More than 39% of participants were aged 75 and older, and 65% were female. Forty-seven percent used at least one type of pain medication. The frequency of pain medication use according to pharmaceutical class was nonopioid, 33%; opioid, 12%; adjuvant, 9%; and other drug, 8%. Seventy-seven percent of nonopioids were nonsteroidal anti-inflammatory drugs ( NSAIDs), which 25% of participants with hypertension, 28% with stroke, 26% with kidney disease, and 28% with gastrointestinal problems used. Ninety-eight percent of participants who used NSAIDs, 98% experienced potentially inappropriate medication ( PIM) use, 69% experienced drug duplication, and 65% experienced drug-drug interactions. This study suggests severe mismanagement of pain in underserved older African Americans, particularly those with comorbidity, multiple providers, and limited access to health care. The use of pain medication was associated with drug-drug interactions, drug duplication, and PIM use. The data show that many participants with severe pain are not taking pain medication or experience PIM use. One in four participants was taking NSAIDs, which can cause serious side effects in older African Americans with multiple chronic conditions. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which is concerned with research which investigated an intervention to prevent falls in elderly adults living in a residential home.

A letter to the editor is presented which addresses a randomized controlled rehabilitation trial involving the best practices for mobility recovery in the aftermath of a hip fracture, and it mentions the recovery of lower extremity performance, as well as prefracture and postdischarge mobility.

Objectives To test a new cognitive behavioral therapy for insomnia ( CBT-I) program designed for use by nonclinicians. Design Randomized controlled trial. Setting Department of Veterans Affairs healthcare system. Participants Community-dwelling veterans aged 60 and older who met diagnostic criteria for insomnia of 3 months duration or longer (N = 159). Intervention Nonclinician 'sleep coaches' delivered a five-session manual-based CBT-I program including stimulus control, sleep restriction, sleep hygiene, and cognitive therapy (individually or in small groups), with weekly telephone behavioral sleep medicine supervision. Controls received five sessions of general sleep education. Measurements Primary outcomes, including self-reported (7-day sleep diary) sleep onset latency ( SOL-D), wake after sleep onset ( WASO-D), total wake time ( TWT-D), and sleep efficiency ( SE-D); Pittsburgh Sleep Quality Index ( PSQI); and objective sleep efficiency (7-day wrist actigraphy, SE-A) were measured at baseline, at the posttreatment assessment, and at 6- and 12-month follow-up. Additional measures included the Insomnia Severity Index ( ISI), depressive symptoms (Patient Health Questionnaire-9 ( PHQ-9)), and quality of life (Medical Outcomes Study 12-item Short-form Survey version 2 ( SF-12v2)). Results Intervention subjects had greater improvement than controls between the baseline and posttreatment assessments, the baseline and 6-month assessments, and the baseline and 12-month assessments in SOL-D (−23.4, −15.8, and −17.3 minutes, respectively), TWT-D (−68.4, −37.0, and −30.9 minutes, respectively), SE-D (10.5%, 6.7%, and 5.4%, respectively), PSQI (−3.4, −2.4, and −2.1 in total score, respectively), and ISI (−4.5, −3.9, and −2.8 in total score, respectively) (all P < .05). There were no significant differences in SE-A, PHQ-9, or SF-12v2. Conclusion Manual-based CBT-I delivered by nonclinician sleep coaches improves sleep in older adults with chronic insomnia. [ABSTRACT FROM AUTHOR]

Objectives To estimate the prevalence of new initiation of long-acting opioids since introduction of national efforts to increase prescriber and public awareness on safe use of transdermal fentanyl patches. Design Cross-sectional. Setting U.S. nursing homes ( NHs). Participants Medicare-enrolled long-stay NH residents (N = 22,253). Measurements Minimum Data Set 3.0 was linked with Medicare enrollment, hospital claims, and prescription drug transaction data (January-December 2011) and used to determine the prevalence of new initiation of a long-acting opioid prescribed to residents in NHs. Results Of NH residents prescribed a long-acting opioid within 30 days of NH admission (n = 12,278), 9.4% (95% confidence interval = 8.9-9.9%) lacked a prescription drug claim for a short-acting opioid in the previous 60 days. The most common initial prescriptions of long-acting opioids were fentanyl patch (51.9% of opioid-naïve NH residents), morphine sulfate (28.1%), and oxycodone (17.2%). Conclusion New initiation of long-acting opioids-especially fentanyl patches, which have been the subject of safety communications-persists in NHs. [ABSTRACT FROM AUTHOR]

Objectives To evaluate frequency of use of two anti-dementia drug classes approved for treatment of symptoms, whether populations most likely to benefit are treated, and correlates of treatment initiation. Design Nationally representative cohort study. Setting Fee-for-service Medicare. Participants Elderly adults with dementia enrolled in Medicare Parts A, B, and D in 2009 (N = 433,559) and a subset with incident dementia (n = 185,449). Measurements Main outcome was any prescription fill for antidementia drugs (cholinesterase inhibitors (ChEIs) or memantine) within 1 year. Results Treatment with antidementia drugs occurred in 55.8% of all participants with dementia and 49.3% of those with incident dementia. There was no difference between ChEIs and memantine use according to dementia severity (measured as death within first year or living in residential care vs in a community setting) even though memantine is not indicated in mild disease. In incident cases, initiation of treatment was lower in residential care (relative risk (RR) = 0.82, 95% confidence interval (CI) = 0.81-0.83) and with more comorbidities (RR = 0.96, 95% CI = 0.96-0.96). Sixty percent of participants were managed in primary care alone. Seeing a neurologist (RR = 1.07, 95% CI = 1.06-1.09) or psychiatrist (RR = 1.17, 95% CI = 1.16-1.19) was associated with higher likelihood of treatment than seeing a primary care provider alone, and seeing geriatrician was associated with with lower likelihood (RR = 0.96, 95% CI = 0.93-0.99). Across the United States, the proportion of newly diagnosed individuals started on antidementia treatment varied from 32% to 66% across hospital referral regions. Conclusion Antidementia drugs are used less often in people with late disease, but there is no differentiation in medication choice. Although primary care providers most often prescribe antidementia medication without specialty support, differences in practice between specialties are evident. [ABSTRACT FROM AUTHOR]

