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Background: The National Institute on Aging (NIA)/Alzheimer’s Association (AA) 2018 framework conceptualizes Alzheimer’s disease (AD) biologically. Evidence of brain amyloid by biomarkers defines AD pathologic change and the Alzheimer’s continuum. The presence of tau or neurodegeneration in the absence of amyloid defines non-AD pathologic change. Objective: To examine the relation of in vivo amyloid and neurodegeneration with verbal learning, one of the cognitive abilities affected early in AD, in late middle age. Methods: This was a cross-sectional study of amyloid and neurodegeneration biomarkers in a community-based cohort of 350 late-middle aged Hispanics without dementia (mean age: 64.15±3.34; 72.0%women). Amyloid (A) was measured as global standardized uptake value ratio (SUVR) with 18F-Florbetaben positron emission tomography (PET). Neurodegeneration (N) was ascertained as cortical thickness (CT) in AD signature areas using brain magnetic resonance imaging. We examined A/N continuously, categorically, by A/N profiles, and profile categories. The amyloid threshold for positivity was defined using the K means method. The CT threshold was defined as 2 standard deviations below the mean CT. Verbal learning was ascertained using total recall and delayed recall in the Buschke Selective Reminding test (SRT). Results: Higher cortical thickness was associated with higher performance in SRT delayed recall. Amyloid SUVR was not related to SRT performance. The low CT category was associated with lower performance in SRT delayed recall, while Amyloid categories were not related to any SRT score. The non-AD pathologic change group (A-N+) performed worse in SRT delayed recall compared to the Normal A/N profile group (A-N-). Conclusion: In late middle-aged Hispanics without dementia, non-AD pathologic change, but not the Alzheimer’s continuum, was related to verbal learning.

Background: Because early recognition of symptoms and timely treatment of stroke can reduce mortality and the long-term effects of such events, efforts to make many people both aware of these symptoms and knowledgeable about what to do when recognising them are critical for reducing impacts from stroke. Objectives: To assess the impact of a stroke preparedness film (intervention) and stroke preparedness pamphlets (usual care) on self-efficacy for stroke recognition and action. Design: Two-arm cluster randomised trial conducted between July 2013 and August 2018. Setting: A total of 13 church sites located in economically disadvantaged urban neighbourhoods in New York. Of the 883 churchgoers approached, 503 expressed interest, 375 completed eligibility screening and 312 were randomised. Participant inclusion criteria were Black or Hispanic churchgoers, aged 34 years or older, without stroke history, but at a high risk for stroke. The intervention consisted of two 12-minute stroke films: Gospel of Stroke, in English for Black participants, and Derrame Cerebral, in Spanish for Hispanic participants. Method: Participants were pre–post-tested (at baseline, 6-month follow-up and 12-month follow-up) for self-efficacy. Descriptive analysis, a linear mixed model and t tests were used to assess the effects of a stroke preparedness film and stroke preparedness pamphlets on self-efficacy. Results: Findings are based on intention-to-treat analysis. A total of 310 participants completed the study (99% retention rate). About half (53.8%) of participants were Black and 46.2% Hispanic in the intervention group; 48.3% were Black and 51.7% were Hispanic in the usual care group. Overall, both groups evidenced higher self-efficacy (i.e. lower predicted means) over time ( p < .0001), although a significant benefit was not observed for the intervention relative to usual care. Conclusion: Both stroke preparedness films and stroke preparedness pamphlets improved self-efficacy with respect to stroke recognition and action among minority churchgoers.

ObjectiveTo examine in vivo amyloid burden in relation to APOEε4 genotype in middle-aged Hispanics. We hypothesize higher amyloid levels among APOE ε4 carriers vs APOE ε4 noncarriers.MethodsThis is a cross-sectional study in a community-based sample of 249 middle-aged Hispanics in New York City who underwent a 3T brain MRI and PET with the amyloid radioligand 18F-florbetaben. APOE genotype was the primary exposure. The primary outcome was amyloid positivity. The secondary outcome was subthreshold amyloid levels examined as a continuous variable.ResultsAPOE ε4 carriers (n = 85) had a higher frequency (15.3%) of amyloid positivity compared to APOE ε4 noncarriers (n = 164, 1.8%). In the subthreshold group of amyloid-negative participants (n = 233), APOE ε4 carriers (n = 72) had a 0.02 (95% confidence interval [CI] 0.01–0.04) higher global brain amyloid standardized uptake value ratio (SUVR) compared to APOE ε4 noncarriers (n = 161). Compared to participants with the ε3/ε3 genotype, participants with ε4/ε4 had the highest frequency of amyloid positivity (28.6%), followed by those with ε3/ε4 (11%). Among amyloid-negative participants (n = 233), compared to participants with ε3/ε3 (n = 134), those with ε4/ε4 (n = 5) had a 0.12 (95% CI 0.07–0.17) higher global brain amyloid SUVR, and those with ε3/ε4 had a 0.02 higher SUVR (95% CI 0.003–0.04). Results were similar when a median split was used for elevated amyloid, when continuous amyloid SUVR was analyzed in all participants, and in nonparametric Mann-Whitney comparisons.ConclusionMiddle-aged Hispanic APOE ε4 carriers have higher in vivo brain amyloid burden compared with noncarriers, as reported in non-Hispanics.

Background Resident-to-resident elder mistreatment (R-REM) is defined as negative and aggressive physical, sexual, or verbal interactions between (long-term care) residents that in a community setting would likely be construed as unwelcome and have high potential to cause physical and/or psychological harm and distress. R-REM has been established as a serious problem that has a negative impact on the safety, physical well-being, and quality-of-life of residents living in nursing homes. Although there are no in-depth studies, there is evidence that it is prevalent in assisted living residences and associated with a variety of person, environmental, and facility characteristics. The authors conducted the first systematic, prospective study of resident-to-resident elder mistreatment in nursing homes and developed an intervention for direct care staff to enhance knowledge of R-REM and increase reporting and resident safety by reducing falls and associated injuries. The study aim was to examine the effects of this intervention in assisted living residences. The primary distal outcome is falls and injuries, and the key process outcomes are staff knowledge and reporting. Methods Twelve larger licensed assisted living residences with special care dementia units in two New York State regions will be enrolled on a rolling basis and randomized to intervention or usual care. Data derived from five sources, (1) resident interviews, (2) staff informants, (3) observational data, (4) chart, and (5) incident/accident report data, will be collected at baseline and 6 and 12 months with respect to 1050 residents (750 “downstate” and 300 “upstate”). The intervention is three training modules delivered on-site after baseline data collection for front line staff on all shifts in facilities randomized to the intervention. Modules relate to recognition, management, and reporting of resident-to-resident elder mistreatment. Discussion Given the movement toward alternative congregate living arrangements for older individuals with significant comorbidities, including cognitive impairment; it is critical to enhance resident safety measured by falls, accidents, and injuries and staff knowledge related to recognition, reporting, and treatment of resident-to-resident aggressive and related negative interactions in such settings. This project is important in developing approaches for ameliorating and preventing R-REM in assisted living residences and enhancing resident safety and quality of life. Trial registration ClinicalTrials.gov NCT03383289. Registered on 26 December 2017

