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The article highlights the U13 Bench-to-Bedside (B2B) conference series, a collaborative effort by the American Geriatrics Society (AGS) and the National Institute on Aging. Topics include the transition of the AGS/National Institute on Aging (NIA) U13 B2B conference series from 2004 to 2017, progressive exploration of key issues in geriatrics reflected in the series of conferences, and an overview of the conferences in the series from 2018 to 2023.

Objective: Although animal models suggest a role for blood–brain barrier dysfunction in postoperative delirium‐like behavior, its role in postoperative delirium and postoperative recovery in humans is unclear. Thus, we evaluated the role of blood–brain barrier dysfunction in postoperative delirium and hospital length of stay among older surgery patients. Methods: Cognitive testing, delirium assessment, and cerebrospinal fluid and blood sampling were prospectively performed before and after non‐cardiac, non‐neurologic surgery. Blood–brain barrier dysfunction was assessed using the cerebrospinal fluid‐to‐plasma albumin ratio (CPAR). Results: Of 207 patients (median age = 68 years, 45% female) with complete CPAR and delirium data, 26 (12.6%) developed postoperative delirium. Overall, CPAR increased from before to 24 hours after surgery (median change = 0.28, interquartile range [IQR] = −0.48 to 1.24, Wilcoxon p = 0.001). Preoperative to 24 hours postoperative change in CPAR was greater among patients who developed delirium versus those who did not (median [IQR] = 1.31 [0.004 to 2.34] vs 0.19 [−0.55 to 1.08], p = 0.003). In a multivariable model adjusting for age, baseline cognition, and surgery type, preoperative to 24 hours postoperative change in CPAR was independently associated with delirium occurrence (per CPAR increase of 1, odds ratio = 1.30, 95% confidence interval [CI] = 1.03–1.63, p = 0.026) and increased hospital length of stay (incidence rate ratio = 1.15, 95% CI = 1.09–1.22, p < 0.001). Interpretation: Postoperative increases in blood–brain barrier permeability are independently associated with increased delirium rates and postoperative hospital length of stay. Although these findings do not establish causality, studies are warranted to determine whether interventions to reduce postoperative blood–brain barrier dysfunction would reduce postoperative delirium rates and hospital length of stay. ANN NEUROL 2023;94:1024–1035 [ABSTRACT FROM AUTHOR]

The objectives of this article are to introduce a conceptual framework for physical resilience in the context of ageing and to discuss key elements and challenges in the design of studies of physical resilience after health stressors. Advancing age is associated with increasing exposure to multiple stressors and declining capacity to respond to health stressors. Resilience is defined broadly as the ability to resist or recover well from the adverse effects of a health stressor. In ageing‐related study designs of physical resilience after a health stressor, this dynamic resilience response can be observed as changes in repeated measures of function or health status in various domains important to older adults. Methodologic issues in selecting the study population, defining the stressor, covariates, outcomes, and analytic strategies are highlighted in the context of an ongoing prospective cohort study of physical resilience after total knee replacement surgery. The article concludes with approaches to intervention development to optimize resilience. [ABSTRACT FROM AUTHOR]

Resilience, which relates to one's ability to respond to stressors, typically declines with age and the development of comorbid conditions in older organisms. Although progress has been made to improve our understanding of resilience in older adults, disciplines have employed different frameworks and definitions to study various aspects of older adults' response to acute or chronic stressors. "Overview of the Resilience World: State of the Science," a bench‐to‐bedside conference on October 12–13, 2022, was sponsored by the American Geriatrics Society and National Institute on Aging. This conference, summarized in this report, explored commonalities and differences among the frameworks of resilience most commonly used in aging research in the three domains of resilience: physical, cognitive, and psychosocial. These three main domains are intertwined, and stressors in one domain can lead to effects in other domains. The themes of the conference sessions included underlying contributors to resilience, the dynamic nature of resilience throughout the life span, and the role of resilience in health equity. Although participants did not agree on a single definition of "resilience(s)," they identified common core elements of a definition that can be applied to all domains and noted unique features that are domain specific. The presentations and discussions led to recommendations for new longitudinal studies of the impact of exposures to stressors on resilience in older adults, the use of new and existing cohort study data, natural experiments (including the COVID‐19 pandemic), and preclinical models for resilience research, as well as translational research to bring findings on resilience to patient care. [ABSTRACT FROM AUTHOR]

This report summarizes the presentations, discussions, and recommendations of the most recent American Geriatrics Society and National Institute on Aging research conference, "Cancer and Cardiovascular Disease," on October 18–19, 2021. The purpose of this virtual meeting was to address the interface between cancer and heart disease, which are the two leading causes of death among older Americans. Age‐related physiologic changes are implicated in the pathogenesis of both conditions. Emerging data suggest that cancer‐related cardiovascular disease (CVD) involves disrupted cell signaling and cellular senescence. The risk factors for CVD are also risk factors for cancer and an increased likelihood of cancer death, and people who have both cancer and CVD do more poorly than those who have only cancer or only CVD. Issues addressed in this bench‐to‐bedside conference include mechanisms of cancer and CVD co‐development in older adults, cardiotoxic effects of cancer therapy, and management of comorbid cancer and CVD. Presenters discussed approaches to ensure equitable access to clinical trials and health care for diverse populations of adults with CVD and cancer, mechanisms of cancer therapy cardiotoxicity, and management of comorbid CVD and cancer, including the role of patient values and preferences in treatment decisions. Workshop participants identified many research gaps and questions that could lead to an enhanced understanding of comorbid CVD and cancer and to better and more equitable management strategies. [ABSTRACT FROM AUTHOR]

Objective: Numerous investigators have theorized that postoperative changes in Alzheimer's disease neuropathology may underlie postoperative neurocognitive disorders. Thus, we determined the relationship between postoperative changes in cognition and cerebrospinal (CSF) tau, p‐tau‐181p, or Aβ levels after non‐cardiac, non‐neurologic surgery in older adults. Methods: Participants underwent cognitive testing before and 6 weeks after surgery, and lumbar punctures before, 24 h after, and 6 weeks after surgery. Cognitive scores were combined via factor analysis into an overall cognitive index. In total, 110 patients returned for 6‐week postoperative testing and were included in the analysis. Results: There was no significant change from before to 24 h or 6 weeks following surgery in CSF tau (median [median absolute deviation] change before to 24 h: 0.00 [4.36] pg/mL, p = 0.853; change before to 6 weeks: −1.21 [3.98] pg/mL, p = 0.827). There were also no significant changes in CSF p‐tau‐181p or Aβ over this period. There was no change in cognitive index (mean [95% CI] 0.040 [−0.018, 0.098], p = 0.175) from before to 6 weeks after surgery, although there were postoperative declines in verbal memory (−0.346 [−0.523, −0.170], p = 0.003) and improvements in executive function (0.394, [0.310, 0.479], p < 0.001). There were no significant correlations between preoperative to 6‐week postoperative changes in cognition and CSF tau, p‐tau‐181p, or Aβ42 changes over this interval (p > 0.05 for each). Interpretation: Neurocognitive changes after non‐cardiac, non‐neurologic surgery in the majority of cognitively healthy, community‐dwelling older adults are unlikely to be related to postoperative changes in AD neuropathology (as assessed by CSF Aβ, tau or p‐tau‐181p levels or the p‐tau‐181p/Aβ or tau/Aβ ratios). Trial Registration: clinicaltrials.gov (NCT01993836). [ABSTRACT FROM AUTHOR]