Objectives To examine the cognitive and neural effects of vision-based speed-of-processing ( VSOP) training in older adults with amnestic mild cognitive impairment ( aMCI) and contrast those effects with an active control (mental leisure activities ( MLA)). Design Randomized single-blind controlled pilot trial. Setting Academic medical center. Participants Individuals with aMCI (N = 21). Intervention Six-week computerized VSOP training. Measurements Multiple cognitive processing measures, instrumental activities of daily living ( IADLs), and two resting state neural networks regulating cognitive processing: central executive network ( CEN) and default mode network ( DMN). Results VSOP training led to significantly greater improvements in trained (processing speed and attention: F1,19 = 6.61, partial η2 = 0.26, P = .02) and untrained (working memory: F1,19 = 7.33, partial η2 = 0.28, P = .01; IADLs: F1,19 = 5.16, partial η2 = 0.21, P = .03) cognitive domains than MLA and protective maintenance in DMN ( F1, 9 = 14.63, partial η2 = 0.62, P = .004). VSOP training, but not MLA, resulted in a significant improvement in CEN connectivity ( Z = −2.37, P = .02). Conclusion Target and transfer effects of VSOP training were identified, and links between VSOP training and two neural networks associated with aMCI were found. These findings highlight the potential of VSOP training to slow cognitive decline in individuals with aMCI. Further delineation of mechanisms underlying VSOP-induced plasticity is necessary to understand in which populations and under what conditions such training may be most effective. [ABSTRACT FROM AUTHOR]

Objectives To compare the effects of 12 months of vitamin D3 supplementation with that placebo on lean mass, bone mineral density ( BMD), and muscle strength in overweight or obese postmenopausal women completing a structured weight-loss program. Design Double-blind, placebo-controlled randomized clinical trial. Setting Fred Hutchinson Cancer Research Center, Seattle, Washington. Participants Postmenopausal women aged 50 to 75 with a body mass index ( BMI) of 25 kg/m2 or greater and a serum 25-hydroxyvitamin D (25(OH)D) concentration between 10.0 and 32.0 ng/mL (insufficient) (N = 218). Intervention Oral vitamin D3 2,000 IU/d or placebo in combination with a lifestyle-based weight loss intervention consisting of a reduction of 500 kcal to 1,000 kcal per day and 225 min/wk of moderate- to vigorous-intensity aerobic exercise. Measurements Serum 25(OH)D, body composition, and muscle strength were measured before randomization (baseline) and at 12 months. Mean changes of the groups were compared (intention to treat) using generalized estimating equations. Results Change in 25(OH)D was significantly different between the vitamin D and placebo groups at 12 months (13.6 ng/mL vs −1.3 ng/mL, P < .001), but no differences in change in lean mass (−0.8 kg vs −1.1 kg, P = .53) or BMD of the spine (−0.01 g/cm2 vs 0.0 g/cm2, P = .82) or right femoral neck (both −0.01 g/cm2, P = .49) were detected between the groups. Leg strength decreased in the vitamin D group but not in the placebo group (−2.6 pounds vs 1.8 pounds, P = .03). In women randomized to vitamin D, achieving repletion (25(OH)D ≥ 32 ng/mL) did not alter results. Conclusion Vitamin D3 supplementation during weight-loss decreased leg strength but did not alter changes in lean mass or BMD in postmenopausal women with vitamin D insufficiency. [ABSTRACT FROM AUTHOR]

Objectives To examine potentially inappropriate medication ( PIM) use in older adults initiating an antimuscarinic medication for the treatment of overactive bladder ( OAB). Design Retrospective database analysis. Setting Medical and pharmacy claims data. Participants Medicare Advantage Prescription Drug Plan members aged 65 and older newly initiated on an antimuscarinic OAB treatment were identified and assigned to PIM and non- PIM comparison groups based on 2012 American Geriatrics Society Beers Criteria and/or the presence of an anticholinergic medication interaction at the time of initiation of treatment (N = 66,275). Measurements Healthcare costs and OAB medication use. Results Of members initiated on an antimuscarinic OAB medication, 31.1% had a drug-drug or drug-disease or syndrome interaction. Dementia was the most common disease or syndrome interaction (11.3%), followed by constipation (8.6%) and delirium (2.9%). Paroxetine (2.6%), amitriptyline (2.2%), cyclobenzaprine (1.7%), and meclizine (1.6%) were the most common interacting medications. Subjects in the PIM group had greater healthcare costs over 12 months of follow-up ($12,001) than those in the non- PIM group ($9,373) after controlling for baseline characteristics ( P < .001). There was no difference between the PIM and the non- PIM groups in odds of discontinuing OAB treatment at 12 months after controlling for baseline characteristics (odds ratio = 0.98, 95% confidence interval = 0.89-1.07, P = .63). Conclusion Potentially inappropriate medication use was highly prevalent and was associated with greater total healthcare costs. Providers should carefully consider medical history and concurrent medication use when initiating antimuscarinic medication for the treatment of OAB. Development of interventions to reduce potentially inappropriate use of antimuscarinics in individuals with OAB is warranted. [ABSTRACT FROM AUTHOR]

