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Objectives To confirm associations of apolipoprotein E ( Apo E) ε4 carrier status, sex, and time-dependent cognitive status with mortality risk and to investigate these joint effects of these associations in a cohort of community-dwelling U.S. adults. Design Prospective cohort study. Setting The Baltimore Longitudinal Study of Aging ( BLSA). Participants Of 3,047 BLSA participants aged 17 to 98 at first visit (60.1% male), 1,704 with complete ApoE genotype data were included, of whom 1,461 aged 50 and older with one or more visits were eligible. Measurements Time to death from all, cardiovascular, and noncardiovascular causes. Results Probability of survival was lower for Apo E ε4 carriers, particularly those who were older. A Cox proportional hazards model for all-cause mortality yielded a hazard ratio ( HR) for Apo E ε4 carrier versus noncarriers of 1.31 (95% confidence interval ( CI) = 1.02-1.68). This association was also found for cardiovascular mortality. Time-dependent all-cause dementia ( HR = 1.73, 95% CI = 1.33-2.26) and mild cognitive impairment ( HR = 1.95, 95% CI = 1.42-2.67) increased all-cause mortality risk, associations that were also detected for noncardiovascular mortality. When individuals were free of cognitive impairment, a dose-response relationship with ε4 alleles was found for all-cause mortality ( HR = 1.40, 95% CI = 0.94-2.07 for 1 ε4; HR = 2.61, 95% CI = 1.12-6.07 for 2 ε4). After onset of Alzheimer's disease ( AD), carrying only one ε4 allele resulted in an approximately 77% greater all-cause mortality risk than in noncarriers. ApoE ε4 carrier status increased all-cause mortality risk in men and interacted with time-dependent AD to increase the risk of this outcome (relative excess risk due to interaction = 2.15, 95% CI = 1.22-3.07). Conclusion ApoE ε4 carrier status was found to increase all-cause and cardiovascular mortality risks and interacted with sex and time-dependent AD status to affect all-cause mortality. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which is concerned with research which investigated the relationship between high cortisol and low folate and Alzheimer's disease in patients older than 75.

Objectives To better understand the antibiotic prescribing process in assisted living ( AL) communities given the growing rate of antibiotic resistance. Design Cross-sectional survey. Setting Four AL communities in North Carolina. Participants Assisted living residents who received antibiotics (n = 30) from October 20, 2010, to March 31, 2011, a primary family member, staff, and the prescribing medical provider. Measurements Semistructured interviews that were conducted regarding prescribing included the information available at the time of prescribing and the perceptions of the quality of communication between providers, staff, residents and family members about the resident. Providers were asked an open-ended question regarding how to improve the communication process related to antibiotic prescribing for AL residents. Results For the 30 residents who received antibiotic prescriptions, providers often had limited information about the case and lacked familiarity with the residents, the residents' families, and staff. They also felt that cases were less severe and less likely to require an antibiotic than did residents, families, and staff. Providers identified several ways to improve the communication process, including better written documentation and staff and family presence. Conclusion In a small sample of AL communities, providers faced an array of challenges in making antibiotic prescribing decisions. This work confirms the complex nature of antibiotic prescribing in AL communities and indicates that further work is needed to determine how to improve the appropriateness of antibiotic prescribing. [ABSTRACT FROM AUTHOR]

Objectives To examine the association between successful aging without subsequent cognitive decline ( SA- ND) and the Northern Manhattan Study ( NOMAS) global vascular risk score ( GVRS), which is predictive of stroke, myocardial infarction, and vascular death. Design Prospective cohort study. Setting A stroke-free sample of Hispanic, black, and white participants living in the same community enrolled in a magnetic resonance imaging ( MRI) substudy of NOMAS, a population-based prospective cohort study. Participants One thousand two hundred ninety individuals in whom a cognitive screen was administered at baseline and at enrollment in the MRI substudy. Measurements SA- ND was based on disease, disability, and cognitive function. The GVRS includes age, sex, race and ethnicity, waist circumference, alcohol intake, smoking, physical activity, blood pressure, antihypertensive medication use, fasting blood sugar, lipid levels, and peripheral vascular disease. Results Data at baseline and follow-up were available for 1,162 participants (mean age 70 ± 9; 61% women; 13% white, 16% black, 69% Hispanic; mean GVRS 8.6 ± 0.9). Logistic regression, adjusted for education, socioeconomic status, and follow-up time, showed that the odds of SA- ND were 38% greater for each additional 1-point decrease on the GVRS (odds ratio = 1.38, 95% confidence interval = 1.17-1.61; P < .001). An inverse dose-response was observed between quartiles of GVRS and SA- ND. Greater diastolic blood pressure in participants taking antihypertensive medication and a history of claudication ( P = .003) or peripheral arterial disease ( P < .001) were inversely associated with SA- ND in the fully adjusted model. Conclusion Potentially modifiable vascular risk factors were independently associated with SA- ND in a multiethnic community-based sample. Improvements in GVRSs could help promote healthy longevity in the aging population. [ABSTRACT FROM AUTHOR]

Objectives To identify older adults with comorbidities or poor functional status at high risk of postoperative venous thromboembolism ( VTE). Design Retrospective cohort study. Setting Veterans Affairs Medical Center ( VAMC). Participants Older adults who underwent total hip and knee replacement ( THR and TKR) from 2002 to 2009. Measurements Using multivariate logistic regression, the independent effect of cardiopulmonary comorbidities and diabetes on VTE was analyzed. Functional status expressed in a summary physical component score ( PCS) was also analyzed in a subset of individuals in whom information on it was available. Results There were 23,326 THR and TKR surgeries performed at the VAMC during the study period. Individuals with chronic obstructive pulmonary disease ( COPD) had a 25% greater risk of VTE (odds ratio ( OR) = 1.25, 95% confidence interval ( CI) = 1.06-1.48), whereas those with coronary artery disease, congestive heart failure, and cerebrovascular disease did not have a greater risk of VTE. Individuals with diabetes mellitus had a lower risk of VTE ( OR = 0.77, 95% CI = 0.64-0.92). Individuals with low PCS, which were available for 3,169 patients, had a 62% greater risk, although the effect did not reach statistical significance (lowest vs highest quartile OR = 1.62, 95% CI = 0.93-2.80). Conclusion Individuals with COPD had slightly greater risk of VTE, whereas low functional status had a larger effect that did not reach statistical significance. The constraints of administrative data analysis and sample size available for PCS limit conclusions about the role of these comorbidities and functional status. [ABSTRACT FROM AUTHOR]

Objectives To determine whether pain predicts future activity of daily living ( ADL) disability or death in individuals aged 60 and older. Design Prospective cohort study. Setting The 1998 to 2008 Health and Retirement Study ( HRS), a nationally representative study of older community-living individuals. Participants Twelve thousand six hundred thirty-one participants in the 1998 HRS aged 60 and older who did not need help in any ADL. Measurements Participants reporting that they had moderate or severe pain most of the time were defined as having significant pain. The primary outcome was time to development of ADL disability or death over 10 yrs, assessed at five successive 2-year intervals. ADL disability was defined as needing help performing any ADL: bathing, dressing, transferring, toileting, eating, or walking across a room. A discrete hazards survival model was used to examine the relationship between pain and incident disability over each 2-year interval using only participants who started the interval with no ADL disability. Several potential confounders were adjusted for at the start of each interval: demographic factors, seven chronic health conditions, and functional limitations ( ADL difficulty and difficulty with five measures of mobility). Results At baseline, 2,283 (18%) participants had significant pain. Participants with pain were more likely (all P < .001) to be female (65% vs 54%), have ADL difficulty (e.g., transferring 12% vs 2%, toileting 11% vs 2%), have difficulty walking several blocks (60% vs 21%), and have difficulty climbing one flight of stairs (40% vs 12%). Over 10 years, participants with pain were more likely to develop ADL disability or death (58% vs 43%, unadjusted hazard ratio ( HR) = 1.67, 95% confidence interval ( CI) = 1.57-1.79), although after adjustment for confounders, participants with pain were not at greater risk for ADL disability or death ( HR = 0.98, 95% CI = 0.91-1.07). Adjustment for functional status almost entirely explained the difference between the unadjusted and adjusted results. Conclusion Although there are strong cross-sectional relationships between pain and functional limitations, individuals with pain are not at higher risk of subsequent disability or death after accounting for functional limitations. Like many geriatric syndromes, pain and disability may represent interrelated phenomena that occur simultaneously and require unified treatment paradigms. [ABSTRACT FROM AUTHOR]

