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Background: Retirement represents a crucial transitional period for many adults with possible consequences for cognitive aging. We examined trajectories of cognitive change before and after retirement in Black and White adults. Methods: Longitudinal examination of up to 10 years (mean = 7.1 ± 2.2 years) using data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study–a national, longitudinal study of Black and White adults ≥45 years of age. Data were from 2226 members of the REGARDS study who retired around the time when an occupational ancillary survey was administered. Cognitive function was an average of z‐scores for tests of verbal fluency, memory, and global function. Results: Cognitive functioning was stable before retirement (Estimate = 0.05, p = 0.322), followed by a significant decline after retirement (Estimate = −0.15, p < 0.001). The decline was particularly pronounced in White (Estimate = −0.19, p < 0.001) compared with Black (Estimate = −0.07, p = 0.077) participants, twice as large in men (Estimate = −0.20, p < 0.001) compared with women (Estimate = −0.11, p < 0.001), highest among White men (Estimate = −0.22, p < 0.001) and lowest in Black women (Estimate = −0.04, p = 0.457). Greater post‐retirement cognitive decline was also observed among participants who attended college (Estimate = −0.14, p = 0.016). While greater work complexity (Estimate = 0.92, p < 0.05) and higher income (Estimate = 1.03, p < 0.05) were related to better cognitive function at retirement, neither was significantly related to cognitive change after retirement. Conclusion: Cognitive functioning may decline at an accelerated rate immediately post‐retirement, more so in White adults and men than Black adults and women. Lifelong structural inequalities including occupational segregation and other social determinants of cognitive health may obscure the role of retirement in cognitive aging. [ABSTRACT FROM AUTHOR]

Background: Obesity and loss of muscle mass are emerging as risk factors for dementia, but the role of adiposity infiltrating skeletal muscles is less clear. Skeletal muscle adiposity increases with older age and especially among Black women, a segment of the US population who is also at higher risk for dementia. Methods: In 1634 adults (69–79 years, 48% women, 35% Black), we obtained thigh intermuscular adipose tissue (IMAT) via computerized tomography at Years 1 and 6, and mini‐mental state exam (3MS) at Years 1, 3, 5, 8 and 10. Linear mixed effects models tested the hypothesis that increased IMAT (Year 1–6) would be associated with 3MS decline (Year 5–10). Models were adjusted for traditional dementia risk factors at Year 1 (3MS, education, APOe4 allele, diabetes, hypertension, and physical activity), with interactions between IMAT change by race or sex. To assess the influence of other muscle and adiposity characteristics, models accounted for change in muscle strength, muscle area, body weight, abdominal subcutaneous and visceral adiposity, and total body fat mass (all measured in Years 1 and 6). Models were also adjusted for cytokines related to adiposity: leptin, adiponectin, and interleukin‐6. Results: Thigh IMAT increased by 4.85 cm2 (Year 1–6) and 3MS declined by 3.20 points (Year 6–10). The association of IMAT increase with 3MS decline was statistically significant: an IMAT increase of 4.85 cm2 corresponded to a 3MS decline of an additional 3.60 points (p < 0.0001), indicating a clinically important change. Interactions by race and sex were not significant. Conclusions: Clinicians should be aware that regional adiposity accumulating in the skeletal muscle may be an important, novel risk factor for cognitive decline in Black and White participants independent of changes to muscle strength, body composition and traditional dementia risk factors. [ABSTRACT FROM AUTHOR]

Background: The protective effects of allopurinol on physical function in older adults are not well understood, despite its potential to improve functional gains and reduce sarcopenia. This study aims to determine the association between allopurinol, persistent physical disability, and frailty in older gout patients. Methods: This analysis used data from a randomized trial in an older cohort, ASPirin in Reducing Events in the Elderly (ASPREE). ASPREE recruited 19,114 participants aged ≥65 years without prior cardiovascular events, dementia, or independence‐limiting physical disability at trial enrolment. This analysis examined the association of baseline and time‐varying allopurinol use with persistent physical disability and new‐onset frailty in participants with gout at baseline (self‐report or use of any anti‐gout medications). Frailty was measured using the Fried frailty phenotype (score ≥3/5) and a deficit accumulation frailty index (FI) (score >0.21/1.0). Multivariable Cox proportional‐hazards models were used for main analyses. Results: This analysis included 1155 gout participants, with 630 taking allopurinol at baseline and 525 not. During a median follow‐up of 5.7 years, 113 new allopurinol users were identified. Compared with nonusers, baseline allopurinol use was associated with a significant risk reduction of persistent physical disability (Adjusted HR 0.46, 95% CI 0.23–0.92, p = 0.03). The strength of the association was modestly attenuated in the time‐varying analysis (Adjusted HR 0.56, 0.29–1.08, p = 0.08). No significant associations with frailty measures were observed for either baseline allopurinol use (Fried frailty: Adjusted HR 0.83, 0.62–1.12; FI: Adjusted HR 0.96, 0.74–1.24) or time‐varying allopurinol use (Fried frailty: Adjusted HR 0.92, 0.69–1.24; FI: Adjusted HR 1.02, 0.78–1.33). Conclusions: Allopurinol use in older adults with gout is associated with a reduced risk of persistent physical disability but not associated with risk of frailty. [ABSTRACT FROM AUTHOR]

Background: The American Rescue Plan Act of 2021 awarded $500 million toward scaling "strike teams" to mitigate the impact of Coronavirus Disease 2019 (COVID‐19) within nursing homes. The Massachusetts Nursing Facility Accountability and Support Package (NFASP) piloted one such model during the first weeks of the pandemic, providing nursing homes financial, administrative, and educational support. For a subset of nursing homes deemed high‐risk, the state offered supplemental, in‐person technical infection control support. Methods: Using state death certificate data and federal nursing home occupancy data, we examined longitudinal all‐cause mortality per 100,000 residents and changes in occupancy across NFASP participants and subgroups that varied in their receipt of the supplemental intervention. Results: Nursing home mortality peaked in the weeks preceding the NFASP, with a steeper increase among those receiving the supplemental intervention. There were contemporaneous declines in weekly occupancy. The potential for temporal confounding and differential selection across NFASP subgroups precluded estimation of causal effects of the intervention on mortality. Conclusions: We offer policy and design suggestions for future strike team iterations that could inform the allocation of state and federal funding. We recommend expanded data collection infrastructure and, ideally, randomized assignment to intervention subgroups to support causal inference as strike team models are scaled under the direction of state and federal agencies. See related Commentary by Berry et al. in this issue. [ABSTRACT FROM AUTHOR]

Background: Sodium‐glucose cotransporter‐2 inhibitor (SGLT2I) use has increased among community‐dwelling populations, but little is known about how clinicians have prescribed them for US nursing home (NH) residents. We described the adoption of SGLT2Is by prescribers caring for long‐stay NH residents by clinician specialty and over time, compared with sulfonylureas, an older diabetes medication class. Methods: We conducted a retrospective cohort study of prescribers of SGLT2Is and sulfonylureas for all long‐stay US NH residents aged 65 years or older (2017–2019). Using 100% of Medicare Part D claims linked to prescriber characteristics data, we identified all dispensings of SGLT2Is and sulfonylureas for long‐stay NH residents and their associated prescribers. We described the distribution of prescriber specialties for each drug class over time as well as the number of NH residents prescribed SGLT2s versus sulfonylureas. We estimated the proportions of prescribers who prescribed both drug classes versus only sulfonylureas or only SGLT2Is. Results: We identified 36,427 unique prescribers (SGLT2I: N = 5811; sulfonylureas: N = 35,443) for 117,667 NH residents between 2017 and 2019. For both classes, family medicine and internal medicine physicians accounted for most prescriptions (75%–81%). Most clinicians (87%) prescribed only sulfonylureas, 2% prescribed SGLT2Is only, and 11% prescribed both. Geriatricians were least likely to prescribe only SGLT2Is. We observed an increase in the number of residents with SGLT2I use from n = 2344 in 2017 to n = 5748 in 2019. Conclusions: Among NH residents, most clinicians have not incorporated SGLT2Is into their prescribing for diabetes, but the extent of use is increasing. Family medicine and internal medicine physicians prescribed the majority of diabetes medications for NH residents, and geriatricians were the least likely to prescribe only SGLT2Is. Future research should explore provider concerns regarding SGLT2I prescribing, particularly adverse events. [ABSTRACT FROM AUTHOR]

