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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]

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 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]

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 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 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 examine whether the total burden of comorbidity and pattern of co-occurring conditions varies in individuals with heart failure ( HF) with preserved left ventricular ejection fraction ( LVEF) ( HF-P) or HF with reduced LVEF ( HF-R). Design Cross-sectional cohort study. Setting Four participating health plans within the National Heart, Lung, and Blood Institute-sponsored Cardiovascular Research Network. Participants All members aged 65 and older with HF based on hospital discharge and ambulatory visit diagnoses. Measurements Participants with a LVEF of 50% or greater were classified as having HF-P. Presence of cardiac and noncardiac comorbidities was obtained from health plan administrative databases. Results Of 23,435 individuals identified with HF and LVEF information, 53% (12,407) had confirmed HF-P (mean age 79.6; 60% female). More than three-quarters of the sample had three or more co-occurring conditions in addition to HF, and half had five or more cooccurring conditions. Participants with HF-P had a slightly higher burden of comorbidity than those with HF-R (mean 4.5 vs 4.4, P = .002). Patterns of how specific conditions co-occurred did not vary in participants with preserved or reduced systolic function. Conclusion There is a high degree of comorbidity and multiple morbidity in individuals with HF. The burden and pattern of comorbidity varies only slightly in individuals with preserved or reduced LVEF. [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 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]

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 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 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 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 the development of vascular risk factor levels at four points over 15 years in relation to late-life cognitive functioning. Design Longitudinal population-based study. Setting The Hoorn Study, a community-based cohort study of glucose metabolism and cardiovascular risk. Participants Three hundred eighty individuals without dementia (mean baseline age 57.7 ± 5.5). Measurements Four extensive medical examinations were conducted over 15 years. Cognition was assessed in detail at the fourth examination. The time course of vascular risk factors across the examinations was compared between individuals in the highest tertile (good performance) and those in the lowest tertile (poor performance) of cognitive functioning on three cognitive domains (memory, information processing speed, and attention and executive functioning ( A& EF)). Results Individuals with poor information processing speed had higher levels of systolic blood pressure at baseline (mean difference (standard error) 11.6 (2.6) mm Hg, P < .001) than those with good information processing speed. Individuals with poor A& EF had a higher waist:hip ratio (3.03 (1.15), P = .009), glycosylated hemoglobin (0.29% (0.10%), P = .005) and total cholesterol:high-density lipoprotein cholesterol ratio (0.38 (0.19), P = .04) at baseline than individuals with good A& EF, although the differences in vascular risk factor levels between the poor and good cognition group diminished with increasing age. Conclusion High blood pressure, adiposity, hypercholesterolemia, and hyperglycemia at midlife are associated with late-life cognitive dysfunction, but for most risk factors, this relationship gradually attenuates with increasing age. These results suggest that timing of vascular treatment strategies to prevent cognitive impairment is critical. [ABSTRACT FROM AUTHOR]

Objectives To characterize longitudinal patterns of musculoskeletal pain in a community sample of older adults over a 6-year period and to identify factors associated with persistence of pain. Design Secondary analysis of the Cardiovascular Health Study. Setting Community-based cohort drawn from four U.S. counties. Participants Five thousand ninety-three men and women aged 65 and older. Measurements Over a 6-year period, pain was assessed each year using a single question about the presence of pain in any bones or joints during the last year. If affirmative, participants were queried about pain in seven locations (hands, shoulders, neck, back, hips, knees, feet). Participants were categorized according to the percentage of time that pain was present and according to the intermittent or chronic pattern of pain. Factors associated with persistent pain during five remaining years of the study were identified. Results Over 6 years, 32% of participants reported pain for three or more consecutive years, and 32% reported pain intermittently. Of those who reported pain the first year, 54% were pain free at least once during the follow-up period. Most of the pain at specific body locations was intermittent. Factors associated with remission of pain over 5 years included older age, male sex, better self-rated health, not being obese, taking fewer medications, and having fewer depressive symptoms. Approximately half of those with pain reported fewer pain locations the following year. Conclusion Musculoskeletal pain in older adults, despite high prevalence, is often intermittent. The findings refute the notion that pain is an inevitable, unremitting, or progressive consequence of aging. [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 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 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]

Objectives To examine the effect of cardiovascular and metabolic diseases on initial cognitive test performance and rate of change in three cognitive measures. Design Prospective cohort study. Setting General practices in six towns throughout Germany. Participants Three thousand three hundred twenty-seven participants aged 75 and older (average 79.7 ± 3.6). Measurements Data were collected during home visits every 18 months and included sociodemographic variables, depression, disease status, drug intake, and cognition. Results Although the presence of transient ischemic attack ( TIA) or stroke and diabetes mellitus was related to poor initial cognitive test performance, the presence of those and other far-reaching chronic diseases or a higher disease burden were not related to the rate of change in cognition over time. Conclusion Diabetes mellitus, stroke and TIA affect cognitive test performance beyond well-known sociodemographic variables and depressive symptoms, although none of these diseases contributed to cognitive decline over time. In practical terms, prevention and diagnosis of cardiovascular and metabolic diseases may be essential to cognitively healthy aging. [ABSTRACT FROM AUTHOR]