Objectives To determine whether sociodemographic, clinical, healthcare system, psychosocial, and behavioral factors are differentially associated with low antihypertensive medication adherence scores in older men and women. Design Cross-sectional analysis of baseline data. Setting Cohort Study of Medication Adherence in Older Adults (N = 2,194). Measurements Low antihypertensive medication adherence was defined as a score less than 6 on the 8-item Morisky Medication Adherence Scale. Information on risk factors for low adherence was collected using telephone surveys and administrative databases. Results The prevalence of low medication adherence scores did not differ according to sex (women, 15.0%; men 13.1%; P = .21). In sex-specific multivariable models, having problems with medication cost and practicing fewer lifestyle modifications for blood pressure control were associated with low adherence scores in men and women. Factors associated with low adherence scores in men but not women were poor sexual functioning (odds ratio ( OR) = 2.03, 95% confidence interval ( CI) = 1.31-3.16 for men and OR = 1.28, 95% CI = 0.90-1.82 for women), and body mass index of 25.0 kg/m2 or more ( OR = 3.23, 95% CI = 1.59-6.59 for men; OR = 1.23, 95% CI = 0.82-1.85 for women). Factors associated with low adherence scores in women but not men included dissatisfaction with communication with their healthcare provider ( OR = 1.75, 95% CI = 1.16-2.65 for women; OR = 1.16, 95% CI = 0.57-2.34 for men) and depressive symptoms ( OR = 2.29, 95% CI = 1.55-3.38 for women; OR = 0.93, 95% CI = 0.48-1.80 for men). Conclusion Factors associated with low antihypertensive medication adherence scores differed according to sex. Interventions designed to improve adherence in older adults should be customized to account for the sex of the target population. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which is concerned with research which investigated the use of meditation in adults with mild cognitive impairment.

Objectives To assess the feasibility of refining physician quality indicators of screening mammography use based on patient life expectancy. Design Retrospective population-based cohort study. Setting Texas. Participants Three thousand five hundred ninety-five usual care providers ( UCPs) with at least 10 female patients aged 67 and older on January 1, 2008, with an estimated life expectancy of 7 years or more (222,584 women) and at least 10 women with an estimated life expectancy of less than 7 years (90,903 women), based on age and comorbidity. Measurements Screening mammography use in 2008-09 by each provider in each population. Results The average adjusted mammography screening rates for UCPs were 31.1% for women with a life expectancy of less than 7 years and 55.2% for women with a life expectancy of 7 years or longer. For women with limited life expectancy, 3.7% of UCPs had significantly lower and 9.2% had significantly higher than average adjusted mammography screening rates. For women with longer life expectancy, 16.7% of UCPs had significantly lower and 19.7% had significantly higher than average rates. UCP adjusted screening rates were stable over time (2006-07 vs 2008-09, correlation coefficient ( r) = 0.65, P < .001). There was a strong correlation between UCP screening rates for their female patients with a life expectancy of less than 7 years and 7 years or longer ( r = 0.67, P < .001). Most physician characteristics associated with higher screening rates (e.g., being female and foreign trained) in women with longer life expectancy were also associated with higher screening rates in women with limited life expectancy. Conclusion Providers with high mammography screening rates for women with longer life expectancy also tend to screen women with limited life expectancy. Quality indicators for screening practice can be improved by distinguishing appropriate use from overuse based on patient life expectancy. [ABSTRACT FROM AUTHOR]

Objectives To describe the trajectory of functional decline after an individual is referred to hospice. Design Electronic health record-based retrospective cohort study. Setting Three hospice programs in the U.S. southeast, northeast, and midwest. Participants Individuals in hospice. Main outcome measures Palliative Performance Scale ( PPS) scores measured at intervals between hospice enrollment and death, on a scale from 10 to 100. Results In 8,669 decedents, there was an average 13.8-point decline in PPS score. After adjusting for baseline PPS score and length of stay in hospice, three distinct trajectories were identified, each of which consisted of two diagnoses whose rates of decline had 95% confidence intervals ( CIs) that overlapped. The most rapid decline was observed for individuals with cancer (adjusted decline 8.44 points/wk; 95% CI = 8.03-8.82) and stroke (adjusted decline 7.67 points/wk, 95% CI = 7.08-8.29). A significantly slower decline was observed in individuals with pulmonary disease (adjusted decline 5.02 points/wk, 95% CI = 4.24-5.75) and cardiac disease (adjusted decline 4.53 points/wk, 95% CI = 4.05-5.05). Individuals with debility (adjusted decline 1.86 points/wk, 95% CI = 0.95-2.78) and dementia (adjusted decline 1.98 points/wk, 95% CI = 1.01-2.89) had the slowest decline. In an inverse probability-weighted sample of individuals who had a PPS score recorded in the last day of life (n = 1,959, 22.6%), 35.9% had a PPS score of at least 40, indicating some oral intake, variable mental status, limited self-care, and an ability to get out of bed for at least part of the day. Conclusion Although functional status generally declines in individuals in hospice, this decline is heterogeneous. Some individuals retain some physical and cognitive function until the last day of life. [ABSTRACT FROM AUTHOR]

Objectives To assess differences in resource use and cost between older adults with and without mild cognitive impairment ( MCI) over time. Design Multicenter, longitudinal study. Setting Sixty-eight Alzheimer's Disease Cooperative Study ( ADCS) sites in the United States. Participants Two hundred fifty-nine individuals diagnosed with MCI and 107 cognitively normal elderly adults followed annually for 3 years. Measurements The Resource Use Instrument ( RUI) was used to capture medical and nonmedical care use. Generalized linear latent and mixed models were used to estimate differences in resource use and costs in older adults with and without MCI after controlling for clinical and demographic characteristics. Results At baseline, average annual direct medical cost per person was substantially higher for participants with MCI ($6,499) than for those without ($2,969) P < .001). Informal care use was also substantially higher (33% vs 8.4%, P < .001). Results from multivariate analyses of longitudinal data show that, after controlling for participant and informant characteristics, direct medical costs were 44% higher for participants with MCI than for those without. Participants with MCI were almost five times as likely to use informal care as those without. Number of medical conditions and older age were associated with higher medical cost. Worse functional and cognitive status, older age, being married, and being female were associated with higher likelihood of informal care use. Having an adult child informant was associated with higher likelihood of using informal care. Conclusion The RUI captured differences in resource use and costs between individuals with and without MCI. Clinicians who care for individuals with MCI should address informal care needs early in the disease course. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the changes in types of medications prescribed for pain before and after withdrawal of certain selective cyclooxygenase 2 ( COX-2) inhibitors in 2004 and to determine whether there was an association with fall events in elderly adults with a diagnosis of osteoarthritis ( OA). Design A nested case-control design using electronic medical records compiled between 2001 and 2009. Setting Electronic medical records for care provided in an integrated health system in rural Pennsylvania over a 9-year period (2001-09), the midpoint of which rofecoxib and valdecoxib were pulled from the market. Participants Thirteen thousand three hundred fifty-four individuals aged 65 to 89 with a diagnosis of OA. Measurements The incidence of falls and fractures was examined in relation to analgesics prescribed: narcotics, COX-2 inhibitors, and nonsteroidal anti-inflammatory drugs ( NSAIDs). The comparison sample of individuals who did not fall was matched 3:1 with those who fell according to age, sex, and comorbidity. Results Narcotic analgesic prescriptions were associated with a significantly greater risk of falls and fractures. The likelihood of experiencing a fall/fracture was higher in participants prescribed narcotic analgesics than those prescribed a COX-2 inhibitor (odds ratio ( OR) = 3.3, 95% confidence interval ( CI) = 2.5-4.3) or NSAID ( OR = 4.1, 95% CI = 3.7-4.5). Conclusion Use of narcotic analgesics is associated with risk of falls and fractures in elderly adults with OA, an observation that suggests that the current guidelines for the treatment of pain, which include first-line prescription of narcotics, should be reevaluated. [ABSTRACT FROM AUTHOR]

Objectives To determine how the number of geriatric syndromes is associated with incident disability in community-based populations of older adults. Design Longitudinal analysis from the Women's Health Initiative Observational Study ( WHI- OS). Setting Community. Participants Twenty-nine thousand five hundred forty-four women aged 65 and older enrolled in the WHI- OS and free of disability in activities of daily living ( ADLs) at baseline. Measurements Geriatric syndromes (high depressive symptoms, dizziness, falls, hearing or visual impairment, osteoporosis, polypharmacy, syncope, sleep disturbance, and urinary incontinence) were self-reported at baseline and 3-year follow-up. Disability was defined as dependence in any ADL and was assessed at baseline and follow-up. Chronic diseases were measured according to a modified Charlson Index. Results Geriatric syndromes were common in this population of women; 76.3% had at least one syndrome at baseline. Greater number of geriatric syndromes at baseline was significantly associated with greater risk of incident ADL disability at follow-up ( P ≤ .001). Adjusted risk ratios were 1.21 (95% confidence interval ( CI) = 0.78-1.87) for a single syndrome and 6.64 (95% CI = 4.15-10.62) for five or more syndromes compared with no syndromes. These results were only slightly attenuated after adjustment for number of chronic diseases or pain. Conclusion Geriatric syndromes are significantly associated with onset of disability in older women; this association is not simply a result of chronic disease or pain. A better understanding of how these conditions contribute to disablement is needed. Geriatric syndrome assessment should be considered along with chronic disease management in the prevention of disability in older women. [ABSTRACT FROM AUTHOR]