Background: Dietary supplement and complementary and alternative medication (CAM) use can contribute to drug interactions, polypharmacy, nonadherence with prescription medications, and healthcare expenses, whereas evidence supporting benefits of using these products is sparse. There is a lack of current published literature describing the patterns or predictors of their use in community‐dwelling older adults. Materials and Methods: We performed a cross‐sectional analysis of community‐dwelling adults from Australia and the US, aged 70 years and older (65 years for US minorities), enrolled in the ASPirin in Reducing Events in the Elderly (ASPREE) study. At study enrollment, eligible participants were required to be without concurrent 5‐year life‐limiting illness and free of documented evidence of cardiovascular disease, dementia, or significant physical disability. During the final study visit, a questionnaire was administered to collect information about supplement/CAM use. Data from 15,729 participants who completed this questionnaire between January 2017 and January 2018 were analyzed. Descriptive statistics were used to report the prevalence and types of products used. Factors associated with use were determined using multivariate regression. Results: Mean age of respondents was 79.6 years; 56.4% were female, 88.8% were from Australia, 56.5% reported 12 years of education or less, and 98.7% were living at home. Two‐thirds (66.2%) of participants reported use of one or more supplement/CAM in the previous month. Products most commonly used included vitamin D (33.8% of participants), fish oil (22.7%), calcium (20.6%), glucosamine (14.8%), and multivitamin (12.9%). Female sex, US residency, higher education, polypharmacy (prescription medications), and frailty (in women) were significantly associated with higher use of supplements/CAMs. Conclusions: Dietary supplement and CAM use is common among community‐dwelling older adults in the United States and Australia. Given the high prevalence of use, collaboration between healthcare providers and older adult patients is important to insure safe and optimal use of these products. [ABSTRACT FROM AUTHOR]

Background: Asian and Pacific Islander (Asian/PI) adults have lower hip fracture incidence than non‐Hispanic White (NHW) adults, but data regarding Asian/PI subgroups are limited. We compared hip fracture incidence among older US Asian/PI and NHW populations, including ethnic subgroup differences. Methods: Using observational data from a California healthcare system, we identified Asian/PI and NHW adults aged ≥50 years (2000–2019) and followed subjects to 2021 for hip fracture determined by principal/primary hospital diagnosis or by secondary hospital diagnosis with hip/femur procedure codes. Age‐adjusted hip fracture incidence was calculated with 95% confidence intervals (CIs). Log‐Poisson regression was used to determine fracture incidence rate ratios (IRRs, [CI]; NHW or Chinese as reference) adjusting for age and year. Results: Among 215,359 Asian/PI and 776,839 NHW women, hip fracture incidence was 1.34 (1.28–1.40) and 2.97 (2.94–3.01) per 1000 person‐years, respectively, with IRR 0.45 (0.43–0.47). Among 188,328 Asian/PI and 697,046 NHW men, hip fracture incidence was 0.62 (0.58–0.67) and 1.81 (1.78–1.84) per 1000 person‐years, respectively, with IRR 0.34 (0.32–0.37). For the four largest Asian/PI subgroups, Filipina women (IRR 0.85 [0.75–0.96]) had lower, and Japanese (IRR 1.36 [1.20–1.54]) and South Asian (IRR 1.36 [1.07–1.72]) women had higher hip fracture incidence compared to Chinese women. Hip fracture incidence was only higher among South Asian (IRR 1.61 [1.21–2.14]) compared to Chinese men. Conclusion: Hip fracture incidence among US Asian/PI adults was 55% (women) and 66% (men) lower than NHW adults, but incidence varied by Asian/PI subgroup. The heterogeneity among Asian/PI adults highlights the importance of examining fracture risk by ethnic subgroup. [ABSTRACT FROM AUTHOR]

Background: The contemporary uptake of lipid‐lowering therapies (LLT), including more intensive treatment with high‐intensity statins and non‐statin LLT, among U.S. older adults (≥75 years old) with ASCVD is unknown. Methods: In this multicenter retrospective cohort study of a large geographically diverse sample of commercially insured U.S. older adults with ASCVD, we assessed treatment with LLT. Secondary measures included LDL‐C above target ≥70 mg/dl, persistence and adherence to therapy. Results: Treatment with statins, high‐intensity statins, ezetimibe, and PCSK9 inhibitors was assessed in 194,503 older adults (49.9% female) with known ASCVD on January 31st, 2019. 49.3% of older adults with ASCVD were on any statin, with 16.6% receiving a high‐intensity statin and 32.7% on low‐or moderate‐intensity statins. Treatment with ezetimibe (2.4%) or PCSK9 inhibitors (0.24%) was rare and 62.6% of the overall cohort had an LDL‐C above target at ≥70 mg/dl. Patients on high‐intensity statins were more frequently male, had a diagnosis of coronary artery disease, and were more frequently seen by a cardiologist compared with those on low‐or moderate‐intensity statins and untreated individuals (p < 0.0001). The majority of older adults on high‐intensity statins remained on therapy at 12 months (91.9%) and 85.7% had ≥75% adherence to treatment. Conclusions: Less than half of eligible older adults with ASCVD are on statins and only a minority of patients are receiving more intensive lipid‐lowering to improve outcomes. [ABSTRACT FROM AUTHOR]

Background: Heart failure (HF) is the leading cause of hospitalization among older adults in the United States and results in high rates of post-acute care (PAC) utilization. Federal policies have focused on shifting PAC to less intensive settings and reducing length of stay to lower spending. This study evaluates the impact of policy changes on PAC use among Medicare beneficiaries hospitalized with HF between 2008 and 2015 by (1) characterizing trends in PAC use and cost and (2) evaluating changes in readmission, mortality, and days in the community, overall and by frailty. Methods: Annual cross-section prospective cohorts of all HF admissions between 1/1/2008 and 9/30/2015 among a 20% random sample of all Medicare Fee-for-Service beneficiaries (n = 718,737). The Claims-based Frailty Index (CFI) was used to classify frailty status. Multivariable regression models were used to evaluate trends in first discharge location, readmissions, mortality, days alive in the community, and costs; overall and by frailty status. Results: Frailty was prevalent among HF patients: 54.1% were prefrail, 37.0% mildly frail, and 6.9% moderate to severely frail. Between 2008 and 2015, almost 4% more HF beneficiaries received PAC, with most of the increase concentrated in skilled nursing facilities (SNF) (+2.3%) and home health agencies (HHA) (+1.1%), and PAC cost increased by $123 (3.5%). Over the 180-days follow-up after hospitalization, hospital readmissions decreased significantly (-3.4% at 30-day; -6.3% at 180-day), days alive in the community increased (+1.5), and 180-day Medicare costs declined $2948 (-18.7%) without negative impact in mortality (except a minor increase in the pre-frail group). Gains were greatest among the frailest patients. Conclusions: Medicare beneficiaries hospitalized with HF spent more time in the community and experienced lower rehospitalization rates at lower cost without significant increases in mortality. However, important opportunities remain to optimize care for frail older adults hospitalized with HF. [ABSTRACT FROM AUTHOR]

Introduction: Medication reconciliation, a technique that assists in aligning a care team's understanding of an individual's true medication regimen, is vital to optimize medication use and prevent medication errors. Historically, most medication reconciliation research has focused on institutional settings and transitional care, with comparatively little attention given to medication reconciliation in community settings. To optimize medication reconciliation for community‐dwelling older adults, healthcare professionals and older adults must be engaged in co‐designing processes that create sustainable approaches. Methods: Academic researchers, older adults, and community‐ and health system‐based healthcare professionals engaged in a participatory process to better understand medication reconciliation barriers and co‐design solutions. The initiative consisted of two participatory research approaches: (1) Sparks Innovation Studios, which synthesized professional expertise and opinions, and (2) a Community Consultation Studio with older adults. Input from both groups informed a list of possible solutions and these were ranked based on evaluative criteria of feasibility, person‐centeredness, equity, and sustainability. Results: Sparks Innovation Studios identified a lack of ownership, fragmented healthcare systems, and time constraints as the leading barriers to medication reconciliation. The Community Consultation Studio revealed that older adults often feel dismissed in medical encounters and perceive poor communication with and among providers. The Community Consultation Studio and Sparks Innovation Studios resulted in four highly‐ranked solutions to improve medication reconciliation: (1) support for older adults to improve health literacy and ownership; (2) ensuring medication indications are included on prescription labels; (3) trainings and incentives for front‐line staff in clinic settings to become champions for medication reconciliation; and (4) electronic health record improvements that simplify active medication lists. Conclusion: Engaging community representatives with academic partners in the research process enhanced understanding of community priorities and provided a practical roadmap for innovations that have the potential to improve the well‐being of community‐dwelling older adults. [ABSTRACT FROM AUTHOR]