Objectives To investigate the independent and combined contributions to the risk of Alzheimer's disease ( AD) of three important domains of cognitive assessment: neuropsychological measurement, self-reports, and informant reports. Design Longitudinal, community-based sample. Setting Einstein Aging Study. Participants Six hundred twenty-seven individuals without dementia aged 70 and older systematically recruited from the Bronx, New York. Measurements Comprehensive assessment included neurological examination, behavioral questions, and neuropsychological testing. AD diagnoses were based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria assigned at a multidisciplinary consensus case conference. The major statistical analyses used Cox proportional hazards models (with age as the time scale) adjusted for sex, education, and depressive symptoms. Results Forty-eight participants developed incident AD during a median of 3.3 years of follow-up. Self- and informant reports of cognitive status and baseline scores on tests of episodic memory and psychomotor speed predicted the onset of AD, but in models examining all the variables simultaneously, only the episodic memory tests and informant reports were associated with risk of AD. A likelihood ratio test confirmed the incremental effect of informant reports in addition to the neuropsychological test scores ( P = .03). Conclusion Informant ratings improved the prediction of AD conversion in addition to objective memory impairment in older adults without dementia. Combining these cognitive measures may provide a useful, empirical method for identifying individuals at high risk of future AD. [ABSTRACT FROM AUTHOR]

Objectives To examine the association between routine physical activity and risk of 3-year mortality in Mexican Americans aged 75 and older. Design Longitudinal 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 ( TX, CO, AZ, NM, CA). Participants Mexican- American men and women aged 75 and older ( N = 948) participating in the H- EPESE. Measurements Responses to the Physical Activity Scale for the Elderly ( PASE) were assessed in 2005-06. Mortality was determined according to report of relatives at 3-year follow-up and from the National Death Index. Covariates included sociodemographic characteristics, financial strain, smoking status, body mass index, activities of daily living, depressive symptoms, cognitive function, and comorbid conditions. Results The mean age of the sample was 82.2 ± 4.5. Cox proportional hazard regression estimated that the hazard ratios of death for persons in the low, moderate, and high quartiles of physical activity ( PASE scale) ranged from 0.36 (95% confidence interval ( CI) = 0.21-0.62) to 0.50 (95% CI = 0.31-0.82) compared to persons in the sedentary quartile after adjusting for covariates. Conclusion Routine physical activity involving household and leisure activities was associated with lower 3-year risk of mortality in a sample of older Mexican Americans living in the community. [ABSTRACT FROM AUTHOR]

Objectives To investigate whether there are racial differences in gait velocity in elderly adults. Design Cross-sectional analysis. Setting Bronx, New York. Participants Two hundred thirteen participants of the Einstein Aging Study (157 Caucasian, 56 African American), a longitudinal study of community-residing elderly adults recruited using Medicare and voter registration records. Measurements Demographic characteristics, medical history, Geriatric Depression Scale, Blessed Information- Memory- Concentration Test, Total Pain Index, gait velocity. Results Caucasians were older (median 79.9 vs 75.5, P = .002) and more educated (median 14 vs 12 years, P = .007) and had lower body mass index (mean 26.9 ± 4.3 vs 28.9 ± 6.4, P = .03). African Americans were more likely to be female (80.4% vs 59.9%, P = .006) and to have diabetes mellitus (28.6% vs 13.4%, P = .01). Pain levels were not significantly different between Caucasians and African Americans. African Americans had a significantly slower gait velocity (mean 90.2 ± 17.9 vs 99.1 ± 20.1 cm/s, P = .004). This difference persisted after adjusting for multiple covariates. Differences in common factors known to influence gait did not explain a 7.79-cm/s slower gait speed in African Americans than Caucasians. Conclusion Differences in gait velocity persist between African Americans and Caucasians despite adjusting for many confounders. Increases of just 10 cm/s are associated with lower mortality. Further studies are needed to evaluate whether there are modifiable risk factors that may explain this difference and whether an intervention could reduce the discrepancy between the groups. [ABSTRACT FROM AUTHOR]

