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One-third of opioid (OPI) overdose deaths involve concurrent benzodiazepine (BZD) use. Little is known about concurrent opioid and benzodiazepine use (OPI-BZD) most associated with overdose risk. We aimed to examine associations between OPI-BZD dose and duration trajectories, and subsequent OPI or BZD overdose in US Medicare.Retrospective cohort study.US Medicare.Using a 5% national Medicare data sample (2013-16) of fee-for-service beneficiaries without cancer initiating OPI prescriptions, we identified 37 879 beneficiaries (age ≥ 65 = 59.3%, female = 71.9%, white = 87.6%, having OPI overdose = 0.3%).During the 6 months following OPI initiation (i.e. trajectory period), we identified OPI-BZD dose and duration patterns using group-based multi-trajectory models, based on average daily morphine milligram equivalents (MME) for OPIs and diazepam milligram equivalents (DME) for BZDs. To label dose levels in each trajectory, we defined OPI use as very low ( 25 MME), low (25-50 MME), moderate (51-90 MME), high (91-150 MME) and very high (150 MME) dose. Similarly, we defined BZD use as very low ( 10 DME), low (10-20 DME), moderate (21-40 DME), high (41-60 DME) and very high ( 60 DME) dose. Our primary analysis was to estimate the risk of time to first hospital or emergency department visit for OPI overdose within 6 months following the trajectory period using inverse probability of treatment-weighted Cox proportional hazards models.We identified nine distinct OPI-BZD trajectories: group A: very low OPI (early discontinuation)-very low declining BZD (n = 10 598; 28.0% of the cohort); B: very low OPI (early discontinuation)-very low stable BZD (n = 4923; 13.0%); C: very low OPI (early discontinuation)-medium BZD (n = 4997; 13.2%); D: low OPI-low BZD (n = 5083; 13.4%); E: low OPI-high BZD (n = 3906; 10.3%); F: medium OPI-low BZD (n = 3948; 10.4%); G: very high OPI-high BZD (n = 1371; 3.6%); H: very high OPI-very high BZD (n = 957; 2.5%); and I: very high OPI-low BZD (n = 2096; 5.5%). Compared with group A, five trajectories (32.3% of the study cohort) were associated with increased 6-month OPI overdose risks: E: low OPI-high BZD [hazard ratio (HR) = 3.27, 95% confidence interval (CI) = 1.61-6.63]; F: medium OPI-low BZD (HR = 4.04, 95% CI = 2.06-7.95); G: very high OPI-high BZD (HR = 6.98, 95% CI = 3.11-15.64); H: very high OPI-very high BZD (HR = 4.41, 95% CI = 1.51-12.85); and I: very high OPI-low BZD (HR = 6.50, 95% CI = 3.15-13.42).Patterns of concurrent opioid and benzodiazepine use most associated with overdose risk among fee-for-service US Medicare beneficiaries initiating opioid prescriptions include very high-dose opioid use (MME 150), high-dose benzodiazepine use (DME 40) or medium-dose opioid with low-dose benzodiazepine use.

Objectives To examine the association between central nervous system (CNS) medication dosage burden and risk of serious falls, including hip fractures, in individuals with a history of a recent fall. Design Nested case–control study. Setting Veterans Health Administration (VHA) Community Living Centers (CLCs). Participants CLC residents aged 65 and older with a history of a fall or hip fracture in the year before a CLC admission between July 1, 2005, and June 30, 2009. Each case (n = 316) was matched to four controls (n = 1264) on age, sex, and length of stay. Measurements Outcomes were serious falls identified using International Classification of Diseases, Ninth Revision (ACD‐9) or Current Procedural Terminology (CPT) E codes, diagnosis codes, or procedure codes associated with a VHA emergency department visit or hospitalization during the CLC stay. Bar code medication administration data were used to calculate CNS standardized daily doses (SDDs) for opioid and benzodiazepine receptor agonists, some antidepressants, antiepileptics, and antipsychotics received in the 6 days before the outcome date by dividing residents' actual CNS daily doses by the minimum effective geriatric daily doses and adding the results. Multivariable conditional logistic regression models were used to evaluate the association between total CNS medication dosage burden, categorized as 0, 1 to 2, and 3 or more SDDs, and the outcome of recurrent serious falls. Results More cases (44.3%) than controls (35.8%) received 3.0 or more CNS SDDs (p = .02). Risk of serious falls was greater in residents with 3.0 or more SDDs than in those with 0 (adjusted odds ratio (aOR)=1.49, 95% confidence interval (CI)=1.03–2.14). Those with 1.0 to 2.9 SDDs had a risk similar to that of those with 0 SDDs (aOR=1.03, 95%CI=0.72–1.48). Conclusion Nursing home residents with a history of a fall or hip fracture receiving 3.0 or more CNS SDDs were more likely to have a recurrent serious fall than those taking no CNS medications. Interventions targeting this vulnerable population may help reduce serious falls. J Am Geriatr Soc 67:74–80, 2019.