Objectives To test whether women aged 55 and older with increasing evidence of a frailty phenotype would have greater risk of fractures, disability, and recurrent falls than women who were not frail, across geographic areas ( Australia, Europe, and North America) and age groups. Design Multinational, longitudinal, observational cohort study. Setting Global Longitudinal Study of Osteoporosis in Women ( GLOW). Participants Women (N = 48,636) aged 55 and older enrolled at sites in Australia, Europe, and North America. Measurements Components of frailty (slowness and weakness, poor endurance and exhaustion, physical activity, and unintentional weight loss) at baseline and report of fracture, disability, and recurrent falls at 1 year of follow-up were investigated. Women also reported health and demographic characteristics at baseline. Results Women younger than 75 from the United States were more likely to be prefrail and frail than those from Australia, Canada, and Europe. The distribution of frailty was similar according to region for women aged 75 and older. Odds ratios from multivariable models for frailty versus nonfrailty were 1.23 (95% confidence interval ( CI) = 1.07-1.42) for fracture, 2.29 (95% CI = 2.09-2.51) for disability, and 1.68 (95% CI = 1.54-1.83) for recurrent falls. The associations for prefrailty versus nonfrailty were weaker but still indicated statistically significantly greater risk of each outcome. Overall, associations between frailty and each outcome were similar across age and geographic region. Conclusion Greater evidence of a frailty phenotype is associated with greater risk of fracture, disability, and falls in women aged 55 and older in 10 countries, with similar patterns across age and geographic region. [ABSTRACT FROM AUTHOR]

Objectives To examine educational gradients in dementia care and whether the effect of a dementia collaborative care management intervention varied according to the educational attainment of the informal caregiver. Design Analysis of data from a cluster-randomized controlled trial. Setting Eighteen clinics in three healthcare organizations in southern California. Participants Dyads of Medicare recipients aged 65 and older with a diagnosis of dementia and an eligible caregiver. Intervention Collaborative care management for dementia. Measurements Caregiver educational attainment, adherence to four dimensions of guideline-recommended processes of dementia care (assessment, treatment, education and support, and safety) before and after the intervention, and the adjusted intervention effect ( IE) for each dimension stratified according to caregiver education. Each IE was estimated by subtracting the difference between pre- and postintervention scores for the usual care participants from the difference between pre- and postintervention scores in the intervention participants. Results At baseline, caregivers with lower educational attainment provided poorer quality of dementia care for the Treatment and Education dimensions than those with more education, but less-educated caregivers had significantly more improvement after the intervention on the assessment, treatment, and safety dimensions. The IEs for those who had not graduated from high school were 44.4 for the assessment dimension, 36.9 for the treatment dimension, and 52.7 for the safety dimension, versus 29.5, 15.7, and 40.9 respectively, for college graduates ( P < .001 for all three). Conclusions Collaborative care management was associated with smaller disparities in dementia care quality between caregivers with lower educational attainment and those with more education. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the effect of a theory-based oral health promotion intervention in a community environment by a nondental peer educator on the oral hygiene and gingival health of independent-living Italian older adults. Design A quasiexperimental design with a pretest-posttest nonequivalent control group with no intervention. Setting Ten Melbourne-based Italian social clubs participated in this evaluation. Participants One hundred forty-four active members of the social clubs. Intervention A series of oral health seminars and four supervised brushing sessions at club premises. The intervention did not involve any direct oral health professional clinical care. Clubs were allocated to the control or intervention group. Measurements Dental plaque levels and gingival bleeding scores were determined. A series of one-way analyses of covariance were conducted using the baseline measures as covariates. Results Controlling for pretest scores, the experimental group was significantly more likely than the control group to have improved gingival status and self-efficacy. No significant effects were found regarding dental plaque. Conclusion Within the setting of Italian social clubs, the intervention was effective at increasing self-efficacy and reducing gingival bleeding. As such, it represents a useful approach for the design of oral health interventions in older migrant adults. [ABSTRACT FROM AUTHOR]

Objectives To examine the long-term association between midlife physical activity ( PA) and lower extremity function ( LEF) in late life. Design Longitudinal study with an average of 25 years of follow-up. Setting Community-dwelling old population in Reykjavik, Iceland. Participants Four thousand seven hundred fifty-three community-dwelling men and women (mean age 76 ± 6) in Reykjavik, Iceland. Measurements On the basis of weekly hours of regular PA reported at the midlife examination, participants were classified as active or inactive. Measures of LEF in late life were gait speed on a 6-m walk, Timed Up and Go ( TUG), and knee extension ( KE) strength tests. Linear regression analysis was used to examine the association. Results Participants who were active in midlife had significantly better LEF (faster gait speed, β = 0.50, P ≤ .001; faster TUG time, β = -0.53 P ≤ .001; stronger KE strength, β = 1.3, P ≤ .001) in late life than those who were not active in midlife after adjusting for sociodemographic and cardiovascular risk factors. After adjustment for cognitive function in late life (speed of processing, memory, and executive function), participants who were active in midlife had significantly faster gait speed (β = 0.04, P ≤ .001), faster TUG time (β = −0.34, P ≤ .001), and greater KE strength (β = 0.87, P ≤ .001) in old age than those who were not active in midlife. Conclusion Regular PA in midlife is associated with better performance of LEF in later life, even after controlling for late-life cognitive function. [ABSTRACT FROM AUTHOR]

Objectives To investigate the relationship between periodontal disease and cognitive decline. Design Analysis of a prospective cohort study. Setting The Health, Aging and Body Composition ( Health ABC) Study. Participants One thousand fifty-three participants who were administered the Modified Mini-Mental State Examination (3 MS) at Year 1 (baseline) and Year 3 and had participated in a comprehensive periodontal examination at Year 2. Measurements The prospective association between a range of oral health parameters and cognitive function was examined. Decline in 3 MS score from Year 3 to 5 was investigated in 947 (89.9%) participants. Covariates included age, sex, education, race, cardiovascular disease and risk, and depressive symptoms. Results Most indicators of adverse oral health at Year 2 were associated with cognitive impairment based on averaged 3 MS scores less than 80 for Years 1 and 3, but education and race substantially confounded these associations. Higher gingival index, a measure of gingival inflammation, at Year 2 remained independently associated with this definition of cognitive impairment and, in fully adjusted analyses, was also an independent predictor of a more-than-5-point cognitive decline from Year 3 to 5. Conclusion Periodontitis may be a risk factor for cognitive decline. Gingivitis is reversible, and periodontitis to some degree is preventable and controllable when manifest. Therefore, further research is needed to clarify potential underlying mechanisms and oral health interventions that might ameliorate cognitive decline. [ABSTRACT FROM AUTHOR]

Objectives To determine which older adults tend to receive potentially inappropriate medications ( PIMs), how this may differ according to cognitive status, and how the trajectories of PIM use change over time. Design Ten-year longitudinal cohort study. Setting Three clinical sites in the United States. Participants One thousand four hundred eighty-four community-dwelling women aged 75 and older. Measurements At follow-up, cognitive status was ascertained and classified as normal, mild cognitive impairment ( MCI), or dementia. Beers 2003 criteria and other literature were used to identify PIMs from detailed medication inventory performed at three time points. Anticholinergic load was measured using the Anticholinergic Cognitive Burden Scale ( ACB), which assigns medications a value from 0 to 3 depending on anticholinergic properties. Results At baseline, 23.9% of women were taking at least one PIM and the mean ± SD ACB score was 1.41 ± 1.69. The most frequently reported PIMs were anticholinergics (15.2%), benzodiazepines (8.6%), and antispasmodics (8.0%). Over 10 years, PIM use increased for women with dementia (24.9-33.1%; P = .02) but remained fairly constant for women with MCI (23.9-23.0%; P = .84) and normal cognitive status (22.2-19.8%; P = .17). Mean ACB score increased significantly ( P < .001) over time for all groups (dementia: 1.28-2.05; MCI: 0.98-1.66; normal: 0.99-1.48). Conclusion PIM use and anticholinergic load in a community-dwelling population of older women was high, especially in women who later developed dementia. Future guidelines should limit PIM use and seek safer alternatives. [ABSTRACT FROM AUTHOR]

