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Importance: Many older women are screened for breast cancer beyond guideline-recommended thresholds. Messaging holds promise to reduce overscreening., Objective: To investigate the effect of a message on older women's support for and intentions of stopping breast cancer screening., Design, Setting, and Participants: A 2-wave randomized clinical online survey trial using a nationally representative online panel was performed from May 12 to June 19, 2023. Women 65 years or older without breast cancer were eligible to participate., Intervention: A pilot-tested breast cancer screening cessation message delivered to a hypothetical older woman with serious illnesses and functional impairment. The message was described as from 1 of 3 sources (clinician, news story, or family member). Participants were randomized into 4 groups: no message (group 1 [control]), a single message from a clinician at wave 1 and no message at wave 2 (group 2), a message from a news story (wave 1) and a clinician (wave 2) (group 3), and a message from a family member (wave 1) and a clinician (wave 2) (group 4)., Main Outcomes and Measures: Support for stopping screening in the hypothetical older woman (primary) and screening intentions for oneself (secondary) were assessed on 7-point scales, with higher values indicating stronger support for and intentions to stop screening. Means were compared using analysis of variance. The message effect on screening intentions among participants 75 years or older and those with life expectancy of less than 10 years were also explored., Results: A total of 3051 women participated in wave 1 of the trial. The mean (SD) age was 72.8 (5.9) years; 272 (8.9%) were non-Hispanic Black and 2506 (82.1%) were non-Hispanic White. Of these women, 2796 (91.6%) completed wave 2. Group 2 had significantly higher support for screening cessation in the hypothetical patient at wave 2 (mean score, 3.14 [95% CI, 2.99-3.29]) compared with group 1 (mean score, 2.68 [95% CI, 2.54-2.82]; P < .001). The effect was even stronger in group 3 (mean score, 4.23 [95% CI, 4.09-4.38]) and group 4 (mean score, 4.12 [95% CI, 3.97-4.27]) compared with both groups 1 and 2 (all P < .001). Message effects on self-screening intentions followed a similar pattern, with larger effects among participants 75 years or older or with limited life expectancy., Conclusions and Relevance: In this randomized clinical trial, a breast cancer screening cessation message significantly increased older women's support for and intentions of screening cessation. The strongest effects were observed when the message was delivered over time from multiple sources. Future work needs to engage potential message sources to examine the feasibility and acceptability of multilevel messaging strategies and their effect on screening behavior., Trial Registration: ClinicalTrials.gov Identifier: NCT05821023.

Physiological stress levels in response to sexual behavior stigma among men who have sex with men (MSM) in the United States (US) are understudied. The current study aims to explore the relationship between sexual behavior stigma and salivary cortisol both overall and stratified by race/ethnicity. If such an association exists, it may suggest that sexual behavior stigma can be physiologically measured or indicated by the presence of heightened salivary cortisol. A subsample of 667 MSM participants from the 2019 American Men's Internet Survey (AMIS; N = 10,129) submitted morning (AM) and evening (PM) saliva cortisol samples using at-home mail-in collection kits. Average daily cortisol and daily cortisol change were calculated; simple linear regressions estimated associations between cortisol measures and sexual behavior stigma characterized in four different ways (ever and recent experience of individual stigma items; average ever and recent experience of three stigma scales: stigma from family and friends, anticipated healthcare stigma, general social stigma). Participants reported a mean age of 36.0 years (SD = 14.9), with most being non-Hispanic white (n = 480, 72.0%), Hispanic (n = 164, 12.3%), or Black/African American (n = 146, 10.9%), and identified as homosexual/gay (n = 562, 84.3%). Reporting ever experiencing healthcare providers gossiping was significantly associated with higher PM cortisol (β = 0.12, p = 0.001) and higher average daily cortisol (β = 0.11, p = 0.004), while reporting ever experiencing police refusing to protect was associated with higher AM cortisol (β = 0.08, p = 0.03) and higher average daily cortisol (β = 0.09, p = 0.02). Recent experiences of stigma were not significant predictors of any measure of cortisol. Measures of salivary cortisol may be used to characterize sexual behavior stigma among MSM populations, however more insight is needed to determine its exact relationship and strength., (© 2023. Springer Nature Limited.)

Objectives: To examine whether physical frailty onset before, after, or in concert with cognitive impairment is differentially associated with fall incidence in community-dwelling older adults., Design: A longitudinal observational study., Setting and Participants: Data from 1337 older adults age ≥65 years and free of physical frailty or cognitive impairment at baseline were obtained from the National Health Aging Trends Study (2011‒2017), a nationally representative cohort study of US older adult Medicare beneficiaries., Methods: Participants were assessed annually for frailty (physical frailty phenotype) and cognitive impairment (bottom quintile of clock drawing test or immediate and delayed recall; or proxy-report of diagnosis of dementia or AD8 score of ≥2). Incident falls were ascertained annually via self-report. Multinomial logistic regression was performed to estimate the association between order of first onset of cognitive impairment and/or frailty and incident single or repeated falls in the 1-year interval following their first onset., Results: Of the 1,337, 832 developed cognitive impairment first (termed "CI first"), 286 developed frailty first (termed "frailty first") and 219 had co-occurrence of cognitive impairment and frailty within one year (termed "CI-frailty co-occurrence") over 5 years. Overall, 491 (34.5%) had at least 1 fall during the 1-year interval following the onset of physical frailty and/or cognitive impairment. After adjustment, "CI-frailty co-occurrence" was associated with a more than 2-fold increased risk of repeated falls than "CI first" (odds ratio 2.35, 95% confidence interval 1.51‒3.67; P < .001). No significant difference was found between participants with "frailty first" and "CI first" (P = .07). In addition, the order of onset was not associated with risk of a single fall., Conclusions and Implications: Older adults experiencing "CI-frailty co-occurrence" had the greatest risk of repeated falls compared with those with "CI first" and "frailty first". Fall risk screening should consider the order and timing of onset of physical frailty and cognitive impairment., (Copyright © 2023 AMDA – The Society for Post-Acute and Long-Term Care Medicine. All rights reserved.)