Background There is no gold standard to assess potential anticholinergic burden of medications.

OBJECTIVES: To compare falls and fall-related injuries that a fall evaluator or hospital incident report identified with injuries identified according to discharge International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for the same set of inpatient episodes of care. DESIGN: Prospective, descriptive study. SETTING: Sixteen adult general medical and surgical units in a major urban teaching hospital. PARTICIPANTS: All adults who sustained a fall with injury during a 5-year period (380 falls with injury). MEASUREMENTS: Falls that a fall evaluator or hospital incident report identified were classified according to their injury severity. Discharge abstracts provided diagnosis codes (ICD-9-CM) for the discharge, including fall-related injury codes. RESULTS: Three hundred forty-three inpatient falls with injury (90.2%) resulted in temporary harm to the individual; the remaining 37 falls (9.8%) resulted in more-serious harm. Sixteen of the 37 falls with injury extending hospitalization or resulting in death were identified using Centers for Medicare and Medicaid Services (CMS)-targeted injury code ranges combined with present-on-admission indicators. Of the 21 falls with injury that were not identified, nine (42.9%) lacked documentation of any injury, and seven (33.3%) identified other injuries outside the CMS-targeted injury code ranges. CONCLUSION: The CMS-targeted ICD-9-CM codes used to identify fall-related injuries in claims data do not always detect the most-serious falls. Language: en

Objectives: To evaluate whether the use of angiotensin-converting enzyme (ACE) inhibitors and statins is associated with a lower risk of incident mobility limitation in older community dwelling adults. Design: Longitudinal cohort study. Setting: Health, Aging and Body Composition (Health ABC) study. Participants: Three thousand fifty-five participants who were well functioning at baseline (no mobility limitations). Measurements: Summated standardized daily doses (low, medium, high) and duration of ACE inhibitor and statin use were computed. Mobility limitation (two consecutive self-reports of having any difficulty walking one-quarter of a mile or climbing 10 steps without resting) was assessed every 6 months after baseline. Multivariable Cox proportional hazards analyses were conducted, adjusting for demographics, health status, and health behaviors. Results: At baseline, 15.2% used ACE inhibitors and 12.9% used statins; use of both was greater than 25% by Year 6. Over 6.5 years of follow-up, 49.8% had developed mobility limitation. In separate multivariable models, neither ACE inhibitor (multivariate hazard ratio (HR) = 0.95, 95% confidence interval (CI) = 0.82�1.09) nor statin use (multivariate HR = 1.02, 95% CI = 0.87�1.17) was associated with lower risk of mobility limitation. Similar findings were seen in analyses examining dose�response and duration�response relationships and a sensitivity analysis restricted to those with hypertension. Conclusion: ACE inhibitors and statins widely prescribed to treat hypertension and hypercholesterolemia, respectively, do not lower risk of mobility limitation, an important indicator of quality of life.

OBJECTIVES: To evaluate whether use of certain medications with potential urological effects is associated with development of incident urinary incontinence in community-resident older women. DESIGN: Longitudinal cohort study. SETTING: Pittsburgh, PA, and Memphis, TN. PARTICIPANTS: Nine hundred fifty-nine healthy black and white women aged 65 and older enrolled in the Health, Aging and Body Composition Study without baseline (Year 1) self-reported urinary incontinence. MEASUREMENTS: Use of alpha blockers, anticholinergics, central nervous system medications (opioids, benzodiazepines, antidepressants, antipsychotics), diuretics (thiazide, loop, potassium sparing), and estrogen (all dosage forms) was determined during Year 3 interviews. Self-reported incident (≥weekly) incontinence in during the previous 12 months was assessed at Year 4 interviews. RESULTS: Overall, 20.5% of these women reported incident incontinence at Year 4 (3 years from baseline). The most common medication used with potential urological activity was a thiazide diuretic (24.3%), followed by estrogen (22.2%); alpha blockers were the least commonly used (2.3%). Multivariable logistic regression analyses revealed that current users of alpha blockers (adjusted odds ratio (AOR)=4.98, 95% confidence interval (CI)=1.96–12.64) and estrogen (AOR=1.60, 95% CI=1.08–2.36) had a greater risk of urinary incontinence than nonusers. There was no greater risk (P>.05) of urinary incontinence with the current use of anticholinergics, central nervous system medications, or diuretics. No statistically significant race-by–medication use interactions were found (all P>.05). CONCLUSION: These results corroborate earlier reports that, in elderly women, use of alpha blockers or estrogens is associated with risk of self-reported incident urinary incontinence.

