Search

OBJECTIVES: To determine the effects of chronic pain on the development of disability and decline in physical performance over time in older adults. DESIGN: Longitudinal cohort study with 18 months of follow-up. SETTING: Urban and suburban communities. PARTICIPANTS: Community-dwelling older adults aged 65 and older (N = 634). MEASUREMENTS: Chronic pain assessment consisted of musculoskeletal pain locations and pain severity and pain interference according to the subscales of the Brief Pain Inventory. Disability was self-reported as any difficulty in mobility and basic and instrumental activities of daily living (ADLs, IADLs). Mobility performance was measured using the Short Physical Performance Battery (SPPB). Relationships between baseline pain and incident disability in 18 months were determined using risk ratios (RRs) from multivariable Poisson regression models. RESULTS: Almost 65% of participants reported chronic musculoskeletal pain at baseline. New onset of mobility difficulty at 18 months was strongly associated with baseline pain distribution: 7% (no sites), 18% (1 site), 24% (multisite), and 39% (widespread pain, P-value for trend < .001). Similar graded effects were found for other disability measures. Elderly adults with multisite or widespread pain had at a risk of onset of mobility difficulty at least three times as great as that of their peers without pain after adjusting for disability risk factors (multisite pain: risk ratio (RR) = 2.95, 95% confidence interval (CI) 1.58–5.50; widespread pain: RR = 3.57, 95% CI = 1.71–7.48). Widespread pain contributed to decline in mobility performance (1-point decline in SPPB, RR = 1.47, 95% CI = 1.08– 2.01). Similar associations were found for baseline pain interference predicting subsequent mobility decline and ADL and IADL disability. Weaker and less-consistent associations were observed with pain severity. CONCLUSION: Older community-dwelling adults living with chronic pain in multiple musculoskeletal locations have a substantially greater risk for developing disability over time and for clinically meaningful decline in mobility performance than those without pain. J Am Geriatr Soc 62:1007– 1016, 2014.

Hospitalized individuals with advanced dementia often receive care that is of limited clinical benefit and inconsistent with preferences. An advanced dementia consultation service was designed, and a pre and post pilot study was conducted in a Boston hospital to evaluate it. Geriatricians and a palliative care nurse practitioner conducted consultations, which consisted of structured consultation, counseling and provision of an information booklet to the family, and postdischarge follow-up with the family and primary care providers. Individuals aged 65 and older with advanced dementia who were admitted were identified, and consultations were solicited using pop-ups programmed into the computerized provider order entry (POE) system. In the initial 3-month period, 24 subjects received usual care. In the subsequent 3-month period, consultations were provided to five subjects for whom they were requested. Data were obtained from the electronic medical record and proxy interviews (admission, 1 month after discharge). Mean age of the combined sample (N = 29) was 85.4, 58.6% were from nursing homes, and 86.2% of their proxies stated that comfort was the goal of care. Nonetheless, their hospitalizations were characterized by high rates of intravenous antibiotics (86.2%), more than five venipunctures (44.8%), and radiological examinations (96.6%). Acknowledging the small sample size, there were trends toward better outcomes in the intervention group, including greater proxy knowledge of the disease, better communication between proxies and providers, more advance care planning, lower rehospitalization rates, and fewer feeding tube insertions after discharge. Targeted consultation for advanced dementia is feasible and may promote greater engagement of proxies and goal-directed care after discharge.

Objectives To examine the effect of pain and mild cognitive impairment (MCI)—together and separately—on performance-based and self-reported mobility outcomes in older adults in primary care with mild to moderate self-reported mobility limitations. Design Cross-sectional analysis. Setting Academic community outpatient clinic. Participants Individuals aged 65 and older in primary care enrolled in the Boston Rehabilitative Impairment Study in the Elderly who were at risk of mobility decline (N = 430). Measurements Participants with an average score greater than three on the Brief Pain Inventory (BPI) were defined as having pain. MCI was defined using age-adjusted scores on a neuropsychological battery. Multivariable linear regression models assessed associations between pain and MCI, together and separately, and mobility performance (habitual gait speed, Short Physical Performance Battery), and self-reports of function and disability in various day-to-day activities (Late Life Function and Disability Instrument). Results The prevalence of pain was 34% and of MCI was 42%; 17% had pain only, 25% had MCI only, 17% had pain and MCI, and 41% had neither. Participants with pain and MCI performed significantly worse than all others on all mobility outcomes (P