Background: Older adults with similar health conditions often experience widely divergent outcomes following health stressors. Variable recovery after a health stressor may be due in part to differences in biological mechanisms at the molecular, cellular, or system level, that are elicited in response to stressors. We describe the PRIME‐KNEE study as an example of ongoing research to validate provocative clinical tests and biomarkers that predict resilience to specific health stressors. Methods: PRIME‐KNEE is an ongoing, prospective cohort study that will enroll 250 adults ≥60 years undergoing total knee arthroplasty. Data are collected at baseline (pre‐surgery), during surgery, daily for 7 days after surgery, and at 1, 2, 4, and 6 months post‐surgery. Provocative tests include a cognition‐motor dual‐task walking test, cerebrovascular reactivity assessed by functional near‐infrared spectroscopy, peripheral blood mononuclear cell reactivity ex vivo to lipopolysaccharide toxin and influenza vaccine, and heart rate variability during surgery. Cognitive, psychological, and physical performance batteries are collected at baseline to estimate prestressor reserve. Demographics, medications, comorbidities, and stressor characteristics are abstracted from the electronic medical record and via participant interview. Blood‐based biomarkers are collected at baseline and postoperative day 1. Repeated measures after surgery include items from a delirium assessment tool and pain scales administered daily by telephone for 7 days and cognitive change index (participant and informant), lower extremity activities of daily living, pain scales, and step counts assessed by Garmin actigraphy at 1, 2, 4, and 6 months after surgery. Statistical models use these measures to characterize resilience phenotypes and evaluate prestressor clinical indicators associated with poststressor resilience. Conclusion: If PRIME‐KNEE validates feasible clinical tests and biomarkers that predict recovery trajectories in older surgical patients, these tools may inform surgical decision‐making, guide pre‐habilitation efforts, and elucidate mechanisms underlying resilience. This study design could motivate future geriatric research on resilience. [ABSTRACT FROM AUTHOR]

Fellows and junior faculty conducting aging research have encountered substantial new challenges during the COVID‐19 pandemic. They report that they have been uncertain how and whether to modify existing research studies, have faced difficulties with job searches, and have struggled to balance competing pressures including greater clinical obligations and increased responsibilities at home. Many have also wondered if they should shift gears and make COVID‐19 the focus of their research. We asked a group of accomplished scientists and mentors to grapple with these concerns and to share their thoughts with readers of this journal. See related Special article by Storer et al. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To develop a prognostic model for hospital admissions over a 1‐year period among community‐dwelling older adults with self‐reported hearing and/or vision impairments based on readily obtainable clinical predictors. DESIGN: Retrospective cohort study. SETTING: Medicare Current Beneficiary Survey from 1999 to 2006. PARTICIPANTS: Community‐dwelling Medicare beneficiaries, aged 65 years and older, with self‐reported hearing and/or vision impairment (N = 15,999). MEASUREMENTS: The primary outcome was any hospital admission over a predefined 1‐year study period. Candidate predictors included demographic factors, prior healthcare utilization, comorbidities, functional impairment, and patient‐level factors. We analyzed the association of all candidate predictors with any hospital admission over the 1‐year study period using multivariable logistic regression. The final model was created using a penalized regression method known as the least absolute shrinkage and selection operator. Model performance was assessed by discrimination (concordance statistic (c‐statistic)) and calibration (evaluated graphically). Internal validation was performed via bootstrapping, and results were adjusted for overoptimism. RESULTS: Of the 15,999 participants, the mean age was 78 years and 55% were female. A total of 2,567 participants (16.0%) had at least one hospital admission in the 1‐year study period. The final model included seven variables independently associated with hospitalization: number of inpatient admissions in the previous year, number of emergency department visits in the previous year, activities of daily living difficulty score, poor self‐rated health, and self‐reported history of myocardial infarction, stroke, and nonskin cancer. The c‐statistic of the final model was 0.717. The optimism‐corrected c‐statistic after bootstrap internal validation was 0.716. A calibration plot suggested that the model tended to overestimate risk among patients at the highest risk for hospitalization. CONCLUSION: This prognostic model can help identify which community‐dwelling older adults with sensory impairments are at highest risk for hospitalization and may inform allocation of healthcare resources. [ABSTRACT FROM AUTHOR]

This report summarizes the presentations and recommendations of the eleventh annual American Geriatrics Society and National Institute on Aging research conference, "Osteoporosis and Soft Tissue (Muscle/Fat) Disorders," on March 11‐12, 2019, in Bethesda, Maryland. Falls, fractures, and sarcopenia have a major impact on health in older adults, and they are interconnected by known risk factors. The link between osteoporosis, which is common in older adults, and the risk of falls is well known. Sarcopenia, the age‐related decline in skeletal muscle mass and function, is also associated with an increased risk of falls and fractures because it reduces strength and leads to functional limitations. In addition to increasing the risk of falls, sarcopenia and osteoporosis can lead to frailty, reduced quality of life, morbidity, and mortality. The conference highlighted the impact of bone and soft tissue disorders on quality of life, morbidity, and mortality in older adults. Presenters described factors that contribute to these disorders; health disparities experienced by various subpopulations; and promising biological, pharmacologic, and behavioral interventions to prevent or treat these disorders. The workshop identified many research gaps and questions along with research recommendations that have the potential to enhance the prospect of healthy aging and improved quality of life for older adults. J Am Geriatr Soc 68:31–38, 2019 [ABSTRACT FROM AUTHOR]

OBJECTIVES: Defining common patterns of recovery after an acute health stressor (resiliency groups) has both clinical and research implications. We sought to identify groups of patients with similar recovery patterns across 10 outcomes following hip fracture (stressor) and to determine the most important predictors of resiliency group membership. DESIGN: Secondary analysis of three prospective cohort studies. SETTING: Participants were recruited from various hospitals in the Baltimore Hip Studies network and followed for up to 1 year in their residence (home or facility). PARTICIPANTS: Community‐dwelling adults aged 65 years or older with recent surgical repair of a hip fracture (n = 541). MEASUREMENTS: Self‐reported physical function and activity measures using validated scales were collected at baseline (within 15‐22 d of fracture), 2, 6, and 12 months. Physical performance tests were administered at all follow‐up visits. Stressor characteristics, comorbidities, and psychosocial and environmental factors were collected at baseline via participant report and chart abstraction. Latent class profile analysis was used to identify resiliency groups based on recovery trajectories across 10 outcome measures and logistic regression models to identify factors associated with those groups. RESULTS: Latent profile analysis identified three resiliency groups that had similar patterns across the 10 outcome measures and were defined as "high resilience" (n = 163 [30.1%]), "medium resilience" (n = 242 [44.7%]), and "low resilience" (n = 136 [25.2%]). Recovery trajectories for the outcome measures are presented for each resiliency group. Comparing highest with the medium‐ and low‐resilience groups, self‐reported pre‐fracture function was by far the strongest predictor of high‐resilience group membership with area under the curve (AUC) of.84. Demographic factors, comorbidities, stressor characteristics, environmental factors, and psychosocial characteristics were less predictive, but several factors remained significant in a multivariable model (AUC =.88). CONCLUSION: These three resiliency groups following hip fracture may be useful for understanding mediators of physical resilience. They may provide a more detailed description of recovery patterns in multiple outcomes for use in clinical decision making. J Am Geriatr Soc 67:2519–2527, 2019 [ABSTRACT FROM AUTHOR]