Background/objectives The Hospital Elder Life Program (HELP) has been shown to prevent delirium in hospitalized older adults. The objective of this study was to test the efficacy of HELP adapted to long-term care (HELP-LTC). Design Cluster randomized controlled trial. Setting A 514-bed academic urban nursing home. Participants A total of 219 long-term nursing home residents who developed an acute illness or change in condition were randomly assigned to HELP-LTC (n = 105) or usual care (n = 114) by unit. Intervention HELP-LTC is a multicomponent intervention targeting delirium risk factors of cognitive impairment, immobility, dehydration, and malnutrition. Two certified nursing assistants (CNAs) delivered HELP-LTC components twice daily 7 days per week. In addition, recommendations were given to primary providers to reduce medications associated with delirium. Measurements Delirium (primary outcome) and delirium severity were ascertained each weekday by a research assistant blinded to group assignment, using the Confusion Assessment Method (CAM) and CAM severity score (CAM-S), respectively. Cognitive function was determined using the Cognitive Performance Scale (CPS). Hospitalization was ascertained by chart review. Results Participants were 81.7 years of age on average and 65.3% female. At baseline, usual care group participants had better cognitive function than intervention group participants (CPS = 1.33 vs 2.25; P = .004). Delirium symptoms declined over the course of the episode (mean CAM-S = 3.63 at start vs 3.27 at end). Overall, 33.8% of the total sample experienced incident delirium. After adjusting for baseline cognitive function, no significant differences were found in delirium or delirium severity between intervention and usual care groups. Hospitalization was not significantly different between groups. Conclusion An intervention targeting delirium risk in long-term nursing home residents did not prevent delirium or reduce delirium symptoms. Baseline differences in cognitive function between groups, greater than expected improvements in both groups, quality-enhancing practices such as consistent assignments delivered to both groups, and adaptations of the intervention may have biased results toward null. J Am Geriatr Soc 68:2329-2335, 2020.

Background: A majority of hospice care is delivered at home, with significant caregiver involvement. Identifying factors associated with caregiver-reported quality measures could help improve hospice care in the United States. Objectives: To identify correlates of caregiver-reported quality measures: burden, satisfaction, and quality of end-of-life (EoL) care in home hospice care. Design: A cross-sectional study was conducted from April 2017 through February 2018. Setting/Subjects: A nonprofit, urban hospice organization. We recruited caregivers whose patients were discharged from home hospice care. Eligible caregiver participants had to be 18 years or older, English-speaking, and listed as a primary caregiver at the time the patient was admitted to hospice. Measures: The (1) short version of the Burden Scale for Family Caregivers; (2) Family Satisfaction with Care; and (3) Caregiver Evaluation of the Quality of End-Of-Life Care. Results: Caregivers (n = 391) had a mean age of 59 years and most were female (n = 297, 76.0%), children of the patient (n = 233, 59.7%), and non-Hispanic White (n = 180, 46.0%). The mean age of home hospice patients was 83 years; a majority had a non-cancer diagnosis (n = 235, 60.1%), were female (n = 250, 63.9%), and were non-Hispanic White (n = 210, 53.7%). Higher symptom scores were significantly associated with greater caregiver burden and lower satisfaction with care; but not lower quality of EoL care. Caregivers who were less comfortable managing patient symptoms during the last week on hospice had higher caregiver burden, lower caregiver satisfaction, and lower ratings of quality of EoL care. Conclusion: Potentially modifiable symptom-related variables were correlated with caregiver-reported quality measures. Our study reinforces the important relationship between the perceived suffering/symptoms of patients and caregivers' hospice experiences.

It is unclear whether women have higher brain tau pathology. The objective of this study was to examine whether women have higher tau burden than men, and whether tau differences are independent of amyloid β (Aβ) burden. We conducted a cross-sectional analysis of a multi-ethnic sample of 252 non-demented late middle-aged (mean age: 64.1 years) adults with tau and amyloid Positron Emission Tomography (PET) data. Tau burden was measured as global standardized uptake value ratio (SUVR) in the middle/inferior temporal gyri and medial temporal cortex with (18)F-MK-6240 PET. Aβ was measured as global SUVR with (18)F-Florbetaben PET. Women had higher middle/inferior temporal gyri tau SUVR compared to men. However, no sex differences in the medial temporal cortex were observed. Women had higher brain Aβ SUVR compared to men. Continuous Aβ SUVR was positively correlated with medial temporal cortex and middle/inferior temporal gyri tau SUVR. However, there was no evidence of effect modification by Aβ SUVR on sex and tau. Compared with men, women in late middle age show higher tau burden, independent of Aβ.

Author(s): Gill, Thomas M; Bhasin, Shalender; Reuben, David B; Latham, Nancy K; Araujo, Katy; Ganz, David A; Boult, Chad; Wu, Albert W; Magaziner, Jay; Alexander, Neil; Wallace, Robert B; Miller, Michael E; Travison, Thomas G; Greenspan, Susan L; Gurwitz, Jerry H; Rich, Jeremy; Volpi, Elena; Waring, Stephen C; Manini, Todd M; Min, Lillian C; Teresi, Jeanne; Dykes, Patricia C; McMahon, Siobhan; McGloin, Joanne M; Skokos, Eleni A; Charpentier, Peter; Basaria, Shehzad; Duncan, Pamela W; Storer, Thomas W; Gazarian, Priscilla; Allore, Heather G; Dziura, James; Esserman, Denise; Carnie, Martha B; Hanson, Catherine; Ko, Fred; Resnick, Neil M; Wiggins, Jocelyn; Lu, Charles; Meng, Can; Goehring, Lori; Fagan, Maureen; Correa-de-Araujo, Rosaly; Casteel, Carri; Peduzzi, Peter; Greene, Erich J | Abstract: Background/objectivesIn the Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) study, a multifactorial intervention was associated with a nonsignificant 8% reduction in time to first serious fall injury but a significant 10% reduction in time to first self-reported fall injury relative to enhanced usual care. The effect of the intervention on other outcomes important to patients has not yet been reported. We aimed to evaluate the effect of the intervention on patient well-being including concern about falling, anxiety, depression, physical function, and disability.DesignPragmatic cluster-randomized trial of 5,451 community-living persons at high risk for serious fall injuries.SettingA total of 86 primary care practices within 10 U.S. healthcare systems.ParticipantsA random subsample of 743 persons aged 75 and older.MeasurementsThe well-being measures, assessed at baseline, 12 months, and 24 months, included a modified version of the Fall Efficacy Scale, Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and depression scales, and Late-Life Function and Disability Instrument.ResultsParticipants in the intervention (n = 384) and control groups (n = 359) were comparable in age: mean (standard deviation) of 81.9 (4.7) versus 81.8 (5.0) years. Mean scores were similar between groups at 12 and 24 months for concern about falling, physical function, and disability, whereas the intervention group's mean scores on anxiety and depression were .7 points lower (i.e., better) at 12 months and .6 to .8 points lower at 24 months. For each of these outcomes, differences between the groups' adjusted least square mean changes from baseline to 12 and 24 months, respectively, were quantitatively small. The overall difference in means between groups over 2 years was statistically significant only for depression, favoring the intervention: -1.19 (99% confidence interval, -2.36 to -.02), with 3.5 points representing a minimally important difference.ConclusionsSTRIDE's multifactorial intervention to reduce fall injuries was not associated with clinically meaningful improvements in patient well-being.

Metabolic syndrome (MetS) is associated with dementia, but it is unclear whether MetS is related to Alzheimer's disease (AD). We investigated the association of MetS with brain amyloid, a key AD feature, and neurodegeneration. A community-based sample of 350 middle-aged Hispanics in New York City had cerebral amyloid β (Aβ) burden ascertained with 18F-Florbetaben positron emission tomography. Neurodegeneration was ascertained as cortical thickness in AD signature regions from 3T brain MRI. MetS and its components (glucose, blood pressure, triglycerides, high-density lipoprotein, adiposity) were defined using the National Institutes of Health criteria. Neither the presence of MetS nor the MetS score was associated with Aβ or neurodegeneration. Among the MetS components, elevated glucose was associated with lower Aβ burden, and this association was not explained by diabetes treatment. Glucose and triglycerides were related to smaller cortical thickness. Our findings suggest that MetS as an arbitrary measure of aggregate metabolic and vascular risk does not capture the risk of AD neuropathology in late middle age and that other approaches to measure the aggregate risk should be examined.