Objectives To describe the presentation of suspected urinary tract infections ( UTIs) in nursing home ( NH) residents with advanced dementia and how they align with minimum criteria to justify antimicrobial initiation. Design Twelve-month prospective study. Setting Twenty-five NHs. Participants Two hundred sixty-six NH residents with advanced dementia. Measurements Charts were abstracted monthly for documentation of suspected UTI episodes to determine whether episodes met minimum criteria to initiate antimicrobial therapy according to consensus guidelines. Results Seventy-two residents experienced 131 suspected UTI episodes. Presenting symptoms and signs for these episodes are mental status change (44.3%), fever (20.6%), hematuria (6.9%), dysuria (3.8%), costovertebral tenderness (2.3%), urinary frequency (1.5%), rigor (1.5%), urgency (0%), and suprapubic pain (0%). Only 21 (16.0%) episodes met minimal criteria to initiate antimicrobial therapy based on signs and symptoms. Of the 110 episodes that lacked minimum criteria to justify antimicrobial initiation, 82 (74.5%) were treated with antimicrobial therapy. Urinalyses and urine culture results were available for 101 episodes, of which 80 (79.2%) had positive results on both tests. The proportion of episodes with a positive urinalysis and culture was similar for those that met (83.3%) and did not meet (78.3%) minimum criteria ( P = .06). Conclusion The symptoms and signs necessary to meet minimum criteria to support antimicrobial initiation for UTIs are frequently absent in NH residents with advanced dementia. Antimicrobial therapy is prescribed for the majority of suspected UTIs that do not meet these minimum criteria. Urine specimens are frequently positive regardless of symptoms. These observations underscore the need to reconsider the diagnosis and the initiation of treatment for suspected UTIs in advanced dementia. [ABSTRACT FROM AUTHOR]

Objectives To document the degree of symptom burden in an urban homebound population. Design Cross-sectional survey. Setting The Mount Sinai Visiting Doctors ( MSVD) program. Participants All individuals newly enrolled in the MSVD. Measurements Edmonton Symptom Assessment Scale ( ESAS), which consists of 10 visual analogue scales scored from 0 to 10; symptoms include pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being, shortness of breath, and other. Results ESAS scores were completed for 318 participants. Most participants were aged 80 and older (68%) and female (75%); 36% were white, 22% black, and 32% Hispanic. Forty-three percent had Medicaid, and 32% lived alone. Ninety-one percent required assistance with one or more activities of daily living, 45% had a Karnofsky Performance Scale score between 0 and 40 (unable to care for self), and 43% reported severe burden on one or more symptoms. The most commonly reported symptoms were loss of appetite, lack of well-being, tiredness, and pain; the symptoms with the highest scores were depression, pain, appetite, and shortness of breath. Participants were more likely to have severe symptom burden if they self-reported their ESAS, had chronic obstructive pulmonary disease or diabetes mellitus with end organ damage, or had a Charlson Comorbidity Index greater than 3 and less likely to have severe burden if they had dementia. Conclusion In chronically ill homebound adults, symptom burden is a serious problem that needs to be addressed alongside primary and specialty care needs. [ABSTRACT FROM AUTHOR]

Objectives To understand how drug therapy differently affects older women and men. Design Population-based, retrospective cohort study. Setting Ontario, Canada. Participants Twenty-one thousand five hundred twenty-six older adults (13,760 women, 7,766 men) with dementia newly started on oral atypical antipsychotic therapy between April 1, 2007, and March 1, 2010. Measurements Numbers and rates of serious events. Serious events were defined as a hospital admission or death within 30 days of treatment initiation. Unadjusted and adjusted odds ratios of women and men were compared in the full cohort and in strata based on setting of care, age, Charlson Comorbidity Index ( CCI), and antipsychotic dose. Results Of 21,526 older adults with a median age of 84, 1,889 (8.8%) had a serious event (1,044 women, 7.6%; 845 men, 10.9%). Of these, 363 women (2.6%) and 355 men (4.6%) died. Men were more likely than women to be hospitalized or die during the 30-day follow-up period (adjusted odds ratio = 1.47, 95% confidence interval = 1.33-1.62) and consistently more likely to experience a serious event in each stratum. A gradient of risk according to drug dose was found for the development of a serious event in women and men. Conclusion The risk of developing a serious event shortly after the initiation of antipsychotic therapy was high in women and men with dementia but was consistently higher in older men. This pattern remained the same in strata based on setting of care, age, CCI, and antipsychotic dose. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the association between receiving antipsychotics and the outcomes of a cohort of nursing home ( NH) residents with and without presumed delirium after hip fracture. Design Population-based cohort study. Setting Eleven thousand one hundred nineteen nursing homes nationwide from January 1, 2000, to December 31, 2007. Participants First-time NH admissions with hip fracture (n = 77,759). Measurements The Nursing Home Confusion Assessment Method was used to identify residents with no delirium, subsyndromal delirium, and full delirium. Propensity score reweighting was used, with analyses stratified according to delirium level. Results In subjects with no delirium symptoms, approximately 5% (n = 3,250) received antipsychotic drugs. These individuals were less likely to be discharged home (odds ratio ( OR) = 0.68, P < .001), had a higher likelihood of death before nursing home discharge ( OR = 1.28, P = .03), stayed in nursing homes longer ( β 2.83, P = .05), and had less functional improvement at discharge ( β −0.47, P = .03). Receipt of antipsychotics in participants with mild delirium was associated with a lower likelihood of discharge home ( OR = 0.74, P = .03). Conclusion In NH residents with hip fracture and no delirium symptoms, use of antipsychotics was associated with worse outcomes, with the exception of rehospitalization. No clear benefits were associated with antipsychotic use for those with presumed delirium. [ABSTRACT FROM AUTHOR]

Objectives To determine whether falling would be a marker for future difficulty with activities of daily ( ADLs) that would vary according to fall frequency and associated injury. Design Longitudinal analysis. Setting Community. Participants Nationally representative cohort of 2,020 community-living, functionally independent older adults aged 65 to 69 at baseline followed from 1998 to 2008. Measurements ADL difficulty. Results Experiencing one fall with injury (odds ratio ( OR) = 1.78, 95% confidence interval ( CI) = 1.29-2.48), at least two falls without injury ( OR = 2.36, 95% CI = 1.80-3.09), or at least two falls with at least one injury ( OR = 3.75, 95% CI = 2.55-5.53) in the prior 2 years was independently associated with higher rates of ADL difficulty after adjustment for sociodemographic, behavioral, and clinical covariates. Conclusion Falling is an important marker for future ADL difficulty in younger, functionally independent older adults. Individuals who fall frequently or report injury are at highest risk. [ABSTRACT FROM AUTHOR]

Objectives To determine whether poor functional status is associated with worse outcomes after attempted cardiopulmonary resuscitation ( CPR). Design Retrospective study of individuals who experienced cardiac arrest stratified according to dependence in activities of daily living ( ADLs) and residential status (nursing home ( NH) or community dwelling). Setting Two hundred thirty-five hospitals throughout North America. Participants Adult inpatients aged 65 and older who had experienced a cardiac arrest as reported to the Get with the Guidelines- Resuscitation registry between 2000 and 2008. Measurements Primary outcomes were return of spontaneous circulation ( ROSC) and survival to discharge. Results Twenty-six thousand three hundred twenty-nine individuals who experienced cardiac arrest met inclusion criteria. NH residents dependent in ADLs had a lower odds than community-dwelling independent participants of achieving ROSC (odds ratio ( OR) = 0.73, 95% confidence interval ( CI) = 0.63-0.85), whereas participants dependent in ADLs from either residential setting had lower odds of survival (community-dwelling: OR = 0.76, 95% CI = 0.63-0.92; NH: OR = 0.79, 95% CI = 0.64-0.96) after adjusting for participant and arrest characteristics. Duration of resuscitation and doses of epinephrine or vasopressin were similar between groups and had no significant effect on ROSC or survival, although participants dependent in ADLs were more likely to have a do-not-resuscitate ( DNR) order placed after ROSC. Overall, median time to signing a DNR order after resuscitation was 10 hours (interquartile range 2-70). Conclusion Functional and residential status are important predictors of survival after in-hospital cardiac arrest. Contrary to the hypothesis but reassuring from a quality-of-care perspective, less-aggressive attempts at resuscitation do not appear to contribute to poorer outcomes in individuals dependent in ADL, regardless of residential status. [ABSTRACT FROM AUTHOR]