Objectives—To determine if sensory and motor nerve function was associated cross-sectionally with quadriceps strength or ankle dorsiflexion strength in an older community-based population. Design, Setting, Participants—Health, Aging, and Body Composition Study participants (N=2059; 50% men; 37% black, aged 73-82 years) in 2000-2001.

This article describes medical students' evaluation of a geriatric clerkship in postacute rehabilitative care settings. This was a cross-sectional study of fourth-year medical students who completed a mandatory 2-week rotation at a postacute care facility. Students were provided with three instructional methods: Web-based interactive learning modules; small-group sessions with geriatric faculty; and Geriatric Interdisciplinary Care Summary (GICS), a grid that students used to formulate comprehensive interdisciplinary care plans for their own patients. After the rotation, students evaluated the overall clerkship, patient care activities, and usefulness of the three instructional methods using a 5-point Likert scale (1=poor to 5=excellent) and listed their area of future specialty. Of 156 students who completed the rotation, 117 (75%) completed the evaluation. Thirty (26%) chose specialties providing chronic disease management such as family, internal medicine, and psychiatry; 34 (29%) chose specialties providing primarily procedural services such as surgery, radiology, anesthesiology, pathology, and radiation oncology. Students rated the usefulness of the GICS as good to very good (mean+/-standard deviation 3.3+/-1.0). Similarly, they rated overall clerkship as good to excellent (3.8+/-1.0). Analysis of variance revealed no significant group difference in any of the responses from students with the overall clerkship (F(112, 4)=1.7, P=.20). Students rated the geriatric clerkship favorably and found the multimodal instruction to be useful. Even for students whose career choice was not primary care, geriatrics was a good model for interdisciplinary care training and could serve as a model for other disciplines.

Purpose To evaluate whether CNS medication use in older adults was associated with a higher risk of future incident mobility limitation. Methods This 5-year longitudinal cohort study included 3055 participants from the health, aging and body composition (Health ABC) study who were well-functioning at baseline. CNS medication use (benzodiazepine and opioid receptor agonists, antipsychotics, and antidepressants) was determined yearly (except year 4) during in-home or in-clinic interviews. Summated standardized daily doses (low, medium, and high) and duration of CNS drug use were computed. Incident mobility limitation was operationalized as two consecutive self-reports of having any difficulty walking 1/4 mile or climbing 10 steps without resting every 6 months after baseline. Multivariable Cox proportional hazard analyses were conducted adjusting for demographics, health behaviors, health status, and common indications for CNS medications. Results Each year at least 13.9% of participants used a CNS medication. By year 6, overall 49% had developed incident mobility limitation. In multivariable models, CNS medication users compared to never users showed a higher risk for incident mobility limitation (adjusted hazard ratio (Adj. HR) 1.28; 95% confidence interval (CI) 1.12–1.47). Similar findings of increased risk were seen in analyses examining dose– and duration–response relationships. Conclusions CNS medication use is independently associated with an increased risk of future incident mobility limitation in community dwelling elderly. Further studies are needed to determine the impact of reducing CNS medication exposure on mobility problems. Copyright © 2009 John Wiley & Sons, Ltd.