Background: Symptoms (e.g., pain, shortness of breath, and fatigue) at the end of life (EoL) are common. Although symptoms can contribute to poor quality of life at the EoL, much remains unknown regarding their prevalence and correlates in home hospice care. Objectives: To determine the prevalence and correlates of caregiver-reported symptoms in home hospice patients during the last week before discharge using the Edmonton Symptom Assessment Scale (ESAS). Design: This is a cross-sectional study measuring perceived patient symptoms using caregiver proxy data. Bivariate and multivariate analyses were conducted to examine patient and caregiver characteristics associated with ESAS scores. Setting/Subjects: Subjects were from an urban nonprofit home hospice organization. Measurements: Symptoms were measured using the ESAS. Results: The mean ESAS score was 51.2 (SD ±17.4). In bivariate analyses, higher perceived symptom score was associated with younger patient age (p

BACKGROUND: Females may have a higher risk of dementia than males. It is not clear if sex differences in Alzheimer’s disease (AD) neuropathology explain the higher risk of dementia in females. Sex differences in AD neuropathology might begin in middle age, decades before the sex differences in dementia are apparent. OBJECTIVE: To examine sex differences in in-vivo AD neuropathology in late middle age. METHODS: We conducted a cross-sectional comparison of AD biomarkers among 266 Hispanic males and females (mean age: 64.0; 71.8% females) without dementia. Amyloid burden was measured as global standardized uptake value ratio (SUVR) with (18)F-Florbetaben Positron Emission Tomography (PET). Neurodegeneration was ascertained as cortical thickness in AD signature areas using brain magnetic resonance imaging. Tau burden was measured as tau SUVR in the middle/inferior temporal gyri and medial temporal cortex with (18)F-MK-6240 in 75 of the 266 participants. RESULTS: Females had higher amyloid SUVR and tau SUVR in the middle/inferior temporal gyri than males. However, females had higher cortical thickness than males and performed better in a test of verbal memory despite having higher AD neuropathology burden. CONCLUSION: Higher amyloid and tau in females compared to males in late middle-age may explain the reported higher dementia risk in elderly females compared to males. Longitudinal follow-up is necessary to examine whether higher amyloid and tau burden in late middle age is followed by increased neurodegeneration and cognitive decline in females as compared with males.

Background: Although home hospice organizations provide essential care for and support to terminally ill patients, many day-to-day caregiving responsibilities fall to informal (ie, unpaid) caregivers. Studies have shown that caregivers value receiving clear information about end-of-life (EoL) care. Meeting the information needs of this group is critical in improving their experience in hospice. Objectives: To identify the information needs of informal home hospice caregivers. Design: One hundred five semi-structured phone interviews with informal caregivers were conducted. Study data were analyzed using a standard qualitative method (ie, content analysis). Participants: Informal home hospice caregivers whose loved ones have been discharged (death or live discharge) from an urban, nonprofit hospice organization. Measured: Participants’ information needs were ascertained by assessing whether information regarding hospice was or was not fully explained or whether there was information they wished they knew prior to the hospice transition. Results: Among study participants, 48.6% had unmet information needs related to (1) general information about hospice (n = 17, 16.2%), (2) what to expect at the EoL (n = 19, 18.1%), and (3) support provided by hospice (n = 30, 28.6%). Specifically, caregivers expressed the need for more information on what hospice is, caring for a dying patient, and the day-to-day care hospice provides. Conclusion: Our study indicates that approximately half of the informal caregivers had unmet information needs. Further research is needed to identify efficacious strategies to best meet the information needs of this group. Specific topics that need emphasis include what hospice care is, what to expect at the EoL, and what level of support hospice offers.

Objectives To compare the effectiveness of 2 caregiver interventions with known efficacy: the Resources for Enhancing Caregiver Health‐Offering Useful Treatment (REACH‐OUT) and the New York University Caregiver Intervention (NYUCI). Design 1:1 randomized pragmatic trial. Setting New York City. Participants Informal Hispanic caregivers of persons with dementia (N=221; mean age 58.2, 82.8% female, 63.3% adult children, 31.7% spouses). Intervention Participants were randomized to 6 months of NYUCI (n=110) or REACH‐OUT (n=111), balanced on characteristics at baseline. All participants were referred for social supportive services. Measurements The primary outcomes were changes between baseline and 6 months in depressive symptoms, measured using the Geriatric Depression Scale (GDS), and caregiver burden, measured using the Zarit Caregiver Burden Scale (ZCBS). Results There were no differences in outcomes between NYUCI and REACH‐OUT. Both interventions showed a reduction in burden (REACH‐OUT: 5.2 points, 95% confidence interval (CI)=2.2–8.1, p

The focus of these analyses was to examine the psychometric properties of the Lichtenberg Financial Decision Screening Scale (LFDSS). The purpose of the screen was to evaluate the decisional abilities and vulnerability to exploitation of older adults. Adults aged 60 and over were interviewed by social, legal, financial, or health services professionals who underwent in-person training on the administration and scoring of the scale. Professionals provided a rating of the decision-making abilities of the older adult. The analytic sample included 213 individuals with an average age of 76.9 (SD = 10.1). The majority (57%) were female. Data were analyzed using item response theory (IRT) methodology. The results supported the unidimensionality of the item set. Several IRT models were tested. Ten ordinal and binary items evidenced a slightly higher reliability estimate (0.85) than other versions and better coverage in terms of the range of reliable measurement across the continuum of financial incapacity.

Importance Black individuals and Hispanic individuals are less likely to recognize stroke and call 911 (stroke preparedness), contributing to racial/ethnic disparities in intravenous tissue plasminogen activator use. Objective To evaluate the effect of culturally tailored 12-minute stroke films on stroke preparedness vs the usual care practice of distributing stroke education pamphlets. Design, Setting, and Participants Cluster randomized clinical trial between July 26, 2013, and August 16, 2018, with randomization of 13 black and Hispanic churches located in urban neighborhoods to intervention or usual care. In total, 883 congregants were approached, 503 expressed interest, 375 completed eligibility screening, and 312 were randomized. Sixty-three individuals were ineligible (younger than 34 years and/or did not have at least 1 traditional stroke risk factor). Interventions Two 12-minute stroke films on stroke preparedness for black and Hispanic audiences. Main Outcomes and Measures The primary outcome was the Stroke Action Test (STAT), assessed at baseline, 6 months, and 12 months. Results In total, 261 of 312 individuals completed the study (83.7% retention rate). Most participants were female (79.1%). The mean (SD) age of participants was 58.57 (11.66) years; 51.1% (n = 159) were non-Hispanic black, 48.9% (n = 152) were Hispanic, and 31.7% (n = 99) had low levels of education. There were no significant end-point differences for the STAT at follow-up periods. The mean (SD) baseline STAT scores were 59.05% (29.12%) correct for intervention and 58.35% (28.83%) correct for usual care. At 12 months, the mean (SD) STAT scores were 64.38% (26.39%) correct for intervention and 61.58% (28.01%) correct for usual care. Adjusted by education, a post hoc subgroup analysis revealed a mean (SE) intervention effect of 1.03% (0.44%) (P = .02) increase per month in the low-education subgroup (about a 10% increase in 12 months). In the high-education subgroup, the mean (SE) intervention effect was −0.05% (0.30%) (P = .86). Regarding percentage correct, the low-education intervention subgroup improved from 52.4% (7 of 21) to 66.7% (14 of 21) compared with the other subgroups. Conclusions and Relevance No difference was observed in stroke preparedness at 12 months in response to culturally tailored 12-minute stroke films or conventional stroke education pamphlets. Additional studies are required to confirm findings from a post hoc subgroup analysis that suggested a significant education effect. Trial Registration ClinicalTrials.gov identifier:NCT01909271.

