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Background: Community-dwelling older adults experiencing hip fracture often fail to achieve adequate walking capacity following surgery and rehabilitation. Effects of psychological factors on post-fracture walking capacity are poorly understood. Accordingly, this paper investigates effects of psychological resilience on observed walking capacity measures in older adults following hip fracture, controlling for important covariates., Methods: Data were drawn from the Community Ambulation Project, a clinical trial of 210 community-dwelling adults aged ≥60 years who experienced a minimal trauma hip fracture and were randomized to one of two 16-week home-based physical therapist-guided interventions. Psychological resilience was measured at study baseline using the 6-item Brief Resilience Scale (BRS); scores were classified into groups in order to distinguish levels of self-reported resilience. Walking capacity was assessed at study baseline and 16 weeks later using 4-Meter Gait Speed (4MGS), 50-Foot Walk Test (50FWT), and 6-Minute Walk Distance (SMWD). In multivariate analyses of covariance in which 16-week follow-up values of each walking measure were outcomes, covariates included clinical trial arm, gender, age, and baseline values of: walking measure corresponding to the outcome; body mass index; depressive symptom severity; degree of psychological optimism; cognitive status; informal caregiver need; and days from hospital admission to randomization., Results: Increases between baseline and 16 weeks later in mean gait speed in meters/sec (m/s) and walking distance in meters (m) in 4MGS, 50FWT and SMWD were 0.06 m/s (p = 0.061), 0.11 m/s (p < 0.01), and 25.5 m (p = 0.056) greater, respectively, in the most resilient BRS group compared to the least resilient BRS group., Conclusion: Higher levels of psychological resilience were associated with greater walking speed and distance. Psychological resilience represents a potentially clinically important pathway and intervention target, toward the goal of improving walking capacity among older adults known to have substantial residual disability following hip fracture., (© 2022 The American Geriatrics Society.)

Geriatricians and others must embrace the emerging field of geroscience. Until recently geroscience research was pursued in laboratory animals, but now this field requires specialized expertise in the care of vulnerable older patients with multiple chronic diseases and geriatric syndromes, the population likely to benefit the most from emerging therapies. While chronological aging measures the inevitable passage of clock time that occurs equally for everyone, biological aging varies among individuals, and importantly, it is modifiable. Advances in our understanding of biological aging, the discovery of strategies for modifying its rate, and an appreciation of aging as a shared risk factor for chronic diseases have jointly led to the Geroscience Hypothesis. This hypothesis states that interventions modifying aging biology can slow its progression-resulting in the delay or prevention of the onset of multiple diseases and disorders. Here we wish to report on the Third Geroscience Summit held at National Institutes of Health on November 4-5, 2019, which highlighted the importance of engaging other disciplines including clinicians. Involvement by scientists with expertise in clinical trials, health outcomes research, behavioral and social sciences, health policy, and economics is urgently needed to translate geroscience discoveries from the bench to clinical care and health policy. Adding to the urgency of broadening this geroscience coalition is the emergence of biological aging as one the most important modifiable factors of COVID-19, combined with the inability of our society to once again recognize and confront aging as a priority and opportunity when facing these types of public health emergencies., (© 2021 The American Geriatrics Society.)