OBJECTIVES: To investigate the relationships between uncontrolled and controlled hypertension, orthostatic hypotension (OH), and falls in participants of the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston Study (N=722, mean age 78.1). DESIGN: Prospective population-based study. SETTING: Community. PARTICIPANTS: Seven hundred twenty-two adults aged 70 and older living within a 5-mile radius of the study headquarters at Hebrew Rehabilitation Center in Boston. MEASUREMENTS: Blood pressure (BP) was measured at baseline in the supine position and after 1 and 3 minutes of standing. Systolic OH (SOH) and diastolic OH at 1 and 3 minutes were defined as a 20-mmHg decline in systolic BP and a 10-mmHg decline in diastolic BP upon standing. Hypertension was defined as BP of 140/90 mmHg or greater or receiving antihypertensive medications (controlled if BP

OBJECTIVES: To identify characteristics of nursing home (NH) residents with advanced dementia and their healthcare proxies (HCPs) associated with hospice referral and to examine the association between hospice use and the treatment of pain and dyspnea and unmet needs during the last 7 days of life. DESIGN: Prospective cohort study. SETTING: Twenty-two Boston-area NHs. PARTICIPANTS: Three hundred twenty-three NH residents with advanced dementia and their HCPs. MEASUREMENTS: Data were collected at baseline and quarterly for up to 18 months. Hospice referral, frequency of pain and dyspnea, and treatment of these symptoms was ascertained. HCPs reported unmet needs during the last 7 days of the residents' lives for communication, information, emotional support, and help with personal care. RESULTS: Twenty-two percent of residents were referred to hospice. After multivariable adjustment, factors associated with hospice referral were nonwhite race, eating problems, HCP's perception that the resident's had less than 6 months to live, and better HCP mental health. Residents in hospice were more likely to receive scheduled opioids for pain (adjusted odds ratio (AOR)=3.16; 95% confidence interval (95% CI)=1.57�6.36) and oxygen, morphine, scopolamine, or hyoscyamine for dyspnea (AOR=3.28, 95% CI=1.37�7.86). HCPs of residents in hospice reported fewer unmet needs in all domains during the last 7 days of the residents' life. CONCLUSION: A minority of NH residents with advanced dementia received hospice care. Hospice recipients were more likely to received scheduled opioids for pain and symptomatic treatment for dyspnea and had fewer unmet needs at the end of life.

OBJECTIVES: From among physiological attributes commonly targeted in rehabilitation, to identify those in which changes led to clinically meaningful differences (CMDs) in mobility outcomes. DESIGN: Secondary analysis of data collected for a randomized controlled trial of exercise using binary outcomes defined by recording a large CMD (Short Physical Performance Battery (SPPB)=1 unit; gait speed (GS)=0.1 m/s). Iterative models were performed to evaluate possible confounding between physiological variables and relevant covariates. SETTING: Outpatient rehabilitation centers. PARTICIPANTS: Community-dwelling mobility-limited older adults (n=116) participating in a 16-week randomized controlled trial of two modes of exercise. MEASUREMENTS: Physiological measures included leg power, leg strength, balance as measured according to the Performance-Oriented Mobility Assessment (POMA), and rate pressure product at the maximal stage of an exercise tolerance test. Outcomes included GS and SPPB. Leg power and leg strength were measured using computerized pneumatic strength training equipment and recorded in Watts and Newtons, respectively. RESULTS: Participants were 68% female, had a mean age of 75.2, a mean of 5.5 chronic conditions, and a baseline mean SPPB score of 8.7. After controlling for age, site, group assignment, and baseline outcome values, leg power was the only attribute in which changes were significantly associated with a large CMD in SPPB (odds ratio (OR)=1.48, 95% confidence interval (CI)=1.09�2.02) and GS (OR=1.31, 95% CI=1.01�1.70). CONCLUSION: Improvements in leg power, independent of strength, appear to make an important contribution to clinically meaningful improvements in SPPB and GS.