BACKGROUND Uncontrolled hypertension (HTN) is a leading modifiable stroke risk factor contributing to global stroke disparities. This study is unique in testing a transitional care model aimed at controlling HTN in black and Hispanic poststroke, home health patients, an understudied group. METHODS A 3-arm randomized controlled trial design compared (i) usual home care (UHC), with (ii) UHC plus a 30-day nurse practitioner transitional care program, or (iii) UHC plus nurse practitioner plus a 60-day health coach program. The trial enrolled 495 black and Hispanic, English- and Spanish- speaking adults with uncontrolled systolic blood pressure (SBP ≥ 140 mm Hg) who had experienced a first-time or recurrent stroke or transient ischemic attack. The primary outcome was change in SBP from baseline to 3 and 12 months. RESULTS Mean participant age was 67; 57.0% were female; 69.7% were black, non-Hispanic; and 30.3% were Hispanic. Three-month follow-up retention was 87%; 12-month retention was 81%. SBP declined 9–10 mm Hg from baseline to 12 months across all groups; the greatest decrease occurred between baseline and 3 months. The interventions demonstrated no relative advantage compared to UHC. CONCLUSION The significant across-the-board SBP decreases suggest that UHC nurse/patient/physician interactions were the central component of SBP reduction and that additional efforts to lower recurrent stroke risk should test incremental improvements in usual care, not resource-intensive transitional care interventions. They also suggest the potential value of pragmatic home care programs as part of a broader strategy to overcome HTN treatment barriers and improve secondary stroke prevention globally. CLINICAL TRIALS REGISTRATION Trial Number NCT01918891.

Introduction: Delayed hospital arrival (DHA) after onset of stroke symptoms often precludes minority stroke victims from life-saving interventions. We sought to identify predictors of DHA in a cohort of Black and Hispanic stroke survivors. Methods: We analyzed data from a clinical trial comprising Blacks and Hispanics with recent stroke recruited from New York City stroke centers. Variables associated with pre-hospital behaviors were abstracted from medical records. DHA was defined as arrival to ER >4.5 hours after symptom onset. A GEE model assuming a binomial distribution with a logit link was used in all multivariate analyses adjusting for demographic variables, recurrent stroke, stroke severity, stroke symptomatology, stroke type, being alone at symptom onset, and mode of transportation. Results: Data was available for 209 Hispanics and 202 Blacks. The sample was 44% female with average age 61.9±11.0 years. Annual income was reported to be Conclusions: The frequency of DHA is high and is associated with a failure to activate EMS. The failure to activate EMS may be related to the experience of non-motor symptoms and is associated with being alone during symptom onset. Stroke education efforts should emphasize development of an action plan for alerting EMS that can be implemented when alone and emphasize that stroke symptoms are often non-motor in nature.

Objective: To (1) develop a patient-reported, multidomain functional assessment tool focused on medically ill patients in acute care settings; (2) characterize the measure's psychometric performance; and (3) establish clinically actionable score strata that link to easily implemented mobility preservation plans. Design: This article describes the approach that our team pursued to develop and characterize this tool, the Functional Assessment in Acute Care Multidimensional Computer Adaptive Test (FAMCAT). Development involved a multistep process that included (1) expanding and refining existing item banks to optimize their salience for hospitalized patients; (2) administering candidate items to a calibration cohort; (3) estimating multidimensional item response theory models; (4) calibrating the item banks; (5) evaluating potential multidimensional computerized adaptive testing (MCAT) enhancements; (6) parameterizing the MCAT; (7) administering it to patients in a validation cohort; and (8) estimating its predictive and psychometric characteristics. Setting: A large (2000-bed) Midwestern Medical Center. Participants: The overall sample included 4495 adults (2341 in a calibration cohort, 2154 in a validation cohort) who were admitted either to medical services with at least 1 chronic condition or to surgical/medical services if they required readmission after a hospitalization for surgery (N=4495). Intervention: Not applicable. Main Outcome Measures: Not applicable. Results: The FAMCAT is an instrument designed to permit the efficient, precise, low-burden, multidomain functional assessment of hospitalized patients. We tried to optimize the FAMCAT's efficiency and precision, as well as its ability to perform multiple assessments during a hospital stay, by applying cutting edge methods such as the adaptive measure of change (AMC), differential item functioning computerized adaptive testing, and integration of collateral test-taking information, particularly item response times. Evaluation of these candidate methods suggested that all may enhance MCAT performance, but none were integrated into initial MCAT parameterization. Conclusions: The FAMCAT has the potential to address a longstanding need for structured, frequent, and accurate functional assessment among patients hospitalized with medical diagnoses and complications of surgery.

An increasing proportion of hemodialysis patients are ineligible for transplant. Often these patients are elderly, with multiple comorbidities and decreased functional status. Such patients may benefit from modified treatment goals to reduce symptom burden.To demonstrate the feasibility of a trial of reduced-intensity treatment in nontransplantable patients with end-stage renal disease (ESRD).A 6-week study randomized patients to a reduced-intensity intervention versus usual care. Intervention subjects were treated with liberalized goals for serum phosphorus and parathyroid hormone (PTH) as well as predialysis blood pressure in comparison with usual care subjects. Outcomes included assessed feasibility of recruitment, randomization, and data collection.Sixteen transplant-ineligible hemodialysis patients were recruited from two urban units.Blood pressure was recorded weekly, while serum PTH and phosphorus were assessed every 10 days. A quality-of-life measure was administered before and after the trial.Of 300 patients, 51 were eligible and 16 consented. All were randomized and completed the trial. Patients in the intervention group received significantly lower doses of phosphorus binders and vitamin D analogues, and were less likely to have their dry weight reduced. All patient surveys were completed.High-risk hemodialysis patients may benefit from liberalized treatment guidelines but larger studies are necessary.

Nursing home (NH) residents have a high prevalence of delirium risk factors, experience two to four acute medical conditions (e.g., infections) each year, and have an incidence of delirium during these conditions similar to that of hospitalized older adults. Many NH residents with delirium do not return to their prior level of cognitive function. They are more likely to die, be hospitalized, and less likely to be discharged home than those without delirium. Research on the prevention or treatment of delirium in NHs is limited. This article describes the development and pilot testing of a multicomponent delirium prevention intervention in the NH setting adapted from the Hospital Elder Life Program (HELP-LTC). Activities to reduce the risk of delirium that were appropriate for functionally impaired NH residents were developed and delivered during treatment for and recovery from acute illness, a novel resident-targeting approach. Expertly trained certified nursing assistants (CNAs - a total of 1.4 full-time equivalent (FTE) positions-) visited residents throughout the facility and delivered the activities. The current study reports on incident delirium, delirium remission, cognitive and physical function change, hospitalization, and death associated with acute medical conditions as ascertained by a program coordinator. The integration and acceptance of the CNAs' activities by residents and staff are also reported on. Hospitalization and death were ascertained in a nonintervention comparison group. Findings support a test of the intervention in a controlled trial. The potential effect is great; there are approximately 1.4 million NH residents in the United States and an estimated 1 million with dementia or cognitive impairment, an important delirium risk factor. An intervention would be broadly adoptable if a reduction in healthcare costs through prevention of hospitalization offset the cost of the program's CNAs.