Background/objectives: Delirium is common in older adults, especially following hospitalization. Because low vitamin D levels may be associated with increased delirium risk, we aimed to determine the prognostic value of blood vitamin D levels, extending our previous genetic analyses of this relationship., Design: Prospective cohort analysis., Setting: Community-based cohort study of adults from 22 cities across the United Kingdom (the UK Biobank)., Participants: Adults aged 60 and older by the end of follow-up in the linked hospital inpatient admissions data, up to 14 years after baseline (n = 351,320)., Measurements: At baseline, serum vitamin D (25-OH-D) levels were measured. We used time-to-event models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between vitamin D deficiency and incident hospital-diagnosed delirium, adjusted for age, sex, assessment month, assessment center, and ethnicity. We performed Mendelian randomization genetic analysis in European participants to further investigate vitamin D and delirium risk., Results: A total of 3,634 (1.03%) participants had at least one incident hospital-diagnosed delirium episode. Vitamin D deficiency (<25 nmol/L) predicted a large incidence in delirium (HR = 2.49; 95% CI = 2.24-2.76; P = 3*10 -68 , compared with >50 nmol/L). Increased risk was not limited to the deficient group: insufficient levels (25-50 nmol/L) were also at increased risk (HR = 1.38; 95% CI = 1.28-1.49; P = 4*10 -18 ). The association was independent of calcium levels, hospital-diagnosed fractures, dementia, and other relevant cofactors. In genetic analysis, participants carrying more vitamin D-increasing variants had a reduced likelihood of incident delirium diagnosis (HR = .80 per standard deviation increase in genetically instrumented vitamin D: .73-.87; P = 2*10 -7 )., Conclusion: Progressively lower vitamin D levels predicted increased risks of incident hospital-diagnosed delirium, and genetic evidence supports a shared causal pathway. Because low vitamin D levels are simple to detect and inexpensive and safe to correct, an intervention trial to confirm these results is urgently needed., (© 2020 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Objectives: To characterize the cumulative risk factors of social and behavioral determinants of health (SDoH) and examine their association with self-rated general health, functional limitations, and use of health services among US older adults., Design: Cross-sectional analysis of the 2013-2014 National Health and Nutrition Examination Survey., Setting: Nationally representative health interview survey in the United States., Participants: Survey respondents aged 65 or older (n = 1,306 unweighted)., Measurements: A cumulative risk score of SDoH, developed by the National Academy of Medicine expert panel, was assessed using validated measures. Outcome variables included self-rated general health, functional limitations (eg, activities of daily living), and use of health services (eg, usual source of care and overnight hospitalization). We quantified the cumulative risk score of SDoH in older adults and used multivariable-adjusted logistic and Poisson regression analyses to assess the association of SDoH with self-rated health, functional limitations, and use of health services, adjusting for other covariates., Results: About 25.7% of older adults, representative of 11.0 million people nationwide, reported having three or more cumulative SDoH risk factors. These older adults were more likely to have functional limitations (eg, activities of daily living) and less likely to report their general health as "very good" or "excellent" than those with two or fewer cumulative SDoH risk factors (P < .001 for each). Each additional cumulative SDoH risk factor was associated with increased odds of not having a usual source of care (adjusted odds ratio = 1.57; 95% confidence interval = 1.09-2.27)., Conclusion: The SDoH index score may be a useful tool to predict access to care and quality of care in older adults. J Am Geriatr Soc 68:1731-1738, 2020., (© 2020 The American Geriatrics Society.)