Objectives To examine the relationship between fruit and vegetable intake, physical activity, and all-cause mortality in older women. Design Six Cox proportional hazards models examined independent and additive relationships between physical activity, carotenoids, and all-cause mortality. Additional models tested whether physical activity and carotenoids were conjointly related to mortality. Models were adjusted for age, education, and race and ethnicity. Setting Baltimore, Maryland. Participants Seven hundred thirteen women aged 70 to 79 participating in the Women's Health and Aging Studies. Measurements Total serum carotenoids, a marker of fruit and vegetable intake, and physical activity were measured at baseline. Physical activity was measured according to kilocalorie expenditure. Results During 5 years of follow-up, 82 (11.5%) participants died. Measured continuously, physical activity improved survival ( HR = 0.52, 95% CI = 0.41-0.66, P < .001). The most active women were more likely to survive than the least physically active women ( HR = 0.28, 95% CI = 0.13-0.59, P < .001). Continuous measures of carotenoids improved survival ( HR = 0.67, 95% CI = 0.51-0.89, P = .01). Women in the highest tertile of total carotenoids were more likely to survive those in the lowest ( HR = 0.50, 95% CI = 0.27-0.91, P = .03). When examined in the same model, continuous measures of physical activity ( HR = 0.54, 95% CI = 0.42-0.68, P < .001) and carotenoids ( HR = 0.76, 95% CI = 0.59-0.98, P = .04) predicted survival during follow-up. Conclusion The combination of low total serum carotenoids and low physical activity, both modifiable risk factors, strongly predicted earlier mortality. These findings provide preliminary support that higher fruit and vegetable intake and exercise improve survival. [ABSTRACT FROM AUTHOR]

Objectives To determine whether anemia is a risk factor for functional decline in nursing home ( NH) residents with chronic kidney disease. Design Prospective 26-week observational study. Setting Eighty-two geographically representative NHs in the United States. Participants Three hundred eleven NH residents with chronic kidney disease ( CKD; estimated glomerular filtration rate <60 mL/min per 1.73 m2) who had anemia (hemoglobin <12 g/dL for women, <13 g/dL for men, n = 177) or not (n = 134). Measurements The primary outcome was the distance walked or wheeled for 10 minutes. Secondary outcomes were single chair stand time, grip strength, leg extension strength, Dartmouth Primary Care Cooperative Information scores, Modified Barthel Index, falls, hospitalization, and mortality. Results Mixed-effects model analysis of distance walked or wheeled showed that changes between weeks 2 and 14 but not between weeks 2 and 26 were significantly different between participants with CKD with anemia and those without anemia. There were no significant differences for the other physical performance or self-report measures. After adjustment for an anemia propensity score, participants with CKD with anemia did not have higher rates of hospitalization or death at 26 weeks than those without anemia. Conclusion Nursing home residents with CKD and anemia experienced greater decline than those with CKD without anemia only for a mobility distance task over a 3-month but not a 6-month period and not for other performance or self-report measures. Anemia may not increase the risk of functional decline in NH residents with CKD, but further research is necessary to confirm these findings and evaluate whether a lower hemoglobin cutpoint confers greater risk for functional decline in this population. [ABSTRACT FROM AUTHOR]

Objectives To determine the efficacy of multimodal, nondrug therapy on symptoms of dementia and need for care in institutionalized individuals with degenerative dementia. Design Randomized, controlled, longitudinal trial. Data were analyzed using multiple linear regression. Setting Five German nursing homes. Participants One hundred thirty-nine nursing home residents with primary degenerative dementia ( Mini- Mental State Examination score < 24). Intervention The 6-month intervention comprised three components: motor stimulation, activities of daily living, and cognitive stimulation ( MAKS). Groups of 10 patients led by two therapists participated in the standardized intervention for 2 hours, 6 days a week. The intervention was described in detail in an intervention manual. Adherence to the manual was high. Controls received treatment as usual. Measurements Overall geriatric symptoms were recorded using the Nurses' Observation Scale for Geriatric Patients, functional independence using the Barthel Index, and care time using the Resource Utilization in Dementia- Formal Care. Results Of 646 individuals screened, 146 were eligible, and 130 were included in the intention-to-treat analysis. At 6 months, results of the per-protocol analysis (n = 119) showed improvement in overall dementia symptoms in the MAKS group and no change in the control group (adjusted mean difference ( AMD) = −6.8, 95% confidence interval ( CI) = −10.3 to −3.3; P < .001, Cohen d = 0.66). This effect was greatest on the social behavior ( AMD = −1.9, 95% CI = −2.9 to −0.8; P < .001; Cohen d = 0.54) and instrumental activity of daily living ( IADL) ( AMD = −1.4, 95% CI = −2.5 to −0.30; P = .01; Cohen d = 0.43) subscales. No effect was seen on functional independence or total care time. Conclusion This 6-month nondrug multimodal intervention improved dementia symptoms in nursing home residents, especially in social behavior and IADL capabilities. Registration Identifier: ISRCTN87391496. [ABSTRACT FROM AUTHOR]