Objectives To test whether a multifaceted prospective memory intervention improved adherence to antihypertensive medications and to assess whether executive function and working memory processes moderated the intervention effects. Design Two-group longitudinal randomized control trial. Setting Community. Participants Individuals aged 65 and older without signs of dementia or symptoms of severe depression who were self-managing prescribed medication. Measurements After 4 weeks of initial adherence monitoring using a medication event monitoring system, individuals with 90% or less adherence were randomly assigned to groups. Intervention The prospective memory intervention was designed to provide strategies that switch older adults from relying on executive function and working memory processes (that show effects of cognitive aging) to mostly automatic associative processes (that are relatively spared with normal aging) for remembering to take medications. Strategies included establishing a routine, establishing cues strongly associated with medication taking actions, performing the action immediately upon thinking about it, using a medication organizer, and imagining medication taking to enhance encoding and improve cuing. Results There was significant improvement in adherence in the intervention group (57% at baseline to 78% after the intervention), but most of these gains were lost after 5 months. The control condition started at 68% and was stable during the intervention, but dropped to 62%. Executive function and working memory moderated the intervention effect, with the intervention producing greater benefit for those with lower executive function and working memory. Conclusion The intervention improved adherence, but the benefits were not sustained. Further research is needed to determine how to sustain the substantial initial benefits. [ABSTRACT FROM AUTHOR]

Objectives To explore the association between the number of physicians providing care and anticholinergic drug burden in older persons newly initiated on cholinesterase inhibitor therapy for the management of dementia. Design Population-based cross-sectional study. Setting Community and long-term care, Ontario, Canada. Participants Community-dwelling (n = 79,067, mean age 81.0, 60.8% female) and long-term care residing (n = 12,113, mean age 84.3, 67.2% female) older adults (≥66) newly dispensed cholinesterase inhibitor drug therapy. Measurements Anticholinergic drug burden in the prior year measured using the Anticholinergic Risk Scale. Results Community-dwelling participants had seen an average of eight different physicians in the prior year. The odds of high anticholinergic drug burden (Anticholinergic Risk Scale score ≥ 2) were 24% higher for every five additional physicians providing care to individuals in the prior year (adjusted odds ratio = 1.24, 95% confidence interval = 1.21-1.26). Female sex, low-income status, previous hospitalization, and higher comorbidity score were also associated with high anticholinergic drug burden. Long-term care facility residents had seen an average of 10 different physicians in the prior year. After a sensitivity analysis, the association between high anticholinergic burden and number of physicians was no longer statistically significant in the long-term care group. Conclusion In older adults newly started on cholinesterase inhibitor drug therapy, greater number of physicians providing care was associated with higher anticholinergic drug burden scores. Given the potential risks of anticholinergic drug use, improved communication among physicians and an anticholinergic medication review before prescribing a new drug are important strategies to improve prescribing quality. [ABSTRACT FROM AUTHOR]

Objectives To examine whether 12 months of aerobic training ( AT) moderated the relationship between change in mobility and change in basal ganglia volume than balance and toning ( BAT) exercises in older adults. Design Secondary analysis of a randomized controlled trial. Setting Champaign-Urbana, Illinois. Participants Community-dwelling older adults (N = 101; mean age 66.4). Intervention Twelve-month exercise trial with two groups: AT and BAT. Measurements Mobility was assessed using the Timed Up and Go test. Basal ganglia (putamen, caudate nucleus, pallidum) was segmented from T1-weighted magnetic resonance images using the Oxford Centre for Functional Magnetic Resonance Imaging of the Brain Software Library Integrated Registration and Segmentation Tool. Measurements were obtained at baseline and trial completion. Hierarchical multiple regression was conducted to examine whether exercise mode moderates the relationship between change in mobility and change in basal ganglia volume over 12 months. Age, sex, and education were included as covariates. Results Exercise significantly moderated the relationship between change in mobility and change in left putamen volume. Specifically, for the AT group, volume of the left putamen did not change, regardless of change in mobility. Similarly, in the BAT group, those who improved their mobility most over 12 months had no change in left putamen volume, although left putamen volume of those who declined in mobility levels decreased significantly. Conclusion The primary finding that older adults who engaged in 12 months of BAT training and improved mobility exhibited maintenance of brain volume in an important region responsible for motor control provides compelling evidence that such exercises can contribute to the promotion of functional independence and healthy aging. [ABSTRACT FROM AUTHOR]

