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Background: To assess whether vitamin D 3 supplementation attenuates the decline in daily physical activity in low-functioning adults at risk for falls., Methods: Secondary data analyses of STURDY (Study to Understand Fall Reduction and Vitamin D in You), a response-adaptive randomized clinical trial. Participants included 571 adults aged 70 years and older with baseline serum 25(OH)D levels of 10-29 ng/mL and elevated fall risk, who wore a wrist accelerometer at baseline and at least one follow-up visit and were randomized to receive: 200 IU/day (control), 1000, 2000, or 4000 IU/day of vitamin D 3 . Objective physical activity quantities and patterns (total daily activity counts, active minutes/day, and activity fragmentation) were measured for 7-days, 24-h/day, in the free-living environment using the Actigraph GT9x over up to 24-months of follow-up., Results: In adjusted models, physical activity quantities declined (p < 0.001) and became more fragmented, or "broken up", (p = 0.017) over time. Supplementation with vitamin D 3 did not attenuate this decline. Changes in physical activity were more rapid among those with baseline serum 25(OH)D <20 ng/mL compared to those with baseline 25(OH)D levels of 20-29 ng/mL (time*baseline 25(OH)D, p < 0.05)., Conclusion: In low-functioning older adults with serum 25(OH)D levels 10-29 ng/mL, vitamin D 3 supplementation of 1000 IU/day or higher did not attenuate declines in physical activity compared with 200 IU/day. Those with baseline 25(OH)D <20 ng/mL showed accelerated declines in physical activity. Alternative interventions to supplementation are needed to curb declines in physical activity in older adults with low serum 25(OH)D., (© 2023 The American Geriatrics Society.)

Background: Social isolation can influence whether older adults develop dementia. We examine the association between social isolation and incident dementia among older adults in a nationally representative sample of community dwelling older adults in the United States (U.S.). We also investigate whether this association varies by race and ethnicity., Methods: Data (N = 5022) come from the National Health and Aging Trends Study, a longitudinal and nationally representative cohort of older adults in the U.S. A composite measure of social isolation was used to classify older adults as socially isolated or not socially isolated at baseline. Demographic and health factors were measured at baseline via self-report. Dementia was measured at each round of data collection. Discrete-time proportional hazard time-to-event models were used to assess the association between social isolation and incident dementia over 9 years (2011-2020)., Results: Of 5022 older adults, 1172 (23.3%) were socially isolated, and 3850 (76.7%) were not socially isolated. Adjusting for demographic and health factors, being socially isolated (vs. not socially isolated) was associated with a 1.28 (95% CI: 1.10-1.49) higher hazard of incident dementia over 9 years. There was no statistically significant difference by race and ethnicity., Conclusion: Social isolation among older adults is associated with greater dementia risk. Elucidating the pathway by which social isolation impacts dementia may offer meaningful insights for the development of novel solutions to prevent or ameliorate dementia across diverse racial and ethnic groups., (© 2023 The American Geriatrics Society.)

Background: The quality of communication (QOC) questionnaire has been widely used to assess foundational aspects of patient-clinician communication about end-of-life (EOL) care. However, this instrument has never before been fielded with primary care patients who have cognitive impairment and their caregivers, a population with unique communication needs., Design: We report on baseline data from a completed pilot study and ongoing efficacy trial of advance care planning involving dyads of primary care patients ages 80 and older with cognitive impairment and their family care partners. Two QOC subscales assessed ratings of general communication and EOL care communication from 0 ("worst") to 10 ("best"). Due to challenges piloting the EOL subscale, we integrated skip logic to improve cognitive accessibility and measurement precision. Participants were first asked whether EOL communication occurred (yes/no); those responding affirmatively were subsequently asked to rate communication. We report experiences with EOL subscale adaptations from our ongoing trial (NCT04593472)., Results: Using the original instrument in our pilot (13 dyads), mean patient and family general communication ratings were similar (9.65 and 9.60, respectively), but EOL ratings diverged (4.23 and 5.88, respectively), and "Don't Know" comprised 5% of patient and 32% of family responses. Interviewers reported patient and family participants expressed confusion when asked to rate EOL communication behaviors that had not occurred. Using the adapted instrument in our efficacy trial (43 dyads), EOL communication behaviors were most often reported as not having occurred (76% of patient and 73% of family responses across all items). Mean patient and family EOL subscale ratings were similar (2.23 and 2.26) and responses of "Don't Know" were minimal (<1%)., Conclusion: The original QOC EOL subscale involves rating conversations that rarely occur in primary care but are important for older adults with cognitive impairment. Subscale adaptations may reduce confusion and response uncertainty and improve measurement accuracy., (© 2022 The American Geriatrics Society.)