Objectives To examine the associations between depressive symptoms, antidepressant use, and duration of use with incident frailty 3 years later in nonfrail women aged 65 and older. Design Secondary analysis of the Women's Health Initiative Observational Study ( WHI- OS), a prospective cohort study. Setting WHI- OS was conducted in 40 U. S. clinical centers. Participants Women aged 65 to 79, not frail at baseline. Measurements Antidepressant use was assessed through medication container inspection at baseline. Four groups were created according to baseline use and Burnam depression screen (range 0-1, 0.06 cutoff): antidepressant nonusers without depressive symptoms (reference group), antidepressant nonusers with depressive symptoms, antidepressant users without depressive symptoms, and antidepressant users with depressive symptoms. Frailty components included slowness or weakness, exhaustion, low physical activity, and unintended weight loss, ascertained through self-report and physical measurements at baseline and Year 3. Results Of 27,652 women at baseline, 1,350 (4.9%) were antidepressant users and 1,794 (6.5%) were categorized as depressed. At Year 3, 4,125 (14.9%) were frail. All groups had a greater risk of incident frailty than the reference group. Odds ratios ( ORs) ranged from 1.73 (95% confidence interval ( CI) = 1.41-2.12) in antidepressant users who were not depressed to 3.63 in antidepressant users who were depressed (95% CI = 2.37-5.55). All durations of use were associated with incident frailty (<1 year OR = 1.95, 95% CI = 1.41-2.68; 1-3 years OR = 1.99, 95% CI = 1.45-2.74; >3 years OR = 1.60, 95% CI = 1.20-2.14). Conclusion In older adult women, depressive symptoms and antidepressant use were associated with frailty after 3 years of follow-up. [ABSTRACT FROM AUTHOR]

Objectives To investigate whether delirium is associated with an unbalanced inflammatory response or a dysfunctional interaction between the cholinergic and immune systems. Design Cohort observational study. Setting General hospital orthopedic ward. Participants One hundred one individuals aged 60 and older with no previous cognitive impairment undergoing elective arthroplasty. Measurements Incidence of postoperative delirium, plasma cholinesterase activity (acetylcholinesterase ( AChE) and butyrylcholinesterase (BuChE)) and inflammatory mediators (C-reactive protein ( CRP), interleukin ( IL)-1 beta, tumor necrosis factor alpha, IL-6, IL-8, IL-10) before and after surgery. Results Thirty-seven participants developed postoperative delirium and had greater production of CRP and proinflammatory to anti-inflammatory ratio after surgery. In participants with delirium, but not in controls, preoperative levels of plasma cholinesterase activity correlated with Δ CRP ( AChE: ρ = 0.428, P = .008 and BuChE: ρ = 0.423, P = .009), Δ IL-6 ( AChE: ρ = 0.339, P = .04), and ΔP/A ratio ( AChE: ρ = 0.346, P = .04). Conclusion Delirium was associated not only with an unbalanced inflammatory response, but also with a dysfunctional interaction between the cholinergic and immune systems. Comprehensive understanding of the relationship between the cholinergic and immune systems is crucial to developing new insights into delirium pathophysiology and novel therapeutic interventions. [ABSTRACT FROM AUTHOR]

Objectives To examine frailty transitions in Mexican American ( MA) and European American ( EA) older adults. Design Longitudinal, observational cohort study. Setting Socioeconomically diverse neighborhoods in San Antonio, Texas. Participants Three hundred twelve MA and 285 EA community-dwelling older adults (≥65) with frailty information at baseline (1992-1996) and transition information at follow-up (2000/01) in the San Antonio Longitudinal Study of Aging. Measurements Five frailty characteristics (weight loss, exhaustion, weakness, slowness, and low physical activity), frailty score (0-5), and overall frailty state (nonfrail = 0 characteristics, prefrail = 1 or 2, frail = ≥3) were assessed at baseline. Transitions (progressed, regressed, or no change) were assessed for frailty score and state. Odds ratios ( ORs) of progression and regression in individual characteristics were estimated using generalized estimating equations adjusted for age, sex, ethnic group, socioeconomic status, comorbidity, diabetes, and follow-up interval. Results Diabetes mellitus with macrovascular complications ( OR = 1.84, 95% confidence interval ( CI) = 1.02-3.33), fewer years of education ( OR = 0.96, 95% CI = 0.93-1.0) and follow-up interval ( OR = 1.3, 95% CI = 1.17-1.46) were significant predictors of progression in any frailty characteristic. Mortality increased with greater frailty state, and prefrail individuals were more likely than frail individuals to regress. Conclusion Diabetes mellitus with macrovascular complications and fewer years of education are important predictors of progression in any frailty characteristic. Because of greater risk of death than for the nonfrail state and greater likelihood of regression than for the frail state, the prefrail state may be an optimal target for intervention. [ABSTRACT FROM AUTHOR]