Low levels of symptom recognition by staff have been "gateway" barriers to the management of depression in long-term care. The study aims were to refine a depression training program for front-line staff in long-term care and provide evaluative knowledge outcome data. Three primary training modules provide an overview of depression symptoms; a review of causes and situational and environmental contributing factors; and communication strategies, medications, and clinical treatment strategies. McNemar's chi-square tests and paired t-tests were used to examine change in knowledge. Data were analyzed for up to 143 staff members, the majority from nursing. Significant changes (p

Older adults with cognitive impairment are a population at great risk for financial exploitation. At-risk older adults often have difficulty reporting on their own financial abilities. Collecting information from trusted others is vital for professionals investigating the financial exploitation older adults. There are few reliable, valid, and standardized informant-report measures of financial capacity, and none that assess decisional abilities for an ongoing, real-world financial transaction. The present study sought to examine the psychometric properties of a new informant-report scale of financial decisional abilities in older adults. One hundred fifty participants were recruited to complete the Family and Friends and Interview regarding a known older adult's financial decisional abilities. A factor analysis identified two subscales. The full scale had adequate sensitivity and specificity to detect an informant's current concerns regarding financial exploitation. The Family and Friends Scale is a useful tool for collecting informant-report regarding an older adult's ability to make financial transactions.

Significant racial and ethnic disparities in stroke risk factors, occurrence and outcomes persist in the United States. This article examines socio-economic and health disparities in a diverse, hypertensive sample of 495 post-stroke Black, non-Hispanic and Hispanic home health patients at risk of a recurrent stroke due to elevated systolic blood pressure (SBP), defined as SBP ≥ 140 mmHg. The article, which analyzes cross-sectional data, focuses on correlates of patients’ SBP – the leading modifiable cause of stroke – and physical function – a key stroke sequela and indicator of post-stroke quality of life. Of the 495 participants, 69.7% were Black, non-Hispanic, and 30.3% Hispanic. Black participants had significantly higher mean SBP than Hispanics. After controlling for multiple potential confounders/predictors, being Black was associated with a 3.55 mmHg elevation in SBP relative to being Hispanic. There were no significant Black/Hispanic differences in physical function measures. Seven independent variables significantly predicted better physical function: being male, younger, having fewer comorbidities, lower BMI, fewer depressive symptoms, higher health literacy and current alcohol drinking (vs abstinence). Our data provide a unique comparison of homebound Black and Hispanic stroke survivors at heightened risk of recurrent stroke absent targeted intervention. The finding of a significant Black/Hispanic disparity in SBP is striking in this narrowly defined home health care population all of whom are at risk for recurrent stroke. Priority should be given to culturally tailored interventions designed to link vulnerable home care patients to continuous, responsive hypertension care.

Background: Mobile health applications (mHealth apps) represent a rapidly emerging technology that is being used to improve health-care delivery. In home hospice, informal caregivers play an essential role in attending to the day-to-day needs of their terminally ill loved ones. Using mHealth apps by caregivers in this setting could potentially improve the support provided to both patients and caregivers at the end of life (EoL). Objectives: To explore informal caregivers’ receptivity and concerns in using mHealth apps along with app features, caregivers perceived to be most useful in home hospice care. Design: Eighty semistructured phone interviews were conducted with informal caregivers who received care from a nonprofit hospice organization. Study data were analyzed using content analysis, coding for themes of receptivity and interest. Results: Sixty-two (78%) participants were receptive to using an mHealth app in home hospice care. Informal caregivers were interested in features that addressed: (1) communication to improve patient care (n = 44, 70%), (2) access to patient care information (n = 30, 48%), (3) education (n = 24, 39%), and (4) updates from health-care personnel and scheduling services (n = 10, 16%). Conclusions: A substantial majority of informal caregivers voiced receptivity to using mHealth apps and expressed interest in features that enhance communication and provide information to improve patient care. Although more research is needed to examine how to incorporate this technology into existing home hospice care, our study suggests that informal caregivers are likely to use this technology they feel will help enhance home-based EoL care delivery.

Resident-to-resident elder mistreatment (R-REM) occurs frequently in long-term services and support settings. The purpose of the current study was to evaluate the effect of a R-REM training program for nursing and other front-line staff on resident falls and injuries in a cluster randomized trial of units within four nursing homes. Interview and observational data from a sample of 1,201 residents ( n = 600 and n = 601 in the usual care and intervention groups, respectively) and staff were collected at baseline and 6 and 12 months. A generalized linear model was used to model the falls/injuries outcome. The net reduction in falls and injuries was 5%, translating to 10 saved events per year in an averagesized facility. Although the result did not reach statistical significance due to low power, the findings of fall prevention associated with implementing the intervention in long-term care facilities is clinically important. [ Journal of Gerontological Nursing, 44 (6), 15–23.]

OBJECTIVES To examine the association of glycemia and diabetes status with cognition among 600 Hispanics aged 55 to 64 years from Northern Manhattan. METHODS Diabetes was ascertained by history or hemoglobin A1c. Normal glucose tolerance and prediabetes were ascertained with hemoglobin A1c. Memory was assessed with the Selective Reminding Test. Executive abilities were assessed using the Color Trails 1 and 2 and verbal fluency test. The cross-sectional association of glycemia and diabetes status with cognitive performance was examined using linear regression. RESULTS Participants had a mean age of 59.2 (2.9) years, 76.7% were women, and more than 65% had prediabetes or diabetes. HbA1C (β = -0.97, p < .001) and diabetes (β = -2.06, p = .001) were related with lower Selective Reminding Test total recall after adjustment for demographics, education, and vascular risk factors. Prediabetes was associated with worse performance in Color Trail 2 (β = -6.45 p = .022) after full adjustment. CONCLUSIONS Higher glycemia and diabetes are related to worse memory and executive abilities in late middle age, whereas prediabetes is related only to worse executive abilities. Longitudinal follow-up is needed to understand the order and progression of these deficits.

Resident-to-resident elder mistreatment (R-REM) in nursing homes is frequent and leads to adverse outcomes. Nursing home staff responses may significantly mitigate R-REM's impact, but little is known about current practices. The objective was to identify common staff responses to R-REM. The authors interviewed 282 certified nursing assistants (CNAs) in five urban nursing homes on their responses during the previous 2 weeks to R-REM behaviors of residents under their care. Ninety-seven CNAs (34.4%) reported actions responding to R-REM incidents involving 182 residents (10.8%), describing 22 different responses. Most common were physically intervening/separating residents (51), talking calmly to settle residents down (50), no intervention (39), and verbally intervening to defuse the situation (38). Less common were notifying a nurse (13) or documenting in behavior log (4). Nursing home staff report many varied responses to R-REM, a common and dangerous occurrence. CNAs seldom documented behaviors or reported them to nurses.

Introduction. We describe the design and implementation of a psychiatric collaborative care model in a university-based geriatric primary care practice. Initial results of screening for anxiety and depression are reported. Methods and Materials. Screens for anxiety and depression were administered to practice patients. A mental health team, consisting of a psychiatrist, mental health nurse practitioner, and social worker, identified patients who on review of screening and chart data warranted evaluation or treatment. Referrals for mental health interventions were directed to members of the mental health team, primary care physicians at the practice, or community providers. Results. Subjects (N=1505) comprised 38.2% of the 3940 unique patients seen at the practice during the 4-year study period. 37.1% (N=555) screened positive for depression, 26.9% (N=405) for anxiety, and 322 (21.4%) screened positive for both. Any positive score was associated with age (P<0.033), female gender (P<0.006), and a nonsignificant trend toward living alone (P<0.095). 8.87% had suicidal thoughts. Conclusions. Screening captured the most affectively symptomatic patients, including those with suicidal ideation, for intervention. The partnering of mental health professionals and primary care physicians offers a workable model for addressing the scarcity of expertise in geriatric psychiatry.