OBJECTIVES: To determine whether a delirium abatement program (DAP) can shorten duration of delirium in new admissions to postacute care (PAC). DESIGN: Cluster randomized controlled trial. SETTING: Eight skilled nursing facilities specializing in PAC within a single metropolitan region. PARTICIPANTS: Four hundred fifty-seven participants with delirium at PAC admission. INTERVENTION: The DAP consisted of four steps: assessment for delirium within 5 days of PAC admission, assessment and correction of common reversible causes of delirium, prevention of complications of delirium, and restoration of function. MEASUREMENTS: Trained researchers screened eligible patients. Those with delirium defined according to the Confusion Assessment Method were eligible for participation using proxy consent. Regardless of location, researchers blind to intervention status re-assessed participants for delirium 2 weeks and 1 month after enrollment. RESULTS: Nurses at DAP sites detected delirium in 41% of participants, versus 12% in usual care sites (P

Objectives Many medications commonly used to treat chronic conditions have unclear benefits for nursing home (NH) residents with advanced dementia. This study describes the pattern and factors associated with daily medication use in this population.

Frailty has become a particularly important geriatric topic since a 1990 American Medical Association report emphasized the growing population of vulnerable older adults. 1 This vulnerable population has been identified as older adults with an intrinsic vulnerability to stressors and increased risk for decline and adverse health-related characteristics such as disability and comorbidity, and has been described as frail. For reasons related to difficulties distinguishing these entities, and because many factors have been reported to be associated with frailty in older adults, there is no single consensus definition of frailty despite numerous definitions proposed by researchers. There is general agreement in the literature that frailty is a biologic syndrome of decreased reserve and resistance to stressors resulting from cumulative declines across multiple physiologic systems that cause vulnerability to adverse outcomes. 2 In an attempt to solidify the concept of frailty and operationalize its definition, Fried et al. 2 proposed a phenotype of frailty involving at least 3 of the following 5 components: unintentional weight loss, self-reported reduced energy level, reduced grip strength, slow walking speed, and a low level of physical energy. Using a frailty index based on this phenotype, Fried et al. and other researchers 2-8 have reported its association with falls, hospitalization, disability, and death. This index has been useful in identifying frail older adults, though its use is impractical in the clinical setting. Assessing strength, walking speed, and physical activity (3 components of this index) not only depends on gender and body mass but also requires knowledge of the underlying distribution of the measure in a given population. Moreover, assessing some of these components may not be feasible. For example, physical activity assessments and timed walks are often impractical to evaluate in a clinic due to schedule and space constraints. 6 Recently, Ensrud et al. 6 proposed a simpler frailty index, requiring at least 2 of 3 components (weight loss, the inability to rise from a chair 5 times without the use of arms, and self-reported reduced energy level). This index might be more suitable for assessing frailty in a busy clinical practice setting. Based on a prospective cohort study (N=6701) designed to examine osteoporosis and fractures in older women, Ensrud et al. 6 compared their frailty index to the Fried et al. frailty index on outcomes such as falls, recurrent falls, disability, fractures and death. Both indexes were strongly associated with these outcomes and their effect measures (i.e., hazard ratios and odds ratios) were very similar. Ensrud et al. concluded that their simpler index had very similar predictive properties compared to the Fried et al. frailty index, provided a useful definition of frailty, and could be used to identify older women at risk of adverse health outcomes in clinical practice setting. However, one important shortcoming of this study was its limited generalizability, as it did not include men or African-American women. The objective of this study was to validate and compare these two indexes using an independent diverse sample of men and women (including African-Americans). We examined the indexes' ability to predict recurrent falls, overnight hospitalizations, emergency room visits, and their association with disability, chronic medical conditions, self-reported health, physical function, cognitive function (including executive function) and depression. To our knowledge, this is the first validation and comparison of these two indexes using an independent data source that includes men and African-American women. It is also the first to examine executive function measures across frailty levels.