Objectives To examine the association between plasma levels of pterins and amino acids and postoperative delirium. Design Prospective cohort study. Setting Cardiothoracic service in an university hospital in Rotterdam, the Netherlands. Participants One hundred twenty-five individuals aged 70 and older undergoing elective cardiac surgery. Measurements Plasma pterins and amino acids were measured pre- and postoperatively. Using multiple logistic regression analyses, the associations between pterins and amino acid levels and postoperative delirium were examined in relation to age, sex, comorbidity, cognitive functioning (Mini-Mental State Examination ( MMSE) score), and cardiac risk factors. Results Delirium incidence in the main study group was 31.3%. The preoperative measures associated with delirium were neopterin (odds ratio ( OR) = 1.05, P = .009); MMSE score less than 28 ( OR = 4.39, P = .001); European System for Cardiac Operative Risk Evaluation score greater than 6 ( OR = 2.84, P = .03); and combined coronary artery bypass graft ( CABG) and aortic, mitral, or tricuspid valve surgery ( OR = 4.32, P = .01). Postoperative measures associated with delirium were neopterin ( OR = 3.84, P = .02), homovanillic acid ( HVA, OR = 1.01, P = .04), and preoperative MMSE score less than 28 ( OR = 3.32, P = .008). Conclusion Preoperatively high neopterin levels predicted delirium after cardiac surgery in older adults, in addition to the well-known risk factors of poor cognitive function, high cardio-surgical risk, and combined CABG and valve surgery. Postoperative neopterin and HVA levels were also found to be associated with delirium, together with preoperative cognitive functioning. Plasma neopterin may be a candidate biomarker for delirium after cardiac surgery in these older adults. [ABSTRACT FROM AUTHOR]

Objectives To examine the prognostic value of prestroke disability in predicting inpatient mortality and length of hospital stay ( LOS) independent of age, sex, and stroke type and severity. Design Retrospective analysis of prospectively collected stroke registers. Setting United Kingdom. Participants Fourteen thousand four hundred thirty-seven individuals (52.9% female, mean age 75.4 ± 12.1) with stroke (82% ischemic) admitted to three university hospitals. Measurements Data were examined from three hospital registers: Aintree (2005-2010), Newcastle (2000-2005), and Norwich (1997-2010). Risk of inpatient death and prolonged hospital stay according to prestroke disability using the modified Rankin Score ( mRs) were assessed using logistic regression adjusting for age, sex, and stroke subtype (ischemic vs hemorrhagic) and severity. Results Inpatient death was 20.8%. In fully adjusted models, higher prestroke mRs was associated with significantly greater risk of mortality (for mRs = 1, 2, 3, 4, and 5 vs mRs = 0: odds ratio (OR)=1.28, 95% confidence interval (CI)=1.09-1.50; OR = 1.50, 95% CI = 1.29-1.75; OR = 1.85, 95% CI = 1.60-2.13; OR = 2.56, 95% CI = 2.15-3.04; and OR = 4.48, 95% CI = 3.47-5.80, respectively). The relationship appeared to be linear, and each point increase in mRs equated to being approximately 5 years older. Although age and stroke type appear to be strong independent predictors of LOS, premorbid mRs also predicted longer LOS regardless of discharge status. The predictability of the model using these parameters was very good (receiver operating characteristic: 0.82 for death and 0.65-0.70 for LOS). Conclusion Prestroke disability predicts inpatient death and LOS, independent of age, sex, and stroke type and severity. Whether this is related to mental or physical disability should be examined in future prospective studies. [ABSTRACT FROM AUTHOR]

Objectives To examine the extent to which receipt of recommended monitoring of diabetes mellitus (DM) differed for participants with and without comorbid dementia, as well as the effect of other comorbidities on monitoring of DM in individuals with comorbid dementia. Design Retrospective cohort study. Setting Secondary analysis of 2005/2006 claims and enrollment data for a 5% national random sample of Medicare beneficiaries. Participants Two hundred eighty-eight thousand eight hundred five Medicare fee-for-service beneficiaries with a diagnosis of DM before 2006, 44,717 (16%) of whom had evidence of comorbid dementia in claims. Measurements Established algorithms were used to determine whether patients received at least one glycosylated hemoglobin ( Hb A1c) test, one low-density lipoprotein cholesterol ( LDL- C) test, and one annual eye examination in 2006 and to construct variables representing comorbidities common in DM, sociodemographic characteristics, and patterns of healthcare utilization. Results In unadjusted and fully adjusted models, the presence of dementia reduced the likelihood of receiving Hb A1c tests, LDL- C tests, and eye examinations, with effects being smallest for Hb A1c tests. The effects of other comorbidities on DM monitoring in participants with dementia varied according to the nature of the comorbidity and the specific test. Conclusion Dementia reduces the likelihood that individuals with DM will receive recommended annual monitoring for DM. More research is needed to understand reasons for lower monitoring in this subgroup and how this affects functioning, adverse events, and quality of life. [ABSTRACT FROM AUTHOR]