Background: We aimed to study whether physical frailty and cognitive impairment (CI) increase the risk of recurrent hospitalizations in older adults, independent of comorbidity, and disability., Methods: Two thousand five hundred forty-nine community-dwelling participants from the National Health and Aging Trends Study (NHATS) with 3 + years of continuous Medicare coverage from linked claims data were included. We used the marginal means/rates recurrent events model to investigate the association of baseline CI (mild CI or dementia) and physical frailty, separately and synergistically, with the number of all-source vs. Emergency Department (ED)-admission vs. direct admission hospitalizations over 2 years., Results: 17.8% of participants had at least one ED-admission hospitalization; 12.7% had at least one direct admission hospitalization. Frailty and CI, modeled separately, were both significantly associated with risk of recurrent all-source (Rate Ratio (RR) = 1.24 for frailty, 1.21 for CI; p < .05) and ED-admission (RR = 1.49 for frailty, 1.41 for CI; p < .05) hospitalizations but not direct admission, adjusting for socio-demographics, obesity, comorbidity and disability. When CI and frailty were examined together, 64.3% had neither (Unimpaired); 28.1% CI only; 3.5% Frailty only; 4.1% CI + Frailty. Compared to those Unimpaired, CI alone and CI + Frailty were predictive of all-source (RR = 1.20, 1.48, p < .05) and ED-admission (RR = 1.36, 2.14, p < .05) hospitalizations, but not direct admission, in our adjusted model., Conclusions: Older adults with both CI and frailty experienced the highest risk for recurrent ED-admission hospitalizations. Timely recognition of older adults with CI and frailty is needed, paying special attention to managing cognitive impairment to mitigate preventable causes of ED admissions and potentiate alternatives to hospitalization., (© 2022. The Author(s).)

Background: Physical frailty is defined as a syndrome of decreased physiologic reserve conferring vulnerability to functional decline, mortality, and other adverse outcomes upon experiencing stressors. Self-efficacy, which is confidence in one's ability to perform well in a domain of life, is modifiable. Self-efficacy is associated with improved health behavior and decreased chronic disease burden. Its relationship to frailty is unknown. The purpose of this study was to evaluate whether a general self-efficacy proxy predicts incident frailty., Methods: A nationally representative sample of 4825 U.S. older adults aged 65 and older living in the community or non-nursing home care setting enrolled in the National Health and Aging Trends Study from 2011 to 2018 was used. Self-efficacy was dichotomized into low and high groups using the one-item self-efficacy proxy measure. The Physical Frailty Phenotype was used to categorize participants as frail and non-frail. A discrete time hazard model using data from eight rounds was used to obtain incident hazard ratios of frailty in two models. Model 1 was adjusted for age, race, sex, education, and income. Model 2 contained Model 1 covariates and added disability and comorbidities., Results: Among people without frailty at baseline, risk of developing frailty over 7 years was increased by 41% among those with low versus high self-efficacy after adjustment for sociodemographics (P = 0.002), and by 27% after further adjustment for disability and comorbidities (P = 0.032)., Conclusion: This study generates a rationale to further explore self-efficacy in frailty research. Self-efficacy may be a key modifiable element to incorporate into multimodal physical frailty interventions., (© 2021 The American Geriatrics Society.)