Background: Geriatricians are often confronted with unexpected health outcomes in older adults with complex multimorbidity. Aging researchers have recently called for a focus on physical resilience as a new approach to explaining such outcomes. Physical resilience, defined as the ability to resist functional decline or recover health following a stressor, is an emerging construct. Methods: Based on an outline of the state‐of‐the‐art in research on the measurement of physical resilience, this article describes what tests to predict resilience can already be used in clinical practice and which innovations are to be expected soon. Results: An older adult's recovery potential is currently predicted by static tests of physiological reserves. Although geriatric medicine typically adopts a multidisciplinary view of the patient and implicitly performs resilience management to a certain extent, clinical management of older adults can benefit from explicitly applying the dynamical concept of resilience. Two crucial leads for advancing our capacity to measure and manage the resilience of individual patients are advocated: first, performing multiple repeated measurements around a stressor can provide insight about the patient's dynamic responses to stressors; and, second, linking psychological and physiological subsystems, as proposed by network studies on resilience, can provide insight into dynamic interactions involved in a resilient response. Conclusion: A big challenge still lies ahead in translating the dynamical concept of resilience into clinical tools and guidelines. As a first step in bridging this gap, this article outlines what opportunities clinicians and researchers can already exploit to improve prediction, understanding, and management of resilience of older adults. J Am Geriatr Soc 67:2650–2657, 2019 [ABSTRACT FROM AUTHOR]

Understanding the factors that influence functional ability over the life course is integral to identifying clinical and public health policies to facilitate successful aging. The World Health Organization has advocated a conceptual framework to clarify the policy discussion. We have sought to translate this general framework into an explicit system dynamics model of the interaction of physiological loss, stressors and endogenous responses to produce a familiar variety of trajectories of functional ability over the life courses. Simulation experiments were implemented for both a 30‐month duration with only one major stressor; and for the life course with an initial major stressor and subsequent stressors determined by the level of functional ability. For both contexts, variations in the few parameters in the scenarios led to a realistic range of trajectories of function over time. © 2019 System Dynamics Society [ABSTRACT FROM AUTHOR]

Although declines in cognitive capacity are assumed to be a characteristic of aging, increasing evidence shows that it is age‐related disease, rather than age itself, that causes cognitive impairment. Even so, older age is a primary risk factor for cognitive decline, and with individuals living longer as a result of medical advances, cognitive impairment and dementia are increasing in prevalence. On March 26 to 27, 2018, the American Geriatrics Society convened a conference in Bethesda, MD, to explore cognitive impairment across the subspecialties. Bringing together representatives from several subspecialties, this was the third of three conferences, supported by a U13 grant from the National Institute on Aging, to aid recipients of Grants for Early Medical/Surgical Specialists' Transition to Aging Research (GEMSSTAR) in integrating geriatrics into their subspecialties. Scientific sessions focused on the impact of cognitive impairment, sensory contributors, comorbidities, links between delirium and dementia, and issues of informed consent in cognitively impaired populations. Discussions highlighted the complexity not only of cognitive health itself, but also of the bidirectional relationship between cognitive health and the health of other organ systems. Thus, conference participants noted the importance of multidisciplinary team science in future aging research. This article summarizes the full conference report, "The Impact of Cognitive Impairment Across Specialties," and notes areas where GEMSSTAR scholars can contribute to progress as they embark on their careers in aging research. J Am Geriatr Soc 67:2011–2017, 2019 [ABSTRACT FROM AUTHOR]

This article summarizes the presentations and discussions from a workshop, "Using Functional Assessment to Define Therapeutic Goals and Treatment," which took place on November 30 to December 1, 2017. This workshop brought together transdisciplinary leaders in the fields of function and disability and clinical investigators engaged in research on geriatric populations to outline opportunities and challenges for incorporating measures of function in clinical research. Topics addressed included reliable and clinically feasible measures of function and key domains of health (eg, musculoskeletal, cognitive, and sensory) that are most strongly associated with patients' perceptions of well‐being, independence, and quality of life across a wide array of diseases and interventions. The workshop also focused on the importance of function in medical decision making to inform communications between specialty physicians and patients about prognosis and goals of care. Workshop participants called for more research on the role of function as a predictor of an intervention's effectiveness and an important treatment outcome. Such research would be facilitated by development of a core set of simple, short, functional measures that can be used by all specialties in the clinical setting to allow "big data" analytics and a pragmatic research. J Am Geriatr Soc 67:1782–1790, 2019 [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine the association between self‐reported vision impairment (VI), hearing impairment (HI), and dual‐sensory impairment (DSI), stratified by dementia status, on hospital admissions, hospice use, and healthcare costs. DESIGN: Retrospective analysis. SETTING: Medicare Current Beneficiary Survey from 1999 to 2006. PARTICIPANTS: Rotating panel of community‐dwelling Medicare beneficiaries, aged 65 years and older (N = 24 009). MEASUREMENTS: VI and HI were ascertained by self‐report. Dementia status was determined by self‐report or diagnosis codes in claims data. Primary outcomes included any inpatient admission over a 2‐year period, hospice use over a 2‐year period, annual Medicare fee‐for‐service costs, and total healthcare costs (which included information from Medicare claims data and other self‐reported payments). RESULTS: Self‐reported DSI was present in 30.2% (n = 263/871) of participants with dementia and 17.8% (n = 4112/23 138) of participants without dementia. In multivariable logistic regression models, HI, VI, or DSI was generally associated with increased odds of hospitalization and hospice use regardless of dementia status. In a generalized linear model adjusted for demographics, annual total healthcare costs were greater for those with DSI and dementia compared to those with DSI without dementia ($28 875 vs $3340, respectively). Presence of any sensory impairment was generally associated with higher healthcare costs. In a model adjusted for demographics, Medicaid status, and chronic medical conditions, DSI compared with no sensory impairment was associated with a small, but statistically significant, difference in total healthcare spending in those without dementia ($1151 vs $1056; P < .001) but not in those with dementia ($11 303 vs $10 466; P = .395). CONCLUSION: Older adults with sensory and cognitive impairments constitute a particularly prevalent and vulnerable population who are at increased risk of hospitalization and contribute to higher healthcare spending. J Am Geriatr Soc 67:1617–1624, 2019 [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES: Every year, up to 40% of the more than 16 million older Americans who undergo anesthesia/surgery develop postoperative cognitive dysfunction (POCD) or delirium. Each of these distinct syndromes is associated with decreased quality of life, increased mortality, and a possible increased risk of Alzheimer's disease. One pathologic process hypothesized to underlie both delirium and POCD is neuroinflammation. The INTUIT study described here will determine the extent to which postoperative increases in cerebrospinal fluid (CSF) monocyte chemoattractant protein 1 (MCP‐1) levels and monocyte numbers are associated with delirium and/or POCD and their underlying brain connectivity changes. DESIGN: Observational prospective cohort. SETTING: Duke University Medical Center, Duke Regional Hospital, and Duke Raleigh Hospital. PARTICIPANTS: Patients 60 years of age or older (N = 200) undergoing noncardiac/nonneurologic surgery. MEASUREMENTS: Participants will undergo cognitive testing before, 6 weeks, and 1 year after surgery. Delirium screening will be performed on postoperative days 1 to 5. Blood and CSF samples are obtained before surgery, and 24 hours, 6 weeks, and 1 year after surgery. CSF MCP‐1 levels are measured by enzyme‐linked immunosorbent assay, and CSF monocytes are assessed by flow cytometry. Half the patients will also undergo pre‐ and postoperative functional magnetic resonance imaging scans. 32‐channel intraoperative electroencephalogram (EEG) recordings will be performed to identify intraoperative EEG correlates of neuroinflammation and/or postoperative cognitive resilience. Eighty patients will also undergo home sleep apnea testing to determine the relationships between sleep apnea severity, neuroinflammation, and impaired postoperative cognition. Additional assessments will help evaluate relationships between delirium, POCD, and other geriatric syndromes. CONCLUSION: INTUIT will use a transdisciplinary approach to study the role of neuroinflammation in postoperative delirium and cognitive dysfunction and their associated functional brain connectivity changes, and it may identify novel targets for treating and/or preventing delirium and POCD and their sequelae. J Am Geriatr Soc 67:794–798, 2019. [ABSTRACT FROM AUTHOR]