Background: Injuries are a leading cause of emergency department (ED) visits among older adults, and individuals with Alzheimer's disease and related dementias (ADRD) may be at particular risk. We compared injury‐related ED use among assisted living (AL) residents with and without ADRD and assessed differences in the risk of injury‐related ED visits among individuals with ADRD residing in ALs with memory care designation versus general AL. Methods: Using Medicare claims, we identified a cohort of fee‐for‐service beneficiaries who lived in AL in 2018 and resided in one of 20 states with site‐specific information on memory care designation (n = 116,754). Outcomes included all injury‐related ED visits and injury‐related ED visits resulting in hospitalization in the calendar year 2018. We fit multilevel models of the association between ADRD and outcomes, adjusting for resident demographic characteristics and chronic conditions, license type characteristics, and AL characteristics, with random intercepts at the AL and license type levels. Among residents with ADRD, we examined whether memory care licensure was associated with injury‐related ED visits. Results: The adjusted risk of injury‐related ED use during the year was 20.1% (95% CI: 19.6%, 20.6%) for residents with ADRD compared to 16.1% for residents without ADRD (95% CI: 15.7%, 16.5%; p < 0.001). The adjusted risk of injury‐related ED use ending in hospitalization was 4.9% (95% CI: 4.6%, 5.1%) for AL residents with ADRD and 3.9% for residents without ADRD (95% CI: 3.8%, 4.1%; p < 0.001). There were no significant differences in injury‐related ED visits between residents with ADRD in ALs with memory care designation and residents in general AL. Conclusions: Injury‐related ED visits are common among AL residents with ADRD and residents in memory care, but residents in memory care AL experienced similar risks of injury as those in general AL. Further research should identify modifiable factors that can prevent injury among AL residents with ADRD. [ABSTRACT FROM AUTHOR]

Background: Traumatic brain injury (TBI) is a leading cause of death and disability in older adults. The aim of this study was to characterize the burden of TBI in older adults by describing demographics, care location, diagnoses, outcomes, and payments in this high‐risk group. Methods: Using 2016–2019 Centers for Medicare & Medicaid Services (CMS) Inpatient Standard Analytical Files (IPSAF), patients >65 years with TBI (>1 injury ICD‐10 starting with "S06") were selected. Trauma center levels were linked to the IPSAF file via American Hospital Association Hospital Provider ID and fuzzy‐string matching. Patient variables were compared across trauma center levels. Results: Three hundred forty‐eight thousand eight hundred inpatients (50.4% female; 87.1% white) from 2963 US hospitals were included. Level I/II trauma centers treated 66.9% of patients; non‐trauma centers treated 21.5%. Overall inter‐facility transfer rate was 19.2%; in Level I/II trauma centers transfers‐in represented 23.3% of admissions. Significant TBI (Head AIS ≥3) was present in 70.0%. Most frequent diagnoses were subdural hemorrhage (56.6%) and subarachnoid hemorrhage (30.6%). Neurosurgical operations were performed in 10.9% of patients and operative rates were similar regardless of center level. Total unadjusted mortality for the sample was 13.9%, with a mortality of 8.1% for those who expired in‐hospital, and an additional 5.8% for those discharged to hospice. Medicare payments totaled $4.91B, with the majority (73.4%) going to Level I/II trauma centers. Conclusions: This study fills a gap in TBI research by demonstrating that although the majority of older adult TBI patients in the United States receive care at Level I/II trauma centers, a substantial percentage are managed at other facilities, despite 1 in 10 requiring neurosurgical operation regardless of level of trauma center. This analysis provides preliminary data on the function of regionalized trauma care for older adult TBI care. Future studies assessing the efficacy of early care guidelines in this population are warranted. [ABSTRACT FROM AUTHOR]

Objectives To determine whether elderly veterans with posttraumatic stress disorder ( PTSD) and dementia are more likely to be prescribed second-generation antipsychotics ( SGAs) than those with PTSD alone. Design National serial cross-sectional study. Setting Veterans Health Affairs inpatient and outpatient settings. Participants Veterans aged 65 and older with PTSD (excluding schizophrenia or bipolar disorder) with or without concomitant dementia who received care from the Veterans Health Administration between 2003 and 2010 were identified using International Classification of Diseases, Ninth Revision, codes (N = 93,068; 11.1% with dementia). Measurements Trends in SGA prescribing and odds of being prescribed an SGA were determined using a multivariable logistic regression model adjusted for clinical, sociodemographic, and geographic covariates. Results Between 2004 and 2009, SGA prescribing declined annually from 7.0% to 5.1% of elderly veterans with PTSD without dementia and 13.2% to 8.9% in those with dementia; findings over time consistently indicated that veterans with PTSD and dementia had at least twice the odds of being prescribed an SGA as those without PTSD (odds ratios 2.03 (95% confidence interval ( CI) = 1.82-2.26) to 2.33 (95% CI = 2.10-2.58). Conclusion Although the prescribing of SGAs to elderly veterans with PTSD has decreased, prescribing an SGA to those with dementia remained consistently higher than for those with PTSD alone and is problematic given the high prevalence of medical comorbidities in this aging population coupled with the lack of compelling evidence for effectiveness of SGAs in individuals with dementia. [ABSTRACT FROM AUTHOR]

Objectives To determine the association between homebound status and mortality. Design Cross-sectional. Setting Annual, in-person interviews. Participants A nationally representative sample of community-dwelling, Medicare beneficiaries aged 65 and older enrolled in the National Health and Aging Trends Study between 2011 and 2013 (N = 6,400). Measurements Two-year mortality and prevalence of homebound status in the year before death are described using three categories of homebound status: homebound (never or rarely left home in the last month), semihomebound (left home with assistance, needed help or had difficulty), and nonhomebound (left home without help or difficulty). Results In unadjusted analyses, 2-year mortality was 40.3% in homebound participants, 21.3% in those who were semihomebound and 5.8% in those who were nonhomebound. Homebound status was associated with greater 2-year mortality, adjusted for sociodemographic characteristics, comorbidities, and functional status (hazard ratio = 2.08; 95% confidence interval = 1.63-2.65, P < .001). Half of older community-dwelling Medicare beneficiaries were homebound in the year before death. Conclusion Homebound status is associated with greater risk of death independent of functional impairment and comorbidities. To improve outcomes for homebound older adults and the many older adults who will become homebound in the last year of life, providers and policymakers need to extend healthcare services from hospitals and clinics to the homes of vulnerable individuals. [ABSTRACT FROM AUTHOR]

Objectives To investigate the association between sociodemographic and economic factors and the presence of simple home modifications ( HMs) among older adults in the United States. Design Cross-sectional. Setting National Health and Aging Trends Study (2011, Round 1). Participants Community-dwelling Medicare enrollees aged 65 and older (N = 6,628). Measurements The primary dependent variable was the reported presence or absence of simple HMs (grab bars in the shower or near the toilet, shower seats, raised toilet seats). Results Of the individuals sampled, 60.7% reported having at least one HM of interest. Black (odds ratio ( OR) = 0.79, 95% confidence interval ( CI) = 0.68-0.91) and Hispanic ( OR = 0.60, 95% CI = 0.45-0.78) respondents were less likely than white, non-Hispanic respondents to have HMs. Those with more education (high school graduate: OR = 1.20, 95% CI = 1.01-1.42; >high school: OR = 1.36, 95% CI = 1.14-1.62) and larger social networks (≥4 people; OR = 1.46, 95% CI = 1.12-1.89) were more likely to have at least one HM, whereas being divorced ( OR = 0.57, 95% CI = 0.43-0.74) was associated with lower likelihood. Income ( OR = 1.01, 95% CI = 0.97-1.05), Medicaid enrollment ( OR = 0.98, 95% CI = 0.77-1.25), and living alone ( OR = 1.02, 95% CI = 0.85-1.23) were not significantly associated with the presence of HMs. Conclusion Minorities, individuals with less education, and those with less social support are less likely to have HMs. Awareness of these disparities and the shortcomings of the HM delivery system is important to clinicians and policy-makers who seek to prevent falls and facilitate aging in place for all older Americans. [ABSTRACT FROM AUTHOR]

Objectives To define multimorbidity 'classes' empirically based on patterns of disease co-occurrence in older Americans and to examine how class membership predicts healthcare use. Design Retrospective cohort study. Setting Nationally representative sample of Medicare beneficiaries in file years 1999-2007. Participants Individuals aged 65 and older in the Medicare Beneficiary Survey who had data available for at least 1 year after index interview (N = 14,052). Measurements Surveys (self-report) were used to assess chronic conditions, and latent class analysis ( LCA) was used to define multimorbidity classes based on the presence or absence of 13 conditions. All participants were assigned to a best-fit class. Primary outcomes were hospitalizations and emergency department visits over 1 year. Results The primary LCA identified six classes. The largest portion of participants (32.7%) was assigned to the minimal disease class, in which most persons had fewer than two of the conditions. The other five classes represented various degrees and patterns of multimorbidity. Usage rates were higher in classes with greater morbidity, but many individuals could not be assigned to a particular class with confidence (sample misclassification error estimate = 0.36). Number of conditions predicted outcomes at least as well as class membership. Conclusion Although recognition of general patterns of disease co-occurrence is useful for policy planning, the heterogeneity of persons with significant multimorbidity (≥3 conditions) defies neat classification. A simple count of conditions may be preferable for predicting usage. [ABSTRACT FROM AUTHOR]