Background: Physical frailty and cognitive impairment have been separately associated with falls. The purpose of the study is to examine the associations of physical frailty and cognitive impairment separately and jointly with incident recurrent falls among older adults., Methods: The analysis included 6000 older adults in community or non-nursing home residential care settings who were at least 65 years old and participated in the National Health and Aging Trends Study. Frailty was assessed using the physical frailty phenotype; cognitive impairment was defined by bottom quintile of the clock-drawing test or immediate and delayed 10-word recall, or self/proxy-report of diagnosis of dementia, or AD8 score at least 2. The marginal means/rates models were used to analyze the associations of frailty and cognitive impairment with recurrent falls over 6 years of follow-up between 2011 and 2017., Results: Of the 6000 older adults, 1787 (29.8%) had cognitive impairment only, 334 (5.6%) had frailty only, 615 (10.3%) had both, and 3264 (54.4%) had neither. After adjusting for age, sex, race, education, living alone, obesity, disease burden, and mobility disability, those with frailty (with or without cognitive impairment) at baseline had higher rates of recurrent falls than those without cognitive impairment and frailty (frailty only: rate ratio [RR] = 1.31, 95% confidence interval [CI] = 1.18-1.44; both: RR = 1.28, 95% CI = 1.17-1.40). The association was marginally significant for those with cognitive impairment only (RR = 1.07, 95% CI = 1.00-1.13)., Conclusions: Frailty and cognitive impairment were independently associated with recurrent falls in noninstitutionalized older adults. There was a lack of synergistic effect between frailty and cognitive impairment., (© The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aims: Physical frailty is a commonly encountered geriatric syndrome among older adults without coronary heart disease (CHD). The impact of frailty on the incidence of long-term cardiovascular outcomes is not known.We aimed to evaluate the long-term association of frailty, measured by the Fried frailty phenotype, with all-cause-mortality and MACE among older adults without a history of CHD at baseline in the National Health and Aging Trends Study., Methods and Results: We used the National Health and Aging Trends Study, a prospective cohort study linked to a Medicare sample. Participants with a prior history of CHD were excluded. Frailty was measured during the baseline visit using the Fried physical frailty phenotype. Cardiovascular outcomes were assessed during a 6-year follow-up.Of the 4656 study participants, 3259 (70%) had no history of CHD 1 year prior to their baseline visit. Compared to those without frailty, subjects with frailty were older (mean age 82.1 vs. 75.1 years, P < 0.001), more likely to be female (68.3% vs. 54.9%, P < 0.001), and belong to an ethnic minority. The prevalence of hypertension, falls, disability, anxiety/depression, and multimorbidity was much higher in the frail and pre-frail than the non-frail participants. In a Cox time-to-event multivariable model and during 6-year follow-up, the incidences of death and of each individual cardiovascular outcomes were all significantly higher in the frail than in the non-frail patients including major adverse cardiovascular event (MACE) [hazard ratio (HR) 1.77, 95% confidence interval (CI) 1.53, 2.06], death (HR 2.70, 95% CI 2.16, 3.38), acute myocardial infarction (HR 1.95, 95% CI 1.31, 2.90), stroke (HR 1.71, 95% CI 1.34, 2.17), peripheral vascular disease (HR 1.80, 95% CI 1.44, 2.27), and coronary artery disease (HR 1.35, 95% CI 1.11, 1.65)., Conclusion: In patients without CHD, frailty is a risk factor for the development of MACEs. Efforts to identify frailty in patients without CHD and interventions to limit or reverse frailty status are needed and, if successful, may limit subsequent adverse cardiovascular events., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Objectives: frail older adults may be more vulnerable to stressors, resulting in steeper declines in cognitive function. Whether the frailty-cognition link differs by cognitive domain remains unclear; however, it could lend insight into underlying mechanisms., Methods: we tested whether domain-specific cognitive trajectories (clock-drawing test, (CDT), immediate and delayed recall, orientation to date, time, president and vice-president naming) measured annually (2011-2016) differ by baseline frailty (physical frailty phenotype) in the National Health and Aging Trends Study (n = 7,439), a nationally representative sample of older adult U.S. Medicare beneficiaries, using mixed effects models to describe repeated measures of each cognitive outcome. To determine if the association between frailty and subsequent cognitive change differed by education, we tested for interaction using the Wald test., Results: we observed steeper declines for frail compared to non-frail participants in each domain-specific outcome, except for immediate recall. Largest differences in slope were observed for CDT (difference = -0.12 (standard deviations) SD/year, 95%CI: -0.15, -0.08). By 2016, mean CDT scores for frail participants were 1.8 SD below the mean (95%CI: -1.99, -1.67); for non-frail participants, scores were 0.8 SD below the mean (95%CI: -0.89, -0.69). Associations differed by education for global cognitive function (Pinteraction < 0.001) and for each domain-specific outcome: CDT (Pinteraction < 0.001), orientation (Pinteraction < 0.001), immediate (Pinteraction < 0.001) and delayed (Pinteraction < 0.001) word recalls., Conclusion: frailty is associated with lower levels and steeper declines in cognitive function, with strongest associations for executive function. These findings suggest that aetiologies are multifactorial, though primarily vascular related; further research into its association with dementia sub-types and related pathologies is critical., (© The Author(s) 2021. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Frailty (physical frailty phenotype [PFP]) and its criteria (slow gait, weakness, weight loss, low activity, and exhaustion) are each associated with cognitive dysfunction. The extent to which the PFP is associated with cognition beyond that expected from its component parts remains uncertain., Method: We used the National Health and Aging Trends Study to quantify associations between PFP criteria and cognitive performance (level/change) using adjusted mixed effects models. We tested whether frailty was associated with excess cognitive vulnerability (synergistic/excess effects, Cohen's d) beyond criteria contributions by assessing interactions between each criterion and frailty., Results: Among 7439 community-dwelling older adults (mean age = 75.2 years) followed for a mean of 3.2 years (SE = 0.03), 14.1% were frail. The PFP and PFP criteria were all associated with lower baseline cognitive performance, among which slow gait (-0.31 SD, SE = 0.02) and frailty (-0.23 SD, SE = 0.02) were strongest. Only slow gait (-0.03 SD/year, SE = 0.01), frailty (-0.02 SD/year, SE = 0.01), weight loss (-0.02 SD/year, SE = 0.01), and weakness (-0.02 SD/year, SE = 0.01) were associated with cognitive decline. Frailty was associated with cognitive performance above and beyond each criterion (excess effects ranging from -0.07 SD [SE = -0.05] for slow gait to -0.23 SD [SE = 0.03] for weakness); the same was not true for cognitive decline. Slow gait was the only criterion associated with cognitive change among both frail and nonfrail participants (frail: Cohen's d/year = -0.03, SE = 0.01; nonfrail: Cohen's d/year = -0.02, SE = 0.01)., Conclusions: PFP is an important frailty measure that is cross-sectionally associated with lower cognitive performance, but not with subsequent cognitive decline, above and beyond its criteria contributions. Further research into the construct of frailty as a "syndrome" correlated with cognition and other adverse outcomes is needed., (© The Author(s) 2020. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Importance: Guidelines recommend against routine breast and prostate cancer screenings in older adults with less than 10 years' life expectancy. One study using a claims-based prognostic index showed that receipt of cancer screening itself was associated with lower mortality, suggesting that the index may misclassify individuals when used to inform cancer screening, but this finding was attributed to residual confounding because the index did not account for functional status., Objective: To examine whether cancer screening remains significantly associated with all-cause mortality in older adults after accounting for both comorbidities and functional status., Design, Setting, and Participants: This cohort study included individuals older than 65 years who were eligible for breast or prostate cancer screening and who participated in the 2004 Health and Retirement Study. Data were linked to Medicare claims from 2001 to 2015. Data analysis was conducted from January to November 2020., Main Outcomes and Measures: A Cox model was used to estimate the association between all-cause mortality over 10 years and receipt of screening mammogram or prostate-specific antigen (PSA) test, adjusting for variables in a prognostic index that included age, sex, comorbidities, and functional status. Potential confounders (ie, education, income, marital status, geographic region, cognition, self-reported health, self-care, and self-perceived mortality risk) of the association between cancer screening and mortality were also tested., Results: The breast cancer screening cohort included 3257 women (mean [SD] age, 77.8 [7.5] years); the prostate cancer screening cohort included 2085 men (mean [SD] age, 76.1 [6.8] years). Receipt of screening mammogram was associated with lower hazard of all-cause mortality after accounting for all index variables (adjusted hazard ratio [aHR], 0.67; 95% CI, 0.60-0.74). A weaker, but still statistically significant, association was found for screening PSA (aHR 0.88; 95% CI, 0.78-0.99). None of the potential confounders attenuated the association between screening and mortality except for cognition, which attenuated the aHR for mammogram from 0.67 (95% CI, 0.60-0.74) to 0.73 (95% CI, 0.64-0.82) and the aHR for PSA from 0.88 (95% CI, 0.78-0.99) to 0.92 (95% CI, 0.80-1.05), making PSA screening no longer statistically significant., Conclusions and Relevance: In this study, cognition attenuated the observed association between cancer screening and mortality among older adults. These findings suggest that existing mortality prediction algorithms may be missing important variables that are associated with receipt of cancer screening and long-term mortality. Relying solely on algorithms to determine cancer screening may misclassify individuals as having limited life expectancy and stop screening prematurely. Screening decisions need to be individualized and not solely dependent on life expectancy prediction.