Background/Objectives: To address the underrepresentation of older adults in clinical research, the National Institutes of Health will require investigators to include individuals across the lifespan. As investigators from other fields endeavor to recruit participants who are more representative of the patient population, geriatricians may have the opportunity to influence a broad range of research studies in older adults. Our aims were to elicit challenges to inclusion of older adults in clinical research and to develop a preliminary framework for communicating these challenges to non–geriatrics‐trained researchers. Design: Communication framework development. Setting: Academic hospital and Veterans Affairs Medical Center. Participants: Nongeriatrician researchers and staff, aging research experts. Measurements: Interviews were used to elicit challenges nongeriatrician investigators and research staff experience when conducting research that includes older adults and then solicit experienced aging researchers' responses to these challenges. Results: Challenges described by nongeriatrician investigators included lack of knowledge, rigid study structures, and a disease‐focused approach. Responses from our geriatrics experts included communicating practical advice for avoiding common pitfalls. Our resulting framework is the 5Ts: Target Population, Team, Tools, Time, and Tips to Accommodate. This tool complements the 5Ms (Mind, Mobility, Medications, Multicomplexity, and Matters Most to Me) model for geriatric care and emphasizes representation of the Target Population, building research Teams that include aging expertise, incorporating appropriate Tools for function and patient‐reported outcomes, anticipating Time for longer study visits, and accommodating common needs with practical Tips. Limitations include convenience sampling and lack of formal qualitative thematic analysis. Conclusion: Communicating with nongeriatrician researchers using the 5Ts may offer a practical approach to avoiding barriers to inclusion of older adults in research and complements an existing framework for communicating the value of geriatric medicine. Next steps in developing the 5Ts will be to include additional stakeholders (eg, national samples of nongeriatrician investigators, older adults and their families) and evaluating the impact of its implementation. J Am Geriatr Soc 67:342–346, 2019. See related Editorial by George Kuchel in this issue. [ABSTRACT FROM AUTHOR]

This article summarizes the presentations and recommendations of the tenth annual American Geriatrics Society and National Institute on Aging Bench‐to‐Bedside research conference, "Sensory Impairment and Cognitive Decline," on October 2–3, 2017, in Bethesda, Maryland. The risk of impairment in hearing, vision, and other senses increases with age, and almost 15% of individuals aged 70 and older have dementia. As the number of older adults increases, sensory and cognitive impairments will affect a growing proportion of the population. To limit its scope, this conference focused on sensory impairments affecting vision and hearing. Comorbid vision, hearing, and cognitive impairments in older adults are more common than would be expected by chance alone, suggesting that some common mechanisms might affect these neurological systems. This workshop explored the mechanisms and consequences of comorbid vision, hearing, and cognitive impairment in older adults; effects of sensory loss on the aging brain; and bench‐to‐bedside innovations and research opportunities. Presenters and participants identified many research gaps and questions; the top priorities fell into 3 themes: mechanisms, measurement, and interventions. The workshop delineated specific research questions that provide opportunities to improve outcomes in this growing population. J Am Geriatr Soc 66:2052–2058, 2018. [ABSTRACT FROM AUTHOR]

Understanding the factors that influence functional ability over the life course is integral to identifying clinical and public health policies to facilitate successful aging. The World Health Organization has advocated a conceptual framework to clarify the policy discussion. We have sought to translate this general framework into an explicit system dynamics model of the interaction of physiological loss, stressors and endogenous responses to produce a familiar variety of trajectories of functional ability over the life courses. Simulation experiments were implemented for both a 30‐month duration with only one major stressor; and for the life course with an initial major stressor and subsequent stressors determined by the level of functional ability. For both contexts, variations in the few parameters in the scenarios led to a realistic range of trajectories of function over time. © 2019 System Dynamics Society [ABSTRACT FROM AUTHOR]

Objectives To prioritize research topics relevant to the care of the growing population of older adults with multiple chronic conditions ( MCCs). Design Survey of experts in MCC practice, research, and policy. Topics were derived from white papers, funding announcements, or funded research projects relating to older adults with MCCs. Setting Survey conducted through the Health Care Systems Research Network ( HCSRN) and Claude D. Pepper Older Americans Independence Centers ( OAICs) Advancing Geriatrics Infrastructure and Network Growth Initiative, a joint endeavor of the HCSRN and OAICs. Participants Individuals affiliated with the HCSRN or OAICs and national MCC experts, including individuals affiliated with funding agencies having MCC-related grant portfolios. Measurements A 'top box' methodology was used, counting the number of respondents selecting the top response on a 5-point Likert scale and dividing by the total number of responses to calculate a top box percentage for each of 37 topics. Results The highest-ranked research topics relevant to the health and healthcare of older adults with MCCs were health-related quality of life in older adults with MCCs; development of assessment tools (to assess, e.g., symptom burden, quality of life, function); interactions between medications, disease processes, and health outcomes; disability; implementation of novel (and scalable) models of care; association between clusters of chronic conditions and clinical, financial, and social outcomes; role of caregivers; symptom burden; shared decision-making to enhance care planning; and tools to improve clinical decision-making. Conclusion Study findings serve to inform the development of a comprehensive research agenda to address the challenges relating to the care of this 'high-need, high-cost' population and the healthcare delivery systems responsible for serving it. [ABSTRACT FROM AUTHOR]