Objectives To examine the clinical characteristics, motor impairments, and drug treatments of nursing home residents with Parkinson's disease ( PD). Design Cross-sectional study. Setting Nursing homes in the southeast of the Netherlands. Participants Nursing home residents with PD and a Mini- Mental State Examination score of 18 or greater seen by a physician with experience in movement disorders. Measurements Participant characteristics, motor function, and dopaminergic medications were assessed. The Short Parkinson's Evaluation Scale/ SCales for Outcomes in Parkinson's disease ( SPES- SCOPA) was used to assess motor impairments and disabilities. Results Seventy-three nursing home residents with PD (mean age 78.7; 45% male; mean disease duration 10.1 years; Hoehn and Yahr 4 (38%) and 5 (49%)) were included. Most residents were severely disabled, 49% being wheelchair bound. According to the SPES- SCOPA, 44% of residents were 'off' (in a motor state in which they are slow and stiff) most of the time. Dyskinesias were encountered infrequently. Most residents were mainly treated with levodopa monotherapy, and daily doses varied widely (20-1,600 mg, mean 673 mg); 25% of residents were treated with less than 400 mg levodopa daily, and 8% received no levodopa at all. The movement disorders specialist considered 32 residents to be possibly undertreated. Conclusion These findings show that PD in nursing home residents is characterized by severe motor impairment and a high proportion of daily 'off' time, which underscores the need for better management of PD in nursing homes, for example within specialized institutions or with periodic consultations by a movement disorders expert. [ABSTRACT FROM AUTHOR]

Objectives To test the hypothesis that presepsis depressive symptoms are associated with risk of new cognitive impairment in survivors of severe sepsis. Design Prospective longitudinal cohort study. Setting Population-based cohort of older U.S. adults interviewed as part of the Health and Retirement Study (1998-2006). Participants Four hundred forty-seven individuals with normal presepsis cognition who survived 540 hospitalizations for severe sepsis and completed at least one follow-up interview. Measurements Severe sepsis was identified using a validated algorithm in Medicare claims. Depressive symptoms were assessed prospectively using a modified version of the Center for Epidemiologic Studies Depression Scale. Cognitive function was assessed using versions of the Telephone Interview for Cognitive Status ( TICS). Logistic regression with robust standard errors was used to examine associations between substantial depressive symptoms at any interview before sepsis and incident cognitive impairment (mild or moderate to severe cognitive impairment) at any interview after sepsis. Results The prevalence of substantial depressive symptoms in participants with normal cognition before sepsis was 38% (95% confidence interval ( CI) = 34-42%). After severe sepsis, 18% (95% CI = 15-20%) of survivors had incident cognitive impairment. In unadjusted analyses, presepsis substantial depressive symptoms were associated with postsepsis incident cognitive impairment (odds ratio ( OR) = 2.56, 95% CI = 1.53-4.27). After adjustment for demographics, health-risk behaviors, clinical characteristics of the sepsis episode, and presepsis TICS scores, substantial presepsis depressive symptoms remained the strongest factor associated with postsepsis incident cognitive impairment ( OR = 2.58, 95% CI = 1.45-4.59). Conclusion Substantial presepsis depressive symptoms are independently associated with incident postsepsis cognitive impairment. Depressed older adults may be particularly at risk of developing cognitive impairment after a serious medical illness. [ABSTRACT FROM AUTHOR]

Objectives To determine the relationship between depressive symptoms after hospitalization and survival and functional outcomes. Design Secondary analysis of a prospective cohort study. Setting General medical service of two urban, teaching hospitals in Ohio. Participants Hospitalized individuals aged 70 and older. Measurements Ten depressive symptoms, instrumental activities of daily living ( IADLs), and basic activities of daily living ( ADLs) were measured at hospital discharge and 1, 3, 6, and 12 months later. Participant-specific changes in depressive symptoms (slopes) were determined using all data points. Four groups were also defined according to number of depressive symptoms (≤3 symptoms, low; 4-10 symptoms, high) at discharge and follow-up: low-low, low-high, high-low, and high-high. Mortality was measured 3, 6, and 12 months after hospital discharge. Results Participant-specific discharge depressive symptoms and change in depressive symptoms over time (slopes) were associated ( P < .05) with functional and mortality outcomes. At 1 year, more participants in the low-low depressive symptom group (49%) were alive and independent in IADLs and ADLs than in the low-high group (37%, P = .02), and more participants in the high-low group (39%) were alive and independent in IADLs and ADLs than in the high-high group (19%, P < .001). Conclusion Number of depressive symptoms and change in number of depressive symptoms during the year after discharge were associated with functional and mortality outcomes in hospitalized older adults. Fewer participants with persistently high or increasing depressive symptoms after hospitalization were alive and functionally independent 1 year later than participants with decreasing or persistently low symptoms, respectively. [ABSTRACT FROM AUTHOR]

Objective To describe Confusion Assessment Method ( CAM) core symptoms of delirium occurring before and after incident episodes of delirium in older long-term care ( LTC) residents. A secondary objective was to describe the mean number of symptoms before and after episodes by dementia status. Design Secondary analysis of data collected for a prospective cohort study of delirium, with repeated weekly assessments for up to 6 months. Setting Seven LTC facilities in Montreal and Quebec City, Canada. Participants Forty-one older LTC residents who had at least one CAM-defined incident episode of delirium. Measurements The Mini- Mental State Examination ( MMSE), CAM, Delirium Index ( DI), Hierarchic Dementia Scale, Barthel Index, and Cornell Scale for Depression were completed at baseline. The MMSE, CAM, and DI were repeated weekly for 6 months. The frequency, mean number, type, and duration of CAM core symptoms of delirium occurring before and after incident episodes were examined using descriptive statistics, frequency analysis, and survival analysis. Results CAM core symptoms of delirium preceded 38 (92.7%) episodes of delirium for many weeks; core symptoms followed 37 (90.2%) episodes for many weeks. Symptoms of inattention and disorganized thinking occurred most commonly. The mean number of symptoms was higher in residents with dementia but not significantly so. Conclusion CAM core symptoms of delirium were frequent and protracted before and after most incident episodes of delirium in LTC residents with and without dementia. If replicated, these findings have potentially important implications for clinical practice and research in LTC settings. [ABSTRACT FROM AUTHOR]

Objectives To describe the prevalence of pharmacological ( PS) and nonpharmacological ( NPS) pain management approaches used by older adults with persistent pain and to identify characteristics associated with use of these approaches. Design Population-based cohort. Setting Urban and suburban communities in the Boston, Massachusetts, area. Participants Seven hundred sixty-five adults aged 64 and older underwent a home interview and clinic examination. Those reporting any persistent pain were included in this analysis (N = 599). Measurements All prescription and nonprescription medications were recorded during the home interview. NPS modalities for pain management were assessed using a modification of the Pain Management Inventory. The baseline assessment included extensive measures of pain, health, and functioning. Results More than one-third (37.5%) of participants reported using both PS and NPS modalities. Thirty-one percent reported use of NPS modalities alone, and 11.5% used PS modalities alone. NPS modalities (68.4%) were reported more frequently than PS modalities (49%). Women (odds ratio ( OR) = 2.2, 95% confidence interval ( CI) = 1.26-3.82), individuals with knee osteoarthritis ( OR = 3.07, 95% CI = 1.6-5.9), and individuals with moderate to severe pain ( OR = 5.02, 95% CI = 2.23-11.28) were more likely to report combined use of PS and NPS modalities. Characteristics associated with individual NPS modalities varied greatly. Conclusion Only one-third of older adults with persistent pain reported pain management strategies consistent with current guidelines. Further research is required to understand reasons behind choices, barriers to adherence, and the benefits of multiple modalities that older adults with persistent pain use. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the association between various blood pressure ( BP) measures at age 85 and future decline in physical and cognitive function the oldest old. Design Longitudinal study. Setting The population-based Leiden 85-plus Study. Participants Five hundred seventy-two 85-year-old community-dwelling individuals. Measurements BP was measured at age 85 during home visits. Activities of daily living ( ADLs) and Mini- Mental State Examination ( MMSE) were assessed at age 85 and annually thereafter up to age 90. On average, participants were followed for 3.2 years. Cross-sectional and longitudinal analyses were performed using linear regression models using systolic BP ( SBP), diastolic BP ( DBP), mean arterial pressure ( MAP), and pulse pressure ( PP) as the determinants. All analyses were adjusted for sociodemographic and cardiovascular factors. Results At age 85, higher SBP and PP were associated with lower ADL disability scores (both P = .01). Similarly, higher SBP, DBP, and MAP were associated with higher MMSE scores (all P < .05). From age 85 onward, higher SBP ( P < .001), MAP ( P = .01), and PP ( P = .003) at age 85 were associated with lower annual increases in ADL disability scores. Likewise, higher SBP ( P = .03) and PP ( P = .008) at age 85 were associated with lower annual declines in MMSE scores. Additional analyses showed that the association between high BP and lower annual decline in MMSE score was most pronounced in participants with high ADL disability. Conclusion In the oldest old, higher SBP and PP are associated with resilience to physical and cognitive decline, especially in individuals with pre-existing physical disability. [ABSTRACT FROM AUTHOR]