Background Elderly adults (65 years of age and older) are of particular concern for traumatic amputations due to age-related changes in vision and coordination, making them more susceptible to injury. Objectives The objective of this study is to describe the epidemiology of traumatic amputations in the elderly adults treated in United States emergency departments (ED). Design A retrospective analysis using data from the National Electronic Injury Surveillance System from 2010 to 2013. Participants People aged 65 years and older treated in U.S. hospital EDs for traumatic amputations from 2010 to 2013. Results There were 15,611 elderly patients treated for amputations from 2010 to 2013, averaging 3,902 amputations per year in the United States. The frequency of amputations declined with increasing age. The mean age was 74 years old. Males represented 84% of the cohort. The majority of the injuries that were recorded took place at home (71%). The most common associated consumer products were saws, lawnmowers, and doors. Saws accounted for approximately 45% of amputations. In females, doors were the most common consumer product associated with amputations. Approximately 45% of amputations were complete amputations. The most common digit to be amputated was the thumb (24%). Approximately 72% of the cases in the cohort were treated and released from the ED. Conclusion Traumatic amputations in elderly adults were frequently due to saws and lawnmowers. An increase in injury prevention efforts in this patient population is warranted. [ABSTRACT FROM AUTHOR]

Objectives To investigate the effects of number of medications and Drug Burden Index ( DBI) on transitions between frailty stages and death in community-dwelling older men. Design Cohort study. Setting Sydney, Australia. Participants Community-dwelling men aged 70 and older (N = 1,705). Measurements Self-reported questionnaires and clinic visits were conducted at baseline and 2 and 5 years. Frailty was assessed at all three waves according to the modified Fried frailty phenotype. The total number of regular prescription medications and DBI (a measure of exposure to sedative and anticholinergic medications) were calculated over the three waves. Data on mortality over 9 years were obtained. Multistate modeling was used to characterize the transitions across three frailty states (robust, prefrail, frail) and death. Results Each additional medication was associated with a 22% greater risk of transitioning from the robust state to death (adjusted 95% confidence interval ( CI) = 1.06-1.41). Every unit increase in DBI was associated with a 73% greater risk of transitioning from the robust state to the prefrail state (adjusted 95% CI = 1.30-2.31) and a 2.75 times greater risk of transitioning from the robust state to death (adjusted 95% CI = 1.60-4.75). There was no evidence of an adjusted association between total number of medications or DBI and the other transitions. Conclusion Although the possibility of confounding by indication cannot be excluded, additional medications were associated with greater risk of mortality in robust community-dwelling older men. Greater DBI was also associated with greater risk of death and transitioning from the robust state to the prefrail state. [ABSTRACT FROM AUTHOR]

Objectives To compare the effectiveness of chemotherapy in prolonging survival according to age in breast and colon cancer. Design Retrospective cohort study with a matched cohort analysis based on the conditional probability of receiving chemotherapy. Setting The 16 Surveillance, Epidemiology, and End Results ( SEER) areas from the SEER- Medicare linked database. Participants Women diagnosed with Stage I to IIIa hormone receptor-negative breast cancer (n = 14,440) and 26,893 men and women with Stage III colon cancer (n = 26,893) aged 65 and older in 1992 to 2009. Measurements The main exposure was the receipt of chemotherapy, and the main outcome was mortality. Results In women with breast cancer aged 65 to 69, the risk of all-cause mortality was statistically significantly lower in those who received chemotherapy than in those who did not in the entire cohort (hazard ratio ( HR) = 0.70, 95% confidence interval ( CI) = 0.57-0.88) and in a propensity-matched cohort ( HR = 0.82, 95% CI = 0.70-0.96) after adjusting for measured confounders. These patterns were similar in participants aged 70 to 74 and 75 to 79, but in women aged 80 to 84 and 85 to 89, risk of all-cause mortality was no longer significantly lower in those receiving chemotherapy in the entire and matched cohorts, except that, in a small number of women who received doxorubicin (Adriamycin) and cyclophosphamide (Cytoxan), risk of mortality was significantly lower for those aged 80 to 84. Chemotherapy appeared to be effective in all ages from 65 through 84 in participants with Stage III colon cancer. For example, in those aged 85 to 89, chemotherapy was significantly associated with lower risk of mortality in the entire cohort ( HR = 0.79, 95% CI = 0.67-0.92) and the matched cohort ( HR = 0.79, 95% CI = 0.66-0.95). Conclusion The effectiveness of chemotherapy decreased with age in participants with breast cancer, in whom chemotherapy appears to be effective until age 79 except for the doxorubicin-cyclophosphamide combination, which was effective in participants aged 80 to 84. In individuals with Stage III colon cancer, chemotherapy appears to be effective to age 89. These findings were consistent with those of randomized clinical trials. [ABSTRACT FROM AUTHOR]

Objectives To assess the association between the use of medications with anticholinergic activity and the subsequent risk of injurious falls in older adults. Design Prospective, population-based study using data from The Irish Longitudinal Study on Ageing. Setting Irish population. Participants Community-dwelling men and women without dementia aged 65 and older (N = 2,696). Measurements Self-reported injurious falls reported once approximately 2 years after baseline interview. Self-reported regular medication use at baseline interview. Pharmacy dispensing records from the Irish Health Service Executive Primary Care Reimbursement Service in a subset (n = 1,553). Results Nine percent of men and 17% of women reported injurious falls. In men, the use of medications with definite anticholinergic activity was associated with greater risk of subsequent injurious falls (adjusted relative risk ( aRR) = 2.55, 95% confidence interval ( CI) = 1.33-4.88), but the risk of having any fall and the number of falls reported were not significantly greater. Greater anticholinergic burden was associated with greater injurious falls risk. No associations were observed for women. Findings were similar using pharmacy dispensing records. The aRR for medications with definite anticholinergic activity dispensed in the month before baseline and subsequent injurious falls in men was 2.53 (95% CI = 1.15-5.54). Conclusion The regular use of medications with anticholinergic activity is associated with subsequent injurious falls in older men, although falls were self-reported after a 2-year recall and so may have been underreported. Further research is required to validate this finding in men and to consider the effect of duration and dose of anticholinergic medications. [ABSTRACT FROM AUTHOR]