Objectives To define multimorbidity 'classes' empirically based on patterns of disease co-occurrence in older Americans and to examine how class membership predicts healthcare use. Design Retrospective cohort study. Setting Nationally representative sample of Medicare beneficiaries in file years 1999-2007. Participants Individuals aged 65 and older in the Medicare Beneficiary Survey who had data available for at least 1 year after index interview (N = 14,052). Measurements Surveys (self-report) were used to assess chronic conditions, and latent class analysis ( LCA) was used to define multimorbidity classes based on the presence or absence of 13 conditions. All participants were assigned to a best-fit class. Primary outcomes were hospitalizations and emergency department visits over 1 year. Results The primary LCA identified six classes. The largest portion of participants (32.7%) was assigned to the minimal disease class, in which most persons had fewer than two of the conditions. The other five classes represented various degrees and patterns of multimorbidity. Usage rates were higher in classes with greater morbidity, but many individuals could not be assigned to a particular class with confidence (sample misclassification error estimate = 0.36). Number of conditions predicted outcomes at least as well as class membership. Conclusion Although recognition of general patterns of disease co-occurrence is useful for policy planning, the heterogeneity of persons with significant multimorbidity (≥3 conditions) defies neat classification. A simple count of conditions may be preferable for predicting usage. [ABSTRACT FROM AUTHOR]

An editorial is presented which addresses the authors' views about physical resilience in older people, and it mentions how physical resilience differs from frailty. According to the article, physical resilience is an individual's ability to adapt and deal with functional decline following the onset of acute or chronic health issues. Physiological vulnerability to a stressor such as surgery is addressed, along with the impact of biological processes on resilience.

Objective: The aim of this study was to examine the association between physical frailty and neurocognitive performance in late-life depression (LLD).Methods: Cross-sectional design using baseline data from a treatment study of late-life depression was used in this study. Individuals aged 60 years and older were diagnosed with major depressive disorder at time of assessment (N = 173). All participants received clinical assessment of depression and completed neuropsychological testing during a depressive episode. Physical frailty was assessed using an adaptation of the FRAIL scale. Neuropsychological domains were derived from a factor analysis that yielded three factors: (i) speeded executive and fluency, (ii) episodic memory, and (iii) working memory. Associations were examined with bivariate tests and multivariate models.Results: Depressed individuals with a FRAIL score >1 had worse performance than nonfrail depressed across all three factors; however, speeded executive and fluency was the only factor that remained significant after controlling for depression symptom severity and demographic characteristics.Conclusions: Although physical frailty is associated with broad neurocognitive deficits in LLD, it is most robustly associated with deficits in speeded executive functions and verbal fluency. Causal inferences are limited by the cross-sectional design, and future research would benefit from a comparison group of nondepressed older adults with similar levels of frailty. Research is needed to understand the mechanisms underlying associations among depression symptoms, physical frailty, and executive dysfunction and how they are related to the cognitive and symptomatic course of LLD. [ABSTRACT FROM AUTHOR]

Objectives To classify older adults in the emergency department ( ED) according to healthcare use and to examine associations between group membership and future ED visits and hospital admissions. Design Secondary analysis. Setting Medicare Current Beneficiary Survey. Participants Adults aged 65 and older with at least one treat-and-release ED visit between January 1, 2000, and September 30, 2007 (N = 4,964). Measurements Measures of health service use included primary care visits, treat-and-release ED visits, and hospital days in the 12 months preceding the index ED visit. Results Five groups of individuals in the ED with distinct patterns of health service use were identified. 'Primary Carederly' (39%) had low rates of ED and hospital use and a high mean number of primary care visits. 'Wellderly' (34%) had fewer visits of all types than other groups. 'Chronically Illderly' (14%) had the highest mean number of primary care visits and hospital days. 'Acute Carederly' (9.8%) had lowest mean number of primary care visits but higher ED visits and hospital days than all other groups except the 'Sickest Elderly.' Sickest Elderly (3.2%) had the highest number of ED visits; mean number of hospital days was more than four times that of any other group. Primary Carederly and Wellderly had a lower risk of hospital admission within 30 days of the index ED visit than the other groups. Conclusion In older adults released from an ED, group membership was associated with future health services use. Classification of individuals using readily available previous visit data may improve targeting of interventions to improve outcomes. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the association between six nondisease-specific problems (problems that cross multiple domains of health) and mortality in middle-aged and older adults. Design Prospective, observational cohort. Setting U.S. population sample. Participants Participants included 23,669 black and white U. S. adults aged 45 and older enrolled in the REasons for Geographic and Racial Differences in Stroke ( REGARDS) study. Measurements Nondisease-specific problems included cognitive impairment, depressive symptoms, exhaustion, falls, impaired mobility, and polypharmacy. Age-stratified (<65, 65-74, ≥75) hazard ratios for all-cause mortality were calculated for each problem individually and according to number of problems. Results One or more nondisease-specific problems occurred in 40% of participants younger than 65, 45% of those aged 65 to 74, and 55% of those aged 75 and older. Compared with participants with none of these problems, the multivariable adjusted hazard ratio for all-cause mortality associated with each additional nondisease-specific problem was 1.34 (95% confidence interval (CI) = 1.23-1.46) for participants younger than 65, 1.24 (95% CI = 1.15-1.35) for those aged 65 to 74, and 1.30 (95% CI = 1.21-1.39) for those aged 75 and older. Conclusion Nondisease-specific problems were associated with mortality across a wide age spectrum. Future studies should explore whether treating these problems will improve survival and identify innovative healthcare models to address multiple nondisease-specific problems simultaneously. [ABSTRACT FROM AUTHOR]

Objectives To examine whether performance on a brief memory test is related to functional outcomes in older individuals undergoing low-vision rehabilitation ( LVR) for macular disease. Design Observational cohort study of individuals receiving outpatient LVR. Setting Academic center. Participants Ninety-one individuals (average age 80.1) with macular disease. Measurements Memory was assessed at baseline using a 10-word list; memory deficit was defined as immediate recall of two or fewer words. Vision-related function was measured using the 25-item Visual Function Questionnaire ( VFQ-25) administered at baseline and during subsequent interviews (mean follow-up, 115 days). Linear mixed models were constructed to compare average trajectories of four VFQ-25 subscales: near activities, distance activities, dependency, and role difficulty. Results The 29.7% of participants with memory deficits tended to decline in ability to accomplish activities that involved near vision. Controlling for age, sex, and education, the functional trajectory of participants with memory deficit differed significantly from that of those with better memory ( P = .002), who tended to report improvements in ability to accomplish near activities. Conclusion Of older adults receiving LVR for macular disease, those with memory deficits experienced worse functional trajectories in their ability to perform specific visually mediated tasks. A brief memory screen may help explain variability in rehabilitation outcomes and identify individuals who might require special accommodations. [ABSTRACT FROM AUTHOR]