OBJECTIVES: To determine the prevalence and associated characteristics of traumatic intracranial hemorrhage (ICH) in elderly fallers presenting to the emergency department (ED) without focal findings. DESIGN: Retrospective cohort study. SETTING: University-affiliated teaching hospital ED. PARTICIPANTS: Patients aged 65 and older presenting with a fall to the ED and undergoing a head computed tomography (CT) scan. MEASUREMENTS: Electronic medical records and CT scans of 404 consecutive patients were reviewed. Characteristics of patients with and without ICH were compared using unadjusted analyses. Patients taking warfarin, aspirin, or clopidogrel alone or in combination were compared with those not taking these medications. Multivariate logistic regression analyses were performed to determine variables independently associated with ICH. RESULTS: Forty-seven of 404 elderly fallers (11.6%) without focal findings had an ICH. Unadjusted analyses in these pilot data showed that warfarin was not significantly associated with ICH. Multivariate analyses indicated that elderly people living in at home were more likely to have ICH than those living in nursing homes or assisted living facilities (odds ratio (OR)=3.2, 95% confidence interval (CI)=1.30-8.13) and that those with head trauma were more likely to have ICH than those without (OR=3.9, 95% CI=1.25-7.80). Aspirin was found to be protective (OR=0.49, 95% CI=0.24-0.98). CONCLUSION: ICH is common in elderly fallers presenting to the ED without focal findings. Anticoagulation alone did not appear to increase the risk of ICH, and aspirin was found to be protective, but prospective studies are needed to better assess this relationship. Language: en

OBJECTIVES: To describe the medical decisions confronting healthcare proxies (HCPs) of nursing home (NH) residents with advanced dementia and to identify factors associated with greater decision-making satisfaction. DESIGN: Prospective cohort study. SETTING: Twenty-two Boston-area NHs. PARTICIPANTS: Three hundred twenty-three NH residents with advanced dementia and their HCPs. MEASUREMENTS: Decisions made by HCPs over 18 months were ascertained quarterly. After making a decision, HCPs completed the Decision Satisfaction Inventory (DSI) (range 0–100). Independent variables included HCP and resident sociodemographic characteristics, health status, and advance care planning. Multivariable linear regression identified factors associated with higher DSI scores (greater satisfaction). RESULTS: Of 323 HCPs, 123 (38.1%) recalled making at least one medical decision; 232 decisions were made, concerning feeding problems (27.2%), infections (20.7%), pain (12.9%), dyspnea (8.2%), behavior problems (6.9%), hospitalizations (3.9%), cancer (3.0%), and other complications (17.2%). Mean DSI score±standard deviation was 78.4±19.5, indicating high overall satisfaction. NH provider involvement in shared decision-making was the area of least satisfaction. In adjusted analysis, greater decision-making satisfaction was associated with the resident living on a special care dementia unit (P=.002), greater resident comfort (P=.004), and the HCP not being the resident's child (P=.02). CONCLUSION: HCPs of NH patients with advanced dementia can most commonly expect to encounter medical decisions relating to feeding problems, infections, and pain. Inadequate support from NH providers is the greatest source of HCP dissatisfaction with decision-making. Greater resident comfort and care in a special care dementia unit are potentially modifiable factors associated with greater decision-making satisfaction.

OBJECTIVES To examine the association between persistent delirium and one-year mortality in newly admitted delirious post-acute care (PAC) facility patients, who were followed regardless of residence.

OBJECTIVES: To examine the mediating role between educational attainment and risk for incidence delirium of activity participation and to examine the contribution of participation in specific activities to the development of delirium. DESIGN: Prospective cohort study. SETTING: Urban teaching hospital in New Haven, Connecticut. PARTICIPANTS: Participants were drawn from two prospective cohort studies of 779 newly hospitalized patients aged 70 and older without dementia. MEASUREMENTS: The main outcome was delirium, measured using the full Confusion Assessment Method (CAM) algorithm, which consisted of acute onset and fluctuating course, inattention, and disorganized thinking or altered level of consciousness, as rated by trained clinical interviewers. RESULTS: Bivariable results indicated a significant relationship between education and the development of delirium (odds ratio (OR)=0.92, 95% confidence interval (CI)=0.88–0.97) and between activity and delirium (OR= 0.60, 95% CI=0.46–0.79). In multivariable analysis, activity mediated the relationship between education and risk for delirium. Considering each activity separately, multivariable logistic regression analysis showed that regular exercise significantly lowered the risk for developing delirium (OR=0.76, 95% CI=0.60–0.96). CONCLUSION: In older persons without dementia, activity participation before hospitalization is a mediator between education and incidence of delirium. Specifically, it was found that participation in regular exercise was found to be significantly protective against delirium.