Objectives To compare characteristics of indoor and outdoor recurrent fallers and explore some implications for clinical practice, in which a fall risk assessment for all recurrent fallers has been recommended. Design Prospective cohort study. Setting Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston Study, a study of falls etiology in community-dwelling older individuals from randomly sampled households in the Boston, Massachusetts, area. Participants Seven hundred thirteen women and men, mostly aged 70 and older, with at least 1 year of follow-up. Measurements Data at baseline and from an 18-month follow-up examination were collected by questionnaire and comprehensive clinic examination. During follow-up, participants recorded falls on daily calendars. A telephone interview queried location and circumstances of each fall. Results One hundred forty-five participants reported recurrent falls (≥2) during the first year. Those who had fallen only outdoors had good health characteristics, whereas those who had fallen only indoors were generally in poor health. For instance, 25.5% of indoor-only recurrent fallers had gait speeds of slower than 0.6 m/s, compared with 2.9% of outdoor-only recurrent fallers; the respective percentages were 44.7% and 8.8% for Berg balance score less than 48. Recurrent indoor fallers generally had poor health characteristics regardless of their activity at the time of their falls, whereas recurrent outdoor fallers who fell during vigorous activity or walking were especially healthy. A report of any recurrent falls in the first year did not predict number of positive findings on a comprehensive or abbreviated fall risk assessment at the 18-month follow-up examination. Conclusion Characteristics of community-dwelling older people with recurrent indoor and outdoor falls are different. If confirmed, these results suggest that different types of fall risk assessment are needed for specific categories of recurrent fallers. [ABSTRACT FROM AUTHOR]

Objectives To compare the risk of major medical events in nursing home residents newly initiated on conventional or atypical antipsychotic medications ( APMs). Design Cohort study, using linked Medicaid, Medicare, Minimum Data Set, and Online Survey Certification and Reporting data. Propensity score-adjusted proportional hazards models were used to compare risks for medical events at a class and individual drug level. Setting Nursing homes in 45 U.S. states. Participants Eighty-three thousand nine hundred fifty-nine Medicaid-eligible residents aged 65 and older who initiated APM treatment after nursing home admission in 2001 to 2005. Measurements Hospitalization for myocardial infarction, cerebrovascular events, serious bacterial infections, and hip fracture within 180 days of treatment initiation. Results Risks of bacterial infections (hazard ratio ( HR) = 1.25, 95% confidence interval ( CI) = 1.05-1.49) and possibly myocardial infarction ( HR = 1.23, 95% CI = 0.81-1.86) and hip fracture ( HR = 1.29, 95% CI = 0.95-1.76) were higher, and risks of cerebrovascular events ( HR = 0.82, 95% CI = 0.65-1.02) were lower in participants initiating conventional APMs than in those initiating atypical APMs. Little variation existed between individual atypical APMs, except for a somewhat lower risk of cerebrovascular events with olanzapine ( HR = 0.91, 95% CI = 0.81-1.02) and quetiapine ( HR = 0.89, 95% CI = 0.79-1.02) and a lower risk of bacterial infections ( HR = 0.83, 95% CI = 0.73-0.94) and possibly a higher risk of hip fracture ( HR = 1.17, 95% CI = 0.96-1.43) with quetiapine than with risperidone. Dose-response relationships were observed for all events ( HR = 1.12, 95% CI = 1.05-1.19 for high vs low dose for all events combined). Conclusion These associations underscore the importance of carefully selecting the specific APM and dose and monitoring their safety, especially in nursing home residents who have an array of medical illnesses and are undergoing complex medication regimens. [ABSTRACT FROM AUTHOR]

Objectives To evaluate whether the Enhanced Feedback for Effective Cardiac Treatment ( EFFECT) scale for 30-day prediction of mortality is applicable to elderly adults with acute heart failure ( AHF) in emergency departments ( EDs) and whether discriminatory power is added with the inclusion of the Barthel Index ( BI) to this scale ( BI- EFFECT scale). Design BI-EFFECT is a multipurpose, nonintervention, multicenter cohort study. Setting Twenty EDs. Participants Individuals aged 65 and older with AHF. Measurements Information on baseline and episode characteristics and 30-day mortality was collected, and participants were categorized according to the EFFECT scale. Baseline degree of functional dependence was measured using the BI. Receiver operating characteristic ( ROC) curves were made of the EFFECT and BI- EFFECT scales to predict mortality. Results One thousand sixty-eight participants were included. Thirty-day mortality was 5.1% and was directly and independently associated with high and very high risk categories of the EFFECT scale and with severe dependence. These two variables remained significant after adjustment of the model for both ( OR = 4.5, 95% CI = 1.8-11.1 and OR = 2.9, 95% CI = 1.6-5.4, respectively). The EFFECT and the BI- EFFECT scales had significant ROC curves (area under the ROC curve ( AUC) = 0.69, 95% CI = from 0.62 to 0.76; and AUC = 0.75, 95% CI = 0.69-0.81, respectively), and the difference in discriminatory power between the second and the first was also statistically significant ( P = .02). Conclusion The EFFECT scale may be applied in the elderly population, and inclusion of functional status according to the BI in the new BI- EFFECT scale significantly improves the model for the prediction of 30-day mortality. [ABSTRACT FROM AUTHOR]