Objectives To determine whether readily collected perioperative information might identify older surgical patients at higher risk of complications. Design Retrospective cohort study. Setting Medical chart review at a single academic institution. Participants One hundred two individuals aged 65 and older who underwent abdominal surgery between January 2007 and December 2009. Measurements Primary predictor variables were first postoperative Braden Scale score (within 24 hours of surgery) and a Deficit Accumulation Index ( DAI) constructed based on 39 available preoperative variables. The primary outcome was presence or absence of complication within 30 days of surgery. Results Of 102 patients, 64 experienced at least one complication, with wound infection being the most common. In models adjusted for age, race, sex, and open versus laparoscopic surgery, lower Braden Scale scores were predictive of 30-day postoperative complication (odds ratio ( OR) = 1.30, 95% confidence interval ( CI) = 1.06-1.60), longer length of stay (β = 1.44 (0.25) days; P ≤ .001), and discharge to an institution rather than home ( OR = 1.23, 95% CI = 1.02-1.48). The cut-off value for the Braden score with the highest predictive value for complication was ≤ 18 ( OR = 3.63, 95% CI = 1.43-9.19; c statistic 0.744). The DAI and several traditional surgical risk factors were not significantly associated with 30-day postoperative complications. Conclusion This is the first study to identify the perioperative Braden Scale score, a widely used risk-stratifier for pressure ulcers, as an independent predictor of other adverse outcomes in geriatric surgical patients. Further studies are needed to confirm this finding and to investigate other uses for this tool, which correlates well to phenotypic models of frailty. [ABSTRACT FROM AUTHOR]

Objectives To characterize longitudinal patterns of musculoskeletal pain in a community sample of older adults over a 6-year period and to identify factors associated with persistence of pain. Design Secondary analysis of the Cardiovascular Health Study. Setting Community-based cohort drawn from four U.S. counties. Participants Five thousand ninety-three men and women aged 65 and older. Measurements Over a 6-year period, pain was assessed each year using a single question about the presence of pain in any bones or joints during the last year. If affirmative, participants were queried about pain in seven locations (hands, shoulders, neck, back, hips, knees, feet). Participants were categorized according to the percentage of time that pain was present and according to the intermittent or chronic pattern of pain. Factors associated with persistent pain during five remaining years of the study were identified. Results Over 6 years, 32% of participants reported pain for three or more consecutive years, and 32% reported pain intermittently. Of those who reported pain the first year, 54% were pain free at least once during the follow-up period. Most of the pain at specific body locations was intermittent. Factors associated with remission of pain over 5 years included older age, male sex, better self-rated health, not being obese, taking fewer medications, and having fewer depressive symptoms. Approximately half of those with pain reported fewer pain locations the following year. Conclusion Musculoskeletal pain in older adults, despite high prevalence, is often intermittent. The findings refute the notion that pain is an inevitable, unremitting, or progressive consequence of aging. [ABSTRACT FROM AUTHOR]

Objectives To describe the association between an increasing number of coexisting conditions and locus of control ( LOC), a psychological construct reflecting the degree to which one perceives circumstances to be controlled by personal actions (internal LOC) versus outside factors (external LOC) in older adults. Design Cross-sectional study using survey data from the North Carolina Established Population for Epidemiologic Studies of the Elderly ( NC EPESE) data set. Setting Community. Participants Three thousand two hundred twelve community-dwelling adults aged 68 and older. Measurements Nine common medical conditions were assessed according to self-report. LOC was measured using a standard questionnaire. Analyses were adjusted for demographics, functional status (self-reported activities of daily living), cognition (Short Portable Mental Status Questionnaire), and depression score (Center for Epidemiologic Studies Depression Scale). Results A higher number of chronic conditions was associated with external LOC (β = 0.37, P < .001). This relationship persisted after adjustment for age, race, sex, functional status, cognition, and depression (β = 0.17, P < .001). Most individual conditions were not associated with LOC, although vision impairment ( P < .001) and arthritis ( P = .02) were associated with more-internal LOC. Conclusion These results suggest that medically complex patients tend to exhibit a more-external LOC, meaning that they perceive little personal control over circumstances and environment. Clinicians should be aware of this tendency, because external LOC may impede an older adult's willingness to engage in the considerable task of managing multiple chronic conditions. [ABSTRACT FROM AUTHOR]

Objectives To identify generalizable ways that comorbidity affects older adults' experiences in a health service program directed toward an index condition and to develop a framework to assist clinicians in approaching comorbidity in the design, delivery, and evaluation of such interventions. Design A qualitative data content analysis of interview transcripts to identify themes related to comorbidity. Setting An outpatient low-vision rehabilitation program for macular disease. Participants In 2007/08, 98 individuals undergoing low-vision rehabilitation and their companions provided 624 semistructured interviews that elicited perceptions about barriers and facilitators of successful program participation. Results The interviews revealed five broad themes about comorbidity: (i) 'good days, bad days,' reflecting participants' fluctuating health status during the program because of concurrent medical problems; (ii) 'communication barriers.' which were sometimes due to participant impairments and sometimes situational; (iii) 'overwhelmed,' which encompassed pragmatic and emotional concerns of participants and caregivers; (iv) 'delays,' which referred to the tendency of comorbidities to delay progress in the program and to confer added inconvenience during lengthy appointments; and (v) value of companion involvement in overcoming some barriers imposed by comorbid conditions. Conclusion This study provides a taxonomy and conceptual framework for understanding consequences of comorbidity in the experience of individuals receiving a health service. If confirmed in individuals receiving interventions for other index diseases, the framework suggests actionable items to improve care and facilitate research involving older adults. [ABSTRACT FROM AUTHOR]

To describe the independent contributions of selected medical conditions to the disparity between black and white people in disability rates, controlling for demographic and socioeconomic factors. Cross-sectional analysis of a community-based cohort. Urban and rural counties of central North Carolina. Two thousand nine hundred sixty-six adults aged 68 and older participating in the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE). Self-reported data on sociodemographic characteristics and medical conditions, Short Portable Mental Status Questionnaire, activities of daily living (ADLs). Fifty-five percent of the cohort was black. Blacks were more likely than whites to report disability (odds ratio=1.39, 95% confidence interval= 1.15-1.68). Controlling for age, sex, marital status, and socioeconomic status, blacks were more likely to be obese and have diabetes mellitus, and less likely to report vision problems, fractures, and heart attacks. The higher prevalence of obesity and diabetes mellitus in blacks, after adjustment for sociodemographic factors, accounted for more than 30% of the black-white difference in disability. Conversely, the black-white disability gap would be approximately 45% wider if whites had a lower prevalence of fractures and vision impairment, similar to their black peers. Higher rates of obesity and diabetes mellitus in older black Americans account for a large amount of the racial disparity in disability, even after controlling for socioeconomic differences. Culturally appropriate interventions that lower the prevalence or the functional consequences of obesity and diabetes mellitus in blacks could substantially decrease this racial health disparity. [ABSTRACT FROM AUTHOR]