Objectives To examine whether life expectancy influences treatment pattern of nonmelanoma skin cancer, or keratinocyte carcinoma ( KC), the most common malignancy and the fifth most costly cancer to Medicare. Design Nationally representative cross-sectional study. Setting Nationally representative Health and Retirement Study linked to Medicare claims. Participants Treatments (N = 9,653) from individuals aged 65 and older treated for basal or squamous cell carcinoma between 1992 and 2012 (N = 2,702) were included. Measurements Limited life expectancy defined according to aged 85 and older, medical comorbidities, Charlson Comorbidity Index score of 3 or greater, difficulty in at least one activity of daily living ( ADL), and a Lee index of 13 or greater. Treatment type (Mohs micrographic surgery ( MMS) (most intensive, highest cost), excision, or electrodesiccation and curettage ( ED&C) (least intensive, lowest cost)), according to procedure code. Results Most KCs (61%) were treated surgically. Rates of MMS (19%), excision (42%), and ED&C (39%) were no different in participants with limited life expectancy and those with normal life expectancy. For example, 19% of participants with difficulty or dependence in ADLs, 20% of those with a Charlson comorbidity score greater than 3, and 15% of those in their last year of life underwent MMS; participants who died within 1 year of diagnosis were treated in the same way as those who lived longer. Conclusion A one-size-fits-all approach in which advanced age, health status, functional status, and prognosis are not associated with intensiveness of treatment appears to guide treatment for KC, a generally nonfatal condition. Although intensive treatment of skin cancer when it causes symptoms may be indicated regardless of life expectancy, persons with limited life expectancy should be given choices to ensure that the treatment matches their goals and preferences. [ABSTRACT FROM AUTHOR]

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

Objectives To examine the relationship between individual characteristics and potential correlates of elder abuse in older adults who present with fractures. Design Cross-sectional analysis of deidentified data extracted from medical records. Setting Academic medical center. Participants Individuals aged 65 and with a primary diagnosis of any fracture admitted to an outpatient department or emergency department ( ED) in a single southern California medical center over a 36-month period (N = 652). Measurements Participant characteristics included demographic characteristics, number of medical visits, and point of service. Corresponding International Classification of Diseases, Ninth Revision ( ICD-9) codes, E-codes, and V-codes were extracted to identify cause, location, and type of fracture. The presence of 13 potential correlates of abuse as captured by ICD-9 codes were extracted and summed. Descriptive statistics and regression models were used for analyses. Results Mean age of participants was 77.2, 58% were female (58%), 60% were white (60%), and 46% had one or more potential correlates of abuse. In bivariate analyses, older age (≥80), dementia, seeking care in the ED (vs inpatient or outpatient clinics), only one visit to a medical facility (vs multiple visits) in the 36-month study period, cause of fracture as something other than a fall, and fractures of the head or face were more likely to have at least one correlate of abuse. In logistic regression, dementia (B = 0.794, standard error ( SE) = 0.280); seeking care in the ED (vs outpatient or outpatient clinics) (B = 1.86, SE = 0.302); at least two visits to a medical facility (vs multiple visits) (B = −0.585, SE = 0.343); and fracture of the back (B = 0.730, SE = 0.289), head (B = 1.22, SE = 0.333), and face (B = 1.28, SE = 0.474) were associated with the presence of at least one correlate of abuse. Conclusion Certain characteristics in older adults with fracture are associated with potential correlates of abuse. Medical practitioners should have a heightened awareness when these signs are present. [ABSTRACT FROM AUTHOR]

Objectives To determine hospital-level predictors of readmission after hip fracture or potentially related inpatient care processes. Design Retrospective cohort study. Setting U.S. acute care hospitals. Participants Fee-for-service Medicare beneficiaries who underwent hip fracture surgery between 2007 and 2009 (N = 458,526). Measurements Information was obtained on hospital case volumes, teaching status, bed count, nurse staffing, and technological capabilities from Medicare files, and multivariable logistic regression was used to measure the association between these factors and an endpoint of readmission or death at 30 days and between these factors and the timing of surgery. Results Participants treated in the highest-volume hospitals (>175 cases for the study period) had lower odds of readmission or death at 30 days than those treated in low-volume hospitals (≤12; adjusted odds ratio ( aOR) = 0.87, 95% confidence interval ( CI) = 0.83-0.92, P < .001). Higher nurse skill mix ( aOR = 0.88, 95% CI = 0.8-0.96; P = .007) and higher ratio of nurses to beds ( aOR = 0.98; 95% CI = 0.97-0.99; P < .001) were also associated with better 30-day outcomes. Greater hospital case volume was associated with lower odds of surgical delay beyond 48 hours. Conclusion Better nurse staffing and higher case volumes are associated with lower rates of readmission and mortality after hip fracture surgery; individuals treated at high-volume centers experienced fewer delays in treatment, potentially indicating better inpatient care processes. [ABSTRACT FROM AUTHOR]

Objectives To examine the prevalence of dementia in the absence of a reported dementia diagnosis and whether potentially unsafe activities and living conditions vary as a function of dementia diagnosis status in a nationally representative sample of older adults. Design Observational cohort study. Setting Community. Participants Medicare beneficiaries aged 65 and older enrolled in the National Health and Aging Trends Study (N = 7,609). Measurements Participants were classified into four groups based on self-report of dementia diagnosis, proxy screening interview, and cognitive testing: probable dementia with reported dementia diagnosis (n = 457), probable dementia without reported dementia diagnosis (n = 581), possible dementia (n = 996), or no dementia (n = 5,575). Potentially unsafe activities (driving, preparing hot meals, managing finances or medications, attending doctor visits alone) and living conditions (falls, living alone, and unmet needs) were examined according to dementia status subgroups in stratified analyses and multivariate models, adjusting for sociodemographic factors, medical comorbidities, and physical capacity. Results The prevalence of driving (22.9%), preparing hot meals (31.0%), managing finances (21.9%), managing medications (36.6%), and attending doctor visits alone (20.6%) was lowest in persons with probable dementia; however, but in persons with probable dementia, the covariate-adjusted rates of driving, preparing hot meals, managing finances, managing medications, and attending doctor visits alone were significantly higher in those without reported dementia diagnosis than in those with reported diagnosis (all odds ratios ≥2.00, all P < .01). Conclusion Older adults with probable dementia who are not aware of a dementia diagnosis are more likely to report engaging in potentially unsafe behaviors. Understanding the prevalence of potentially unsafe activities and living conditions can help clinicians focus safety screening and counseling in older adults with diagnosed or suspected dementia. [ABSTRACT FROM AUTHOR]

Objectives To assess the relationship between comorbid depression, diabetes mellitus ( DM), and cognitive decline in Mexican Americans aged 65 and older. Design Retrospective cohort study with longitudinal analysis. Setting Texas, New Mexico, Colorado, Arizona, and California. Participants Hispanic Established Populations for the Epidemiologic Study of the Elderly. Measurements Cognition was assessed using the Mini-Mental State Examination ( MMSE). Depression was defined as a score of 16 or greater on the Center for Epidemiologic Studies Depression Scale. DM was defined as according to self-reported history or taking insulin or oral hypoglycemic medication. Results Participants with depression and DM declined an average of 6.5 points on the MMSE; depression only, 4.4 points; DM only, 7.8 points; and neither condition, 4.2 points across the six examination waves. Participants with DM declined an average of 0.18 more points on the MMSE per year ( P = .001) than those with neither DM nor depression, and those with comorbid DM and depression declined 0.25 more points per year ( P = .002). Depression was associated with significantly greater cognitive decline ( [ABSTRACT FROM AUTHOR]

Objectives To compare processes and cost of care of older adults with diabetes mellitus cared for by nurse practitioners ( NPs) with processes and cost of those cared for by primary care physicians ( PCPs). Design Retrospective cohort study. Setting Primary care in communities. Participants Individuals with a diagnosis of diabetes mellitus in 2009 who received all their primary care from NPs or PCPs were selected from a national sample of Medicare beneficiaries (N = 64,354). Measurements Propensity score matching within each state was used to compare these two cohorts with regard to rate of eye examinations, low-density lipoprotein cholesterol ( LDL-C) and glycosylated hemoglobin (HbA1C) testing, nephropathy monitoring, specialist consultation, and Medicare costs. The two groups were also compared regarding medication adherence and use of statins, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (for individuals with a diagnosis of hypertension), and potentially inappropriate medications ( PIMs). Results Nurse practitioners and PCPs had similar rates of LDL-C testing (odds ratio (OR) = 1.01, 95% confidence interval (CI) = 0.94-1.09) and nephropathy monitoring (OR = 1.05, 95% CI = 0.98-1.03), but NPs had lower rates of eye examinations (OR = 0.89, 95% CI = 0.84-0.93) and HbA1C testing (OR = 0.88, 95% CI = 0.79-0.98). NPs were more likely to have consulted cardiologists (OR = 1.29, 95% CI = 1.21-1.37), endocrinologists (OR = 1.64, 95% CI = 1.48-1.82), and nephrologists (OR = 1.90, 95% CI = 1.67-2.17) and more likely to have prescribed PIMs (OR = 1.07, 95% CI = 1.01-1.12). There was no statistically significant difference in adjusted Medicare spending between the two groups ( P = .56). Conclusion Nurse practitioners were similar to PCPs or slightly lower in their rates of diabetes mellitus guideline-concordant care. NPs used specialist consultations more often but had similar overall costs of care to PCPs. [ABSTRACT FROM AUTHOR]