Objectives: To examine the effects of a telephone-delivered intervention, Family Intervention: Telephone Tracking-Caregiver (FITT-C), on community support and healthcare use by dementia caregivers., Design: Randomized, controlled trial., Setting: Academic medical center., Participants: Dyads (n = 250) of distressed informal dementia caregivers and care recipients., Intervention: Caregivers were randomly assigned to receive the FITT-C (n = 133) or telephone support (TS; n = 117). Both groups received 16 telephone contacts from a master's-level therapist over 6 months. The FITT-C intervention provided psychoeducation, problem solving, and other directive approaches based on assessment of critical areas (e.g., mood, behavior, family functioning, social support). TS provided supportive therapeutic strategies., Measurements: Outcome variables were caregiver report of community support service use, number of visits to the emergency department (ED) for caregivers and care recipients, and hospital stays for caregivers during the interventions., Results: Intervention groups did not differ in demographic characteristics, use of support services, or use of healthcare resources at baseline. Caregivers who received the FITT-C used community support services at end of treatment significantly more than those receiving TS (P = .02). FITT-C caregivers had a significantly lower rate of ED visits (rate difference 9.5%, P = .048) and hospital stays (rate difference 11.4%, P = .01) over the 6-month course of the intervention than TS caregivers. Care recipient use of community or medical resources did not differ according to group., Conclusion: An entirely telephone-delivered intervention was effective in increasing caregiver engagement in community resources and reducing caregiver use of hospital-based healthcare resources. Results highlight the potential effect of FITT-C on healthcare use., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Objectives: To determine the relationship between depressive symptoms after hospitalization and survival and functional outcomes., Design: Secondary analysis of a prospective cohort study., Setting: General medical service of two urban, teaching hospitals in Ohio., Participants: Hospitalized individuals aged 70 and older., Measurements: Ten depressive symptoms, instrumental activities of daily living (IADLs), and basic activities of daily living (ADLs) were measured at hospital discharge and 1, 3, 6, and 12 months later. Participant-specific changes in depressive symptoms (slopes) were determined using all data points. Four groups were also defined according to number of depressive symptoms (≤3 symptoms, low; 4-10 symptoms, high) at discharge and follow-up: low-low, low-high, high-low, and high-high. Mortality was measured 3, 6, and 12 months after hospital discharge., Results: Participant-specific discharge depressive symptoms and change in depressive symptoms over time (slopes) were associated (P < .05) with functional and mortality outcomes. At 1 year, more participants in the low-low depressive symptom group (49%) were alive and independent in IADLs and ADLs than in the low-high group (37%, P = .02), and more participants in the high-low group (39%) were alive and independent in IADLs and ADLs than in the high-high group (19%, P < .001)., Conclusion: Number of depressive symptoms and change in number of depressive symptoms during the year after discharge were associated with functional and mortality outcomes in hospitalized older adults. Fewer participants with persistently high or increasing depressive symptoms after hospitalization were alive and functionally independent 1 year later than participants with decreasing or persistently low symptoms, respectively., (© 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.)

Type 2 diabetes mellitus is known to affect adults in racial and ethnic minority groups disproportionately. When diabetes mellitus-related symptoms lead to the need for skilled care in the community-dwelling Medicare population, physicians can order the Medicare home health care (HHC) benefit, and Medicare-certified home health agencies can deliver it. Little is known about the extent to which racial and ethnic disparities exist in types and patterns of HHC services delivered to Medicare beneficiaries with diabetes mellitus when they are approved for the Medicare HHC benefit. This was examined by comparing racial and ethnic groups in terms of measures of HHC service use in a nationally representative sample of Medicare HHC beneficiaries with a primary diagnosis of type 2 diabetes mellitus. Uniform clinical data from the Outcome and Assessment Information Set were linked with Medicare HHC claims for beneficiaries who received a complete episode of HHC in 2002. In the study sample (n=9,838), 62% of participants self-identified as white, 22% African American, 12% Hispanic, and 3% Asian. Nearly all (99%) participants in all racial and ethnic groups received skilled nursing services. Controlling for numerous sociodemographic and health-related covariates and geographic region of the country, African-American participants received fewer nurse visits per week and fewer visits per week from all clinical disciplines combined than whites (both P<.001), and Hispanic participants were less likely than whites to receive physical therapy (adjusted odds ratio (AOR)=0.640, 95% confidence interval (CI)=0.543-0.754, P<.001) or home health aide (AOR=0.716, 95% CI=0.582-0.880, P=.002) services. Lower use of skilled nursing and rehabilitation services by African Americans and of rehabilitation services by Hispanics warrant further clinical and research attention., (© 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.)

Objectives: To compare functional outcomes in the year after discharge for older adults discharged from the hospital after an acute medical illness with a new or additional disability in their basic self-care activities of daily living (ADL) (compared with preadmission baseline 2 weeks before admission) with those of older adults discharged with baseline ADL function and identify predictors of failure to recover to baseline function 1 year after discharge., Design: Observational., Setting: Tertiary care hospital, community teaching hospital., Participants: Older (aged >or=70) patients nonelectively admitted to general medical services (1993-1998)., Measurements: Number of ADL disabilities at preadmission baseline and 1, 3, 6, and 12 months after discharge. Outcomes were death, sustained decline in ADL function, and recovery to baseline ADL function at each time point., Results: By 12 months after discharge, of those discharged with new or additional ADL disability, 41.3% died, 28.6% were alive but had not recovered to baseline function, and 30.1% were at baseline function. Of those discharged at baseline function, 17.8% died, 15.2% were alive but with worse than baseline function, and 67% were at their baseline function (P<.001). Of those discharged with new or additional ADL disability, the presence or absence of recovery by 1 month was associated with long-term outcomes. Age, cardiovascular disease, dementia, cancer, low albumin, and greater number of dependencies in instrumental ADLs independently predicted failure to recover., Conclusion: For older adults discharged with new or additional disability in ADL after hospitalization for medical illness, prognosis for functional recovery is poor. Rehabilitation interventions of longer duration and timing than current reimbursement allows, caregiver support, and palliative care should be evaluated.