To estimate the likelihood of, and factors associated with, recovery from exhaustion in older adults. Secondary analysis of a cohort study. Six annual examinations in four U.S. communities. Four thousand five hundred eighty-four men and women aged 69 and older. Exhaustion was considered present when a participant responded 'a moderate amount' or 'most of the time' to either of two questions: 'How often have you had a hard time getting going?' and 'How often does everything seem an effort?' Of the 964 participants who originally reported exhaustion, 634 (65.8%) were exhaustion free at least once during follow-up. When data from all time points were considered, 48% of those who reported exhaustion were exhaustion free the following year. After adjustment for age, sex, race, education, and marital status, 1-year recovery was less likely in individuals with worse self-rated health and in those who were taking six or more medications or were obese, depressed, or had musculoskeletal pain or history of stroke. In proportional hazards models, the following risk factors were associated with more persistent exhaustion over 5 years: poor self-rated health, six or more medications, obesity, and depression. Recovery was not less likely in participants with a history of cancer or heart disease. Exhaustion is common in old age but is dynamic, even in those with a history of cancer and congestive heart failure. Recovery is especially likely in seniors who have a positive perception of their overall health, take few medications, and are not obese or depressed. These findings support the notion that resiliency is associated with physical and psychological well-being. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine the relationship between the reason for an emergency department (ED) visit and subsequent risk of adverse health outcomes in older adults discharged from the ED. DESIGN: Secondary analysis of data from the Medicare Current Beneficiary Survey. SETTING: ED. PARTICIPANTS: One thousand eight hundred fifty-one community-dwelling Medicare fee-for-service enrollees aged 65 and older discharged from the ED between January 2000 and September 2002. MEASUREMENTS: Independent variables were ED discharge diagnosis groups: injury or musculoskeletal (MSK) (e.g., fracture, open wound), chronic condition (e.g., chronic obstructive pulmonary disorder, heart failure), infection, non-MSK symptom (e.g., chest pain, abdominal pain), and unclassified. Adverse health outcomes were hospitalization or death within 30 days of the index ED visit. RESULTS: Injury or MSK was the largest ED diagnosis group (31.4%), followed by non-MSK symptom (22.2%), chronic condition (20.9%), and infection (7.8%); 338 (17.8%) had ED discharge diagnoses that were unclassified. In adjusted analyses, a discharge diagnosis of injury or MSK condition was associated with lower risk of subsequent adverse health outcomes (hazard ratio (HR)=0.69, 95% confidence interval (CI)=0.50–0.96) than for all other diagnosis groups. Patients seen in the ED for chronic conditions were at greater risk of adverse outcomes (HR=1.86, 95% CI=1.37–2.52) than all others. There were no significant differences in risk between patients with infections, those with non-MSK symptoms, and the unclassified group. CONCLUSION: Adverse health outcomes were common in older patients with an ED discharge diagnosis classified as a chronic condition. ED discharge diagnosis may improve risk assessment and inform the development of targeted interventions to reduce adverse health outcomes in older adults discharged from the ED. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To describe the relationship between symptom scores and mobility function measures, assess whether symptom scores and disease scores are similarly associated with mobility function, and identify clusters of symptoms that are most strongly associated with functional status in older adults. DESIGN: Secondary analysis of cross-sectional data from three cohorts. SETTING: Academic medical center. PARTICIPANTS: One hundred ninety-five community-dwelling subjects with poor flexibility or cardiorespiratory fitness (fitness cohort), 211 female retirement community residents with vertebral fractures (VF cohort), and 61 subjects with Parkinson's disease (PD cohort). MEASUREMENTS: Twenty-item self-reported symptom scale, 17-item self-reported disease scale, Medical Outcomes Study 36-item Short Form Survey (SF-36) Physical Functioning Scale, 5-item Nagi Disability scale, 10-m walk time, supine to stand time. RESULTS: Symptom scores correlated with mobility function measures (Spearman correlation coefficients ranged from 0.222 to 0.509) at least as strongly as, if not more strongly than, did disease scores. Symptom scores remained associated with functional outcomes after controlling for disease score and demographic variables. Adding symptom scores to models that contained disease scores significantly increased the association with functional outcomes. In the fitness cohort, muscle weakness was the most explanatory single symptom, associated with an average decrease of 17.8 points on the Physical Functioning Scale. A model that included only muscle weakness, pain, and shortness of breath accounted for 21.2% of the variability in the Physical Functioning Score. CONCLUSION: Symptoms represent useful indicators of disability burden in older adults and are promising targets for interventions to improve function in medically complex patients. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether frail older adults, based on a deficit accumulation index (DAI), are at greater risk of adverse outcomes after discharge from the emergency department (ED). DESIGN AND SETTING: Secondary analysis of data from the Medicare Current Beneficiary Survey. PARTICIPANTS: One thousand eight hundred fifty-one community-dwelling Medicare fee-for-service enrollees, aged 65 and older who were discharged from the ED between January 2000 and September 2002. MEASUREMENTS: The primary dependent variable was time to first adverse outcome, defined as repeat outpatient ED visit, hospital admission, nursing home admission, or death, within 30 days of the index ED visit. RESULTS: Time to first adverse outcome was shortest in individuals with the highest number of accumulated deficits. The frailest participants were at greater risk of adverse outcomes after ED discharge than those who were least frail (hazard ratio (HR)=1.44, 95% confidence interval (CI)=1.06–1.96). The frailest individuals were also at higher risk of serious adverse outcomes, defined as hospitalization, nursing home admission, or death (HR=1.98, 95% CI=1.29–3.05). In contrast, no association was detected between degree of frailty and repeat outpatient ED visits within 30 days (HR=1.06, 95% CI=0.73–1.54). CONCLUSION: The DAI as a construct of frailty was a robust predictor of serious adverse outcomes in the first 30 days after ED discharge. Frailty was not found to be a major determinant of repeat outpatient ED visits; therefore, additional study is needed to investigate this particular type of health service use by older adults. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether satisfaction of on-site nurses with after-hours telephone communication with off-site physicians improved in one long-term care (LTC) facility after a nurse-oriented intervention. DESIGN: Longitudinal quality improvement study. SETTING: Extended Care and Rehabilitation Center (ECRC), Durham Veterans Affairs Medical Center. PARTICIPANTS: Eighteen registered nurses. INTERVENTION: Communicating Health Assessments by Telephone (Project CHAT), a program of individualized training sessions and decision support tools to aid LTC nurses with symptom assessment and communication of health information over the telephone. MEASUREMENTS: Nurses completed six satisfaction surveys (three surveys in the 3 months before Project CHAT and three surveys in the 3 months after Project CHAT). RESULTS: The nurses' average satisfaction scores increased on several items, including those that assessed whether the nurse was pretty sure what pieces of information the physician was going to ask for ( P=.04), felt that the amount of patient information the physician asked for seemed reasonable ( P=.03), felt prepared to answer the questions the physician asked ( P=.01), and felt that the process of gathering patient information for the physician was easy ( P=.01). The percentage of calls that resulted in immediate evaluation by a physician (on-site or in the emergency department) increased from 2.0% in the period before Project CHAT to 8.6% in the period after Project CHAT ( P=.01). CONCLUSION: Nurses' satisfaction with several aspects of after-hours telephone medicine improved after an inexpensive, education-based intervention in one LTC facility. Further research is needed to determine how similar interventions might affect other quality measures, including patient outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To describe after-hours telephone calls from nurses in long-term care (LTC) facilities to doctors in a geriatric medicine training program. DESIGN: Evaluation of 1,928 after-hours calls from LTC facilities over a 10-month period in 2005/06. SETTING: Geriatrics fellowship program and three affiliated LTC facilities. PARTICIPANTS: Eight geriatrics fellows and 40 medicine interns. MEASUREMENTS: Data were collected on call characteristics (such as reason for call and call outcome) and physician attitudes about the call, scored using a 5-point Likert scale. RESULTS: Clinical problems were the focus of 70.4% of the calls. The range of clinical problems was broad; most common reasons for calls were falls (n=377), pain (n=138), and agitation (n=100). The majority of calls resulted in medical intervention, including new medications or treatments (43.4%), diagnostic tests (10.2%), or more-extensive medical evaluation in the emergency department (9.1%) or by an on-site physician (2.4%). Overall, physician trainees had favorable attitudes about most after-hours calls, although medicine interns taking calls had a less-favorable impression and felt less prepared to manage them. CONCLUSION: After-hours telephone calls from LTC facilities are common, reflect the heterogeneity of geriatric health concerns, and typically result in intervention. As the LTC population grows, more study is needed on telephone care and optimal strategies for training physicians in this important aspect of LTC. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine the risk of disability in individuals with coexisting visual and cognitive impairment and to compare the magnitude of risk associated with visual impairment, cognitive impairment, or the multimorbidity. DESIGN: Prospective cohort. SETTING: North Carolina. PARTICIPANTS: Three thousand eight hundred seventy-eight participants in the North Carolina Established Populations for the Epidemiologic Studies of the Elderly with nonmissing visual status, cognitive status, and disability status data at baseline MEASUREMENTS: Short Portable Mental Status Questionnaire (cognitive impairment defined as≥4 errors), self reported visual acuity (visual impairment defined as inability to see well enough to recognize a friend across the street or to read newspaper print), demographic and health-related variables, disability status (activities of daily living (ADLs), instrumental activities of daily living (IADLs), mobility), death, and time to nursing home placement. RESULTS: Participants with coexisting visual and cognitive impairment were at greater risk of IADL disability (odds ratio (OR)=6.50, 95% confidence interval (CI)=4.34–9.75), mobility disability (OR=4.04, 95% CI=2.49–6.54), ADL disability (OR=2.84, 95% CI=1.87–4.32), and incident ADL disability (OR=3.66, 95%, CI=2.36–5.65). In each case, the estimated OR associated with the multimorbidity was greater than the estimated OR associated with visual or cognitive impairment alone, a pattern that was not observed for other adverse outcomes assessed. No significant interactions were observed between cognitive impairment and visual impairment as predictors of disability status. CONCLUSION: Individuals with coexisting visual impairment and cognitive impairment are at high risk of disability, with each condition contributing additively to disability risk. Further study is needed to improve functional trajectories in patients with this prevalent multimorbidity. When visual or cognitive impairment is present, efforts to maximize the other function may be beneficial. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine fracture risk in U.S. stroke patients and identify patient characteristics that predict highest fracture risk in two complementary cohorts. DESIGN: Secondary analyses of two prospective cohorts. SETTING: Veterans Affairs (VA) Medical Centers. PARTICIPANTS: The VA Acute Stroke (VASt) cohort includes 1,073 veterans admitted to nine VA hospitals for stroke between April 1995 and March 1997. The Integrated Stroke Outcomes Database (ISOD) includes 6,578 veterans who received inpatient rehabilitation for stroke at 121 VA facilities during fiscal years 2001 and 2002. MEASUREMENTS: Fractures detected using International Classification of Diseases, 9th Revision, codes in the VA computerized patient record system; baseline patient characteristics and stroke features; Functional Independence Measures scores in ISOD. RESULTS: Estimated 2-year fracture rates after stroke in the VASt and ISOD cohorts were 6.1% and 4.7%, respectively. Longer hospitalizations for stroke ( P=.06) and new motor or sensory impairment ( P=.09) showed trends toward greater risk in the VASt cohort. Female sex ( P <.001), cognitive impairment ( P=.01), and nonblack race ( P=.04) were associated with higher fracture risk in the ISOD. Intermediate functional impairment conferred higher fracture risk than mild or severe functional impairment. CONCLUSION: Veterans who suffer a stroke are at high risk of subsequent fracture, which can lead to further disability. Women, nonblacks, and those with intermediate functional impairment were at particularly high risk of fracture. Future study should investigate therapies to decrease fracture risk in stroke patients. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To identify subject characteristics that predict smoking cessation and describe patterns of cessation and recidivism in a cohort of elderly smokers. DESIGN: Prospective cohort study. SETTING: Piedmont region, North Carolina. PARTICIPANTS: Five hundred seventy-three subjects enrolled in the North Carolina Established Populations for Epidemiologic Studies of the Elderly who responded “yes” to question 179 on the baseline survey (Do you smoke cigarettes regularly now?) and survived at least 3 years, until the next in-person follow-up (1989/90). Subjects were classified as quitters (n=100) or nonquitters (n=473) based on subsequent smoking behavior. MEASUREMENTS: Reported smoking behavior, demographic characteristics of the smokers at baseline or subsequent interviews, 7-year mortality. RESULTS: After controlling for all characteristics studied, subjects who quit smoking were more likely to be female ( P=.03) and showed a trend toward greater likelihood of a recent cancer diagnosis ( P=.11). Recidivism was observed in only 16% (19/119) of subjects who reported no smoking in 1989/90. The percentage of subjects who died during 7 years of follow-up was 44.0% of quitters, compared with 51.6% of nonquitters. Smoking cessation was not associated with a statistically significant decrease in risk of death after controlling for other variables (odds ratio=0.78, 95% confidence interval=0.48–1.26). CONCLUSION: Smoking cessation in this elderly cohort was associated with different subject characteristics from those that predict successful cessation in younger populations, suggesting that older smokers may have unique reasons to stop smoking. Further study is needed to assess potential motives and benefits associated with smoking cessation at an advanced age. [ABSTRACT FROM AUTHOR]