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

Objectives To identify depressive symptom trajectories and factors associated with trajectory group membership in the very old segment of the rapidly growing and long-living Mexican-American population. Design Latent growth curve modeling was used to identify depressive symptom trajectories and multinomial logistic regression to identify factors associated with trajectory group membership. Setting Data spanning three waves and 7 years (2004-05, 2007-08, 2010-11) drawn from the Hispanic Established Populations for Epidemiologic Studies of the Elderly; homes of Mexican-origin elderly adults. Participants Community-dwelling Mexican Americans aged 75 and older living in the southwestern United States (N = 1,487). Measurements The 20-item version of the Center for Epidemiologic Studies Depression Scale. Results Three trajectory groups were identified: low throughout, increasing, and high but decreasing. Activity of daily living disability was the strongest predictor of depressive symptoms, followed by social support. Foreign-born individuals were at greater risk than those who are U.S. born for high but decreasing depressive symptoms than for low depressive symptoms. Conclusion Early detection and treatment of chronic disabling conditions, especially heart disease, cancer, visual impairment, and cognitive impairment, and increasing access to social participation should be the focus of treatment and intervention strategies for depression in very old Mexican Americans. [ABSTRACT FROM AUTHOR]

Objectives To examine the association between sleep complaints, use of sleep-promoting medications, and persistent severe fatigue ( PSF). Design Analysis of data from the National Health Aging Trends Study. Setting Contiguous United States. Participants A representative sample of Medicare beneficiaries aged 65 and older. Measurements Difficulty initiating sleep, difficulty staying asleep, use of sleep-promoting medications, demographic characteristics, presence of pain, use of pain medications, depression, chronic medical disease, physical activity level, and Short Physical Performance Battery score measured at baseline. The outcome of interest was PSF (fatigue that limits daily activities reported at baseline and 12-month follow-up). Results Of 8,245 participants at baseline, 7,075 completed 12-month follow-up; 31% reported severe fatigue at baseline and 31% at follow-up, and 19% reported PSF. In a logistic regression model, difficulty staying asleep some nights (odds ratio ( OR) = 1.32, 95% confidence interval ( CI) = 1.08-1.60) and most nights or every night ( OR = 1.40, 95% CI = 1.09-1.79) and use of sleep-promoting medications most nights or every night ( OR = 1.35, 95% CI = 1.08-1.67) independently predicted PSF. Conclusion The results indicate greater risk of PSF in older adults with difficulty staying asleep and those who use sleep-promoting medications. These findings underscore the significance of sleep problems and present potential targets for interventional studies that aim to improve fatigue in older adults. [ABSTRACT FROM AUTHOR]

Objectives To determine life expectancy for older women with breast cancer. Design Prospective longitudinal study with 10 years of follow-up data. Setting Hospitals or collaborating tumor registries in four geographic regions (Los Angeles, California; Minnesota; North Carolina; Rhode Island). Participants Women aged 65 and older at time of breast cancer diagnosis with Stage I to IIIA disease with measures of self-rated health ( SRH) and walking ability at baseline (N = 615; 17% aged ≥80, 52% Stage I, 58% with ≥2 comorbidities). Measurements Baseline SRH, baseline self-reported walking ability, all-cause and breast cancer-specific estimated probability of 5- and 10-year survival. Results At the time of breast cancer diagnosis, 39% of women reported poor SRH, and 28% reported limited ability to walk several blocks. The all-cause survival curves appear to separate after approximately 3 years, and the difference in survival probability between those with low SRH and limited walking ability and those with high SRH and no walking ability limitation was significant (0.708 vs 0.855 at 5 years, P ≤ .001; 0.300 vs 0.648 at 10 years, P < .001). There were no differences between the groups in breast cancer-specific survival at 5 and 10 years ( P = .66 at 5 years, P = .16 at 10 years). Conclusion The combination of low SRH and limited ability to walk several blocks at diagnosis is an important predictor of worse all-cause survival at 5 and 10 years. These self-report measures easily assessed in clinical practice may be an effective strategy to improve treatment decision-making in older adults with cancer. [ABSTRACT FROM AUTHOR]

Objectives To determine whether acute hospitalization is associated with a change in potentially inappropriate medication ( PIM) use and whether use varies across geographic region. Design Observational. Setting Continental United States. Participants Medicare beneficiaries aged 65 and older hospitalized for acute myocardial infarction (AMI) during 2007-08. Measurements Potentially inappropriate medication use was defined according to the High-Risk Medications in Elderly Adults quality indicator from the Healthcare Effectiveness Data and Information Set. Prevalence of outpatient PIM use was determined at admission and discharge and then used to identify medications discontinued during hospitalization and incident medications started during this period. Results Of 124,051 older adults hospitalized for AMI, 9,607 (7.7%) were outpatient PIM users at admission, which increased to 8.6% at discharge ( P < .001). Admission PIM rates varied according to geographic region, as did the effect of hospitalization. Admission PIM use was lowest in the northeast and remained unchanged during hospitalization (5.1-5.1%, P = .95). In contrast, admission PIM use was highest in the south and increased significantly during hospitalization (9.9-11.4%, P < .001). PIM use also increased from the long-term perspective, with 6-month period prevalence rates of 22.6% before admission and 24.6% after discharge ( P < .001). Conclusion Despite intervention studies demonstrating up to 80% reduction in PIM use during acute hospitalization, a significant increase in PIM use was observed in a naturalistic setting in Medicare beneficiaries with AMI. Further research is needed to develop an approach to minimizing PIM use in the inpatient setting that is cost-effective and suitable for widespread implementation. [ABSTRACT FROM AUTHOR]

Objectives To examine associations between objective measures of activity level and mortality risk in older men. Design Prospective cohort study. Setting Six U.S. sites. Participants Men aged 71 and older followed an average of 4.5 years (N = 2,918). Measurements Time awake spent in sedentary behavior (metabolic equivalent ( MET) level ≤1.50), light activity ( MET level 1.51-2.99), and at least moderate activity ( MET level ≥3.00) measured using an activity monitor worn for 5 days or longer and expressed as quartiles. Deaths were confirmed with death certificates; cause of death was adjudicated by review of certificates and records. Results During follow-up, 409 (14%) men died. After multivariable adjustment, comparing Q4 with Q1, more time spent in sedentary behavior (Q4 vs Q1, hazard ratio ( HR) = 1.51, 95% confidence interval ( CI) = 1.10-2.08), less time spent in light activity (Q1 vs Q4, HR = 1.54, 95% CI = 1.06-2.24), and less time spent in at least moderate activity (Q1 vs Q4, HR = 1.56, 95% CI = 1.09-2.25) were similarly associated with greater mortality risk primarily due to higher risks of cardiovascular and noncardiovascular, noncancer death. The association between time spent in sedentary behavior and mortality varied according to time spent at higher activity level. More time spent in sedentary behavior was associated with greater risk of death in men spending 1.2 (median) h/d or more in at least moderate activity (Q4 vs Q1, HR = 2.09, 95% CI = 1.26-3.49) but not in those spending less time (Q4 vs Q1, HR = 1.02, 95% CI = 0.62-1.66) ( P = .005 for interaction). Conclusion In older men exceeding current guidelines on physical activity, more time spent in sedentary behavior is associated with greater mortality risk. [ABSTRACT FROM AUTHOR]

Objectives To determine whether elderly people with different patterns of magnetic resonance imaging ( MRI) findings have different long-term outcomes. Design Longitudinal cohort study. Setting Cardiovascular Health Study. Participants Individuals aged 65 and older were recruited (N = 5,888); 3,660 of these underwent MRI, and 3,230 without a stroke before MRI were included in these analyses. Measurements Cluster analysis of brain MRI findings was previously used to define five clusters: normal, atrophy, simple infract, leukoaraiosis, and complex infarct. Participants were subsequently classified as healthy if they rated their health as excellent, very good, or good and as able if they did not report any limitations in activities of daily living ( ADLs). Mean years of life (YoL), years of healthy life ( YHL), and years of able life ( YAL) were calculated over 16 years after the MRI and compared between clusters using unadjusted and adjusted regression analyses. Results Mean age of participants was 75.0. With 16 years of follow-up, mean YoL was 11.3; YHL, 8.0; and YAL, 8.4. Outcomes differed significantly between clusters. With or without adjustments, outcomes were all significantly better in the normal than complex infarct cluster. The three remaining clusters had intermediate results, significantly different from the normal and complex infarct clusters but not usually from one another. Over 16 years of follow-up, participants in the complex infarct cluster (n = 368) spent the largest percentage of their 8.4 years alive being sick (38%) and not able (38%). Conclusion Findings on MRI scans in elderly adults are associated not only with long-term survival, but also with long-term self-rated health and limitation in ADLs. The combination of infarcts and leukoaraiosis carried the worst prognosis, presumably reflecting small vessel disease. [ABSTRACT FROM AUTHOR]