Objectives To develop and validate a picture-based memory impairment screen ( PMIS) for the detection of dementia. Design Cross-sectional. Setting Outpatient clinics, Baby Memorial Hospital, Kozhikode city in the southern Indian state of Kerala. Participants Three hundred four community-residing adults aged 55 to 94 with a mean education level of 8 years; 65 were diagnosed with dementia. Measurements PMIS: a culture-fair picture-based cognitive screen designed to be administered by nonspecialists. Diagnostic accuracy estimates (sensitivity, specificity, positive and negative predictive power) of PMIS cut-scores in detecting dementia (range 0-8). Results PMIS scores were worse in participants with dementia (1.5) than in controls (7.7, P < .001). At the optimal cut-score of 5, PMIS had a sensitivity of 95.4% (95% confidence interval ( CI) = 90.3-100.0%) and a specificity of 99.2% (95% CI = 98.0-100.0%) for detecting dementia. In the 167 participants with <10 years of education, PMIS scores of five or less had a sensitivity of 97.8% (95% CI = 93.6-100.0%) and specificity of 99.2% (95% CI = 97.6-100.0%). The PMIS had better specificity than the Mini- Mental State Examination in detecting dementia, especially in older adults with low education. Conclusion The PMIS is a brief and reliable screen for dementia in elderly populations with variable literacy rates. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the association between residential distance to nearest major roadway, as a marker of long-term exposure to traffic pollution, and cognitive function in older adults. Design Prospective cohort study with median follow-up of 16.8 months. Setting Community. Participants Seven hundred sixty-five community-dwelling seniors. Measurements The Mini- Mental State Examination, Hopkins Verbal Learning Test- Revised ( HVLT- R), Trail Making Test ( TMT), category and letter fluency tests, and Clock-in-the- Box Test were administered during home visits on two occasions. The residential distance to the nearest major roadway was calculated, and generalized estimating equations were used to evaluate the association between performance on each test and residential distance to nearest major roadway, adjusting for participant demographics, education, socioeconomic status, and past medical history. Results Shorter distance to major roadway was associated with statistically significantly poorer performance on the immediate and delayed recall components of the HVLT- R, TMT Part B, TMT delta, and letter and category fluency tests. Generally, participants residing less than 100 m from a major roadway performed worst. Performance improved monotonically with increasing distance. Conclusion In this cohort of community-dwelling older adults, residential proximity to a major roadway was associated with poorer performance on cognitive tests of verbal learning and memory, psychomotor speed, language, and executive functioning. If causal, these results add to the growing evidence that living near major roadways is associated with adverse health outcomes. [ABSTRACT FROM AUTHOR]

Objectives To relate the standardized road test to video recordings of naturalistic driving in older adults with a range of cognitive impairment. Design Cross-sectional observational study. Setting Academic medical center memory disorders clinic. Participants One hundred three older drivers (44 healthy, 59 with cognitive impairment) who passed a road test. Measurements Error rate and global ratings of safety (pass with and without recommendations, marginal with restrictions or training, or fail) made by a professional driving instructor. Results There was fair agreement between global ratings on the road test and naturalistic driving. More errors were detected in the naturalistic environment, but this did not affect global ratings. Error scores between settings were significantly correlated, and the types of errors made were similar. History of crashes corrected for miles driven per week was related to road test error scores but not naturalistic driving error scores. Global cognition ( Mini- Mental State Examination) was correlated with road test and naturalistic driving errors. In healthy older adults, younger age was correlated with fewer errors on the road test and more errors in naturalistic driving. Conclusion Road test performance is a reasonable proxy for estimating fitness to drive in older individuals' typical driving environments, but differences between performance assessed using these two methods remain poorly understood and deserve further study. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the effectiveness of a self-help cognitive behavioral intervention in improving sleep quality in older adults reporting insomnia symptoms associated with chronic disease. Design A pragmatic two-arm randomized controlled trial comparing supported self-help with treatment as usual ( TAU). Setting Primary care. Participants One hundred ninety-three self-referred individuals aged 55 to 87 with long-term conditions and chronic insomnia symptoms (as defined according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). Intervention Self-help participants received six consecutive booklets, at weekly intervals, providing structured advice on important components of cognitive behavioral therapy for insomnia ( CBT-I, including self-monitoring, sleep restriction, stimulus control procedures, and cognitive strategies), plus access to a telephone helpline. Control group participants received a single sheet of advice detailing standard sleep hygiene measures. Measurements The primary outcome was sleep quality, measured by the Pittsburgh Sleep Quality Index ( PSQI). Secondary outcomes were the Insomnia Severity Index ( ISI), the subjective sleep efficiency index, and the Fatigue Severity Scale. Results In the self-help group, sleep outcomes showed significant improvements after treatment ( PSQI, P < .001; ISI, P < .001; sleep efficiency, P < .001) and at 3-month ( PSQI, P = .002; ISI, P = .006; sleep efficiency, P = .001) and 6-month ( PSQI, P = .003; ISI, P = .003; sleep efficiency, P = .001) follow-up. Effect sizes were moderate (range of adjusted Cohen d = 0.51-0.75). Treatment had no effect on levels of daytime fatigue. Most treated participants (73%) said they would recommend the self-help program to others. Conclusion Self-help CBT-I offers a practical first-line response to individual reporting insomnia symptoms associated with chronic disease in primary care settings. In these individuals, symptoms of daytime fatigue may be more closely associated with disease processes than with sleep quality. [ABSTRACT FROM AUTHOR]

Objectives To examine the cognitively protective effect of leisure and physical activities while accounting for prior cognitive ability, a rarely considered confounder of the previously reported associations between activity and cognitive aging. Design Longitudinal cohort study. Setting Glostrup, Denmark. Participants Community-dwelling sample of adults recruited into the Glostrup 1914 Cohort (baseline N = 802). All were born in 1914 and were assessed at ages 50, 60, 70, and 80. New participants were recruited during the study to counter attrition. Measurements On each occasion, cognitive ability was assessed using four tests, which defined a general cognitive ability score. Self-reported participation in leisure and physical activities was also collected. In general, physical activity was summarized on a 3- or 4-point scale, and leisure activity as none versus some (ages 50 and 60) or according to participation in a list of common activities (age 70). The effect of activity-leisure and physical-on the level of cognitive ability and cognitive change over time from age 60 to 80 was examined in growth curve models. Results Greater activity (leisure or physical) was consistently associated with a higher level of cognitive ability. Adjusting for baseline cognitive ability (age 50) attenuated these associations, suggesting that associations between activity and cognition reported in old age are largely a consequence of preserved differentiation. A small but significant association remained between greater physical activity at age 60 or 70 and less cognitive decline. Conclusion The association between more-frequent leisure activity and less cognitive decline mainly reflects the positive cross-sectional association between activity and cognition, although the link that remains between greater physical activity and a more-successful cognitive aging trajectory is of particular relevance to those who are developing interventions. [ABSTRACT FROM AUTHOR]

Objectives To examine survival with and without a percutaneous endoscopic gastrostomy ( PEG) feeding tube using rigorous methods to account for selection bias and to examine whether the timing of feeding tube insertion affected survival. Design Prospective cohort study. Setting All U.S. nursing homes ( NHs). Participants Thirty-six thousand four hundred ninety-two NH residents with advanced cognitive impairment from dementia and new problems eating studied between 1999 and 2007. Measurements Survival after development of the need for eating assistance and feeding tube insertion. Results Of the 36,492 NH residents (88.4% white, mean age 84.9, 87.4% with one feeding tube risk factor), 1,957 (5.4%) had a feeding tube inserted within 1 year of developing eating problems. After multivariate analysis correcting for selection bias with propensity score weights, no difference was found in survival between the two groups (adjusted hazard ratio ( AHR) = 1.03, 95% confidence interval ( CI) = 0.94-1.13). In residents who were tube-fed, the timing of PEG tube insertion relative to the onset of eating problems was not associated with survival after feeding tube insertion ( AHR = 1.01, 95% CI = 0.86-1.20, persons with a PEG tube inserted within 1 month of developing an eating problem versus later (4 months) insertion). Conclusion Neither insertion of PEG tubes nor timing of insertion affect survival. [ABSTRACT FROM AUTHOR]

Objectives To determine how poor sleep affects the health of older ethnic minorities. Design Cross-sectional study involving a population-based survey. Setting Hispanic Established Population for the Epidemiologic Study of the Elderly ( H- EPESE) survey conducted in the southwestern United States. Participants Two thousand two hundred fifty-six Mexican- American men and women aged 65 and older. Measurements The association between self-reported sleep problems and mortality over a 15-year period in a population based sample of older Mexican Americans was examined. Using five waves of data (1993-2008) from the H- EPESE, Cox proportional hazard models stratified according to sex were used to model the risk of death as a function of chronic sleep problems. Results Having any sleeping problems during the last month was associated with greater risk of mortality (hazard ratio = 1.14, 95% confidence interval = 1.00-1.29) in unadjusted models, although the association was attenuated after accounting for covariates. Conclusions Similar factors explained the association between sleep and mortality in men and women: health behaviors , depressive symptoms , and health conditions. These factors are related to stress, and both may lead to poor sleep quality. Research is needed to better understand the factors moderating the relationship between sleep, mortality, and sex. [ABSTRACT FROM AUTHOR]