OBJECTIVES: To evaluate whether combined use of multiple central nervous system (CNS) medications over time is associated with cognitive change. DESIGN: Longitudinal cohort study. SETTING: Pittsburgh, Pennsylvania, and Memphis, Tennessee. PARTICIPANTS: Two thousand seven hundred thirty-seven healthy adults (aged ≥65) enrolled in the Health, Aging and Body Composition study without baseline cognitive impairment (modified Mini-Mental State Examination (3MS) score ≥80). MEASUREMENTS: CNS medication (benzodiazepine- and opioid-receptor agonists, antipsychotics, antidepressants) use, duration, and dose were determined at baseline (Year 1) and Years 3 and 5. Cognitive function was measured using the 3MS at baseline and Years 3 and 5. The outcome variables were incident cognitive impairment (3MS score 3 standardized daily doses) (adj HR=1.87, 95% CI=1.25–2.79) of CNS medications suggested greater risk of cognitive decline than with nonuse. CONCLUSION: Combined use of CNS medications, especially at higher doses, appears to be associated with cognitive decline in older adults. Future studies must explore the effect of combined CNS medication use on vulnerable older adults.

OBJECTIVES To determine the utility of a fall evaluation service to improve the ascertainment of falls in acute care.

OBJECTIVES: To examine the association between poorer performance on concurrent walking and reaction time and recurrent falls. DESIGN: Cross-sectional analysis. SETTING: Community. PARTICIPANTS: Three hundred seventy-seven older community-dwelling adults (mean age+/-standard deviation 78+/-3). MEASUREMENTS: Reaction times on push-button and visual-spatial decision tasks were assessed while seated and while walking a 20-m course (straight walk) and a 20-m course with a turn at 10 m (turn walk). Walking times were recorded while walking only and while performing a reaction-time response. Dual-task performance was calculated as the percentage change in task times when done in dual-task versus single-task conditions. A history of recurrent falls (>/=2 vs

Anxiety symptoms are common, affecting from 8% to 18% of community-dwelling older adults and up to half of those with depression,1–3 and can be quite debilitating.4 Several studies link depressive symptoms to functional decline,5,6 but despite the strong interrelationship between anxiety and depression, few have examined anxiety symptoms’ unique contribution to functional decline.7,8 Functional decline is an important consequence of increasing frailty in older adults, characterized by decreasing physical performance and increased reliance on others for assistance in mobility and other basic activities of daily living. Such decline represents an important precursor of disability, loss of independence, and death.9,10 Performance-based and self-report measures have been used to measure functional status, and both are strongly associated with disability and mortality. These measures complement one another, and both can be used to describe decline.11 Prior longitudinal studies of anxiety symptoms and disability suggest high co-occurrence of depression and anxiety.7 These studies have used a variety of screening instruments to define anxiety symptoms, including the Hospital Anxiety and Depression Scale, the Speilberger State Trait Anxiety Inventory, and the Hopkins Symptom Checklist,8,12,13 but none have examined the effect of anxiety symptoms on incident disability independent of depressive symptoms. To better understand the relationship between anxiety symptoms and functional decline, longitudinal data from participants in the Health, Aging and Body Composition (Health ABC) Study were analyzed. It was hypothesized that older adults with anxiety symptoms would experience greater declines in self-reported mobility difficulty and performance-based functional decline over 5 years.

Objectives: To determine whether magnesium intake from supplemental and dietary sources is associated with bone mineral density (BMD) in older men and women. Design: Cross-sectional. Setting: Memphis, Tennessee, and Pittsburgh, Pennsylvania. Participants: Two thousand thirty-eight older black and white men and women aged 70 to 79 at baseline enrolled in the Health, Aging and Body Composition Study. Measurements: Dietary intake of magnesium was assessed using a semiquantitative food frequency questionnaire, and supplement data were collected based on a medication inventory. BMD of the whole body was obtained using a fan-beam densitometer. Additional covariates included age, body mass index (BMI), smoking status, alcohol use, physical activity, estrogen use, and supplemental calcium (Ca) and vitamin D use. Results: In white, but not black, men and women, magnesium intake was positively associated with BMD of the whole body after adjustment for age, self-report of osteoporosis or fracture in adulthood, caloric intake, Ca and vitamin D intake, BMI, smoking status, alcohol intake, physical activity, thiazide diuretic use, and estrogen use in women (P=.05 for men and P=.005 for women). BMD was 0.04 g/cm2 higher in white women and 0.02 g/cm2 higher in white men in the highest than in the lowest quintile of magnesium intake. Conclusion: Greater magnesium intake was significantly related to higher BMD in white women and men. The lack of association observed in black women and men may be related to differences in Ca regulation or in nutrient reporting.