We set out to review the efficacy of Community Health Worker (CHW) interventions to improve glycemia in people with diabetes.Data sources included the Cochrane Central Register of Controlled Trials, Medline, clinicaltrials.gov, Google Scholar, and reference lists of previous publications. We reviewed randomized controlled trials (RCTs) that assessed the efficacy of CHW interventions, as compared to usual care, to lower hemoglobin A1c (A1c). Two investigators independently reviewed the RCTs and assessed their quality. Only RCTs with a follow-up of at least 12 months were meta-analyzed. A random effects model was used to estimate, from unadjusted within-group mean reductions, the standardized mean difference (SMD) in A1c achieved by the CHW intervention, beyond usual care.Thirteen RCTs were included in the narrative review, and nine of them, which had at least 12 months of follow-up, were included in the meta-analysis. Publication bias could not be ruled-out due to the small number of trials. Outcome heterogeneity was moderate (I(2)= 37%). The SMD in A1c (95% confidence interval) was 0.21 (0.11-0.32). Meta-regression showed an association between higher baseline A1c and a larger effect size.CHW interventions showed a modest reduction in A1c compared to usual care. A1c reduction was larger in studies with higher mean baseline A1c. Caution is warranted, given the small number of studies.

Background and Purpose— Deficiencies in stroke preparedness cause major delays to stroke thrombolysis, particularly among economically disadvantaged minorities. We evaluated the effectiveness of a stroke preparedness intervention delivered to preadolescent urban public school children on the stroke knowledge/preparedness of their parents. Methods— We recruited 3070 fourth through sixth graders and 1144 parents from 22 schools into a cluster randomized trial with schools randomized to the HHS (Hip-Hop Stroke) intervention or attentional control (nutrition classes). HHS is a 3-hour culturally tailored, theory-based, multimedia stroke literacy intervention targeting school children, which systematically empowers children to share stroke information with parents. Our main outcome measures were stroke knowledge/preparedness of children and parents using validated surrogates. Results— Among children, it was estimated that 1% (95% confidence interval [CI], 0%–1%) of controls and 2% (95% CI, 1%–4%; P =0.09) of the intervention group demonstrated optimal stroke preparedness (perfect scores on the knowledge/preparedness test) at baseline, increasing to 57% (95% CI, 44%–69%) immediately after the program in the intervention group compared with 1% (95% CI, 0%–1%; P P P =0.0062), with no significant changes (3% identification) among controls. Four children, all in the intervention group, called 911 for real-life stroke symptoms, in 1 case overruling a parent’s wait-and-see approach. Conclusions— HHS is an effective, intergenerational model for increasing stroke preparedness among economically disadvantaged minorities. Clinical Trial Registration— URL: https://clinicaltrials.gov . Unique identifier: NCT01497886.

The objectives of this study were threefold: (1) to empirically test the conceptual model proposed by the Lichtenberg Financial Decision-making Rating Scale (LFDRS); (2) to examine the psychometric properties of the LFDRS contextual factors in financial decision-making by investigating both the reliability and convergent validity of the subscales and total scale, and (3) extending previous work on the scale through the collection of normative data on financial decision-making.A convenience sample of 200 independent function and community dwelling older adults underwent cognitive and financial management testing and were interviewed using the LFDRS. Confirmatory factor analysis, internal consistency measures, and hierarchical regression were used in a sample of 200 community-dwelling older adults, all of whom were making or had recently made a significant financial decision.Results confirmed the scale's reliability and supported the conceptual model. Convergent validity analyses indicate that as hypothesized, cognition is a significant predictor of risk scores. Financial management scores, however, were not predictive of decision-making risk scores.The psychometric properties of the LFDRS support the scale's use as it was proposed.The LFDRS instructions and scale are provided for clinicians to use in financial capacity assessments.

To examine agreement between Minimum Data Set clinician ratings and researcher assessments of depression among ethnically diverse nursing home residents using the 9-item Patient Health Questionnaire.Although depression is common among nursing homes residents, its recognition remains a challenge.Observational baseline data from a longitudinal intervention study.Sample of 155 residents from 12 long-term care units in one US facility; 50 were interviewed in Spanish. Convergence between clinician and researcher ratings was examined for (i) self-report capacity, (ii) suicidal ideation, (iii) at least moderate depression, (iv) Patient Health Questionnaire severity scores. Experiences by clinical raters using the depression assessment were analysed. The intraclass correlation coefficient was used to examine concordance and Cohen's kappa to examine agreement between clinicians and researchers.Moderate agreement (κ = 0.52) was observed in determination of capacity and poor to fair agreement in reporting suicidal ideation (κ = 0.10-0.37) across time intervals. Poor agreement was observed in classification of at least moderate depression (κ = -0.02 to 0.24), lower than the maximum kappa obtainable (0.58-0.85). Eight assessors indicated problems assessing Spanish-speaking residents. Among Spanish speakers, researchers identified 16% with Patient Health Questionnaire scores of 10 or greater, and 14% with thoughts of self-harm whilst clinicians identified 6% and 0%, respectively.This study advances the field of depression recognition in long-term care by identification of possible challenges in assessing Spanish speakers.Use of the Patient Health Questionnaire requires further investigation, particularly among non-English speakers. Depression screening for ethnically diverse nursing home residents is required, as underreporting of depression and suicidal ideation among Spanish speakers may result in lack of depression recognition and referral for evaluation and treatment. Training in depression recognition is imperative to improve the recognition, evaluation and treatment of depression in older people living in nursing homes.

The scarcity of empirically validated assessment instruments continues to impede the work of professionals in a number of fields, including medicine, finance, and estate planning; adult protective services; and criminal justice—and, more importantly, it impedes their ability to effectively assist and, in some case, protect their clients. Other professionals (e.g., legal, financial, medical, mental health services) are in a position to prevent financial exploitation and would benefit from access to new instruments. The Lichtenberg Financial Decision Screening Scale (LFDSS) was introduced in 2016, along with evidence for its convergent validity (Lichtenberg, P. A., Fickern, L., Rahman-Filipiak, A., Tatro, R., Farrell, C., Speir, J. J., … Jackman, J. D. (2016b). The Lichtenberg Financial Decision Screening Scale: A new tool for assessing financial decision making and preventing financial exploitation (2016). Journal of Elder Abuse and Neglect, 28, 134–151. doi:10.1080/08946566.2016.1168333). Using a sample of 213 participants, this study investigated the internal consistency of the LFDSS and its criterion validity based on ratings by professionals using the scale. Results demonstrate that the LFDSS has excellent internal consistency and clinical utility properties. This paper provides support for use of the LFDSS as a reliable and valid instrument. The LFDSS and instructions for its use are included in the article, along with information about online tools and support.

Purpose This was a Phase II pilot study of a problem-solving treatment (PST) to address subsyndromal depression in residents of long-term care facilities. Our goal was to demonstrate PST implementation feasibility and to identify PST’s potential for reducing depressive symptoms in this geriatric health care setting. Methods Eligible participants were randomized to receive a PST treatment (six 1-hour sessions) or a social contact comparison (6 “friendly” visits) after an initial baseline assessment. Follow-up assessments occurred 7 weeks later (after treatment) and 2 months posttreatment. The basic analytic approach was based on an intention-to-treat analysis. Findings We enrolled 21 elderly subjects in the PST group and 16 elderly subjects in the social contact comparison group. The PST group experienced a decline in depression scores compared with the social contact group. Although not statistically significant (likely due to the small sample size), PST was associated with decreased depressive symptom scores for those who were able to complete the intervention. Implementation proved to be difficult in terms of study recruitment and intervention acceptance and adherence. Implications These study findings point to the potential benefits of an integrated mental health component in long-term care, involving rehabilitation professionals who are already working with the older adults in both postacute/short-stay and long-stay settings.