Background: Although nonpharmacological approaches are considered first-line treatments for dementia-related behaviors, it is unclear as to their effectiveness for different racial groups. We evaluated the effects of the Tailored Activity Program (TAP) on agitated and aggressive behaviors in Black and White families., Methods: We conducted a single-blind, two-arm randomized controlled trial involving Black (N = 90) and White (N = 145) families. TAP involved eight home sessions by occupational therapists who provided activities tailored to abilities and interests and instructed caregivers in their use over 3 months. An attention control group received eight sessions by research assistants who provided disease education and home safety tips. Measures included caregiver ratings of frequency by severity for the agitation and aggression subscales of the Neuropsychiatric Inventory-Clinician (NPI-C) at 3 months (main trial primary outcome), number of completed sessions and time spent, changes in behavioral subcomponents of the subscales (frequency, severity, caregiver distress), and percent improving/worsening., Results: Black and White families completed similar numbers of treatment sessions, but White dyads averaged nearly two contact hours more than Black dyads (p = 0.008). At 3 months, an interaction effect (treatment by race) indicated significantly greater reductions in frequency by severity scores for the agitation and aggression subscales for Black TAP dyads versus White TAP dyads and White and Black attention control dyads. Also, significant interaction effects favoring TAP Black dyads were observed for select behavioral components. For TAP dyads with elevated baseline agitation/aggression levels (N = 71), 34.5% of Black versus 11.9% of White dyads improved; whereas 2.6% of Black versus 16.7% of White dyads had worsened agitation/aggression scores., Conclusion: Black families compared to White families derived greater behavioral benefits from TAP for PLWD at 3 months despite having less treatment exposure. Examining differential race effects may enhance precision in using nonpharmacological approaches and promote equity in dementia care for underserved populations., (© 2022 The American Geriatrics Society.)

Background: Care at the end of life is commonly fragmented; however, little is known about commonly used measures of fragmentation of care in the last year of life (LYOL). We sought to understand differences in fragmentation of care by dementia status among seriously ill older adults in the LYOL., Methods: We analyzed data from adults ≥65 years in the National Health and Aging Trends Study who died and had linked 2011-2017 Medicare fee-for-service claims for ≥12 months before death. We categorized older adults as having serious illness due to dementia (hereafter dementia), non-dementia serious illness or no serious illness. For outpatient fragmentation, we calculated the Bice-Boxerman continuity of care index (COC), which measures care concentration, and the known provider of care index (KPC), which measures the proportion of clinicians who were previously seen. For acute care fragmentation, we divided the number of hospitals and emergency departments visited by the total number of visits. We built separate multivariable quantile regression models for each measure of fragmentation., Results: Of 1793 older adults, 42% had dementia, 53% non-dementia serious illness and 5% neither. Older adults with dementia had fewer hospitalizations than older adults with non-dementia serious illness but more than older adults without serious illness (mean 1.9 vs 2.3 vs 1, p = 0.002). In adjusted models, compared to older adults with non-dementia serious illness, those with dementia had significantly less fragmented care across all quantiles of COC (range 0.016-0.110) but a lower predicted 90th percentile of KPC, meaning more older adults with dementia had extremely fragmented care on the KPC measure. There was no significant difference in acute care fragmentation., Conclusions: In the LYOL, older adults with dementia have fewer healthcare encounters and less fragmentation of care by the COC index than older adults with non-dementia serious illness., (© 2022 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Background: Social isolation is a risk factor for morbidity and mortality comparable to well-established risk factors including smoking, hypertension, and a sedentary lifestyle. The specific biological mechanisms that connect social isolation to morbidity and mortality remain unclear. Interleukin-6 (IL-6) and C-reactive protein (CRP) are biological markers that are upregulated during inflammation and can have long-term negative consequences for the health of individuals as they age., Methods: Utilizing Round 7 (2017) data from the National Health and Aging Trends Study (NHATS), we examine the relationship between social isolation and two biological markers: IL-6 and high-sensitivity CRP. This study included a nationally representative sample of 4648 Medicare beneficiaries 65 years and older who provided samples using dried blood spot (DBS) techniques. We defined social isolation utilizing a multi-domained typology that considers living arrangement, core discussion network, religious attendance, and social participation. IL-6 and CRP were obtained via DBS that were collected in Round 7 of the NHATS. We performed linear regression to examine the association between social isolation and biological markers IL-6 and CRP., Results: After adjusting for age, gender, race/ethnicity, income, tobacco use, body mass index, and chronic conditions, we found that severe social isolation and social isolation were significantly associated with higher levels of IL-6 and CRP values among older adults., Conclusions: Social isolation is associated with higher levels of biological markers (IL-6 and CRP). Our findings inform the pathway between social isolation and morbidity and mortality among older adults. IL-6 or CRP could be a proximal outcome measures for future clinical and social interventions that seek to alter the trajectory of social isolation and its associated health outcomes., (© 2021 The American Geriatrics Society.)

Background: Effective communication between skilled home healthcare (SHHC) clinicians and physicians is critical to care coordination. No studies have examined this from the point of view of SHHC clinicians at the national level. The objective is to determine in national sample issues related to how SHHC agency clinicians communicate with physicians., Design: Mailed survey., Methods: Mailed survey to a national representative random sample of SHHC agencies. The survey measured the experiences of SHHC clinicians in communicating with physicians. Multilevel logistic regression models examining odds of adverse patient outcomes associated with communication failures., Results: A total of 265 surveys from 168 SHHC agencies were returned for a response rate of 13.3% at the individual respondent level and 16.8% at the SHHC agency level. Agency-level characteristics were similar between responding and nonresponding agencies. The most common method of contacting physicians during routine SHHC visits was telephone; communication via the electronic health record was uncommon. Nearly 40% of SHHC clinicians report never or rarely being able to reach a physician. SHHC clinicians rate the Center for Medicare and Medicaid Services Home Health Certification and Plan of Care (CMS-485) as a useful means of communication 6.3 (SD, 2.5) scale of 1 (least useful) to 10 (most useful); only 14% could have SHHC orders signed electronically. In multilevel logistic models, compared to SHHC clinicians who could reach a physician nearly every time or always, the odds of an SHHC clinician sending someone to the emergency department were 3.66 (95% confidence interval 1.16-11.5) for SHHC clinicians who were sometimes or often able to reach a physician and 5.43 (95% CI 1.56-18.9) for those who never or rarely reached a physician., Conclusions: In this exploratory study, SHHC clinicians experience significant communication barriers with physicians who order SHHC services. Strategies to enhance meaningful communication between SHHC clinicians and physicians must be developed., (© 2021 The American Geriatrics Society.)