Objectives To examine in cognitively normal elderly adults whether vascular factors predict cognitive decline and whether these associations are mediated by magnetic resonance imaging ( MRI) measures of subclinical vascular brain injury. Design Prospective multisite longitudinal study of subcortical ischemic vascular diseases. Setting Memory and aging centers in California. Participants Seventy-four participants who were cognitively normal at entry and underwent at least two neuropsychological evaluations and two MRI examinations over an average follow-up of 6.9 years. Measurements Item response theory was used to create composite scores of global, verbal memory, and executive functioning. Volumetric MRI measures included white matter hyperintensities ( WMHs), silent brain infarcts ( SBIs), hippocampus, and cortical gray matter ( CGM). Linear mixed-effects models were used to examine the associations between vascular factors, MRI measures, and cognitive scores. Results History of coronary artery disease ( CAD) was associated with greater declines in global cognition, verbal memory, and executive function. The CAD associations remained after controlling for changes in WMHs, SBIs, and hippocampal and CGM volumes. Conclusion History of CAD may be a surrogate marker for clinically significant atherosclerosis, which also affects the brain. Structural MRI measures of WMHs and SBIs do not fully capture the potential adverse effects of atherosclerosis on the brain. Future longitudinal studies of cognition should incorporate direct measures of atherosclerosis in cerebral arteries, as well as more sensitive neuroimaging measures. [ABSTRACT FROM AUTHOR]

Objectives To identify the relationship between functional status and complicated clinical course in older adults in the emergency department ( ED) with suspected infection and to identify other independent predictors of complicated clinical course. Design A prospective observational cohort study. Setting An academic, tertiary care ED with 70,000 visits per year. Participants Aged 65 and older, blood cultures obtained in the ED, and final ED physician diagnosis of acute infection. Measurements Functional status was obtained using the Older Americans Resources Scale ( OARS). Complicated clinical course was defined as in-hospital mortality, need for intensive care unit ( ICU)-level care, or worsening in sepsis criteria within 48 hours. Analysis was performed using multivariable logistic regression. Results One hundred five participants were enrolled, 34 with the primary outcome. OARS was not predictive of complicated clinical course in univariate ( P = .13) or multivariable ( P = .90) models. An OARS score of 25 or less was also not significant ( P = .22). Independent predictors were immunosuppression (odds ratio ( OR) = 3.45, 95% confidence interval ( CI) = 1.06-11.20), systolic blood pressure ( OR = 0.98, 95% CI = 0.96-1.00), pulse ( OR = 1.03, 95% CI = 1.00-1.06), metabolic acidosis ( OR = 3.46, 95% CI = 1.08-11.09), severe sepsis or septic shock ( OR = 10.24, 95% CI = 1.44-72.79), and suspected bloodstream infection ( OR = 3.56, 95% CI = 1.13-11.16). Conclusion For older adults admitted to the ED with infection, functional status did not predict complicated clinical course, but several other variables were predictive, including immunosuppression, several variables associated with hypoperfusion, and suspected bloodstream infection. Emergency physicians could consider these variables as potential indicators of complicated clinical course when making disposition decisions for this population. [ABSTRACT FROM AUTHOR]

Objectives To determine whether being overweight or obese is associated with significant health outcomes in an 85-year-old population. Design A cross-sectional population-based study. Setting Linköping, Sweden. Participants Three hundred thirty-eight people born in 1922 were identified using the local authority's register. Measurements Data related to sociodemographic characteristics, health-related quality of life ( HRQoL), assistance use, and the presence of diseases were collected using a postal questionnaire. Anthropometry and functional status were assessed during home and geriatric clinic visits. Diseases were double-checked in the electronic medical records, and information about health service consumption was obtained from the local healthcare register. Results Overweight (body mass index ( BMI) 25.0-29.9 kg/m2) and obese ( BMI ≥ 30.0 kg/m2) participants perceived more difficulty performing instrumental activities of daily living ( IADLs) and had more comorbidity than their normal-weight counterparts ( BMI 18.5-24.9 kg/m2), but their overall HRQoL and health service costs did not differ from those of normal-weight participants. After controlling for sociodemographic factors, being overweight did not influence IADLs or any comorbidity, but obese participants were more likely to perceive greater difficulty in performing outdoor activities (odds ratio ( OR) = 2.1, 95% confidence interval ( CI) = 1.1-4) and cleaning ( OR = 2.2, 95% CI = 1.2-4.2) than their normal-weight counterparts. Although obesity was also associated with multimorbidity ( OR = 3, 95% CI = 1.2-8), the health service cost of each case of multimorbidity (n = 251) was highest in normal-weight participants and nearly three times as much as in obese participants (ratio: 2.9, 95% CI = 1.1-8.1). Conclusion For 85-year-olds, being obese, as opposed to overweight, is associated with self-reported activity limitations and comorbidities. Overweight older adults living in their own homes in this population had well-being similar to that of those with normal weight. [ABSTRACT FROM AUTHOR]