Objectives To investigate a nosocomial outbreak of influenza. Design Prospective outbreak investigation with active case finding and molecular typing. Setting A large academic geriatric hospital in Switzerland. Participants Elderly hospitalized adults. Measurements Based on syndromic surveillance, a nosocomial influenza outbreak was suspected in February 2012. All suspected cases were screened for respiratory viruses using real-time reverse transcription polymerase chain reaction of nasopharyngeal swabs. Infection control procedures (droplet precautions with single room isolation whenever possible) were implemented for all suspected or confirmed cases. Specimens positive for influenza viruses were processed and sequenced whenever possible to track transmission dynamics. Results Respiratory samples from 155 suspected cases were analyzed during the outbreak period, of which 69 (44%) were positive for influenza virus, 26 (17%) were positive for other respiratory viruses, and 60 (39%) were negative. Three other cases fulfilled clinical criteria for influenza infection but were not sampled, and one individual was admitted with an already positive test, resulting in a total of 73 influenza cases, of which 62 (85%) were classified as nosocomial. Five distinct clusters of nosocomial transmission were identified using viral sequencing, with epidemiologically unexpected in-hospital transmission dynamics. Seven of 23 patients who experienced influenza complications died. Sixteen healthcare workers experienced an influenza-like illness (overall vaccination rate, 36%). Conclusion Nosocomial influenza transmission caused more secondary cases than repeated community importation during this polyclonal outbreak. Molecular tools revealed complex transmission dynamics. Low healthcare worker vaccination rates and gaps in recommended infection control procedures are likely to have contributed to nosocomial spread of influenza, which remains a potentially life-threatening disease in elderly adults. [ABSTRACT FROM AUTHOR]

Although traditional Chinese medicine ( TCM) is widely used, its effect on health outcomes is not well understood. This study employed a cohort sequential design to investigate levels and rates of change in health from midlife to older adulthood in TCM users and nonusers. A sample of 1,302 community-dwelling adults aged 53 to 80 was selected from individuals interviewed in the 1999 Taiwan Longitudinal Study on Aging ( TLSA) and reinterviewed in 2003 and 2007. TCM users were identified as participants who reported visiting a Chinese medicine clinic in the year before each of the three interviews. Health outcomes included physical function, self-rated health, cognitive function, and depressive symptoms. Approximately one in five adults reported that they used TCM in at least one wave of the 3 interview years, but less than one in twenty across all waves. Controlling for time-varying sociodemographic and health conditions, levels and rates of change in physical and cognitive function did not differ according to TCM use. Although adults who reported using TCM had higher depressive symptoms ( β TCM = 0.979, 95% confidence interval ( CI) = 0.200-1.758) and poorer self-rated health ( β TCM = −0.267, 95% CI = −0.267 to −0.081) at baseline, their rates of change in these outcomes did not differ from those who did not use TCM. Subgroup analyses revealed that TCM use benefited adults with higher depressive symptoms by attenuating worsening depressive symptoms ( β TCM×Age = −0.221, 95% CI = −0.434 to −0.007). Further research aimed at understanding the specific mechanisms by which TCM affects health outcomes is warranted. [ABSTRACT FROM AUTHOR]

The article discusses research which was conducted to investigate whether symptoms associated with carotid sinus hypersensitivity indicate cerebral hypoperfusion and whether patients with carotid sinus hypersensitivity are at a greater risk of white matter hyperintensities. Researchers evaluated 272 subjects. They found that symptoms during carotid sinus massage and not hemodynamic change are associated with white matter hyperintensity volume.

Objectives To determine whether the postoperative administration of tryptophan would be beneficial for elderly adults undergoing surgery who are at risk of developing postoperative delirium. Design Randomized, double-blind, placebo-controlled trial. Setting Denver Veterans Affairs Medical Center. Participants Individuals aged 60 and older undergoing major elective operations requiring a postoperative intensive care unit ( ICU) admission (n = 325). Intervention L-tryptophan, 1 g orally three times a day or placebo was started after surgery and continued for up to 3 days postoperatively. Measurements Delirium and its motor subtypes were measured using the Confusion Assessment Method-Intensive Care Unit (CAM-ICU) and the Richmond Agitation and Sedation Scale. The primary outcome for between-group comparison was the incidence of excitatory (mixed and hyperactive) postoperative delirium. The secondary outcomes for comparison were the incidence and duration of overall postoperative delirium. Results The overall incidence of postoperative delirium was 39% (95% confidence interval = 34-44%) (n = 116). Seventeen percent of participants in the tryptophan group and 9% in the placebo group had excitatory delirium ( P = .18), and the duration of excitatory delirium was 3.3 ± 1.7 days for tryptophan and 3.1 ± 1.9 days for placebo ( P = .74). Forty percent of participants in the tryptophan group and 37% in the placebo group had overall delirium ( P = .60), and the duration of overall delirium was 2.9 ± 1.8 days for tryptophan and 2.4 ± 1.6 days for placebo ( P = .17). Conclusion Postoperative tryptophan supplementation in older adults undergoing major elective operations requiring postoperative ICU admission did not reduce the incidence or duration of postoperative excitatory delirium or overall delirium. [ABSTRACT FROM AUTHOR]