Objectives To describe new users of antihypertensive medications and identify predictors of combination therapy initiation in older Americans. Design Retrospective observational cohort study. Setting Population-based study using U.S. Medicare fee-for-service healthcare claims (2007-2010). Participants Medicare beneficiaries aged 65 and older with no recent diagnoses, procedures, or medications for cardiovascular disease who newly initiated an antihypertensive therapy (n = 275,493; 210,605 initiated monotherapy, 64,888 initiated combination therapy). Measurements Multivariable Poisson regression was used to assess factors associated with initiation of combination therapy versus monotherapy, including participant characteristics, prescriber characteristics, and participant encounters with the healthcare system. Results Initiation of combination therapy increased from 21.9% in 2007 to 24.7% in 2010. The most frequently initiated combinations were angiotensin-converting enzyme inhibitors with thiazide (29.7%) and angiotensin II receptor antagonists with thiazide (18.7%). Blacks (prevalence ratio ( PR) = 1.48, 95% confidence interval ( CI) = 1.45-1.51 vs whites), individuals seeing a generalist ( PR = 1.10, 95% CI = 1.07-1.14), individuals seeing more than one doctor ( PR = 3.38, 95% CI = 3.33-3.44), and participants with no pharmacy claims in the previous 6 months ( PR = 1.34, 95% CI = 1.30-1.37 vs ≥3 unique drug classes) were more likely to initiate combination therapy, whereas those who had more outpatient visits in the previous 12 months were less likely to initiate combination therapy (per five visits, PR = 0.82, 95% CI = 0.80-0.83). Conclusion Nearly one in four new users of antihypertensive medications aged 65 and older started treatment with combination therapy. Blacks, individuals living in the south, and those with fewer outpatient physician office visits were more likely to initiate combination therapy. Further research is needed to determine whether this approach to managing hypertension is being well targeted to individuals who will require combination treatment. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the prevalence of respiratory impairment and dyspnea and their associations with objectively measured physical inactivity and performance-based mobility in sedentary older persons. Design Cross-sectional. Setting Lifestyle Interventions and Independence for Elders Study. Participants Community-dwelling older persons (n = 1,635, mean age 78.9) who reported being sedentary (<20 min/wk of regular physical activity and <125 min/wk of moderate physical activity in past month). Measurements Respiratory impairment was defined as low ventilatory capacity (forced expiratory volume in 1 second less than lower limit of normal ( LLN)) and respiratory muscle weakness (maximal inspiratory pressure < LLN). Dyspnea was defined as moderate to severe ratings on the modified Borg index, immediately after a 400-m walk test (400- MWT). Physical inactivity was defined according to high sedentary time as the highest quartile of participants with accelerometry-measured activity of <100 counts/min. Performance-based mobility was evaluated using the Short Physical Performance Battery (≤7 defined as moderate to severe mobility impairment) and 400- MWT gait speed (<0.8 m/s defined as slow). Results Prevalence rates were 17.7% for low ventilatory capacity, 14.7% for respiratory muscle weakness, 31.6% for dyspnea, 44.7% for moderate to severe mobility impairment and 43.6% for slow gait speed. Significant associations were found between low ventilatory capacity and slow gait speed (adjusted odds ratio (a OR) = 1.41, 95% confidence interval ( CI) = 1.03-1.92), between respiratory muscle weakness and moderate to severe mobility impairment (a OR = 1.42, 95% CI = 1.03-1.95), and between dyspnea and high sedentary time (a OR = 1.98, 95% CI = 1.28-3.06) and slow gait speed (a OR = 1.70, 95% CI = 1.22-2.38). Conclusion Respiratory impairment and dyspnea are prevalent in sedentary older persons and are associated with objectively measured physical inactivity and poor performance-based mobility. Because they are modifiable, respiratory impairment and dyspnea should be considered in the evaluation of sedentary older persons. [ABSTRACT FROM AUTHOR]

Objectives To assess uptake of postfracture care guidelines in community-dwelling Medicare recipients with fractures. Design Retrospective observational cohort study. Setting Claims-based study using U.S. Medicare administrative inpatient, outpatient (2003-2010), and prescription (2006-2010) data. Participants Individuals aged 68 and older who survived at least 12 months after a fracture of the hip, radius, or humerus. Measurements Poisson regression modeled factors, including participant characteristics, comorbidities and hospital referral region (HRR), associated with bone density testing or osteoporosis pharmacotherapy in the 6 months after fracture. Models were repeated for participants with no osteoporosis care observed before fracture (attention naïve). Results In 61,832 individuals with fractures, mean age was 80.6, 87.0% were female, 88.5% were white, 2.6% were black, and 62.1% were attention naïve at the time of fracture; 21.8% received testing, pharmacotherapy, or both in the 6 months after fracture. In adjusted models, factors associated with significantly lower likelihood of receiving this care were black race, male sex, and an upper extremity fracture (vs hip). In models restricted to attention-naïve participants, the same factors were associated with lower relative risk of receiving care. Adjusted HRR-level care rates ranged from 14.7% to 22.9% (10th to 90th percentile). The proportion receiving care increased from 2006 to 2009. Conclusion Postfracture osteoporosis care was uncommon, particularly in black and male participants. Care increased over time, but for most, a fracture was insufficient to trigger effective secondary prevention, especially for participants who were not receiving prefracture osteoporosis attention. Clinicians and policy-makers must consider effective remedies to this persistent care gap. [ABSTRACT FROM AUTHOR]

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

This article discusses the contribution that international comparisons of the health and well-being of older people make. The comparability of the "HRS family" of studies that have been modeled on the U.S. Health and Retirement Study (HRS) is discussed. The Irish Longitudinal Study of Ageing (TILDA) is introduced, and the comparability of TILDA data with respect to the HRS family and other studies is described, along with what TILDA will add to international aging research. Data from the 2010 waves of TILDA, HRS and the English Longitudinal Study of Ageing are used to compare the physical and cognitive health of older Irish adults with that of the U.S. and English populations. The study shows that the physical and cognitive health of older people in Ireland is closer to that of their English counterparts than of those in the United States and that similar health inequalities exist in all three countries. [ABSTRACT FROM AUTHOR]

Objectives To examine receipt of mammography screening according to life expectancy in women aged 75 and older. Design Population-based survey. Setting United States. Participants Community dwelling U.S. women aged 75 and older who participated in the 2008 or 2010 National Health Interview Survey. Measurements Using a previously developed and validated index, women were categorized according to life expectancy (>9, 5-9, <5 years). Receipt of mammography screening in the past 2 years was examined according to life expectancy, adjusting for sociodemographic characteristics, access to care, preventive orientation (e.g., receipt of influenza vaccination), and receipt of a clinician recommendation for screening. Results Of 2,266 respondents, 27.1% had a life expectancy of greater than 9 years, 53.4% had a life expectancy of 5 to 9 years, and 19.5% had a life expectancy of less than 5 years. Overall, 55.7% reported receiving mammography screening in the past 2 years. Life expectancy was strongly associated with receipt of screening ( P < .001), yet 36.1% of women with less than 5 years life expectancy were screened, and 29.2% of women with more than 9 years life expectancy were not screened. A clinician recommendation for screening was the strongest predictor of screening independent of life expectancy. Higher educational attainment, age, receipt of influenza vaccination, and history of benign breast biopsy were also independently associated with being screened. Conclusion Despite uncertainty of benefit, many women aged 75 and older are screened with mammography. Life expectancy is strongly associated with receipt of screening, which may reflect clinicians and patients appropriately considering life expectancy in screening decisions, but 36% of women with short life expectancies are still screened, suggesting that new interventions are needed to further improve targeting of screening according to life expectancy. Decision aids and guidelines encouraging clinicians to consider patient life expectancy in screening decisions may improve care. [ABSTRACT FROM AUTHOR]

Objectives To examine the association between body size and composition and erectile dysfunction ( ED) in older men. Design Cross-sectional analysis of the Osteoporotic Fractures in Men study. Setting Six U.S. clinical sites. Participants Community-dwelling men aged 65 and older. Measurements Body composition measures using anthropometry (body weight, body mass index ( BMI)) and dual X-ray absorptiometry (total body fat percentage, trunk fat percentage, ratio of trunk and total body fat). ED was assessed using the single-item Massachusetts Male Aging Study ( MMAS) scale and the five-item International Index of Erectile Function questionnaire ( IIEF-5). Results In men completing the MMAS scale (n = 4,108), prevalence of complete ED was 42%. In sexually active men completing the IIEF-5 questionnaire (n = 1,659), prevalence of moderate to severe ED was 56%. In multivariate-adjusted analyses reporting prevalence ratios ( PRs) and 95% confidence intervals ( CIs), the prevalence of MMAS-defined complete ED was significantly greater in men in the highest quartile of body weight ( PR = 1.24, 95% CI = 1.16-1.34), total body fat percentage ( PR = 1.25, 95% CI = 1.13-1.40), and trunk fat percentage ( PR = 1.24, 95% CI = 1.15-1.38), and was greater in men with a BMI greater than 30.0 kg/m2 than in those with BMI of 22.0 to 24.9 kg/m2 ( PR = 1.17, 95% CI = 1.05-1.31). Associations appeared similar for IIEF-5-defined moderate to severe ED in analyses adjusted for age and study site. Conclusion In a cohort of older men, high body weight, BMI, and total body fat percentage were independently associated with greater prevalence of moderate to severe and complete ED. Future studies should investigate whether interventions to promote weight loss and fat loss will improve erectile function in older men. [ABSTRACT FROM AUTHOR]