Objectives To identify care-related factors associated with hospital-acquired pressure ulcers ( HAPUs). Design Prospective cohort study. Setting Nine hospitals in Baltimore Hip Studies network. Participants Six hundred fifty-eight individuals aged 65 and older who underwent surgery for hip fracture. Measurements Skin examinations at baseline and on alternating days until hospital discharge. Participants were deemed to have a HAPU if they developed one or more new Stage 2 or higher pressure ulcers ( PUs) during the hospital stay. Results Longer emergency department stays were associated with lower HAPU incidence (>4-6 hours: adjusted incidence rate ratio ( aIRR) = 0.68, 95% confidence interval (CI) = 0.48-0.96; >6 hours: aIRR = 0.68, 95% CI = 0.46-0.99, both vs ≤ 4 hours). Participants with 24 hours or longer between admission and surgery had a higher postsurgery HAPU rate than those with less than 24 hours ( aIRR = 1.62, 95% CI = 1.24-2.11). Surgery with general anesthesia had a lower postsurgery HAPU rate than surgery with other types of anesthesia ( aIRR = 0.66, 95% CI = 0.49-0.88). There was no significant association between HAPU incidence and timing of transport to the hospital, type of transport to the hospital, or surgery duration. Conclusion Most of the factors hypothesized to be associated with higher PU incidence were associated with lower incidence or were not significantly associated, suggesting that HAPU development may not be as sensitive to care-related factors as commonly believed. Rigorous studies of innovative preventive interventions are needed to inform policy and practice. [ABSTRACT FROM AUTHOR]

Objectives To examine vitamin D status and its association with physical performance and muscle mass in older Chinese men. Design Cross-sectional and prospective cohort study design. Setting Hong Kong, People's of Republic of China. Participants Nine hundred thirty-nine community-dwelling men aged 65 and older for cross-sectional analysis and 714 for longitudinal analysis. Measurements Baseline serum 25-hydroxyvitamin D (25 OHD) was measured using a competitive radioimmunoassay kit. Baseline and 4-year physical performance measures (grip strength, 6-m walking speed, step length in a 6-m walk, time to complete five chair stands) were measured, and appendicular skeletal muscle mass ( ASM) was assessed using dual-energy X-ray absorptiometry. Data were collected for confounding factors: demographic, number of diseases, smoking, alcohol use, body mass index, physical activity, diet, season of blood sampling, and serum parathyroid hormone ( PTH) level. Multivariate regression analyses were performed with adjustments for confounding factors. Results Mean ± standard deviation serum 25 OHD level of this sample of Chinese community-dwelling older men who had a high level of baseline physical function was 77.9 ± 20.5 nmol/L; 94.1% of participants had serum 25 OHD levels of 50 nmol/L or greater. Median (interquartile range) serum PTH level was 4.1 pmol/L (3.1-5.5 pmol/L). After adjustment for potential confounding factors, serum 25 OHD levels were not associated with baseline or 4-year change in physical performance measures and ASM. Conclusion In Chinese older men who are vitamin D replete and have a high level of baseline physical function, vitamin D may not have an important role in physical function and muscle mass. [ABSTRACT FROM AUTHOR]

Objectives To examine whether overall depressive symptoms and symptom clusters are associated with fall risk and to determine whether chronic pain mediates the relationship between depression and fall risk in aging. Design Prospective cohort study. Setting Boston, Massachusetts, and surrounding communities. Participants Older community-dwelling adults (N = 722, mean age 78.3). Measurements Depressive symptomatology was assessed at baseline using the 20-item Hopkins Revision of the Center for Epidemiologic Studies Depression Scale ( CESDR) as overall depression and two separate domains: cognitive and somatic symptoms. Chronic pain was examined at baseline as number of pain sites (none, single site, or multisite), pain severity, and pain interference with activities of daily living. Participants recorded falls on monthly postcards during a subsequent 18-month period. Results According to negative binomial regression, the rate of incident falls was highest in those with the highest burden of depressive symptoms (according to total CESDR and the cognitive and somatic CESDR domains). After adjustment for multiple confounders and fall risk factors, fall rate ratios comparing the highest three CESDR quartiles with the lowest quartile were 1.91, 1.26, and 1.11, respectively. Similarly graded associations were observed according to the CESDR domains. Although pain location and interference were mediators of the relationship between depression and falls, adjustment for pain reduced fall risk estimates only modestly. There was no interaction between depression and pain in relation to fall risk. Conclusion Depressive symptoms are associated with fall risk in older adults and are mediated in part by chronic pain. Research is needed to determine effective strategies for reducing fall risk and related injuries in older people with pain and depressive symptoms. [ABSTRACT FROM AUTHOR]