Background/objectives: To obtain national and regional estimates of prevalence of frailty with or without cognitive impairment, and cognitive impairment with or without frailty among older adults in the United States, and to identify profiles of characteristics that distinguish their joint versus separate occurrence., Design: Cross-sectional., Setting: Community or non-nursing home residential care settings., Participants: A U.S. nationally representative sample of 7,497 older adults aged 65 and older from the National Health and Aging Trends Study., Measurements: Frailty was measured by the physical frailty phenotype. Cognitive impairment was assessed by cognitive performance testing of executive function and memory or by proxy reports. Multinomial logistic regression was used to identify profiles of demographic, socioeconomic, health, behavioral, and psychosocial characteristics that distinguish four subgroups: not-frail and cognitively intact ("neither"), not-frail and cognitively impaired ("Cog. only"), frail and cognitively intact ("frailty only"), and frail and cognitively impaired ("both")., Results: The prevalence of "Cog. only," "frailty only," and "both" was 25.5%, 5.6%, and 8.7%, respectively. Individuals with"frailty only" had the highest prevalence of obesity, current smoking, comorbidity, lung disease, and history of surgery. The "both" group had the highest prevalence of dementia, depression, cardiovascular diseases, and disability. No significant differences were found between the "Cog. only" group and the "neither" group with respect to history of surgery and comorbidity burden. The prevalence of dementia in the "Cog. only" was less than half of that in the "both" group., Conclusion: The finding of sizable subgroups having physical frailty but not cognitive impairment, and vice versa, suggests that the two cannot be considered necessarily as antecedent or sequela of one another. The study provided empirical data supporting the prioritization of comorbidity, obesity, surgery history, and smoking status in clinical screening of frailty and cognitive impairment before formal diagnostic assessments., (© 2020 The American Geriatrics Society.)