This article describes an educational program to inform nursing and care staff of the management of resident-to-resident elder mistreatment (R-REM) in nursing homes, using the SEARCH ( S upport, E valuate, A ct, R eport, C are plan, and H elp to avoid) approach. Although relatively little research has been conducted on this form of abuse, there is mounting interest in R-REM because such aggression has been found to be extensive and can have both physical and psychological consequences for residents and staff. The goal of the SEARCH approach is to support staff in the identification and recognition of R-REM as well as to suggest recommendations for management. The educational program and the SEARCH approach are described. Three case studies from the research project are presented, illustrating how nurses and care staff can use the SEARCH approach to manage R-REM in nursing homes. Resident and staff safety and well-being can be enhanced by the use of the evidence-based SEARCH approach. J Contin Educ Nurs. 2014;45(3):112–121.

The Family Satisfaction with End-of-Life Care (FAMCARE) has been used widely among caregivers to individuals with cancer. The aim of this study was to evaluate the psychometric properties of this measure using item response theory (IRT). The analytic sample was comprised of caregivers to 1,983 patients with advanced cancer. Among the patients, 56 % were females, with mean age 59.9 years (s.d. = 11.8), 20 % were non-Hispanic Black. The majority were family members either living with (44 %) or not living with (35 %) the patient. Factor analyses and IRT were used to examine the dimensionality, information, and reliability of the FAMCARE. Although a bi-factor model fit the data slightly better than did a unidimensional model, the loadings on the group factors were very low. Thus, a unidimensional model appears to provide adequate representation for the item set. The reliability estimates, calculated along the satisfaction (theta) continuum, were adequate (>0.80) for all levels of theta for which subjects had scores. Examination of the category response functions from IRT showed overlap in the lower categories with little unique information provided; moreover, the categories were not observed to be interval. Based on these analyses, a three-response category format was recommended: very satisfied, satisfied, and not satisfied. Most information was provided in the range indicative of either dissatisfaction or high satisfaction. These analyses support the use of fewer response categories and provide item parameters that form a basis for developing shorter-form scales. Such a revision has the potential to reduce respondent burden.

A synthesis of the last decade of literature on elder abuse in residential long-term care (i.e., Nursing Homes and Assisted Living) is discussed. Presented are definitions of abuse, theoretical and conceptual models, prevalence rates of abuse, outcomes and costs, and sources of abuse. The synthesis represents an update to the literature in the influential 2003 National Research Council report. We identify many of the same issues and concerns exist that were surfaced in this prior report. Many theoretical and conceptual models need further elaboration. Conflicting definitions of abuse are pervasive. Rates of abuse are generally inaccurate, and probably under-reported. However, we also identify progress in many areas. An increase in empirical studies that exist in this area (although very few in Assisted Living). Other forms and types of abuse have also been identified as important, such as resident-to-resident abuse. These areas are discussed, along with potential suggestions for additional research.

Elder abuse in long-term care has received considerable attention; however, resident-to-resident elder mistreatment (R-REM) has not been well researched. Preliminary findings from studies of R-REM suggest that it is sufficiently widespread to merit concern, and is likely to have serious detrimental outcomes for residents. However, no evidence-based training, intervention and implementation strategies exist that address this issue.The objective was to evaluate the impact of a newly developed R-REM training intervention for nursing staff on knowledge, recognition and reporting of R-REM.The design was a prospective cluster randomized trial with randomization at the unit level.A sample of 1405 residents (685 in the control and 720 in the intervention group) from 47 New York City nursing home units (23 experimental and 24 control) in 5 nursing homes was assessed. Data were collected at three waves: baseline, 6 and 12 months. Staff on the experimental units received the training and implementation protocols, while those on the comparison units did not. Evaluation of outcomes was conducted on an intent-to-treat basis using mixed (random and fixed effects) models for continuous knowledge variables and Poisson regressions for longitudinal count data measuring recognition and reporting.There was a significant increase in knowledge post-training, controlling for pre-training levels for the intervention group (p0.001), significantly increased recognition of R-REM (p0.001), and longitudinal reporting in the intervention as contrasted with the control group (p=0.0058).A longitudinal evaluation demonstrated that the training intervention was effective in enhancing knowledge, recognition and reporting of R-REM. It is recommended that this training program be implemented in long-term care facilities.

The disproportionately high prevalence of hypertension and its associated mortality and morbidity in minority older adults is a major public health concern in the United States. Despite compelling evidence supporting the beneficial effects of therapeutic lifestyle changes on blood pressure reduction, these approaches remain largely untested among minority elders in community-based settings. The Counseling Older Adults to Control Hypertension trial is a two-arm randomized controlled trial of 250 African-American and Latino seniors, 60 years and older with uncontrolled hypertension, who attend senior centers. The goal of the trial is to evaluate the effect of a therapeutic lifestyle intervention delivered via group classes and individual motivational interviewing sessions versus health education, on blood pressure reduction. The primary outcome is change in systolic and diastolic blood pressure from baseline to 12 months. The secondary outcomes are blood pressure control at 12 months; changes in levels of physical activity; body mass index; and number of daily servings of fruits and vegetables from baseline to 12 months. The intervention group will receive 12 weekly group classes followed by individual motivational interviewing sessions. The health education group will receive an individual counseling session on healthy lifestyle changes and standard hypertension education materials. Findings from this study will provide needed information on the effectiveness of lifestyle interventions delivered in senior centers. Such information is crucial in order to develop implementation strategies for translation of evidence-based lifestyle interventions to senior centers, where many minority elders spend their time, making the centers a salient point of dissemination.

Objectives The aim was to conduct a comparative effectiveness research study to estimate the effects on falls, negative affect and behavior, and the associated societal costs of implementing evidence-based education and best practice programs in nursing homes (NHs). Design A quasi-experimental design, a variant of a cluster randomized trial of implementation research examining transfer of research findings into practice, was used to compare outcomes among three groups of residents in 15 nursing homes per group. Methods Forty-five NHs participated in one of three conditions: (1) standard training, (2) training and implementation modules provided to facility staff, or (3) staff training and implementation modules augmented by surveyor training. After application of exclusion and matching criteria, nursing homes were selected at random within three regions of New York State. Outcomes were assessed using medical records and the Minimum Data Set (MDS). Results The main finding was of a significant reduction of between 5 and 12 annual falls in a typical nursing home. While both intervention groups resulted in fall reduction, the larger and significant reduction occurred in the group without surveyor training. A significant reduction in negative affect associated with training staff and surveyors was observed. Net cost savings from fall prevention was estimated. Conclusions A low cost intervention targeting dissemination of evidence-based best practices in nursing homes can result in the potential for fall reduction, and cost savings.

Pre-Conference Workshop in conjunction with the Annual Meeting of the Geriatrics Society of America San Diego Convention Center, San Diego, CA, USA, 14 November 2012 In 2004, the NIH awarded contracts to initiate the development of high-quality psychological and neuropsychological outcome measures for the improved assessment of health-related outcomes. The workshop introduced these measurement development initiatives, the measures created and the NIH-supported resource (Assessment Center) for internet or tablet-based test administration and scoring. Presentations covered item response theory and assessment of test bias, construction of item banks and computerized adaptive testing, and the different ways in which qualitative analyses contribute to the definition of construct domains and the refinement of outcome constructs. The panel discussion included questions about representativeness of samples and the assessment of cultural bias. © 2013 Expert Reviews Ltd.