This study determined the extent to which fall risk assessment and management practices for older patients were implemented in Medicare-certified home health agencies (HHAs) in a defined geographic area in southern New England that had participated in evidence-based fall prevention training between October 2001 and September 2004. The standardized in-service training sessions taught home health nurses and rehabilitation therapists how to conduct assessments for five evidence-based risk factors for falls in older adults--mobility impairments, balance disturbances, multiple medications, postural hypotension, and home environmental hazards--using techniques shown to be efficacious in clinical trials. Twenty-six HHAs participated in these in-service training sessions; 19 of these participated in a survey of nurses and rehabilitation therapists between October 2004 and September 2005. Self-reported assessment and management practices implemented with older patients during home healthcare visits were measured in this survey, and HHA-level measures for each fall risk factor were constructed based on proportions of clinicians reporting assessment and management practices that were recommended in the fall prevention training sessions. For all fall risk factors except postural hypotension, 80% or more of clinicians in all HHAs reported implementing recommended fall risk management practices. Greater variation was found regarding fall risk assessment practices, with fewer than 70% of clinicians in one or more HHAs reporting recommended assessment practices for all risk factors. Results suggest that evidence-based training for home healthcare clinicians can stimulate fall risk assessment and management practices during home health visits. HHA-level comparisons hold the potential to illustrate the extent of diffusion of evidence-based fall prevention practices within and between agencies.

Objectives: To determine whether a multidisciplinary team intervention minimizes unanticipated transitions from assisted living for persons with dementia., Design: Randomized trial., Setting: Two dementia-specific assisted living facilities in Connecticut owned and managed by the same corporation., Participants: One hundred older adults with dementia who relocated to assisted living., Intervention: Four systematic multidisciplinary assessments by a geriatrician, geriatrics advanced practice nurse, physical therapist, dietitian, and social worker during the first 9 months of relocation to assisted living., Measurements: Permanent relocation to a nursing facility, emergency department (ED) visits, hospitalization, and death., Results: Fifty-five residents experienced any unanticipated transition out of assisted living, on average 84 +/- 74 days after relocation; falls were the primary reason for transition. The intervention reduced the risk of any unanticipated transitions (13%), permanent relocation to a nursing facility (11%), ED visits (12%), hospitalization (45%), and death (63%), but the results did not meet statistical significance. In secondary analysis, more men experienced any unanticipated transition (P<.001), hospitalization (P<.001), or death (P<.001) than women., Conclusion: Although an untargeted multidisciplinary intervention did not significantly reduce the risk of transitions for individuals with dementia relocating to assisted living in this small sample, trends for decreasing hospitalization and death were found. The data further suggest that those at risk for falls and men may benefit from targeted clinical interventions to prevent unanticipated transitions, especially during the first 3 months after relocation.