Overcoming stigma affecting gay, bisexual, and other men who have sex with men (MSM) is a foundational element of an effective response to the human immunodeficiency virus (HIV) pandemic. Quantifying the impact of stigma mitigation interventions necessitates improved measurement of stigma for MSM around the world. In this study, we explored the underlying factor structure and psychometric properties of 13 sexual behavior stigma items among 10,396 MSM across 8 sub-Saharan African countries and the United States using cross-sectional data collected between 2012 and 2016. Exploratory factor analyses were used to examine the number and composition of underlying stigma factors. A 3-factor model was found to be an adequate fit in all countries (root mean square error of approximation = 0.02-0.05; comparative fit index/Tucker-Lewis index = 0.97-1.00/0.94-1.00; standardized root mean square residual = 0.04-0.08), consisting of "stigma from family and friends," "anticipated health-care stigma," and "general social stigma," with internal consistency estimates across countries of α = 0.36-0.80, α = 0.72-0.93, and α = 0.51-0.79, respectively. The 3-factor model of sexual behavior stigma cut across social contexts among MSM in the 9 countries. These findings indicate commonalities in sexual behavior stigma affecting MSM across sub-Saharan Africa and the United States, which can facilitate efforts to track progress on global stigma mitigation interventions., (Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health 2020.)

Objectives: To develop an evidence-based definition of sarcopenia that can facilitate identification of older adults at risk for clinically relevant outcomes (eg, self-reported mobility limitation, falls, fractures, and mortality), the Sarcopenia Definition and Outcomes Consortium (SDOC) crafted a set of position statements informed by a literature review and SDOC's analyses of eight epidemiologic studies, six randomized clinical trials, four cohort studies of special populations, and two nationally representative population-based studies., Methods: Thirteen position statements related to the putative components of a sarcopenia definition, informed by the SDOC analyses and literature synthesis, were reviewed by an independent international expert panel (panel) iteratively and voted on by the panel during the Sarcopenia Position Statement Conference. Four position statements related to grip strength, three to lean mass derived from dual-energy x-ray absorptiometry (DXA), and four to gait speed; two were summary statements., Results: The SDOC analyses identified grip strength, either absolute or scaled to measures of body size, as an important discriminator of slowness. Both low grip strength and low usual gait speed independently predicted falls, self-reported mobility limitation, hip fractures, and mortality in community-dwelling older adults. Lean mass measured by DXA was not associated with incident adverse health-related outcomes in community-dwelling older adults with or without adjustment for body size., Conclusion: The panel agreed that both weakness defined by low grip strength and slowness defined by low usual gait speed should be included in the definition of sarcopenia. These position statements offer a rational basis for an evidence-based definition of sarcopenia. The analyses that informed these position statements are summarized in this article and discussed in accompanying articles in this issue of the journal. J Am Geriatr Soc 68:1410-1418, 2020., (© 2020 The American Geriatrics Society.)

Background/objectives: The extent to which the prevalence of muscle weakness in the US population varies by different putative grip strength constructs developed by the Sarcopenia Definitions and Outcomes Consortium (SDOC) has not been described., Design: Cross-sectional analysis., Setting: Two nationally representative cohorts-2010 and 2012 waves of the Health and Retirement Survey and round 1 (2011) of the National Health and Aging Trends Survey., Participants: Adults aged 65 years and older (n = 12,984) were included in these analyses., Measurements: We analyzed three constructs of muscle weakness developed by the SDOC, and found to be associated with mobility disability for men and women, respectively: absolute grip strength (<35.5 kg and 20 kg); grip strength standardized to body mass index (<1.05 kg/kg/m² and 0.79 kg/kg/m²); and grip strength standardized to weight (<0.45 kg/kg and 0.337 kg/kg). We estimated the prevalence of muscle weakness defined by each of these constructs in the overall older US population, and by age, sex, race, and ethnicity. We also estimated the sensitivity and specificity of each of the grip strength constructs to discriminate slowness (gait speed <0.8 m/s) in these samples., Results: The prevalence of muscle weakness ranged from 23% to 61% for men and from 30% to 66% for women, depending on the construct used. There was substantial variation in the prevalence of muscle weakness by race and ethnicity. The sensitivity and specificity of these measures for discriminating slowness varied widely, ranging from 0.30 to 0.92 (sensitivity) and from 0.17 to 0.88 (specificity)., Conclusions: The prevalence of muscle weakness, defined by the putative SDOC grip strength constructs, depends on the construct of weakness used. J Am Geriatr Soc 68:1438-1444, 2020., (© 2020 The American Geriatrics Society.)