Background: Dementia is associated with increased risk of hospitalization and emergency department (ED) visits. Many persons with dementia are undiagnosed or unaware of their diagnosis, however. Our objective was to determine whether undiagnosed dementia or unawareness affects risk of hospitalization or ED visits., Methods: Retrospective longitudinal cohort study of 3537 community-living adults age ≥65 enrolled in the 2011-2017 National Health and Aging Trends Study with linked fee-for-service Medicare claims. Using self or proxy reported diagnosis, proxy dementia screening questionnaire, cognitive testing, and Medicare claims diagnosis, participants were classified as having (1) no dementia or dementia, for which they were classified as (2) undiagnosed, (3) diagnosed but unaware, or (4) diagnosed and aware. Proportional hazards models evaluated all-cause and potentially preventable hospitalization and ED visit risk by time-varying dementia status, adjusting for older adult characteristics., Results: Most participants (n = 2879) had no dementia at baseline. Among participants with dementia at baseline (n = 658), 187 were undiagnosed, 300 diagnosed but unaware, and 171 diagnosed and aware. In multivariable adjusted proportional hazards models, persons with undiagnosed dementia had lower risk of hospitalization and ED visits compared to persons diagnosed and aware (all-cause hospitalization aHR 0.59 [0.44, 0.79] and ED visit aHR 0.63 [0.47, 0.85]) and similar risks of these outcomes compared to persons without dementia. Individuals diagnosed but unaware had greater risk compared to those without dementia: aHR 1.37 (1.18, 1.59) for all-cause hospitalization and 1.48 (1.28, 1.71) for ED visits; they experienced risk comparable to individuals diagnosed and aware., Conclusion: Older adults with undiagnosed dementia are not at increased risk of acute care utilization after accounting for differences in other characteristics. Individuals unaware of diagnosed dementia demonstrate risk similar to individuals aware of the diagnosis. Increasing diagnosis alone may not affect acute care utilization. The role of awareness warrants further investigation., (© 2021 The American Geriatrics Society.)

Background/objectives: To assess whether vitamin D supplementation prevents specific fall subtypes and sequelae (e.g., fracture)., Design: Secondary analyses of STURDY (Study to Understand Fall Reduction and Vitamin D in You)-a response-adaptive, randomized clinical trial., Setting: Two community-based research units., Participants: Six hundred and eighty-eight participants ≥70 years old with elevated fall risk and baseline serum 25-hydroxyvitamin D levels of 10-29 ng/ml., Intervention: 200 IU/day (control), 1000 IU/day, 2000 IU/day, or 4000 IU/day of vitamin D3., Measurements: Outcomes included repeat falls and falls that were consequential, were injurious, resulted in emergency care, resulted in fracture, and occurred either indoors or outdoors., Results: After adjustment for multiple comparisons, the risk of fall-related fracture was greater in the pooled higher doses (≥1000 IU/day) group compared with the control (hazard ratio [HR] = 2.66; 95% confidence interval [CI]:1.18-6.00). Although not statistically significant after multiple comparisons adjustment, time to first outdoor fall appeared to differ between the four dose groups (unadjusted p for overall difference = 0.013; adjusted p = 0.222), with risk of a first-time outdoor fall 39% lower in the 1000 IU/day group (HR = 0.61; 95% CI: 0.38-0.97; unadjusted p = 0.036; adjusted p = 0.222) and 40% lower in the 2000 IU/day group (HR = 0.60; 95%CI 0.38-0.97; p = 0.037; adjusted p = 0.222), each versus control., Conclusion: Vitamin D supplementation doses ≥1000 IU/day might have differential effects on fall risk based on fall location and fracture risk, with the most robust finding that vitamin D doses between 1000 and 4000 IU/day might increase the risk of first time falls with fractures. Replication is warranted, given the possibility of type 1 error., (© 2021 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Background/objectives: Hospitalization is common among older adults with disability, many of whom receive help from a caregiver and have dementia. Our objective was to evaluate the association between caregiver factors and risk of hospitalization and whether associations differ by dementia status., Design: Longitudinal observational study., Setting: The 1999 and 2004 National Long-Term Care Survey and the 2011 and 2015 National Health and Aging Trends Study, linked caregiver surveys, and Medicare claims., Participants: A total of 2,589 community-living Medicare fee-for-service beneficiaries, aged 65 years or older (mean age = 79 years; 63% women; 31% with dementia), with self-care or mobility disability and their primary family or unpaid caregiver., Measurements: Self-reported characteristics of older adults and their caregivers were assessed from older adult and caregiver survey interviews. Older adult hospitalization over the subsequent 12 months was identified in Medicare claims. Multivariable Cox proportional hazards models adjusted for older adult characteristics and were stratified by dementia status., Results: In this nationally representative cohort, 38% of older adults with disabilities were hospitalized over 12 months following interview. Increased hospitalization risk was associated with having a primary caregiver who helped with healthcare tasks (adjusted hazard ratio (aHR) = 1.22; 95% confidence interval (CI) = 1.05-1.40), reported physical strain (aHR = 1.21; 95% CI = 1.04-1.42), and provided more than 40 hours of care weekly (aHR = 1.26; 95% CI = 1.04-1.54 vs ≤20 hours). Having a caregiver who had helped for 4 years or longer (vs <1 year) was associated with 38% lower risk of hospitalization (aHR = 0.62; 95% CI = 0.49-0.79). Older adults with and without dementia had similar rates of hospitalization (39.5% vs 37.3%; P = .4), and caregiving factors were similarly associated with hospitalization regardless of older adults' dementia status., Conclusion: Select caregiving characteristics are associated with hospitalization risk among older adults with disability. Hospitalization risk reduction strategies may benefit from understanding and addressing caregiving circumstances., (© 2020 The American Geriatrics Society.)

