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Objectives: To determine whether women with surgical menopause have a higher risk of frailty than naturally menopausal women., Design: Prospective cohort study with up to 18 years of follow-up., Setting: Four U.S clinical centers., Participants: Community-dwelling white women aged 65 and older (mean 71.2±5.2) enrolled in the Study of Osteoporotic Fractures (N=7,699)., Measurements: Surgical menopause was based on participant self-report of having undergone bilateral oophorectomy before menopause. The outcome was incident frailty, classified as robust, prefrail, frail, or death at 4 follow-up interviews, conducted 6 to 18 years after baseline. Information on baseline serum total testosterone concentrations was available for 541 participants., Results: At baseline, 12.6% reported surgical menopause. Over the follow-up period, 22.0% died, and 10.1% were classified as frail, 39.7% as prefrail, and 28.3% as robust. Surgically menopausal women had significantly lower total serum testosterone levels (13.2 ± 7.8 ng/dL) than naturally menopausal women (21.7 ± 14.8 ng/dL) (p=0.000), although they were not at greater risk of frailty (adjusted odds ratio (aOR)=0.94, 95% confidence interval (CI)=0.72-1.22), prefrailty (aOR=0.96, 95% CI=0.80-1.10), or death (aOR=1.17, 95% CI=0.97-1.42) after adjusting for age, body mass index, and number of instrumental activity of daily living impairments. There was no evidence that oral estrogen use modified these associations., Conclusion: In postmenopausal women, surgical menopause was not associated with greater risk for frailty than natural menopause, even in the absence of estrogen therapy. Future prospective studies are needed to investigate hormonal mechanisms involved in development of frailty in older postmenopausal women. J Am Geriatr Soc 66:2172-2177, 2018., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Objectives: To provide greater understanding of the "real world" effect of anticoagulation on stroke risk over several years., Design: Cohort study., Setting: Anticoagulation and Risk Factors in Atrial Fibrillation Study community-based cohort., Participants: Adults with nonvalvular atrial fibrillation (AF) between 1996 and 2003 (13,559)., Measurements: All events were clinician adjudicated. Extended Cox regression with longitudinal warfarin exposure was used to estimate cause-specific hazard ratios (HRs) for thromboembolism and the competing risk event (all cause death). The Fine and Gray subdistribution regression approach was used to estimate this association while accounting for competing death events. As a secondary analysis, follow-up was limited to 1, 3, and 5 years., Results: The rate of death was much higher in the group not taking warfarin (8.1 deaths/100 person-years (PY)) than in the group taking warfarin (5.5 deaths/100 PY). The cause-specific HR indicated a large reduction in thromboembolism with warfarin use (adjusted HR = 0.57, 95% confidence interval (CI) = 0.50-0.65), although this association was substantially attenuated after accounting for competing death events (adjusted HR = 0.87, 95% CI = 0.77-0.99). In analyses limited to 1 year of follow-up, with fewer competing death events, the results for models that did and did not account for competing risks were similar., Conclusion: Analyses accounting for competing death events may provide a more-realistic estimate of the longer-term stroke prevention benefits of anticoagulants than traditional noncompeting risk analyses for individuals with AF, particularly those who are not currently treated with anticoagulants., Competing Interests: Dr. Singer serves as a consultant/advisory board member for Bayer Healthcare, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Johnson and Johnson, Pfizer, and St. Jude Medical on matters related to preventing stroke in atrial fibrillation and with CSL Behring related to reversal of warfarin anticoagulation. Additionally, Dr. Singer has research contracts with Medtronic, Inc related to atrial fibrillation and risk of stroke, with Johnson and Johnson related to stroke prevention in atrial fibrillation, and with Bristol-Myers Squibb related to atrial fibrillation and risk of stroke. Dr. Go has received research grants from CSL Behring and iRhythm Technologies., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Objectives: To determine whether slow gait speed increases the risk of costly long-term nursing home residence when accounting for death as a competing risk remains unknown., Design: Longitudinal cohort study using proportional hazards models to predict long-term nursing home residence and subdistribution models with death as a competing risk., Setting: Community-based prospective cohort study., Participants: Older women (mean age 76.3) participating in the Study of Osteoporotic Fractures who were also enrolled in Medicare fee-for-service plans (N = 3,755)., Measurements: Gait speed was measured on a straight 6-m course and averaged over two trials. Long-term nursing home residence was defined using a validated algorithm based on Medicare Part B claims for nursing home-related care., Results: Participants were followed until long-term nursing home residence, disenrollment from Medicare plan, death, or December 31, 2010. Over the follow-up period (median 11 years), 881 participants (23%) experienced long-term nursing home residence, and 1,013 (27%) died before experiencing this outcome. Slow walkers (55% of participants with gait speed <1 m/s) were significantly more likely than fast walkers to reside in a nursing home long-term (adjusted hazards ratio (aHR) = 1.79, 95% confidence interval (CI) = 1.54-2.09). Associations were attenuated in subdistribution models (aHR = 1.52, 95% CI = 1.30-1.77) but remained statistically significant., Conclusion: Older community-dwelling women with slow gait speed are more likely to experience long-term nursing home residence, as well as mortality without long-term residence. Ignoring the competing mortality risk may overestimate long-term care needs and costs., Competing Interests: Several authors received NIH funding for their work on the Study of Osteoporotic Fractures., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Objectives: To determine whether self-reported insomnia symptoms were associated with weight change in older women and whether caregiving, comorbidities, sleep medication, or stress modified this association., Design: One-year prospective study conducted in four communities from 1999 to 2003 nested within a larger cohort study., Setting: Home-based interviews., Participants: Nine hundred eighty-eight participants (354 caregivers and 634 noncaregivers) from the Caregiver--Study of Osteoporotic Fractures., Measurements: Self-reported insomnia symptoms in the previous month: trouble falling asleep, trouble staying asleep, and waking early and having trouble getting back to sleep. Weight was measured at baseline and 12 months., Results: The average weight change was -1.9 ± 7.8 pounds. Trouble staying asleep was significantly associated with an average weight loss of 1.3 pounds (P = .03) in multivariable analyses. Neither of the other insomnia symptoms was associated with weight change. Use of sleep medications modified the association between trouble falling asleep (interaction term P = .03) and weight change. Insomnia symptoms were associated with weight loss only in women not taking sleep medications. Neither caregiving status, presence of multiple comorbidities, nor stress modified the association., Conclusion: Trouble staying asleep was associated with weight loss over 12 months in older women. Practitioners should inquire about sleep habits of patients presenting with weight loss, because this may identify a marker of declining health and may be a factor that can be modified., (© 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.)