Objectives: To determine whether patient age, the presence of comorbid illness, and the number of prescribed medications influence the duration of a physician visit in an ambulatory care setting. Design: A cross-sectional study of ambulatory care visits made by adults aged 45 and older to primary care physicians. Setting: A probability sample of outpatient follow-up visits in the United States using the National Ambulatory Medical Care Survey (NAMCS) 2002 database. Participants: Of 28,738 physician visits in the 2002 NAMCS data set, there were 3,819 visits by adults aged 45 and older included in this study for analysis. Measurements: The primary endpoint was the time that a physician spent with a patient at each visit. Covariates included for analyses were patient characteristics, physician characteristics, visit characteristics, and source of payment. Visit characteristics, including the number of diagnoses and the number of prescribed medications, the major diagnoses, and the therapeutic class of prescribed medications, were compared for different age groups (45–64, 65–74, and ≥75) to determine the complexity of the patient's medical conditions. Endpoint estimates were computed by age group and were also estimated based on study covariates using univariate and multivariate linear regression. Results: The mean time±standard deviation spent with a physician was 17.9±8.5 minutes. There were no differences in the duration of visits between the age groups before or after adjustment for patient covariates. Patients aged 75 and older had more comorbid illness and were prescribed more medications than patients aged 45 to 64 and 65 to 74 (P

Type 2 diabetes may be associated with elevated fracture risk, but the impact on bone loss is unknown. Analysis of 4-year change in hip BMD data from a cohort of white and black well-functioning men and women 70-79 years of age found that white women with diabetes had more rapid bone loss at the femoral neck than those with normal glucose metabolism. Introduction: Type 2 diabetes may be associated with elevated fracture risk in older adults. Although type 2 diabetes is not associated with lower BMD, older diabetic adults have a higher prevalence of other risk factors for fracture, including more frequent falls, functional limitations, and diabetic complications. With this burden of risk factors, loss of BMD could place older adults with diabetes at higher risk of sustaining a fracture. Materials and Methods: To determine if bone loss is increased with type 2 diabetes, we analyzed data from the Health, Aging, and Body Composition Study of white and black well-functioning men and women 70-79 years of age. Hip BMD was measured at baseline and 4 years later in 480 (23%) participants with diabetes, 439 with impaired glucose metabolism, and 1172 with normal glucose homeostasis (NG). Results: Those with diabetes had higher baseline hip BMD and weight, but among white women, had more weight loss over 4 years. White women with diabetes lost more femoral neck and total hip BMD than those with NG in age-adjusted models. After multivariable adjustment, diabetes was associated with greater loss of femoral neck BMD (−0.32%/year; 95% CI: −0.61, −0.02) but not total hip BMD. In men and black women, change in hip BMD was similar for participants with diabetes and NG. Conclusions: Despite having higher baseline BMD, diabetic white women, but not men or black women, had more rapid bone loss at the femoral neck than those with NG. This increased bone loss may contribute to the higher fracture risk observed in older diabetic women.

OBJECTIVE: To determine the prevalence of undiagnosed non-insulin-dependent diabetes mellitus (NIDDM) and impaired glucose tolerance (IGT) in a cohort of older persons with hypertension. To examine the usefulness of screening for NIDDM in this study population. DESIGN: Cross-sectional study. SETTING: University of Tennessee, Memphis and the General Clinical Research Center (GCRC). PATIENTS: Ninety-five participants in the Trial of Nonphar-macologic Interventions in the Elderly (TONE) study who agreed to participate in an ancillary study. MEASUREMENTS: A standard oral glucose tolerance test (OGTT) with insulin and C-peptide levels was performed before the beginning of the TONE intervention. RESULTS: In this cohort, 43 participants (45.3%) had normal glucose tolerance (NGT), 41 (43.2%) had IGT, and 11 (11.6%) had undiagnosed NIDDM. The positive predictive value for NIDDM of a fasting glucose ≥ 115 mg/dL in our participants was 57%. Hyperinsulinemia occurred in only one participant, a subject in the IGT group. CONCLUSIONS: Our data demonstrate that undiagnosed NIDDM is common in our cohort of older persons who are being treated for essential hypertension and that impaired glucose tolerance may be more common than in the general population of the same age. Further, our data show that the vast majority of this older, obese, hypertensive cohort did not have fasting hyperinsulinemia. We also infer that a fasting glucose alone has a low positive predictive value for screening of NIDDM in our older cohort. As the prevalence of NIDDM and impaired glucose tolerance in older hypertensive patients in the general population is unknown, we believe that further investigation is needed to characterize the relationship of hypertension, glycemic status, and hyperinsulinemia in the general population.