Background/objectives: Few studies have rigorously examined the magnitude of changes in well-being after a transition into sustained and substantial caregiving, especially in population-based studies, compared with matched noncaregiving controls., Design: We identified individuals from a national epidemiological investigation who transitioned into caregiving over a 10- to 13-year follow-up and provided continuous in-home care for at least 18 months and at least 5 hours per week. Individuals who did not become caregivers were individually matched with caregivers on age, sex, race, education, marital status, self-rated health, and history of cardiovascular disease at baseline. Both groups were assessed at baseline and follow-up., Setting: REasons for Geographic And Racial Differences in Stroke study., Participants: A total of 251 incident caregivers and 251 matched controls., Measurements: Perceived Stress Scale (PSS), 10-Item Center for Epidemiological Studies-Depression (CES-D), and 12-item Short-Form Health Survey quality-of-life mental (MCS) and physical (PCS) component scores., Results: Caregivers showed significantly greater worsening in PSS, CES-D, and MCS, with standardized effect sizes ranging from 0.676 to 0.796 compared with changes in noncaregivers. A significant but smaller effect size was found for worsening PCS in caregivers (0.242). Taking on sustained caregiving was associated with almost a tripling of increased risk of transitioning to clinically significant depressive symptoms at follow-up. Effects were not moderated by race, sex, or relationship to care recipient, but younger caregivers showed greater increases in CES-D than older caregivers., Conclusion: Persons who began substantial, sustained family caregiving had marked worsening of psychological well-being, and relatively smaller worsening of self-reported physical health, compared with carefully matched noncaregivers. Previous estimates of effect sizes on caregiver well-being have had serious limitations due to use of convenience sampling and cross-sectional comparisons. Researchers, public policy makers, and clinicians should note these strong effects, and caregiver assessment and service provision for psychological well-being deserve increased priority., (© 2020 The American Geriatrics Society.)

Background: Social isolation is a risk factor for poor health that influences the well-being older adults., Objective: We compare advance care planning (ACP) engagement of older adults who were severely socially isolated, socially isolated, and not socially isolated., Design: Cross-sectional analysis of the 2012 National Health and Aging Trends Study (NHATS)., Setting: United States of America., Participants: A total of 2015 older adults (aged ≥65 years) randomly selected from a representative sample of community-dwelling Medicare beneficiaries to participate in an ACP module as part of an annual in-person interview., Measurements: We classified participants in three groups: severely socially isolated, socially isolated, or not socially isolated. ACP refers to three (yes/no) questions regarding whether a participant had a: (1) prior discussion about care preferences in the case of serious illness (EOL Discussion); (2) durable power of attorney (DPOA); and (3) advance directive (AD). We performed logistic regression analyses to examine the association between social isolation and ACP., Results: Approximately 23% of older adults were either severely socially isolated or socially isolated. Older adults who experienced social isolation were less likely to engage in ACP than those who were not socially isolated. In adjusted analysis, older adults who were socially isolated had lower odds of having an EOL discussion (adjusted odds ratio [AOR] = 0.65; 95% confidence interval [CI] = 0.49-0.87) or having a DPOA (AOR = 0.71; 95% CI = 0.53-0.96) compared to those who were not socially isolated., Conclusion: Social isolation is associated with lower engagement in ACP. Clinicians should identify older adults who are at risk for or experience social isolation as they may benefit from targeted ACP efforts. J Am Geriatr Soc 68:841-846, 2020., (© 2019 The American Geriatrics Society.)