Objectives: To investigate the separate and combined effects of caregiver status and high stress on mortality risk over 8 years in elderly women., Design: Prospective cohort study conducted in four U.S. communities followed from 1999/01 (baseline) to December 31, 2007., Setting: Home-based interviews., Participants: Three hundred seventy-five caregiver and 694 noncaregiver participants from the Caregiver-Study of Osteoporotic Fractures (Caregiver-SOF) who participated in the baseline Caregiver-SOF interview., Measurements: Caregiver status was based on SOF respondents' self-report of performing one or more instrumental or basic activities of daily living for a relative or friend with impairments. Two measures of stress were used: Perceived Stress Scale and stress related to caregiving tasks. All-cause mortality was the outcome., Results: Caregivers were more stressed than noncaregivers; 19.7% of caregivers and 27.4% of noncaregivers died. Mortality was lower in caregivers than noncaregivers (adjusted hazard ratio, (AHR)=0.74, 95% confidence interval (CI)=0.56-0.89). High-stress respondents had greater mortality risk than low-stress respondents over the first 3 years of follow-up (AHR=1.81, 95% CI=1.16-2.82) but not in later years. Likewise, high-stress caregivers and noncaregivers had higher mortality risk than low-stress noncaregivers, although low-stress caregivers had significantly lower mortality than did noncaregivers, whether perceived stress or caregiving-related stress was measured (AHR=0.67 and 0.57). Similar results were observed in analyses comparing spouse caregivers with married noncaregivers., Conclusion: Short-term effects of stress, not caregiving per se, may increase the risk of health decline in older caregivers.