Objectives To determine whether readily collected perioperative information might identify older surgical patients at higher risk of complications. Design Retrospective cohort study. Setting Medical chart review at a single academic institution. Participants One hundred two individuals aged 65 and older who underwent abdominal surgery between January 2007 and December 2009. Measurements Primary predictor variables were first postoperative Braden Scale score (within 24 hours of surgery) and a Deficit Accumulation Index ( DAI) constructed based on 39 available preoperative variables. The primary outcome was presence or absence of complication within 30 days of surgery. Results Of 102 patients, 64 experienced at least one complication, with wound infection being the most common. In models adjusted for age, race, sex, and open versus laparoscopic surgery, lower Braden Scale scores were predictive of 30-day postoperative complication (odds ratio ( OR) = 1.30, 95% confidence interval ( CI) = 1.06-1.60), longer length of stay (β = 1.44 (0.25) days; P ≤ .001), and discharge to an institution rather than home ( OR = 1.23, 95% CI = 1.02-1.48). The cut-off value for the Braden score with the highest predictive value for complication was ≤ 18 ( OR = 3.63, 95% CI = 1.43-9.19; c statistic 0.744). The DAI and several traditional surgical risk factors were not significantly associated with 30-day postoperative complications. Conclusion This is the first study to identify the perioperative Braden Scale score, a widely used risk-stratifier for pressure ulcers, as an independent predictor of other adverse outcomes in geriatric surgical patients. Further studies are needed to confirm this finding and to investigate other uses for this tool, which correlates well to phenotypic models of frailty. [ABSTRACT FROM AUTHOR]

Objectives To estimate the relative effects of environment, comorbidities, stage of dementia and other variables on disability onset. Design A 1-year prospective cohort study was conducted in which the walking and eating abilities of long-term care residents were observed fortnightly. Structural equation modeling was used to assess the contributions of individual and environmental factors to the onset of disability. Setting Fifteen nursing homes in western Canada. Participants One hundred twenty residents with middle-stage Alzheimer disease or related dementia. Measurements Environmental quality was assessed using the Professional Environmental Assessment Protocol, comorbidity using the Charlson Comorbidity Index, and stage of dementia using the Global Deterioration Scale. Results More-advanced baseline dementia had a direct effect on onset of walking and eating disability (standardized maximum likelihood estimate ( SMLE) = 0.24, P = .006). Resident environment ( SMLE = −0.25, P = .007) and comorbidities ( SMLE = 0.32, P < .001) influenced disability onset approximately as strongly as stage of dementia. Smaller and publicly owned facilities provided superior environmental quality, which indirectly contributed to a delay in onset of walking and eating disability. Conclusion Environmental quality and extent of comorbidity are at least as important as progression of dementia in initiating or delaying the onset of disability. [ABSTRACT FROM AUTHOR]

Objectives To investigate the relationship between serum albumin and change in muscle mass, grip strength, and leg power. Design Prospective cohort. Setting Six U. S. academic medical centers. Participants Community-dwelling men aged 65 and older participating in the Osteoporotic Fractures in Men ( Mr OS) Study. Measurements Serum albumin was measured at baseline in 5,534 participants. Baseline serum albumin was examined in relation to change in appendicular skeletal muscle ( ASM) mass, grip strength, and leg power after 2 and 4.6 years. Two-year change in serum albumin was examined with respect to simultaneous change in these outcomes in 1,267 participants. Results Baseline serum albumin <40 g/ L was not associated with 2- or 4.6-year change in ASM mass, grip strength, or leg power before or after adjustment for confounders. There was no association between serum albumin change and change in grip strength. A statistically significant trend was observed between serum albumin change and change in ASM mass, but there was substantial overlap across confidence intervals ( CIs). Participants with a marked decrease (>3 g/ L) and mild decrease (1-2 g/ L) in serum albumin over 2 years exhibited a modest change of −8.9 W (95% CI = −25.6 to −7.8 W) and −6.3 W (95% CI = −21.2 to −8.5 W) of leg power, respectively ( P for trend = .02), compared with those with no decrease in albumin concentration. Conclusion Serum albumin demonstrated modest and inconsistent trends with loss of muscle mass and function. Low serum albumin within the normal range is not a risk factor for this process in elderly men. [ABSTRACT FROM AUTHOR]

Objectives To investigate whether higher intake of potassium, calcium, and magnesium reduces the risk of incident dementia. Design Prospective cohort study. Setting The Hisayama Study, in Japan. Participants One thousand eighty-one community-dwelling Japanese individuals without dementia aged 60 and older. Measurements A 70-item semiquantitative food frequency questionnaire was used to assess potassium, calcium, and magnesium intakes. Hazard ratios ( HRs) for the development of all-cause dementia and its subtypes were estimated using Cox proportional hazards model. Results During a 17-year follow-up, 303 participants experienced all-cause dementia; of these, 98 had vascular dementia ( Va D), and 166 had Alzheimer's disease ( AD). The multivariable-adjusted HRs for the development of all-cause dementia were 0.52 (95% confidence interval [ CI] = 0.30-0.91), 0.64 (95% CI = 0.41-1.00), and 0.63 (95% CI = 0.40-1.01) for the highest quartiles of potassium, calcium, and magnesium intake, respectively, compared with the corresponding lowest quartiles. Similarly, the HRs for the development of Va D were 0.20 (95% CI = 0.07-0.56), 0.24 (95% CI = 0.11-0.53), and 0.26 (95% CI = 0.11-0.61) for the highest quartiles of potassium, calcium, and magnesium intake, respectively. There was no evidence of a linear association between these mineral intakes and the risk of AD. Conclusion Higher self-reported dietary intakes of potassium, calcium, and magnesium reduce the risk of all-cause dementia, especially Va D, in the general Japanese population. [ABSTRACT FROM AUTHOR]

Objectives To describe facility-level variation in two measures of potentially inappropriate prescribing prevalent in Veterans Affairs ( VA) facilities-exposure to high-risk medications in elderly adults ( HRME) and drug-disease interactions ( Rx- DIS)-and to identify facility characteristics associated with high-quality prescribing. Design Cross-sectional. Setting VA Healthcare System. Participants Veterans aged 65 and older with at least one inpatient or outpatient visit in 2005-2006 ( N = 2,023,477; HRME exposure) and a subsample with a history of falls or hip fractures, dementia, or chronic renal failure (n = 305,059; Rx- DIS exposure). Measurements Incident use of any HRME ( iHRME) and incident Rx- DIS ( iRx- DIS) and facility-level rates and facility-level predictors of iHRME and iRx- DIS exposure, adjusting for differences in patient characteristics. Results Overall, 94,692 (4.7%) veterans had iHRME exposure. At the facility level, iHRME exposure ranged from 1.6% at the lowest facility to 12.8% at the highest (median 4.7%). In the subsample, 9,803 (3.2%) veterans had iRx-DIS exposure, with a facility-level range from 1.3% to 5.8% (median 3.2%). In adjusted analyses, veterans seen in facilities with formal geriatric education had lower odds of iHRME (odds ratio ( OR) = 0.86, 95% confidence interval ( CI) = 0.77-0.96) and iRx- DIS ( OR = 0.95, 95% CI = 0.88-1.01). Patients seen in facilities caring for fewer older veterans had greater odds of iHRME ( OR = 1.54, 95% CI = 1.35-1.75) and iRx- DIS exposure ( OR = 1.22, 95% CI = 1.11-1.33). Conclusion Substantial variation in the quality of prescribing for older adults exists across VA facilities, even after adjusting for patient characteristics. Higher-quality prescribing is found in facilities caring for a larger number of older veterans and facilities with formal geriatric education. [ABSTRACT FROM AUTHOR]

Objectives To identify patterns and predictors of 1-year change in patient activation in chronically ill older adults. Design Prospective cohort study. Setting Integrated healthcare delivery system. Participants Members of an integrated delivery system from 2007 to 2009 in western Washington state aged 65 and older with diabetes mellitus or heart disease; participants responded to baseline and 1-year follow-up mailed surveys about their health and health care (N = 2,341). Measurements Patient activation was measured using the 13-item Patient Activation Measure ( PAM) at baseline and follow-up. Automated diagnoses and procedure data were extracted from databases. Multinomial logistic regression, stratified according to baseline activation stage, was used to estimate the odds ratios for increasing or decreasing activation stage associated with participant characteristics and serious adverse health events. Results Fifty-two percent of participants changed activation stage between baseline and follow-up. Of people who changed stage, 54% increased, and 46% decreased. Older age and worse baseline self-reported health were independent predictors of activation change in multivariate models. Changes in health status or serious adverse health events such as the occurrence of hospitalizations, new major diagnoses, or procedures were not related to changes in activation in this age group. Conclusion Patient activation, as measured using the PAM, changes over time in elderly adults with chronic diseases. Clinicians and researchers who use the PAM for patient care or as an outcome measure in research studies should be aware of its fluctuation over time in chronically ill older persons. [ABSTRACT FROM AUTHOR]