Objectives To examine the relationship between Physician Orders for Life- Sustaining Treatment ( POLST) for Scope of Treatment and setting of care at time of death. Design Cross-sectional. Setting Oregon in 2010 and 2011. Participants People who died of natural causes. Measurements Oregon death records containing cause and location of death were matched with POLST orders for people with a POLST form in the Oregon POLST registry. Logistic regression was used to measure the association between POLST orders and location of death. Results Of 58,000 decedents, 17,902 (30.9%) had a POLST form in the registry. Their orders for Scope of Treatment were comfort measure only, 11,836 (66.1%); limited interventions, 4,787 (26.7%); and full treatment, 1,153 (6.4%). Comfort measures only ( CMO) orders advise avoiding hospitalization unless comfort cannot be achieved in the current setting; 6.4% of participants with POLST CMO orders died in the hospital, compared with 44.2% of those with orders for full treatment and 34.2% for those with no POLST form in the registry. In the logistic regression, the odds of dying in the hospital of those with an order for limited interventions was 3.97 times as great (95% CI = 3.59-4.39) as of those with a CMO order, and the odds of those with an order for full treatment was 9.66 times as great (95% CI = 8.39-11.13). Conclusions The association with numbers of deaths in the hospital suggests that end-of-life preferences of people who wish to avoid hospitalization as documented in POLST orders are honored. [ABSTRACT FROM AUTHOR]

Objectives To evaluate an integrated telehealth intervention (Integrated Telehealth Education and Activation of Mood (I- TEAM)) to improve chronic illness (congestive heart failure, chronic obstructive pulmonary disease) and comorbid depression in the home healthcare setting. Design Randomized controlled trial. Setting Hospital-affiliated home healthcare setting. Participants Medically frail older homebound individuals (N = 102). Intervention The 3-month intervention consisted of integrated telehealth chronic illness and depression care, with a telehealth nurse conducting daily telemonitoring of symptoms, body weight, and medication use; providing eight weekly sessions of problem-solving treatment for depression; and providing for communication with participants' primary care physicians, who also prescribed antidepressants. Control participants were allocated to usual care with in-home nursing plus psychoeducation ( UC+P). Measurements The two groups were compared at baseline and 3 and 6 months after baseline on clinical measures (depression, health, problem-solving) and 12 months after baseline on health utilization (readmission, episodes of care, and emergency department ( ED) visits). Results Depression scores were 50% lower in the I- TEAM group than in the UC+P group at 3 and 6 months. Those who received the I- TEAM intervention significantly improved their problem-solving skills and self-efficacy in managing their medical condition. The I- TEAM group had significantly fewer ED visits ( P = .01) but did not have significantly fewer days in the hospital at 12 months after baseline. Conclusion Integrated telehealth care for older adults with chronic illness and comorbid depression can reduce symptoms and postdischarge ED use in home health settings. [ABSTRACT FROM AUTHOR]

Objectives To evaluate changes in self-reported nocturia in community-dwelling adults aged 60 and older who received behavioral treatment for chronic insomnia. Design Secondary analysis of a randomized controlled trial of a behavioral intervention for sleep. Setting Academic medical center. Participants Of the 79 enrollees, this analysis focused on 30 who, in addition to insomnia, also reported at least one nightly episode of waking up to void. Intervention The brief behavioral treatment of insomnia ( BBTI) group (n = 14) received instructions on reducing time in bed and setting a regular sleep schedule. The information control ( IC) group (n = 16) received printed materials. A nurse clinician delivered both interventions. Measurements Self-reported nocturnal awakenings to void assessed daily for 14 days at baseline and 4 weeks after the intervention. Participants who reported at least one episode of nocturia per night at baseline were included in this analysis. Results In individuals with nocturia at baseline, the total number of nocturnal voids over the 14-day assessment period decreased by 6.5 ± 4.8 in the BBTI group and increased by 1.3 ± 7.3 in the IC group ( P = .04, effect size 0.82). After adjusting for baseline nocturia episodes, the difference remained significant ( P = .05). Conclusion In older adults with concurrent insomnia and nocturia, behavioral treatment directed solely at insomnia may also improve self-reported nocturia. Behavioral treatment of insomnia should be further investigated for its effect on nocturia in individuals with concurrent insomnia and nocturia. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which describes a questionnaire survey of seasonal influenza vaccination prevalence and attitudes and knowledge about vaccination and health in health care workers in nursing homes in Hong Kong, China.

Objectives To ascertain predictors of initiation of brand-name versus generic narrow therapeutic index ( NTI) drugs. Design Retrospective cohort study. Setting Data from CVS Caremark were linked to Medicare claims and to U.S. census data. Participants Individuals aged 65 and older who initiated an NTI drug in 2006 and 2007 (N = 36,832). Measurements Demographic, health service utilization, and geographic predictors of whether participants initiated a generic or brand-name version of their NTI drug were identified using logistic regression. Results Overall, 30,014 (81.5%) participants started on a generic version of their NTI drug. The most commonly initiated NTI drugs were warfarin (n = 17,790; 48%), levothyroxine (n = 10,779; 29%), and digoxin (n = 6,414; 17%). Older age (odds ratio ( OR) = 1.12, 95% confidence interval ( CI) = 1.02-1.22 comparing aged ≥85 with 65-74), higher burden of comorbidity ( OR = 1.05, 95% CI = 1.04-1.07 for each 1-point increase in comorbidity score), and prior use of any generic drug ( OR = 1.55, 95% CI = 1.29-1.87) were positively associated with generic drug initiation. Independent of other predictors, residing in the census block group with the highest generic use was positively associated with greater odds of generic NTI drug initiation ( OR = 1.24, 95% CI = 1.14-1.35 compared with the lowest quintile). Conclusion Demographic, health service utilization, and geographic characteristics are important determinants of whether individuals initiate treatment with a brand-name or generic NTI drug. These factors may contribute to disparities in care and highlight potential targets for educational campaigns. [ABSTRACT FROM AUTHOR]