Background: To evaluate the discordance in frailty classification between the frailty index (FI) and the physical frailty phenotype (PFP) and identify factors discriminating those with discordant frailty classification from each other and from those for whom the assessments agree., Methods: A prospective observational study of older adults aged 65 and older selected from Medicare eligibility lists in four U.S. communities (n = 5,362). The PFP was measured by the Cardiovascular Health Study PFP. Participants meeting three or more of the five criteria were deemed frail. The FI was calculated as the proportion of deficits in an a priori selected set of 48 measures, and participants were classified as frail if FI is greater than 0.35., Results: The prevalence of frailty was 7.0% by the PFP and 8.3% by the FI. Of the 730 deemed frail by either instrument, only 12% were in agreement, whereas 39% were classified as frail by the PFP, but not the FI, and 48% were classified as frail by the FI, but not the PFP. Participants aged 65-72 years or with greater disease burden were most likely to be characterized as being FI-frail, but not PFP-frail. The associations of frailty with age and mortality were stronger when frailty was measured by the PFP rather than the FI., Conclusions: Despite comparable frailty prevalence between the PFP and the FI, there was substantial discordance in individual-level classification, with highest agreement existing only in the most vulnerable subset. These findings suggest that there are clinically important contexts in which the PFP and the FI cannot be used interchangeably., (© The Author(s) 2019. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: To evaluate whether late-life depression mediates the association of subclinical cardiovascular disease (CVD) with all-cause mortality., Method: Using data from 3,473 Cardiovascular Health Study participants, the Cox proportional hazards model was used to examine the direct and indirect (via late-life depression) effects of the association between baseline subclinical CVD and all-cause mortality with weights derived from multivariable logistic regression of late-life depression on subclinical CVD., Results: Subclinical CVD led to a higher risk of all-cause mortality (hazard ratio [HR] = 1.51, 95% confidence interval, [CI] = [1.42, 1.94]). Total effect of subclinical CVD on all-cause mortality was decomposed into direct (HR = 1.41, 95% CI = [1.37, 1.58]) and indirect (HR = 1.07, 95% CI = [1.01, 1.23]) effects; 16.3% of the total effect of subclinical CVD on all-cause mortality was mediated by late-life depression., Discussion: Late-life depression accounts for little, if any, of the association between subclinical CVD, a risk factor of all-cause mortality, and all-cause mortality.

Background: Disability in activities of daily living (ADLs) is a dynamic process and transitions among different disability states are common. However, little is known about factors affecting recovery from disability. We examined the association between frailty and recovery from disability among nondisabled community-dwelling elders., Methods: We studied 1,023 adults from the Cardiovascular Health Study (CHS) and 685 adults from the Health and Retirement Study (HRS), who were ≥65 years and had incident disability, defined as having difficulty in ≥1 ADL (dressing, eating, toileting, bathing, transferring, walking across a room). Disability recovery was defined as having no difficulty in any ADLs. Frailty was assessed by slowness, weakness, exhaustion, inactivity, and shrinking. Persons were classified as "nonfrail" (0 criteria), "prefrail" (1-2 criteria), or "frail" (3-5 criteria)., Results: In total, 539 (52.7%) CHS participants recovered from disability within 1 year. Almost two-thirds of nonfrail persons recovered, while less than two-fifths of the frail recovered. In the HRS, 234 (34.2%) participants recovered from disability within 2 years. Approximately half of the nonfrail recovered, while less than one-fifth of the frail recovered. After adjustment, prefrail and frail CHS participants were 16% and 36% less likely to recover than the nonfrail, respectively. In the HRS, frail persons had a 41% lower likelihood of recovery than the nonfrail., Conclusions: Frailty is an independent predictor of poor recovery from disability among nondisabled older adults. These findings validate frailty as a marker of decreased resilience and may offer opportunities for individualized interventions and geriatric care based on frailty assessment., (© The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Frailty is an age-related clinical syndrome of decreased resilience to stressors. Among numerous assessments of frailty, the frailty phenotype (FP) scale proposed by Fried et al. has been the most widely used. We aimed to develop a continuous frailty scale that could overcome limitations facing the categorical FP scale and to evaluate its construct validity, predictive validity, and measurement properties. Data were from the Cardiovascular Health Study (n = 4,243) and Health and Retirement Study (n = 7,600), both conducted in the United States. Frailty was conceptualized as a continuous construct, assessed by 5 measures used in the FP scale: gait speed, grip strength, exhaustion, physical activity, and weight loss. We used confirmatory factor analysis to investigate the relationship between the 5 indicators and the latent frailty construct. We examined the association of the continuous frailty scale with mortality and disability. The unidimensional model fit the data satisfactorily; similar factor structure was observed across 2 cohorts. Gait speed and weight loss were the strongest and weakest indicators, respectively; grip strength, exhaustion, and physical activity had similar strength in measuring frailty. In each cohort, the continuous frailty scale was strongly associated with mortality and disability and continued to be associated with outcomes among robust and prefrail persons classified by the FP scale.