Objectives To explore how wheelchair-related factors, mobility, and participation are associated in a sample of long-term care residents who use wheelchairs as their primary means of mobility. Design Cross-sectional survey. Setting Eleven residential care facilities in the lower mainland of British Columbia, Canada. Participants One hundred forty-six self-responding residents and 118 proxy respondents: mean age 84 (range 60-103). Most were female (69%), and a small proportion (9%) drove a power wheelchair. Measurements The Nursing Home Life Space Diameter Assessment was used to measure resident mobility, and the Late Life Function and Disability Instrument: Disability Component was used to measure participation frequency in daily activities. Results Path analysis indicated that wheelchair-related factors were associated with participation frequency directly and indirectly through their relationship with mobility. The final model explained 46% of the variance in resident mobility and 53% of the variance in resident participation frequency. Wheelchair skills, which include the ability to transfer in and out of and propel a wheelchair, were important predictors of life-space mobility and frequency of participation, and life space mobility was a significant predictor of frequency of participation. Depression was associated with poorer wheelchair skills and mobility and less-frequent participation. Counterintuitively, perceived environmental barriers were positively associated with frequency of participation. Conclusion The findings suggest that, by addressing wheelchair-related factors, resident's mobility and participation may be improved, but the efficacy of this approach needs to be confirmed experimentally. [ABSTRACT FROM AUTHOR]

Objectives To determine the relationship between quality of life ( QOL) and environmental factors of temperature, noise, and lighting in nursing home residents with severe dementia. Design Cross-sectional, observational, analytical. Setting Eight public, long-term care nursing homes in the province of Girona, Spain. Participants Random sample of 160 nursing home residents with severe dementia. Measurements Functional and cognitive impairment, pain, neuropsychiatric disturbances, and QOL were determined using standardized instruments. Temperature, noise, and lighting in bedrooms, dining rooms, and living rooms were measured in the morning and afternoon using a multifunction environment meter in a standardized manner. Results Adjusted multivariate linear regression models demonstrated that environmental measures were independently associated with QOL and related factors. High temperature in the bedroom was associated with lower QOL (standardized β = 0.184), high noise levels in the living room were associated with low behavioral signs of social interactions (β = 0.196), and low lighting levels in the bedroom were associated with number of signs of negative affective mood (β = −0.135). Conclusion The QOL of nursing home residents with severe dementia was related to environmental factors such as temperature, noise, and lighting. The monitoring of these environmental factors may improve these individuals' QOL. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the effect of medical Primary Integrated Interdisciplinary Elder Care at Home ( PIECH) on acute hospital use and mortality in a frail elderly population. Design Comparison of acute hospital care use for the year before entering the practice (pre-entry) with the most-recent 12-month period ( May 1, 2010- April 30, 2011, postentry) for active and discharged patients. Setting Community. Participants All 248 frail elderly adults enrolled in the practice for at least 12 months who were living in the community and not in nursing homes in Victoria, British Columbia. Intervention Primary geriatric care provided by a physician, nurse, and physiotherapist in participants' homes. Measurements Acute hospital admissions, emergency department ( ED) contacts that did not lead to admission, reason for leaving practice, and site of death. Results There was a 39.7% (116 vs 70; P = .004) reduction in hospital admissions, 37.6% (1,700 vs 1,061; P = .04) reduction in hospital days, and 20% (120 vs 95; P = .20) reduction in ED contacts after entering the practice. Fifty participants were discharged from the practice, 64% (n = 32) of whom died, 20% (n = 10) moved, and 16% (n = 8) were admitted to nursing homes. Fifteen (46.9%) deaths occurred at home. Conclusion Primary Integrated Interdisciplinary Elder Care at Home may reduce acute hospital admissions and facilitate home deaths. [ABSTRACT FROM AUTHOR]

Objectives To measure 1-year post-hip fracture functional recovery, health-related quality of life ( HRQL), and mortality in nursing home residents. Design Prospective longitudinal cohort study. Setting and Participants Ambulatory nursing home residents with or without impaired cognition consecutively admitted with hip fracture to three Canadian tertiary-care hospitals from March 2008 through November 2009. Measurements Participants or proxy respondents completed the Functional Independence Measure Motor score ( FIMmotor) and Euro Qol5 D index score ( EQ-5 Dindex) in the hospital (prefracture status) and 3, 6, and 12 months after fracture. Complications over the first postfracture year were also ascertained; the primary outcome was functional recovery (change in FIMmotor score). Results Of 92 eligible participants, 60 (64%) were enrolled. The mean age was 86.9 ± 8.1, 42 (70%) were female, and 45 (75%) had three or more comorbidities. Forty-three (72%) walked independently with or without aids before fracture. By 12 months, 27 (45%) participants had died, and 10 (17%) had withdrawn. Of the remaining 23 participants, functional status according to FIMmotor score dropped substantially and significantly after the fracture (3 months, 34.0 ± 19.7; 6 months, 33.2 ± 19.7; 12 months, 32.0 ± 20.0; P < .001 from a baseline FIMmotor score of 50.1 ± 16.1). By 12 months after the fracture, only eight (35%) were walking independently, and 11 (48%) were no longer ambulatory. HRQL according to the EQ-5 Dindex also decreased significantly ( P = .003), from 0.62 ± 0.20 before fracture to 0.42 ± 0.30 by 12 months after fracture. Conclusion Hip fracture for nursing home residents was associated with substantial loss of functional independence, ambulation, and HRQL. Little recovery was evident after the first 3 months; there was almost 50% mortality within 12 months. [ABSTRACT FROM AUTHOR]

Objectives To determine the association between objectively measured sleep and subsequent placement in a nursing home or a personal care home. Design Prospective cohort. Setting Participants' homes and sites of the Study of Osteoporotic Fractures. Participants One thousand six hundred sixty-four community-dwelling women with a mean age of 83 ± 4. Measurements At baseline, participants completed an average of 4 nights of wrist actigraphy; they provided data on place of residence at baseline and at follow-up, 5 years later. Results At baseline, participants had a mean total sleep time of 408 ± 72 minutes, mean wake after sleep onset of 71 ± 43 minutes, and mean sleep efficiency of 79 ± 11%. At follow-up, 71 (4%) were residing in a nursing home, and 127 (8%) were in a personal care home. Women with the most wake after sleep onset (by quartile) had more than twice the odds as those with the least of placement in a nursing home (adjusted odds ratio ( AOR) = 2.94, 95% confidence interval ( CI) = 1.34-6.44) or a personal care home ( AOR = 2.33, 95% CI = 1.26-4.30). Similarly, women with the lowest sleep efficiency had more than three times the odds as those with the highest of nursing home placement ( AOR = 3.25, 95% CI = 1.35, 7.82) and more than twice the odds of placement in a personal care home ( AOR = 2.38, 95% CI = 1.33, 4.24). There was no association between sleep duration and placement. Conclusion In very old community-dwelling women, greater wake after sleep onset and lower sleep efficiency are risk factors for placement in a nursing home or personal care home. Sleep duration alone does not appear to increase the risk of placement in these long-term care settings. [ABSTRACT FROM AUTHOR]

Objectives To investigate whether lower estimated glomerular filtration rate ( eGFR) or chronic kidney disease ( CKD) was associated with subsequent cognitive and instrumental activity of daily living ( IADL) decline in a prospective cohort study. Design Prospective cohort study, followed for up to 4 years. Setting General community. Participants One thousand three hundred fifteen adults aged 55 and older from the Singapore Longitudinal Aging Study. Measurements Baseline data included eGFR levels, presence of CKD ( eGFR < 60 m L/min per 1.73 m2), and known confounders. Cognitive decline was defined as a drop of 2 or more points on the Mini- Mental State Examination ( MMSE) and functional decline as a drop of 2 or more points in IADL score. Results Decreasing levels of eGFR and the presence of CKD were associated with greater odds of cognitive decline at follow-up independent of confounding risk factors in multivariate analyses: estimated 14% increment in odds of cognitive decline per 10 mL/min/1.73 m2 decrease in e GFR (odds ratio = 1.94, 95% confidence interval = 1.23-3.05; P = .004 for CKD vs non- CKD). Similar associations were found in a cognitively normal subgroup ( MMSE > 23) at baseline. In the whole sample, CKD, but not e GFR, was found to be significantly associated with higher risk of IADL decline. Conclusion CKD in older persons was significantly associated with cognitive and functional decline. Future research should target the development and evaluation of strategies to delay or prevent cognitive decline and physical disability in elderly adults with impaired kidney function. [ABSTRACT FROM AUTHOR]