Objectives To compare the efficacy of intensive functional exercise training with that of usual cardiac rehabilitation ( CR) in very old adults soon after coronary bypass surgery ( CABG). Design Randomized controlled trial. Setting In-hospital CR. Participants Individuals aged 75 and older (n = 173, mean 78.5 ± 3.2) participated in inpatient CR, which started soon after surgery (13.1 ± 5.3 days) and lasted for a mean of 20.4 ± 3.2 days. Intervention Participants were randomly assigned to an inpatient CR intervention group ( IG; n = 84) or a control group ( CG; n = 89). All participants participated in the inpatient CR program. In addition, IG participants participated in resistance training and special balance training (5 d/wk). Measurements Six-minute walk test, cardiopulmonary exercise testing, Timed- Up-and- Go Test ( TUG), and a maximal isometric strength test were used to access functional capacity and the Mac New questionnaire to evaluate health-related quality of life ( HRQL). Results There were significant improvements ( P < .001) in all measured variables over the duration of CR. Improvements in functional capacity were significantly greater in the IG than the CG for 6-minute walk distance (6- MWD) ( IG Δ 67.3 ± 49.0 m vs CG Δ 41.9 ± 51.7 m; P = .003), TUG time ( IG Δ −2.4 ± 2.2 seconds vs CG Δ −1.2 ± 3.4 seconds; P = .005), and relative workload ( IG Δ 0.19 ± 0.21 W/kg vs CG Δ 0.13 ± 0.11 W/kg; P = .03). Conclusion There were significant improvements in all measured variables in very old adults participating in CR soon after CABG. With additional functional exercise training, participants randomized to IG improved significantly more than those randomized to CG on 6- MWD, TUG time, and relative workload. [ABSTRACT FROM AUTHOR]

Objectives To review the effectiveness of cognitive behavioral therapy ( CBT) for depression in older people, together with factors associated with its efficacy. Design Online literature databases and registers were searched for randomized controlled trials ( RCTs) of CBT for depression in older people. Random-effects meta-analysis and meta-regression were conducted. Setting Studies involving participants from the community and inpatient and outpatient clinical settings were included in the meta-analysis. Participants Older people with major or minor depression, dysthymia, or depressive symptoms. Measurements Evidence-based outcome measures of depression. Results Four hundred eighty-five studies were identified, of which 23 were included. At the end of the intervention, CBT was significantly more effective at reducing depressive symptoms (irrespective of whether rated by clinicians or participants) than treatment as usual ( TAU) or being on a waiting list but not than active controls. The same pattern of results was found for 6-month follow-up. At all other time-points, pooled effect sizes in favor of CBT were nonsignificant. Clinician-rated outcome measures resulted in larger effect sizes in favor of CBT than self-rated measures. No significant differences in efficacy were found between CBT and other treatment (pharmacotherapy and other psychotherapies). Meta-regression analyses revealed four factors that predicted effect sizes for comparisons between CBT and control conditions, including whether concurrent pharmacotherapy was allowed. Conclusion CBT for depression in older people is more effective than waiting list or TAU, but greater efficacy than active controls or other treatment has not been demonstrated. More high-quality RCTs comparing CBT with active controls need to be conducted before firm conclusions can be drawn about the efficacy of CBT for depression in older people. Other treatment approaches that could be contrasted with or augment CBT (e.g., pharmacotherapy) also need to be explored further. [ABSTRACT FROM AUTHOR]

Objectives To review data from randomized controlled trials ( RCTs) that evaluate adverse bone outcomes in older women using aromatase inhibitors ( AIs) for early-stage hormone receptor-positive breast cancer. Design Systematic review. Setting International RCTs referenced in Medline and EMBASE databases through August 1, 2011. Participants Postmenopausal women with early-stage hormone receptor-positive breast cancer receiving adjuvant endocrine therapy. Measurements Fracture rates and changes in bone turnover markers and bone mineral density. Results Eleven RCTs were identified. The majority of trials included women with a mean age in the 60s; and women aged 75 and older and 80 and older were excluded from two studies. Fracture rates ranged from 0.9% to 11%, with AIs having a 1.5 times higher risk than tamoxifen or placebo. Fracture data were not systematically collected in many of these trials. In a small subpopulation of women, AIs were associated with higher markers of bone turnover and lower bone density. The relationship between age and fracture was not described. Conclusion AIs are associated with low bone density and high fracture risk in women with a mean age in their early 60s. There is a paucity of data describing the effect of baseline fracture risk factors, particularly age, and the longer-term effects on bone health in older women. Future research is needed regarding baseline fracture risk, interventions, and long-term effects on bone in this vulnerable population to inform management decisions to optimize AI duration and ensure quality of life after breast cancer. [ABSTRACT FROM AUTHOR]