Objective: To study whether depression contributes to the association between subclinical cardiovascular disease (CVD) and dementia, and identify the contribution's magnitude., Methods: Among participants from the Cardiovascular Health Study Cognition Study who did not have baseline CVD-related events (N = 2,450), causal mediation methodology was implemented to examine whether late-life depressive symptoms, defined as 10-item Center for Epidemiologic Studies-Depression (mCES-D) Scale scores ≥8 from 2 to 3 years after baseline, partially mediated the association of baseline subclinical CVD (CAC, carotid intimal medial thickness, stenosis, and ankle brachial index) with mild cognitive impairment (MCI)/dementia onset occurring between 5 and 10 years from baseline. The total effect was decomposed into direct and indirect effects (via late-life depressive symptoms), obtained from an accelerated failure time model with weights derived from multivariable logistic regression of late-life depressive symptoms on subclinical CVD. Analyses were adjusted by baseline covariates: age, race, sex, poverty status, marital status, body mass index, smoking status, ApoE4 status, and mCES-D., Results: Participants contributed 20,994 person-years of follow-up with a median follow-up time of 9.4 years. Subclinical CVD was associated with 12% faster time to MCI/dementia (time ratio [TR]: 0.88; 95% CI: 0.83, 0.93). The total effect of subclinical CVD on MCI/dementia onset was decomposed into a direct effect (TR: 0.95, 95% CI: 0.92, 0.98) and indirect effect (TR: 0.92, 95% CI: 0.88, 0.97); 64.5% of the total effect was mediated by late-life depressive symptoms., Conclusions: These data suggest late-life depressive symptoms partially mediate the association of subclinical CVD with MCI/dementia onset., (Copyright © 2017 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Vestibular function declines with age, and emerging evidence suggests that vestibular loss is associated with cognitive impairment. Whether vestibular dysfunction is associated with age-related cognitive decline is unknown., Methods: We used data from the 1999-2002 National Health and Nutrition Examination Surveys to evaluate the influence of vestibular function on cognitive performance in a nationally representative sample of U.S. adults aged ≥60 years (n = 1,303). Vestibular function was measured with the modified Romberg test, and cognitive function was measured by the digit symbol substitution (DSS) score test. We also developed structural equation models (SEMs) to explore whether vestibular dysfunction and associated cognitive impairment mediate the effect of age on falls and activities of daily living (ADL) difficulty., Results: Vestibular dysfunction was present in 58% of the study population. In multivariate analyses, vestibular dysfunction was associated with a 3.4-point lower DSS score (95% confidence interval: -5.2, -1.6; p < .0001), equivalent to the effect of 5 years of age. Vestibular dysfunction was also associated with a significantly higher odds of ADL difficulty (p = .001), and with a 2.6-fold increase in the odds of falling (p = .017). SEMs suggested that vestibular function mediates 14.3% of the effect of age on cognitive performance. Further SEMs suggested that lower cognitive performance mediates the association between vestibular loss and ADL difficulty as well as falls., Conclusions: This study suggests that vestibular dysfunction partially mediates the association between age and cognitive impairment. Moreover, the cognitive impairment that results from vestibular loss may contribute to ADL difficulty and falls in older individuals., (© The Author 2015. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Prognosis is a critical consideration in caring for older adults with multiple chronic conditions, or "multimorbidity". Clinicians are not adequately trained in this area. We describe an innovative curriculum that teaches internal medicine residents how to incorporate prognosis in the care of older adults with multimorbidity., Methods: The curriculum includes three small-group sessions and a clinical exercise; it focuses on the assessment, communication, and application of prognosis to inform clinical decisions. The curriculum was implemented with 20 first-year residents at one university-based residency (intervention group). Fifty-two first-year residents from a separate residency affiliated with the same university served as controls. Evaluation included three components. A survey assessed acceptability. A pre/post survey assessed attitude, knowledge, and self-reported skills (Impact survey). Comparison of baseline and follow-up results used paired t-test and McNemar test; comparison of inter-group differences used t-test and Fisher's exact test. A retrospective, blinded pre/post chart review assessed documentation behavior; abstracted outcomes were analyzed using Fisher's exact test., Results: The curriculum was highly rated (4.5 on 5-point scale). Eighteen intervention group residents (90 %) and 29 control group residents (56 %) responded to the Impact survey. At baseline, there were no significant inter-group differences in any of the responses. The intervention group improved significantly in prognosis communication skills (5.2 to 6.6 on 9-point scale, p < 0.001), usage of evidence-based prognostic tools (1/18 to 14/18 responses, p < 0.001), and prognostic accuracy (1/18 to 9/18 responses, p = 0.005). These responses were significantly different from the control group at follow-up. Of 71 charts reviewed in each group, prognosis documentation in the intervention group increased from 1/25 charts (4 %) at baseline to 8/46 charts (17 %) at follow-up (p = 0.15). No prognosis documentation was identified in the control group at either time point. Inter-group difference was significant at follow-up (p = 0.006)., Conclusion: We developed and implemented a novel prognosis curriculum that had significant short-term impact on the residents' knowledge and communication skills as compared to a control group. This innovative curriculum addresses an important educational gap in incorporating prognosis in the care of older adults with multimorbidity.