Objectives: To comprehensively examine factors associated with long-term nursing home (NH) entry from 6 domains of older adult and family caregiver risk from nationally representative surveys and develop a prognostic model and a simple scoring system for use in risk stratification., Design: Retrospective observational study., Setting: National Long-Term Care Surveys 1999 and 2004 and National Health and Aging Trends Study 2011 and linked caregiver surveys., Participants: Community-living older adults receiving help with self-care disability and their primary family or unpaid caregiver (N=2,676)., Measurements: Prediction of long-term NH entry (>100 days or ending in death) by 24 months follow up, ascertained from Minimum Data Set assessments and dates of death from Medicare enrollment files. Risk factors were measured from survey responses., Results: In total, 16.1% of older adults entered a NH. Our final model and risk scoring system includes 7 independent risk factors: older adult age (1 point/5 years), living alone (5 points), dementia (3 points), 3 or more of 6 self-care activities (2 points), caregiver age (45-64: 1 point, 65-74: 2 points, ≥75: 4 points), caregiver help with money management (2 points), and caregiver report of moderate (2 points) or high (4 points) strain. Using this model, participants were assigned to risk quintiles. Long-term NH entry was 7.0% in the lowest quintile (0-6 points), 20.4% in the middle 3 quintiles (7-14 points), and 30.9% in the highest quintile (15-22 points). The model was well calibrated and demonstrated moderate discrimination (c-statistic=0.670 in the original data, c-statistic=0.647 in bootstrapped samples, c-statistic=0.652 using the point-scoring system)., Conclusion: We developed a prognostic model and simple scoring system that may be used to stratify risk of long-term NH entry of community-living older adults. Our model may be useful for population health and policy applications., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Background/objectives: Social support can prevent or delay long-term nursing home placement (NHP). The purpose of our study was to understand how the availability of a caregiver can affect NHP after ischemic stroke and how this affects different subgroups differently., Design: Nested cohort study., Setting: Nationally based REasons for Geographic and Racial Differences in Stroke (REGARDS) study., Participants: Stroke survivors aged 65 to 100 (256 men, 304 women)., Measurements: Data were from Medicare claims from January 2003 to December 2013 and REGARDS baseline interviews conducted from January 2003 to October 2007. Caregiver support was measured by asking, "If you had a serious illness or became disabled, do you have someone who would be able to provide care for you on an on-going basis?" Diagnosis of ischemic stroke was derived from inpatient claims. NHP was determined using a validated claims algorithm for stays of 100 days and longer. Risk was estimated using Cox regression., Results: Within 5 years of stroke, 119 (21.3%) participants had been placed in a nursing home. Risk of NHP was greater in those lacking available caregivers (log-rank P = .006). After adjustment for covariates, lacking an available caregiver increased the risk of NHP after stroke within 1 year by 70% (hazard ratio (HR) = 1.70, 95% confidence interval (CI) = 0.97-2.99) and within 5 years by 68% (HR = 1.68, 95% CI = 1.10-2.58). The effect of caregiver availability on NHP within 5 years was limited to men (HR = 3.15, 95% CI = 1.49-6.67)., Conclusion: In men aged 65 and older who have survived an ischemic stroke, the lack of an available caregiver is associated with triple the risk of NHP within 5 years., (© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.)

Objectives: To examine 6-month change in life-space mobility as a predictor of subsequent 6-month mortality in community-dwelling older adults., Design: Prospective cohort study., Setting: Community-dwelling older adults from five Alabama counties in the University of Alabama at Birmingham (UAB) Study of Aging., Participants: A random sample of 1,000 Medicare beneficiaries, stratified according to sex, race, and rural or urban residence, recruited between November 1999 and February 2001, followed by a telephone interview every 6 months for the subsequent 8.5 years., Measurements: Mortality data were determined from informant contacts and confirmed using the National Death Index and Social Security Death Index. Life-space was measured at each interview using the UAB Life-Space Assessment, a validated instrument for assessing community mobility. Eleven thousand eight hundred seventeen 6-month life-space change scores were calculated over 8.5 years of follow-up. Generalized linear mixed models were used to test predictors of mortality at subsequent 6-month intervals., Results: Three hundred fifty-four deaths occurred within 6 months of two sequential life-space assessments. Controlling for age, sex, race, rural or urban residence, and comorbidity, life-space score and life-space decline over the preceding 6-month interval predicted mortality. A 10-point decrease in life-space resulted in a 72% increase in odds of dying over the subsequent 6 months (odds ratio = 1.723, P < .001)., Conclusions: Life-space score at the beginning of a 6-month interval and change in life-space over 6 months were each associated with significant differences in subsequent 6-month mortality. Life-space assessment may assist clinicians in identifying older adults at risk of short-term mortality., (© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.)

Objective: To examine the use of antimuscarinics for treating urinary incontinence (UI) in older adults with varying levels of cognition., Design: Cross-sectional., Setting: National Alzheimer's Coordinating Center from 2005 through 2015., Participants: Community-dwelling men and women aged 65 and older (N = 24,106)., Measurements: Clinicians and staff evaluated each participant's dementia status during annual in-person assessments. Participants or their informants reported all medications taken in the 2 weeks before each study visit., Results: Overall, 5.2% (95% confidence interval (CI) = 4.9-5.5%) of the cohort took a bladder antimuscarinic. Participants with impaired cognition were more likely to be taking an antimuscarinic than those with normal cognition. Rates of bladder antimuscarinic use were 4.0% (95% CI = 3.6-4.4%) for participants with normal cognition, 5.6% (95% CI = 4.9-6.3%) for those with mild cognitive impairment, and 6.0% (95% CI = 5.5-6.4%) for those with dementia (p < .001). Of 624 participants with dementia who took antimuscarinics, 16% (95% CI = 13-19%) were simultaneously taking other medicines with anticholinergic properties., Conclusion: Use of bladder antimuscarinics was more common in older adults with impaired cognition than in those with normal cognition. This use is despite guidelines advising clinicians to avoid prescribing antimuscarinics in individuals with dementia because of their vulnerability to anticholinergic-induced adverse cognitive and functional effects. A substantial proportion of cognitively impaired individuals who took antimuscarinics were simultaneously taking other anticholinergic medications. These findings suggest a need to improve the treatment of UI in individuals with impaired cognition., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Objectives: To determine whether there are racial and ethnicity group differences in Resources for Enhancing Alzheimer's Caregiver Health (REACH II) intervention delivery., Design: Randomized controlled trial., Setting: Community-based intervention delivered at five sites across the United States., Participants: Family caregivers of persons with dementia who were randomized to the active intervention condition (N = 323)., Intervention: Nine in-home sessions (90 minutes each) and three telephone sessions (30 minutes each) were intended to be delivered and designed to reduce caregiver burden and depression, improve caregiver self-care and social support, and help caregivers manage behavior problems in persons with dementia., Measurements: Interventionists recorded the type of intervention (home or telephone), start and stop times, and whether specific intervention content modules (e.g., stress management, social support) were administered in each session., Results: Overall, REACH II intervention delivery was high, with more than 80% of randomized caregivers completing at least five in-home sessions and receiving eight or more hours of intervention contact, but black caregivers completed fewer in-home sessions (mean 6.98) than Hispanics (mean 7.84) or whites (mean 8.25) and received less total intervention contact time (mean 683 minutes) than Hispanics (mean 842 minutes) or whites (mean 798 minutes). No significant differences in exposure to content according to race or ethnicity were found after controlling for demographic covariates., Conclusion: Blacks in REACH II received significantly less intervention contact. Similar multicomponent interventions should examine whether there are systematic differences in intervention delivery across specific demographic subgroups and explore implications for treatment outcomes., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