Objectives: To determine whether positive affect is associated with a lower incidence of frailty over 2 years in elderly community-dwelling women and to test the stress-buffering hypothesis by evaluating whether these associations differed in caregivers and noncaregivers., Design: Prospective cohort study with three annual interviews conducted in four U.S. communities between 1999 and 2004., Setting: Home-based interviews., Participants: Three hundred thirty-seven caregiver and 617 noncaregiver participants from the Caregiver-Study of Osteoporotic Fractures (Caregiver-SOF) who were not frail at the baseline Caregiver-SOF interview., Measurements: High and low positive affect and depressive symptoms were derived from the baseline 20-item Center for Epidemiologic Studies Depression Scale. Frailty was the development of three or more indicators (weight loss, exhaustion, slow walking speed, or weak grip strength) at the first or second follow-up interview., Results: Respondents' mean age was 81.2. Caregivers and noncaregivers had similar levels of positive affect (56.3% vs 58.3%) and frailty incidence (15.4% vs 15.9%) but differed in perceived stress (mean Perceived Stress Scale score 16.7 vs 14.8, P<.001). Frailty risk was lower in respondents with high positive affect than in those with low positive affect in the total sample (adjusted hazard ratio (HR)=0.49, 95% confidence interval (CI)=0.35-0.70), caregivers (adjusted HR=0.44, 95% CI=0.24-0.80) and noncaregivers (adjusted HR=0.50, 95% CI=0.32-0.77)., Conclusion: These findings add to the evidence that positive affect protects against health decline in older adults, although it had no additional stress-buffering effect on health in elderly caregivers.

Objectives: To determine whether depressive symptoms modify the association between caregiving and sleep problems in elderly women., Design: Cross-sectional study conducted in four communities in 1999 to 2001., Setting: Home-based interviewer-administered questionnaires., Participants: Three hundred seventy-five caregiver and 694 noncaregiver participants from the Study of Osteoporotic Fractures., Measurements: Self-reported frequency of three sleep problems in the previous month: trouble falling asleep, trouble staying asleep, and waking early and having trouble falling back asleep. Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D), excluding the sleep disturbance item., Results: In adjusted analyses, caregivers did not report more sleep problems than noncaregivers, although respondents with high depressive symptoms (CES-D > or = 16) were twice as likely to report each sleep problem. When depressive symptoms and caregiving were considered together, caregivers with high depressive symptoms were most likely to report sleep problems (adjusted odds ratios ranging from 2.5, 95% confidence interval (CI)=1.2-5.2 for trouble falling asleep to 4.0, 95% CI=2.0-7.8 for waking early, compared with nondepressed noncaregivers). By contrast, there was no difference in sleep problems between caregivers and noncaregivers who were not depressed. The combination of high depressive symptoms and high-stress caregiving situations (e.g., caring for a spouse or a person with dementia, or living with the care recipient) also increased the likelihood of sleep problems., Conclusion: Caregivers with high levels of depressive symptoms reported sleep problems more than nondepressed noncaregivers. These results underscore the importance of screening elderly female caregivers for depressive symptoms and sleep problems.

Objectives: To evaluate whether patients with hip fracture with high positive affect had better functioning than those with low positive affect or depressive symptoms in three performance-based measures over 2 years after the fracture., Design: Longitudinal study with assessments at baseline and 2, 6, 12, 18, and 24 months posthospitalization., Setting: Community., Participants: Four hundred thirty-two patients, aged 65 and older, hospitalized for hip fracture in Baltimore, Maryland, between 1990 and 1991., Measurements: High and low positive affect and depressive symptoms were based on baseline Center for Epidemiologic Studies Depression Scale score, usual and rapid walking speed, one chair stand, demographic factors, comorbidities, and history of cognitive impairment., Results: At each follow-up point, respondents with high positive affect at baseline (36% of sample) had faster walking and chair stand speeds than those with low positive affect (13%) and depressive symptoms (51%). For example, at 6 months, the mean usual walking pace was 0.4 m/s (standard error (SE)=0.02) for respondents with high positive affect, versus 0.4 m/s (SE=0.03) and 0.35 m/s (SE=0.02) for patients with low positive affect and depressive symptoms, respectively; adjusted differences were 0.02 (95% confidence interval (CI)=-0.06-0.09) and 0.06 (95% CI=0.01-0.11). Respondents with high positive affect appeared to achieve their maximum improvement in usual pace approximately 6 months before other respondents, but this interaction was not statistically significant. Respondents with consistently high positive affect had the best functioning over the follow-up period., Conclusion: High positive affect seems to have a beneficial influence on performance-based functioning after hip fracture.