Objectives: To report on the penetration of, and identified barriers to and facilitators of, efforts to incorporate evidence-based fall risk assessment and management into clinical practice throughout a defined geographic area., Design: Dissemination project., Setting: North central Connecticut., Participants: Hospitals, home care agencies, primary care providers, and outpatient rehabilitation facilities., Intervention: Multiple professional behavior-change strategies were used to encourage providers to incorporate evidence-based fall assessment and management into their practices., Measurements: Penetration of dissemination efforts over 36 months; barriers and facilitators identified by provider working groups during the first 2 years of the project., Results: All seven hospitals and 26 home care agencies in the area, 119 of 130 rehabilitation facilities, and 138 of 212 primary care offices participated. Most provider working groups expressed similar barriers and facilitating factors. Reported barriers specific to fall risk management included lack of awareness of fall morbidity and preventability, perceived lack of expertise and Medicare coverage, inadequate referral patterns among providers, and lack of a federal mandate for physicians. Facilitating factors specific to falls included the opportunity to market new services and to develop new networks of professional relationships across disciplines and the Medicare mandate that home care agencies focus on functional outcomes., Conclusion: Dissemination efforts showed notable successes as well as challenges. Although many of the barriers were general to diffusing new practices, several were specific to fall assessment and management that span disciplines and sites. Project results have implications for efforts to diffuse evidence-based practices for multifactorial geriatric conditions such as falls.

Objectives: To determine the extent to which healthcare providers reportedly address evidence-based fall risk factors in older patients after exposure to an educational intervention and to determine barriers reportedly encountered when these healthcare providers intervene with or refer older patients with identified fall-risk factors., Design: Cross-sectional study using a structured interview., Setting: Geographic area of Connecticut where the Connecticut Collaboration for Fall Prevention (CCFP) has been implemented., Participants: Emergency department (ED) physicians, hospital-based discharge planners or care coordinators (nurses or social workers), home health agency nurses, and office-based primary care physicians (total n=33) after exposure to the CCFP implementation team., Measurements: Self-reported practices (direct intervention or referral) and barriers when addressing seven evidence-based risk factors for falls: gait and transfer impairments, balance disturbances, multiple medications, postural hypotension, sensory and perceptive deficits, foot and footwear problems, and environmental hazards., Results: Respondents were most likely to report directly intervening with or referring older patients for gait and transfer impairments (85%) and balance disturbances (82%) and least likely to do so when encountering foot or footwear problems (58%) and sensory or perceptive deficits (61%). ED physicians reported lowest rates of direct intervention or referral for foot or footwear problems (20%), home health agency nurses for sensory or perceptive deficits (50%), and office-based primary care physicians for foot or footwear problems (50%). Patient compliance was the most commonly reported barrier to successful direct intervention across several risk factors, whereas inadequate availability of other healthcare providers and lack of Medicare reimbursement were the most commonly reported barriers to successful patient referrals., Conclusion: After exposure to the CCFP implementation team, the majority of healthcare providers reported directly intervening or referring patients when addressing all risk factors, but results pinpointed specific healthcare provider groups with room for improvement in assessment and management of specific risk factors. Patient education appears to be a necessary adjunct to healthcare provider training, because patient compliance was a reported barrier to optimal intervention by healthcare providers., (Copyright 2004 American Geriatrics Society)

Objectives: To determine whether hospital costs are higher in patients with lower functional status at admission, defined as dependence in one or more activities of daily living (ADLs), after adjustment for Medicare Diagnosis-Related Group (DRG) payments., Design: Prospective study., Setting: General medical service at a teaching hospital., Participants: One thousand six hundred twelve patients aged 70 and older., Measurements: The hospital cost of care for each patient was determined using a cost management information system, which allocates all hospital costs to individual patients., Results: Hospital costs were higher in patients dependent in ADLs on admission than in patients independent in ADLs on admission ($5,300 vs $4,060, P<.01). Mean hospital costs remained higher in ADL-dependent patients than in ADL-independent patients in an analysis that adjusted for DRG weight ($5,240 vs $4,140, P<.01), and in multivariate analyses adjusting for age, race, sex, Charlson comorbidity score, acute physiology and chronic health evaluation score, and admission from a nursing home as well as for DRG weight ($5,200 vs $4,220, P<.01). This difference represents a 23% (95% confidence interval=15-32%) higher cost to take care of older dependent patients., Conclusion: Hospital cost is higher in patients with worse ADL function, even after adjusting for DRG payments. If this finding is true in other hospitals, DRG-based payments provide hospitals a financial incentive to avoid patients dependent in ADLs and disadvantage hospitals with more patients dependent in ADLs.