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., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Objectives: To determine factors mediating the effects of a depression intervention for older African Americans on functional disability and, secondarily, whether functional improvements mediate intervention effects on depressive symptoms., Design: Structural equation modeling to examine mediators in a secondary analysis of a randomized trial with 4-month follow-up., Setting: Philadelphia region., Participants: Community-dwelling African Americans (≥55) with depressive symptoms living in an urban area (N = 208)., Intervention: Up to 10 one-hour sessions over 4 months conducted by licensed social workers who provided care management, referrals and linkages, stress reduction techniques, depression knowledge and symptom recognition, and behavioral activation techniques., Measurements: Main outcome was self-reported functional difficulty level for 18 basic activities. Mediators included depression severity (Patient Health Questionnaire), depression knowledge and symptom recognition, behavioral activation, and anxiety., Results: At 4 months, the intervention had positive effects on functional difficulty and all mediators (P < .001). Separate structural equation models indicated that two factors (reduced depressive symptoms (23.5% mediated) and improved depression knowledge and symptom recognition (52.9% mediated)) significantly mediated the intervention's effect on functional disability. Enhancing behavioral activation and decreasing anxiety were not found to mediate improvements in functional disability. The two significant mediators jointly explained 62.5% of the intervention's total effect on functional disability. Functional improvement was not found to mediate the intervention's effect on depressive symptoms., Conclusion: This multicomponent depression intervention for African Americans has an effect on functional disability that is driven primarily by enhancing symptom recognition and decreasing depressive symptoms. Reduction of functional difficulties did not account for improvements in depressive symptoms. Nonpharmacological treatments for depressive symptoms that enhance symptom recognition in older African Americans can also reduce their functional difficulties with daily living activities., (© 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.)

Objectives: To determine the acceptability of a pre-consultation checklist for older adults who attend medical visits with an unpaid companion and to evaluate its effects on visit communication., Design: Randomized controlled pilot study., Setting: Academic geriatrics ambulatory clinic., Participants: Thirty-two individuals aged 65 and older and their unpaid companions., Intervention: A self-administered checklist was compared with usual care. The checklist was designed to elicit and align patient and companion perspectives regarding health concerns to discuss with the doctor and stimulate discussion about the companion's role in the visit., Primary Outcome: ratio of patient-centered communication, coded from visit audiotapes., Secondary Outcomes: checklist acceptability; visit duration; patient-companion verbal activity; patient- and physician-reported perspectives of the visit., Results: All intervention patients and companions (n = 17) completed the checklist, and all participants (n = 32 dyads) completed the study. Patients and companions stated that the checklist was easy to complete (88%) and useful (91%), and they uniformly (100%) recommended it to other patients. Communication was significantly more patient-centered in intervention group visits (ratio of 1.22 vs 0.71; P = .03). Visit duration (35.0 and 30.6 minutes; P = .34) and percentage of total verbal activity contributed by patients and companions (58.2% and 56.3% of visit statements; P = .50) were comparable in the intervention and control groups, respectively. Physicians were more likely to indicate that intervention companions "helped them provide good care to the patient" (94% vs 60%; P = .02). Intervention patients were more likely to indicate that they "better understood their doctor's advice and explanations" because their companion was present (82% vs 47%; P = .03)., Conclusion: A checklist to elicit and align perspectives of older adults and their companions resulted in enhanced patient-centered medical visit communication., (© 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.)