Objective: To evaluate the relationship between measured weight, weight change, and 6-year mortality risk in a random sample of 648 community-dwelling women aged 65 and older from Baltimore, Maryland., Measurements: Data were collected using a standardized questionnaire and administered in person by trained interviewers. Questionnaires were completed annually from 1984 to 1986, and body weight was measured at each interview. Weight was defined as body mass index (BMI) of low (< 23 kg/m2), average (> or = 23 kg/m2 to < or = 28 kg/m2), and high (> 28 kg/m2). Four mutually exclusive categories of weight change of at least 4.5% in BMI over the three annual interviews were developed to describe all possible weight change patterns: weight gain, weight loss, no change, and weight cycling., Results: During the follow-up period, 106 women (16%) died. Women with low baseline BMI, regardless of weight change, and those who lost weight, regardless of baseline BMI had increased mortality risk. Women with average baseline BMI and weight loss had a very high mortality risk (hazard ratio (HR) 3.84, 95% Confidence interval (CI) 2.14-6.89). Women who weight cycled had increased mortality risk at low and high baseline weights, and a nonsignificant increased risk at average baseline weight (P = .069). Analyses were adjusted for age, education, smoking, alcohol usage, and pre-existing illness and included an interaction between weight change and baseline BMI., Conclusions: These results suggest that white, older, community-dwelling women are at an increased risk of mortality if they are underweight, lose weight, or weight cycle.

Objectives: To investigate the relationship between insomnia and 6-year survival among older, community-dwelling, white women., Design: Longitudinal study., Setting: The sample was selected randomly from a 20-census tract area of Baltimore, Maryland., Participants: In 1984, 778 women aged 65 years and older participated in the baseline survey; 613 were re-interviewed in 1985; 596 were reinterviewed in 1986., Measurements: Insomnia was measured as self-report of at least one of three sleep complaints: trouble initiating sleep, waking at night and trouble falling back to sleep, and waking too early. Cox proportional hazards models were used to assess the relationship between insomnia, as reported at the most recent of three interviews, and mortality., Results: Twenty-nine percent of the sample reported trouble initiating sleep, 22.4% reported waking at night and having trouble falling back to sleep, and 26.6% reported waking too early. Of the sample, 43.2% had insomnia at the baseline interview; 23.2% percent of respondents with insomnia at baseline died during the follow-up period compared with 22.0% of those without insomnia at baseline. Recent insomnia was not associated significantly with mortality in either crude analyses (Hazards Ratio (HR) = 1.11, 95% CI, 0.78-1.60) or analyses adjusted for age, prescription medication use, functional limitations, self-rated health, and number of chronic conditions (HR = 0.74, 95% CI, 0.50-1.09)., Conclusion: Our results, combined with the results from previous studies, suggest strongly that insomnia is not an indicator of approaching mortality in older community-dwelling populations.

Purpose: To identify medical care indicators for nursing home terminal care., Data Sources: Studies examining care of terminally ill patients were identified using computer, bibliography, and expert searches; input from nursing home medical directors in Maryland; and input from expert geriatricians., Study Selection: More than 900 articles, books, and abstracts from meetings covering medical care for terminally ill patients were reviewed. Information from more than 100 publications is included., Data Extraction: Indicators of medical care for terminally ill patients, which can be used to quantify performance with respect to standards, guidelines, and options, were identified initially through review of the literature., Data Synthesis: Indicators were refined by input from medical directors of Maryland long-term care facilities and subsequent review by expert geriatricians., Conclusions: Minimum standards for which 100% performance is expected are communication of advance directives, attention to pain control, and attention to relief of dyspnea. Performance indicators for medical care guidelines and options in terminal care of nursing home patients are also described.