Objectives To describe the influence of age on clinical features of histoplasmosis. Design Retrospective single-center cohort study. Setting Large tertiary care center. Participants All individuals who met criteria for probable or proven histoplasmosis between 1998 and 2008. Measurements Participants were divided into the following categories of histoplasmosis: acute pulmonary, chronic pulmonary, asymptomatic, disseminated, and other. Correcting for immune status, the influence of age at diagnosis on presentation, diagnosis, imaging, treatment, and all-cause mortality was evaluated. Results In 347 participants with histoplasmosis, a number of characteristics were associated with age when evaluating participants according to diagnostic category. An age-associated increase in asymptomatic histoplasmosis was observed ( P < .001). In symptomatic pulmonary histoplasmosis, older adults were less likely to present with chest pain ( P < .001) and less likely to have hilar lymphadenopathy on imaging ( P = .04). Lower rates of seropositivity with older age were seen in asymptomatic ( P = .04) but not other forms of histoplasmosis. Cavitary disease was associated with older age in chronic pulmonary histoplasmosis ( P = .05). Treatment did not change with age. All-cause mortality at 6 months was 4% and was associated with older age ( P = .02). Conclusion Although most studied characteristics of histoplasmosis were similar, notable age-related differences were present. Chronic cavitary disease and asymptomatic histoplasmosis were more common with older age. In acute histoplasmosis, the lack of chest pain and hilar lymphadenopathy may hinder diagnosis in older adults. [ABSTRACT FROM AUTHOR]

Objectives To compare the effectiveness of behavioral treatment with that of antimuscarinic therapy in men without bladder outlet obstruction who continue to have overactive bladder ( OAB) symptoms with alpha-blocker therapy. Design The Male Overactive Bladder Treatment in Veterans (MOTIVE) Trial was a two-site randomized, controlled, equivalence trial with 4-week alpha-blocker run-in. Setting Veterans Affairs Medical Center outpatient clinics. Participants Volunteer sample of 143 men aged 42 to 88 who continued to have urgency and more than eight voids per day, with or without incontinence, after run-in. Interventions Participants were randomized to 8 weeks of behavioral treatment (pelvic floor muscle exercises, urge suppression techniques, delayed voiding) or drug therapy (individually titrated, extended-release oxybutynin, 5-30 mg/d). Measurements Seven-day bladder diaries and a validated urgency scale were used to calculate changes in 24-hour voiding frequency, nocturia, urgency, and incontinence. Secondary outcomes were global patient ratings and American Urological Association Symptom Index. Results Mean voids per day decreased from 11.3 to 9.1 (−18.8%) with behavioral treatment and 11.5 to 9.5 (−16.9%) with drug therapy. Equivalence analysis indicated that posttreatment means were equivalent ( P < .01). After treatment, 85% of participants rated themselves as much better or better; more than 90% were completely or somewhat satisfied, with no between-group differences. The behavioral group showed greater reductions in nocturia (mean = −0.70 vs −0.32 episodes/night; P = .05). The drug group showed greater reductions in maximum urgency scores (mean = −0.44 vs −0.12; P = .02). Other between-group differences were nonsignificant. Conclusion Behavioral and antimuscarinic therapy are effective when added to alpha-blocker therapy for OAB in men without outlet obstruction. Behavioral treatment is at least as effective as antimuscarinic therapy. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to research focusing upon the treatment of giant cell arteritis.

A letter to the editor is presented which addresses the effect of health qigong ba duan jin exercise on the blood pressure (BP) levels of individuals with the essential hypertension medical disorder, and it mentions lowering BPs and traditional Chinese health and fitness qigong exercise routines.

A letter to the editor is presented concerning research into possible associations between the use of acetylcholinesterase inhibitors, drugs used in the treatment of Alzheimer's disease and dementia with Lewy bodies, with increased anxiety and depression in older patients.

The article presents a study to determine the attenuation of postprandial hypotensive (PPH) response in older adults with diabetes mellitus by blocking carbohydrate intake in the small intestine with acarbose. Topics discussed include reduction in middle cerebral arterial (MCA) velocities due to acrabose, attenuation of PPH with acarbose in older adults with diabetes mellitus along with severe autonomic failure, improvement in the cerebral autoregulatory response by acarbose resulting the same.

The article discusses a study on the impact of continuous positive airway pressure (CPAP) on sleep nocturia in people suffering from sleep apnea. Fourteen men diagnosed with obstructive sleep apnea agreed to be treated with CPAP therapy. A significant reduction in the incidence of nocturia events per evening was recorded.

The article reports on research which was conducted to investigate whether the use of cholinesterase inhibitors (ChEIs) was associated with a risk of upper gastrointestinal bleeding in elderly adults with dementia. Researchers evaluated 203,279 dementia patients. They found that there was no significant association between ChEIs and bleeding in elderly adults.

A letter to the editor is presented which is concerned with research which investigated the treatment and outcomes of elderly adults with cerebral aneurysms and subarachnoid hemorrhage at comprehensive stroke centers.

A letter to the editor is presented which is concerned with pemphigus in elderly adults.

A letter to the editor is presented which is concerned with research which investigated the cognitive effects that vitamin D supplementation had in older patients visiting a memory clinic.

A letter to the editor is presented discussing a study on the use of anticholinergic drugs in older adults with mild cognitive impairment.