Objectives: To determine whether cumulative symptom burden predicts hospitalization or emergency department (ED) visits in a cohort of older adults., Design: Prospective, observational study with a baseline in-home assessment of symptom burden., Setting: Central Alabama., Participants: Nine hundred eighty community-dwelling adults aged 65 and older (mean 75.3 ± 6.7) recruited from a random sample of Medicare beneficiaries stratified according to sex, race, and urban/rural residence., Measurements: Symptom burden score (range 0-10). One point was given for each symptom reported: shortness of breath, tiredness or fatigue, problems with balance or dizziness, leg weakness, poor appetite, pain, stiffness, constipation, anxiety, and loss of interest in activities. Dependent variables were hospitalizations and ED visits, assessed every 6 months during the 8.5-year follow-up period. Using Cox proportional hazards models, time from the baseline in-home assessment to the first hospitalization and first hospitalization or ED visit was determined., Results: During the 8.5-year follow-up period, 545 (55.6%) participants were hospitalized or had an ED visit. Participants with greater symptom burden had higher risk of hospitalization (hazard ratio (HR) = 1.09, 95% confidence interval (CI) = 1.05-1.14) and hospitalization or ED visit (HR = 1.10, 95% CI = 1.06-1.14) than those with lower scores. Participants living in rural areas had significantly lower risk of hospitalization (HR = 0.83, 95% CI = 0.69-0.99) and hospitalization or ED visit (HR = 0.80, 95% CI = 0.70-0.95) than individuals in urban areas, independent of symptom burden and comorbidity., Conclusion: Greater symptom burden was associated with higher risk of hospitalization and ED visits in community-dwelling older adults. Healthcare providers treating older adults should consider symptom burden to be an additional risk factor for subsequent hospital utilization., (© 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.)

Objectives: To determine the prevalence and correlates of nocturia in community-dwelling older adults., Design: Planned secondary analysis of cross-sectional data from the University of Alabama at Birmingham Study of Aging population-based survey., Setting: Participants' homes., Participants: One thousand older adults (aged 65-106) recruited from Medicare beneficiary lists between 1999 and 2001. The sample was selected to include 25% each African-American women, African-American men, white women, and white men., Measurements: In-person interviews included sociodemographic information, medical history, Mini-Mental State Examination (MMSE) score, and measurement of body mass index (BMI). Nocturia was defined in the main analyses as rising two or more times per night to void., Results: Nocturia was more common in men than women (63.2% vs 53.8%, odds ratio (OR)=1.48, 95% confidence interval (CI)=1.15-1.91, P=.003) and more common in African Americans than whites (66.3% vs 50.9%, OR=1.89, 95% CI=1.46-2.45, P<.001). In multiple backward elimination regression analysis in men, nocturia was significantly associated with African-American race (OR=1.54) and BMI (OR=1.22 per 5 kg/m(2)). Higher MMSE score was protective (OR=0.96). In women, nocturia was associated with older age (OR=1.21 per 5 years), African-American race (OR=1.64), history of any urine leakage (OR=2.17), swelling in feet and legs (OR=1.67), and hypertension (OR=1.62). Higher education was protective (OR=0.92)., Conclusion: Nocturia in community-dwelling older adults is a common symptom associated with male sex, African-American race, and some medical conditions. Given the significant morbidity associated with nocturia, any evaluation of lower urinary tract symptoms should include assessment for the presence of nocturia.

Objectives: To determine whether counseling and support reduce the burden and depressive symptoms of spouse caregivers of patients with Alzheimer's disease (AD) during the transition to institutionalization., Design: A randomized, controlled trial of an enhanced counseling and support program for spouse caregivers of persons with AD. Structured interviews were conducted with spouse caregivers at baseline, every 4 months during Year 1, and every 6 months thereafter for up to 16 years., Setting: Outpatient research clinic in the New York City metropolitan area., Participants: Referred volunteer sample of 406 spouse caregivers of community-dwelling patients with AD enrolled over a 9.5-year period., Intervention: Enhanced counseling and support consisting of six sessions of individual and family counseling, support group participation, and continuous availability of ad hoc telephone counseling., Measurements: Outcome measures included burden (modified Zarit Burden Interview) and depressive symptoms (Geriatric Depression Scale)., Results: Burden and depressive symptoms were significantly lower for caregivers in the treatment group than for controls receiving usual care at the time of and after institutionalization. Nursing home admission itself significantly reduced burden and depressive symptoms in the intervention and control groups., Conclusion: Institutionalization alone can reduce caregiver burden and depressive symptoms, but enhanced counseling provides additional long-term benefits. The results offer some of the first clinical evidence of the benefits of enhanced counseling during the transition to institutionalization for caregivers of people with AD.

Objectives: To evaluate the relationship between performance-based risk factors and subsequent at-fault motor vehicle collision (MVC) involvement in a cohort of older drivers., Design: Prospective cohort study., Setting: Motor Vehicle Administration (MVA) field sites in Maryland., Participants: Of the 4,173 older drivers invited to participate in the study, 2,114 individuals aged 55 to 96 agreed to do so. These analyses focus on 1,910 individuals recruited through MVA field sites., Measurements: Gross Impairment Screening Battery, which included Rapid Pace Walk, Head/Neck Rotation, Foot Tap, Arm Reach, Cued Recall, Symbol Scan, Visual Closure subtest of the Motor Free Visual Perception Test (MVPT), Delayed Recall, and Trail Making Test with an Abbreviated Part A and standard Part B; Useful Field of View (UFOV) subtest 2; a Mobility Questionnaire; and MVC occurrence., Results: In drivers aged 55 and older with intact vision (20/70 far visual acuity and 140 degrees visual field), age, sex, history of falls, and poorer cognitive performance, as measured using Trails B, MVPT, and UFOV subtest 2, were predictive of future at-fault MVC involvement. After adjusting for annual mileage, participants aged 78 and older were 2.11 as more likely to be involved in an at-fault MVC, those who made four or more errors on the MVPT were 2.10 times as likely to crash, those who took 147 seconds or longer to complete Trails B were 2.01 times as likely to crash, and those who took 353 ms or longer on subtest 2 of the UFOV were 2.02 times as likely to incur an at-fault MVC. Older adults, men, and individuals with a history of falls were more likely to be involved in subsequent at-fault MVCs., Conclusion: Performance-based cognitive measures are predictive of future at-fault MVCs in older adults. Cognitive performance, in particular, is a salient predictor of subsequent crash involvement in older adults. High-risk older drivers can be identified through brief, performance-based measures administered in a MVA setting.