Objectives To determine whether community-dwelling individuals and nursing home ( NH) residents treated by a geriatrician were less likely to use the emergency department ( ED) than individuals treated by other physicians. Design Retrospective cohort study using data from a national sample of older adults with a history of cardiovascular disease. Setting Ambulatory care or NH. Participants Fee-for-service Medicare beneficiaries aged 66 and older diagnosed with one or more geriatric conditions from 2004 to 2007 and followed for up to 3 years. Measurements Emergency department use was measured in Medicare inpatient and outpatient claims; geriatric care was measured as geriatrician visits in ambulatory or NH settings coded in physician claims. Results Multivariable analyses controlled for observed and unobserved subject characteristics that were constant during the study period. For community-dwelling participants, one or more nonhospital geriatrician visits in a 6-month period were associated with 11.3% lower ED use the following month (95% confidence interval ( CI) = 7.5-15.0, N = 287,259). Participants who received primary care from geriatricians were less likely to have ED use than those who had traditional primary care. Results for participants who received consultative care from geriatricians were similar to those for participants who received primary care from geriatricians. Results for NH residents (N = 66,551) were similar to those for community-dwelling participants. Conclusion Geriatric care was associated with an estimated 108 fewer ED visits per 1,000 community-dwelling residents and 133 fewer ED visits per 1,000 NH residents per year. Geriatric consultative care in collaboration with primary care providers may be as effective in reducing ED use as geriatric primary care. Increased provision of collaborative care could allow the existing supply of geriatricians to reach a larger number of individuals. [ABSTRACT FROM AUTHOR]

Objectives To determine patterns of co-occurring diseases in older adults and the extent to which these patterns vary between the young-old and the old-old. Design Observational study. Setting Department of Veterans Affairs. Participants Veterans aged 65 years and older (1.9 million male, mean age 76 ± 7; 39,000 female, mean age 77 ± 8) with two or more visits to Department of Veterans Affairs ( VA) or Medicare settings in 2007 and 2008. Measurements The presence of 23 common conditions was assessed using hospital discharge diagnoses and outpatient encounter diagnoses from the VA and Medicare. Results The mean number of chronic conditions (out of 23 possible) was 5.5 ± 2.6 for men and 5.1 ± 2.6 for women. The prevalence of most conditions increased with advancing age, although diabetes mellitus and hyperlipidemia were 11% to 13% less prevalent in men and women aged 85 and older than in those aged 65 to 74 ( P < .001 for each). In men, the most common three-way combination of conditions was hypertension, hyperlipidemia, and coronary heart disease, which together were present in 37% of men. For women, the most common combination was hypertension, hyperlipidemia, and arthritis, which co-occurred in 25% of women. Reflecting their high population prevalence, hypertension and hyperlipidemia were both present in 9 of the 15 most common three-way disease combinations in men and in 11 of the 15 most common combinations in women. The prevalence of many disease combinations varied substantially between young-old and old-old adults. Conclusions Specific combinations of diseases are highly prevalent in older adults and inform the development of guidelines that account for the simultaneous presence of multiple chronic conditions. [ABSTRACT FROM AUTHOR]

Objectives To determine the extent to which the co-occurrence of chronic obstructive pulmonary disease ( COPD) and cognitive impairment affect adverse health outcomes in older adults. Design Multicenter longitudinal cohort study. Setting California, Pennsylvania, Maryland, and North Carolina. Participants Three thousand ninety-three community-dwelling adults aged 65 and older from the Cardiovascular Health Study. Four hundred thirty-one had chronic obstructive pulmonary disease ( COPD) at study baseline. Measurements Follow-up began at the second CHS visit and continued for 3 years. Spirometric criteria for airflow limitation served to establish COPD using the Lambda- Mu- Sigma method, which accounts for age-related changes in lung function. Cognitive impairment was evaluated using the modified Mini- Mental State Examination and claims data. Outcomes were respiratory-related and all-cause hospitalizations and death. Results Participants with coexisting COPD and cognitive impairment had the highest rates of respiratory-related (adjusted hazard ratio (a HR) = 4.10, 95% confidence interval ( CI) = 1.86-9.05) and all-cause hospitalizations (a HR = 1.34, 95% CI = 1.00-1.80) and death (a HR = 2.29, 95% CI = 1.18-4.45). In particular, individuals with both conditions had a 48% higher rate of all-cause hospitalizations (adjusted synergy index (a SI) = 1.48, 95% CI = 0.19-11.31) and a rate of death nearly three times as high ( aSI = 2.74, 95% CI = 0.43-17.32) as the sum of risks for each respective outcome associated with having COPD or cognitive impairment alone. Nevertheless, tests for interaction were not statistically significant for the presence of synergism between the two conditions contributing to each of the outcomes. Therefore, it cannot be concluded that the combined effect of COPD and cognitive impairment is greater than additive. Conclusion Coexisting COPD and cognitive impairment have an additive effect on respiratory-related and all-cause hospitalizations and death. Optimizing outcomes in older adults with COPD and cognitive impairment will require that how to improve concurrent management of both conditions be determined. [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 determine functional status and mortality rates after colon cancer surgery in older nursing home residents. Design Retrospective cohort study. Setting Nursing homes in the United States. Participants Six thousand eight hundred twenty-two nursing home residents aged 65 and older who underwent surgery for colon cancer in the United States between 1999 and 2005. Measurements Changes in functional status were assessed before and after surgery using the Minimum Data Set Activity of Daily Living ( MDS- ADL) summary scale, a 28-point scale in which score increases as functional dependence increases. Regression techniques were used to identify patient characteristics associated with mortality and functional decline 1 year after surgery. Results On average, residents who underwent colectomy had a 3.9-point worsening in MDS- ADL score at 1 year. One year after surgery, rates of mortality and sustained functional decline were 53% and 24%, respectively. In multivariate analysis, older age (≥80 vs 65-69, adjusted relative risk ( ARR) = 1.53, 95% confidence interval ( CI) = 1.15-2.04, P < .001), readmission after surgical hospitalization ( ARR = 1.15, 95% CI = 1.03-1.29, P = .02), surgical complications ( ARR = 1.11, 95% CI = 1.02-1.21, P = .01), and functional decline before surgery ( ARR = 1.21, 95% CI = 1.11-1.32, P < .001) were associated with functional decline at 1 year. Conclusion Mortality and sustained functional decline are common after colon cancer surgery in nursing home residents. Initiatives aimed at improving surgical outcomes are needed in this vulnerable population. [ABSTRACT FROM AUTHOR]

Objectives To determine whether insufficient help for activity of daily living ( ADL) disability, a potentially modifiable condition, significantly increases disabled older adults' risk of future hospital admissions. Design Prospective study. Setting Community-living participants with ADL disabilities in the 1994, 1999, and 2004 National Long- Term Care Survey ( NLTCS). Participants Medicare recipients with one or more ADL disabilities completed 5,884 surveys. Measurements Times to hospital admission in the year after the NLTCS community survey were obtained from linked Medicare claims. Insufficient ADL help for each ADL limitation was determined from a series of questions common to the three NLTCS community surveys. Results Insufficient help for one or more ADL limitations was reported in 22% of surveys. Respondents to 3,629 surveys did not experience a hospital admission in the year after the survey. Of the remaining 2,255 surveys, one admission occurred for 382 surveys, two admissions for 525 surveys, three admissions for 193 surveys, and four or more admissions for 155 surveys. Participants reporting insufficient help were 14% (hazard ratio = 1.14, 95% confidence interval = 1.01-1.28) more likely to experience one or more hospitalizations than those who did not report insufficient help after controlling for demographic characteristics, comorbidities, prior hospitalizations, and level of ADL disability. Conclusion Self-reports of insufficient help provide prognostic information beyond what typical health assessments can capture. Greater recognition and referral for insufficient help for ADL disability may result in lower rates of hospitalization in a population that is at high risk of hospitalization. [ABSTRACT FROM AUTHOR]