Adherence to diabetes self care is poor for Hispanic American and African-American patients. This study examined the change in adherence over time and in response to a telemedicine intervention for elderly diabetes patients in these groups compared to white diabetes patients. We also examined whether adherence mediated the effect of the intervention on glycemic control (A1c).The Informatics for Diabetes Education and Telemedicine project randomized medically underserved Medicare patients (n=1665) to telemedicine case management (televideo educator visits, individualized goal-setting/problem solving) or usual care. Hispanic and African-American educators delivered the intervention in Spanish if needed.Annual assessment included A1c and self-reported adherence (Summary of Diabetes Self-Care Activities scale). A simple model (only time and group terms) and a model with covariates (e.g., age) were examined for baseline and 5 years of follow-up. SAS PROC Mixed was used with non-linear terms to examine mediating effects of adherence on A1c, by performing tests of the mediating path coefficients.Over time, self-reported adherence improved for the treatment group compared to usual care (p0.001). There was no significant interaction with racial/ethnic group membership, i.e., all groups improved. However, minority subjects were consistently less adherent than whites. Also, greater comorbidity and diabetes symptoms predicted poorer adherence, greater duration of diabetes and more years of education predicted better adherence. Adherence was a significant mediator of A1c (p0.001).A unique, tailored telemedicine intervention was effective in achieving improved adherence to diabetes self care. However, African-American and Hispanic American participants were less adherent than white participants at all time points despite an individualized and accessible intervention. The finding that adherence did mediate glycemic control suggests that unique interventions for minority groups may be needed to overcome this disparity.

The goal of this review is to discuss the state-of-the-science in elder abuse prevention. Findings from evidence-based programs to reduce elder abuse are discussed, drawing from findings and insights from evidence-based programs for child maltreatment and domestic/ intimate partner violence. A conceptual measurement model for the study of elder abuse is presented, and linked to possible measures of risk factors and outcomes. Advances in neuroscience in child maltreatment and novel measurement strategies for outcome assessment are presented.

Little research has been conducted on aggression directed at staff by nursing home residents.To estimate the prevalence of resident-to-staff aggression (RSA) over a 2-week period.Prevalent cohort study.Large urban nursing homes.Population-based sample of 1,552 residents (80 % of eligible residents) and 282 certified nursing assistants.Measures of resident characteristics and staff reports of physical, verbal, or sexual behaviors directed at staff by residents.The staff response rate was 89 %. Staff reported that 15.6 % of residents directed aggressive behaviors toward them (2.8 % physical, 7.5 % verbal, 0.5 % sexual, and 4.8 % both verbal and physical). The most commonly reported type was verbal (12.4 %), particularly screaming at the certified nursing assistant (9.0 % of residents). Overall, physical aggression toward staff was reported for 7.6 % of residents, the most common being hitting (3.9 % of residents). Aggressive behaviors occurred most commonly in resident rooms (77.2 %) and in the morning (84.3 %), typically during the provision of morning care. In a logistic regression model, three clinical factors were significantly associated with resident-to-staff aggression: greater disordered behavior (OR = 6.48, 95 % CI: 4.55, 9.21), affective disturbance (OR = 2.29, 95 % CI: 1.68, 3.13), and need for activities of daily living morning assistance (OR = 2.16, 95 % CI: 1.53, 3.05). Hispanic (as contrasted with White) residents were less likely to be identified as aggressors toward staff (OR = 0.57, 95 % CI: 0.36, 0.91).Resident-to-staff aggression in nursing homes is common, particularly during morning care. A variety of demographic and clinical factors was associated with resident-to-staff aggression; this could serve as the basis for evidence-based interventions. Because RSA may negatively affect the quality of care, resident and staff safety, and staff job satisfaction and turnover, further research is needed to understand its causes and consequences and to develop interventions to mitigate its potential impact.

OBJECTIVE To assess the association between serum adiponectin level and all-cause mortality in people with type 2 diabetes. Because of the insulin-sensitizing, anti-inflammatory, and antiatherogenic effects of adiponectin, we hypothesized that higher adiponectin level would be associated with lower all-cause mortality. RESEARCH DESIGN AND METHODS A total of 609 men and women aged 72 ± 6.3 years with type 2 diabetes and information on total and high molecular weight adiponectin were followed for a median of 5 years. The longitudinal association between adiponectin and all-cause mortality was analyzed with Cox proportional hazards models with time from adiponectin measurement to death as the time-to-event variable. Analyses were adjusted for demographic variables and significant diabetes parameters, significant cardiovascular parameters, and significant diabetes medications. RESULTS Total and high molecular weight adiponectin were highly correlated. The highest adiponectin quartile was strongly associated with higher all-cause mortality compared with the lowest quartile (hazard ratio = 4.0 [95% CI: 1.7–9.2]) in the fully adjusted model. These results did not change in analyses stratified by sex and thiazolidinedione use, after exclusion of people who died within one year of adiponectin measurement, or when change in weight before adiponectin measurement was considered. CONCLUSIONS Contrary to our hypothesis, higher adiponectin level was related to higher all-cause mortality. This association was not explained by confounding by other characteristics, including medications or preceding weight loss.

Purpose: Despite its prevalence and negative consequences, research on elder abuse has rarely considered resident-to-resident aggression (RRA) in nursing homes. This study employed a qualitative event reconstruction methodology to identify the major forms of RRA that occur in nursing homes. Design and methods: Events of RRA were identified within a 2-week period in all units (n = 53) in nursing homes located in New York City. Narrative reconstructions were created for each event based on information from residents and staff who were involved as well as other sources. The event reconstructions were analyzed using qualitative methods to identify common features of RRA events. Results: Analysis of the 122 event reconstructions identified 13 major forms of RRA, grouped under five themes. The resulting framework demonstrated the heterogeneity of types of RRA, the importance of considering personal, environmental, and triggering factors, and the potential emotional and physical harm to residents. Implications: These results suggest the need for person-centered and environmental interventions to reduce RRA, as well as for further research on the topic.

Objective: To examine the effects of electronic health information technology (HIT) on nursing home residents. Methods: The study evaluated the impact of implementing a comprehensive HIT system on resident clinical, functional, and quality of care outcome indicators as well as measures of resident awareness of and satisfaction with the technology. The study used a prospective, quasi-experimental design, directly assessing 761 nursing home residents in 10 urban and suburban nursing homes in the greater New York City area. Results: No statistically significant impact of the introduction of HIT on residents was found on any outcomes, with the exception of a significant negative effect on behavioral symptoms. Residents’ subjective assessment of the HIT intervention were generally positive. Discussion: The absence of effects on most indicators is encouraging for the future development of HIT in nursing homes. The single negative finding suggests that further investigation is needed on possible impact on resident behavior.

doi:10.1111/j.1741-2358.2009.00335.x Correlates of dental visits among community-residing Latino elders: a public health alert Objectives: To examine oral service utilisation in a probability sample of community-residing Latino elders. Background: Older Latinos are at a potential increased risk of oral diseases, given their higher prevalence of co-morbidities and lower rate of dental service utilisation. Methods: A prevalence survey was conducted among a random sample of Latino (largely Puerto Rican) elders (n = 205; mean age = 75.8; SD ± 5.3) in New York City during 2001–2002. A systematic random sample was drawn from the Centers for Medicare and Medicaid Services Beneficiary tape files. Current use of oral health services and self-reported health conditions was obtained. Functional and cognitive impairment were assessed. Results: Less than half of the sample reported a dental visit in the previous year. The average time since the last dental visit was 54 months (SD ± 84.5). Last year dental visit compliers were more likely to be unmarried, living alone, with higher levels of education, fewer health conditions and less impairment with activities of daily living. In multivariate analyses, problem-oriented behaviour, Medicaid beneficiary, education, living alone, chronic health conditions and mobility impairment explained 14% of the ‘time since last dental visit’ variance. Conclusions: Given that socio-demographic and level of functioning determinants appear to influence the frequency of dental visits, a multilevel approach to oral health promotion is imperative.