Objectives: To describe changes in bladder function and voiding frequency associated with behavioral and drug treatment for urge incontinence and to examine whether these variables mediate the positive effects of treatment on the frequency of incontinence., Design: Randomized, double-blinded, placebo-controlled, clinical trial. Eligible patients were stratified according to type of incontinence (urge only vs mixed urge and stress) and severity of incontinence (frequency of accidents as documented in bladder diary)., Setting: University-based outpatient geriatric medicine clinic., Participants: One hundred five ambulatory, nondemented, community-dwelling women; mean age 67.0 (range 55-91); 98% white, 2% African American., Intervention: Four sessions (over 8 weeks) of biofeedback-assisted behavioral training, drug treatment with individually-titrated oxybutynin chloride, or a placebo control condition., Measurements: Two-channel cystometry was performed to determine threshold volumes for first desire to void (FDV), strong desire to void (SDV), bladder capacity, and the volume at which detrusor instability (DI) or leakage occurred, before randomization and after completion of treatment. Two-week bladder diaries were used before and after treatment to document episodes of incontinence and voiding frequency., Results: Bladder capacity increased by 68.9 mL in the oxybutynin group (P <.001) and 17.3 mL in the behavior group and decreased 6.0 mL in the control group. SDV increased 69.9 mL in the oxybutynin group (P <.001), 40.5 in the behavior group (P <.05), and 7.8 mL in the control group. FDV increased by 44.4 mL in the oxybutynin group (P <.001), 18.8 mL in the behavior group, and 8.9 mL in the control group. One of seven patients who presented with DI (12.0%) resolved in the behavior group, seven of eight (87.5%) resolved in the oxybutynin group, and seven of 12 (58.3%) resolved in the control group. These differences were not statistically significant. Voiding frequency was significantly reduced after treatment in both the behavior and the oxybutynin group. Behavioral training resulted in a mean 82.3% reduction in frequency of accidents, oxybutynin (final doses 2.5 mg daily to 5 mg three times a day) resulted in a mean 78.3% reduction, and the control condition resulted in a mean 51.5% reduction (P =.002). Although oxybutynin and behavioral treatment were both effective, and oxybutynin increased SDV and bladder capacity, the structural equation modeling did not demonstrate that the clinical improvement was mediated through the effects of these treatments on urodynamic or voiding frequency measures., Conclusions: Studies using more-complex urodynamics and studies with larger sample sizes are needed to better characterize changes in bladder function and explore other urodynamic changes that may accompany treatment. In addition, other factors, both physiological and behavioral, need to be explored as mechanisms by which conservative therapies improve urge incontinence.

Objectives: The primary purpose of this preliminary study was to investigate the associations between certified nursing assistant (CNA) report of pain, Minimum Data Set (MDS) report of pain, and analgesic medication use in cognitively impaired nursing home residents., Design: Correlational study., Setting: Three nursing homes in the greater Birmingham, Alabama area., Participants: Fifty-seven cognitively impaired nursing home residents with a mean Mini-Mental State Examination (MMSE) score of 11.1., Measurements: Pain was assessed using a three-item proxy pain questionnaire (PPQ), developed by the researchers and administered to the residents' primary CNA. MDS and analgesic medication data corresponding with the time of PPQ data collection were gathered from medical records. Cognitive status was measured with the MMSE., Results: The PPQ elicited substantially higher estimates of pain prevalence than the MDS (48% versus 20%), and the PPQ and the MDS were not well correlated (pain frequency: r=.19, P=.18; pain intensity: r=.22, P=.11). The PPQ was also more strongly associated with analgesic medication use than the MDS. Cognitive status was significantly associated with pain report on the PPQ but not on the MDS. Test-retest reliability coefficients for the three items of the PPQ were excellent, ranging from.84 to.87 (P

Objectives: The objectives of this study were to determine the effects of a strength-training program on walking speed and relative muscular stress, as measured by normalized integrated electromyographic (nIEMG) activity, while carrying a box of groceries and standing from a chair., Design: Prospective intervention study., Setting: Volunteer subjects from the community of Birmingham, Alabama., Participants: Fourteen healthy women aged 60 to 77 years., Intervention: Sixteen weeks of total body strength conditioning., Measurements: Before and after 16 weeks of strength conditioning, the following variables were evaluated for all subjects: (1) strength, six isotonic tests and two isometric tests; (2) walking velocity; (3) nIEMG of the biceps while carrying a box of groceries; and (4) nIEMG of the rectus femoris while standing from a chair., Main Results: After the strength training program, subjects' isotonic strength increased significantly, an average of 52% on the isotonic tests and 31% on the isometric tests. Walking velocity also increased significantly (18%). nIEMG of the biceps decreased 36% while carrying a box of groceries. Rectus femoris nIEMG decreased 40% while standing and 47% while sitting., Conclusions: After strength conditioning, healthy older women showed not only substantially increased strength but also improvements in walking velocity and the ability to carry out daily tasks such as rising from a chair and carrying a box of groceries.