Objectives To investigate patterns in prevalences of chronic medical conditions over the age span of long-term stay nursing home residents and between the sexes with data from the 2004 National Nursing Home Survey ( NNHS). Design Retrospective, cross-sectional study. Setting U.S. nursing homes. Participants Nationally representative sample comprising 11,788 long-term stay residents (3,003 (25%) men, 8,785 (75%) women) aged 65 and older. Measurements Clinical Classifications Software was used to group International Classification of Diseases, Ninth Revision, codes to identify the 20 most-prevalent chronic medical conditions. SAS survey procedures were used to account for design effects of stratification and clustering to generate nationally representative estimates of prevalences of medical conditions. Results Average age was 84, with women older than men (85 vs 81, P = .02) and 67% of women aged 80 to 95. Women required more assistance with activities of daily living. The most frequent chronic medical conditions were hypertension (men 53%, women 56%), dementia (men 45%, women 52%), depression (men 31%, women 37%), arthritis (men 26%, women 35%), diabetes mellitus (men 26%, women 23%), gastroesophageal reflux disease ( GERD) (men 23%, women 23%), atherosclerosis (men 24%, women 20%), congestive heart failure ( CHF) (men 18%, women 21%), cerebrovascular disease ( CVD) (men 24%, women 19%), and anemia (men 17%, women 20%). Sex differences in prevalences existed for all but constipation, GERD, and hypertension. Diabetes mellitus, CVD, and lipid disorders decreased with age in men and women. Atrial fibrillation, anemia, arthritis, CHF, dementia, and thyroid disease increased with age in men and women. Age-related patterns differed between the sexes for diabetes mellitus, hypertension, and Parkinson's disease. Conclusion The profile of chronic medical conditions varies over the age span of nursing home residents and differs between men and women. This knowledge should guide educational and care efforts in long-term care. [ABSTRACT FROM AUTHOR]

Objectives To determine perceived quality of life in a diverse population of elderly adults with late-life disability. Design Qualitative cross-sectional study. Setting Community-dwelling participants were recruited from San Francisco's On Lok Lifeways program, the first Program of All-inclusive Care for the Elderly. On Lok enrollees meet Medicaid criteria for nursing home placement. Participants Sixty-two elderly adults with a mean age of 78 and a mean 2.4 activity of daily living dependencies and 6.6 instrumental activity of daily living dependencies were interviewed. Respondents were 63% female, 24% white, 19% black, 18% Latino, 32% Chinese American, and 6% other race. Measurements Elderly adults who scored higher than 17 points on the Mini-Mental State Examination were interviewed. Interviews were conducted in English, Spanish, and Cantonese. Respondents were asked to rate their overall quality of life on a 5-point scale. Open-ended questions explored positive and negative aspects of participants' daily experiences. Interviews were analyzed using modified grounded theory and digital coding software. Results Eighty-seven percent of respondents rated their quality of life in the middle range of the quality-of-life spectrum (fair to very good). Themes were similar across ethnic groups. Most themes could be grouped into four domains that dependent elderly adults considered important to their quality of life: physical (e.g., pain), psychological (e.g., depression), spiritual or religious (e.g., religious coping), and social (e.g., life-space). Dignity and a sense of control were identified as themes that are the most closely tied to overall quality of life. Conclusion Factors that influence quality of life in late-life disability were similar across ethnic groups. As the number of elderly adults from diverse backgrounds with late life disability increases in the United States, interventions should be targeted to maximize daily sense of control and dignity. [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 examine the association between sleep architecture, sleep-disordered breathing, and cognition in older men. Design Population-based cross-sectional study. Setting Six clinical sites in the United States. Participants Two thousand nine hundred nine community-dwelling men aged 67 and older who were not selected on the basis of sleep problems or cognitive impairment. Measurements Predictors were measured using in-home polysomnography: sleep architecture, nocturnal hypoxemia (any sleep time with arterial oxygen saturation <80%), apnea-hypopnea index ( AHI), and arousal index. Cognitive outcomes were measured using the modified Mini-Mental State Examination (3 MS), Trail-Making Test Part B ( TMT-B), and the Digit Vigilance Test ( DVT). Results Analyses adjusted for age, race, education, body mass index, lifestyle, comorbidities, and medication use showed that participants who spent less percentage of time in rapid eye movement ( REM) sleep had lower levels of cognition; participants in the lowest quartile (<14.8%) took an average of 5.9 seconds longer on the TMT-B and 20.1 seconds longer on the DVT than those in the highest quartile (≥23.7%). Similarly, greater percentage of time spent in Stage 1 sleep was related to poorer cognitive function. Participants in the highest quartile of Stage 1 sleep (≥8.6%) had worse cognitive scores on average than those in the lowest quartile (<4.0%). Those with nocturnal hypoxemia took an average of 22.3 seconds longer to complete the DVT than those without, but no associations were found with 3 MS or the TMT-B. Conclusion Spending less percentage of time in REM sleep and greater percentage of time in Stage 1 sleep and having higher levels of nocturnal hypoxemia were associated with poorer cognition in older men. Further studies are needed to clarify the direction of these associations and to explore potential mechanisms. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To evaluate the literature regarding the effect of Medicare Part D on the under- and overuse of specific medications and corresponding health outcomes. DESIGN: Systematic review. SETTING: Medline search of the peer-reviewed literature from January 1, 2006, to October 8, 2010. PARTICIPANTS: Medicare beneficiaries who obtained drug insurance from the Part D program. MEASUREMENTS: The review evaluated changes in the use of specific drugs or drug classes after implementation of Part D, as described in original, peer-reviewed articles. RESULTS: Nineteen articles met inclusion criteria. Part D's implementation was associated with greater use of essential medications such as clopidogrel and statins, especially in beneficiaries who had been previously uninsured, but increases in inappropriate antibiotic use for the treatment of acute respiratory tract infections and increases in claims for the often overused proton pump inhibitor drug class were also observed. In the Part D transition period, dually eligible beneficiaries' drug use remained largely unchanged. When beneficiary cost sharing increased in the coverage gap, use of essential and overused medications declined. CONCLUSION: Increasing drug coverage led to greater use of underused essential medications and inappropriate, or overused, medications under Medicare Part D. Despite efforts to have it do so, the Part D benefit did not sufficiently discriminate between essential and nonessential medication use. [ABSTRACT FROM AUTHOR]

Objectives To explore strategies used by clinical programs to justify operations to decision-makers using the example of the Hospital Elder Life Program ( HELP), an evidence-based, cost-effective program to improve care for hospitalized older adults. Design Qualitative study design using 62 in-depth, semistructured interviews conducted with HELP staff members and hospital administrators between September 2008 and August 2009. Setting Nineteen HELP sites in hospitals across the United States and Canada that had been recruiting patients for at least 6 months. Participants HELP staff and hospital administrators. Measurements Participant experiences sustaining the program in the face of actual or perceived financial threats, with a focus on factors they believe are effective in justifying the program to decision-makers in the hospital or health system. Results Using the constant comparative method, a standard qualitative analysis technique, three major themes were identified across interviews. Each focuses on a strategy for successfully justifying the program and securing funds for continued operations: interact meaningfully with decision-makers, including formal presentations that showcase operational successes and informal means that highlight the benefits of HELP to the hospital or health system; document day-to-day, operational successes in metrics that resonate with decision-maker priorities; and garner support from influential hospital staff that feed into administrative decision-making, particularly nurses and physicians. Conclusion As clinical programs face financially challenging times, it is important to find effective ways to justify their operations to decision-makers. Strategies described here may help clinically effective and cost-effective programs sustain themselves and thus may help improve care in their institutions. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To identify prevalence and risk factors for exposure to drug-disease interactions included in the Healthcare Effectiveness Data and Information Set (HEDIS) Drug-Disease Interaction (Rx-DIS) measure. DESIGN: Cross-sectional retrospective database analysis. SETTING: Outpatient clinics within the Department of Veterans Affairs (VA). PARTICIPANTS: Individuals aged 65 and older who received VA outpatient care between October 1, 2003, and September 30, 2006. MEASUREMENTS: Rx-DIS exposure based on the HEDIS measure was identified in VA patients with dementia, falls, and chronic renal failure using VA pharmacy and administrative databases. Factors associated with Rx-DIS exposure were examined, including demographic, health status, and access-to-care factors, including VA outpatient health services use and copayment status. RESULTS: Of the 305,041 older veterans who met criteria for inclusion, the 1-year prevalence of Rx-DIS exposure was 15.2%; prevalence was 20.2% for dementia, 16.2% for falls, and 8.5% for chronic renal failure. Patients with high disease burden (physical, psychiatric, number of medications) were significantly more likely to have Rx-DIS exposure, regardless of condition. Hispanics and individuals with no copayments were more likely to have Rx-DIS exposure than whites or those with required copayments. There was variation in other predictors based on the type of Rx-DIS. CONCLUSION: The prevalence of Rx-DIS was common in older VA outpatients. Future studies should examine the risk of Rx-DIS exposure on health outcomes using separate analyses for each type of Rx-DIS separately before combining all Rx-DIS into a single measure of exposure. Studies that examine the effectiveness of interventions to reduce Rx-DIS exposure will also be helpful in improving the quality of care for older adults. [ABSTRACT FROM AUTHOR]