Objectives: To determine whether a simple question about steadiness at admission predicts in-hospital functional decline and whether unsteadiness at admission predicts failure of in-hospital functional recovery of patients who have declined immediately before hospitalization., Design: Prospective cohort study., Setting: One university hospital and one community teaching hospital., Participants: One thousand five hundred fifty-seven hospitalized medical patients aged 70 and older., Measurements: On admission, patients reported their steadiness with walking and whether they could perform independently each of five basic activities of daily living (ADLs) at admission and 2 weeks before admission (baseline). For the primary analysis, the outcome was decline in ADL function between admission and discharge. For the secondary analysis, the outcome was in-hospital recovery to baseline ADL function in patients who experienced ADL decline in the 2 weeks before admission., Results: In the primary cohort (n = 1,557), 25% of patients were very unsteady at admission; 22% of very unsteady patients declined during hospitalization, compared with 17%, 18%, and 10% for slightly unsteady, slightly steady, and very steady patients, respectively (P for trend =.001). After adjusting for age; medical comorbidities; Acute Physiology, Age, and Chronic Health Evaluation II score; and admission ADL, unsteadiness remained significantly associated with ADL decline (odds for decline for very unsteady compared with very steady = 2.6, 95% confidence interval = 1.5-4.5). In the secondary analysis, predicting ADL recovery in patients who declined before hospitalization (n = 563), 46% of patients were very unsteady at admission. In this cohort, 44% of very unsteady patients failed to recover, compared with 35%, 36%, and 33% for each successively higher level of steadiness, respectively (P for trend = 0.06). After multivariate adjustment, greater unsteadiness independently predicted failure of recovery (P for trend = 0.02)., Conclusion: A simple question about steadiness identified patients at increased risk for in-hospital ADL decline and, in patients who lost ADL function immediately before admission, failure to recover.

Objectives: To describe the changes in activities of daily living (ADL) function occurring before and after hospital admission in older people hospitalized with medical illness and to assess the effect of age on loss of ADL function., Design: Prospective observational study., Setting: The general medical service of two hospitals., Participants: Two thousand two hundred ninety-three patients aged 70 and older (mean age 80, 64% women, 24% nonwhite)., Measurements: At the time of hospital admission, patients or their surrogates were interviewed about their independence in five ADLs (bathing, dressing, eating, transferring, and toileting) 2 weeks before admission (baseline) and at admission. Subjects were interviewed about ADL function at discharge. Outcome measures included functional decline between baseline and discharge and functional changes between baseline and admission and between admission and discharge., Results: Thirty-five percent of patients declined in ADL function between baseline and discharge. This included the 23% of patients who declined between baseline and admission and failed to recover to baseline function between admission and discharge and the 12% of patients who did not decline between baseline and admission but declined between hospital admission and discharge. Twenty percent of patients declined between baseline and admission but recovered to baseline function between admission and discharge. The frequency of ADL decline between baseline and discharge varied markedly with age (23%, 28%, 38%, 50%, and 63% in patients aged 70-74, 75-79, 80-84, 85-89, and > or =90, respectively, P <.001). After adjustment for potential confounders, age was not associated with ADL decline before hospitalization (odds ratio (OR) for patients aged > or =90 compared with patients aged 70-74 = 1.26, 95% confidence interval (CI) = 0.88-1.82). In contrast, age was associated with the failure to recover ADL function during hospitalization in patients who declined before admission (OR for patients aged > or =90 compared with patients aged 70-74 = 2.09, 95% CI = 1.20-3.65) and with new losses of ADL function during hospitalization in patients who did not decline before admission (OR for patients aged > or =90 compared with patients aged 70-74 = 3.43, 95% CI = 1.92-6.12)., Conclusion: Many hospitalized older people are discharged with ADL function that is worse than their baseline function. The oldest patients are at particularly high risk of poor functional outcomes because they are less likely to recover ADL function lost before admission and more likely to develop new functional deficits during hospitalization