Background: Frailty assessment provides a means of identifying older adults most vulnerable to adverse outcomes. Attention to frailty in clinical practice is more likely with better understanding of its prevalence and associations with patient characteristics. We sought to provide national estimates of frailty in older people., Methods: A popular, validated frailty phenotype proposed by Fried and colleagues was applied to 7,439 participants in the 2011 baseline of the National Health and Aging Trends Study, a national longitudinal study of persons aged 65 and older. All measures drew on a 2-hour in-person interview. Weighted estimates of frailty prevalence were obtained., Results: Fifteen percent (95% CI: 14%, 16%) of the older non-nursing home population is frail, and 45% is prefrail (95% CI: 44%, 47%). Frailty is more prevalent at older ages, among women, racial and ethnic minorities, those in supportive residential settings, and persons of lower income. Independently of these characteristics, frailty prevalence varies substantially across geographic regions. Chronic disease and disability prevalence increase steeply with frailty. Among the frail, 42% were hospitalized in the previous year, compared to 22% of the prefrail and 11% of persons considered robust. Hip, back, and heart surgery in the last year were associated with frailty. Over half of frail persons had a fall in the previous year., Conclusions: Our findings support the importance of frailty in late-life health etiology and potential value of frailty as a marker of risk for adverse health outcomes and as a means of identifying opportunities for intervention in clinical practice and public health policy., (© The Author 2015. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Current medical models frequently overlook functional limitations and the home environment even though they partially determine healthcare usage and quality of life. The Centers for Medicare and Medicaid Services (CMS) Innovation Center funds projects that have potential to affect the "triple aim," a framework for decreasing costs while improving health and quality of life. This article presents preliminary data from Community Aging in Place, Advancing Better Living for Elders (CAPABLE), a model funded by the CMS Innovation Center and designed to overcome the functional and home environmental barriers of older adults. CAPABLE is a patient-directed, team-based intervention comprising an occupational therapist, a registered nurse, and a handyman to decrease hospitalization and nursing home usage of community-dwelling older adults with functional limitations who are dually eligible for Medicare and Medicaid. Activity of daily living limitations improved in 79% of the first 100 people who completed the intervention. Preliminary findings of this novel intervention may have implications for other older adults with functional limitations., (© 2015 The Authors. The Journal of the American Geriatrics Society published by Wiley Periodicals, Inc. on behalf of The American Geriatrics Society.)

Background: This analysis sought to determine the associations of the Foundation for the National Institutes of Health Sarcopenia Project criteria for weakness and low lean mass with likelihood for mobility impairment (gait speed ≤ 0.8 m/s) and mortality. Providing validity for these criteria is essential for research and clinical evaluation., Methods: Among 4,411 men and 1,869 women pooled from 6 cohort studies, 3-year likelihood for incident mobility impairment and mortality over 10 years were determined for individuals with weakness, low lean mass, and for those having both. Weakness was defined as low grip strength (<26kg men and <16kg women) and low grip strength-to-body mass index (BMI; kg/m(2)) ratio (<1.00 men and <0.56 women). Low lean mass (dual-energy x-ray absorptiometry) was categorized as low appendicular lean mass (ALM; <19.75kg men and <15.02kg women) and low ALM-to-BMI ratio (<0.789 men and <0.512 women)., Results: Low grip strength (men: odds ratio [OR] = 2.31, 95% confidence interval [CI] = 1.34-3.99; women: OR = 1.99, 95% CI 1.23-3.21), low grip strength-to-BMI ratio (men: OR = 3.28, 95% CI 1.92-5.59; women: OR = 2.54, 95% CI 1.10-5.83) and low ALM-to-BMI ratio (men: OR = 1.58, 95% CI 1.12-2.25; women: OR = 1.81, 95% CI 1.14-2.87), but not low ALM, were associated with increased likelihood for incident mobility impairment. Weakness increased likelihood of mobility impairment regardless of low lean mass. Mortality risk patterns were inconsistent., Conclusions: These findings support our cut-points for low grip strength and low ALM-to-BMI ratio as candidate criteria for clinically relevant weakness and low lean mass. Further validation in other populations and for alternate relevant outcomes is needed.

Background: Applying disease-specific guidelines to people with multimorbidity may result in complex regimens that impose treatment burden., Objectives: To describe and validate a measure of healthcare task difficulty (HCTD) in a sample of older adults with multimorbidity., Research Design: Cross-sectional and longitudinal secondary data analysis., Subjects: Multimorbid adults aged 65 years or older from primary care clinics., Measures: We generated a scale (0-16) of self-reported difficulty with 8 HCTD and conducted factor analysis to assess its dimensionality and internal consistency. To assess predictive ability, cross-sectional associations of HCTD and number of chronic diseases, and conditions that add to health status complexity (falls, visual, and hearing impairment), patient activation, patient-reported quality of chronic illness care (Patient Assessment of Chronic Illness Care), mental and physical health (SF-36) were tested using statistical tests for trend (n=904). Longitudinal analyses of the effects of change in HCTD on changes in the outcomes were conducted among a subset (n=370) with ≥1 follow-up at 6 and/or 18 months. All models were adjusted for age, education, sex, race, and time., Results: Greater HCTD was associated with worse mental and physical health [Cuzick test for trend (P<0.05)], and patient-reported quality of chronic illness care (P<0.05). In longitudinal analysis, increasing patient activation was associated with declining HCTD over time (P<0.01). Increasing HCTD over time was associated with declining mental (P<0.001) and physical health (P=0.001) and patient-reported quality of chronic illness care (P<0.05)., Conclusions: The findings of this study establish the construct validity of the HCTD scale.

Objectives: Racial and ethnic minorities in the U.S. underutilize mental health service for mood disorders. This study sought to identify depressive subtypes associated with low use of mental health services across racial and ethnic groups based on a large, nationally representative sample of adults in the U.S., Methods: Based on latent class analysis, we identified the latent profile of depressive symptoms among those who endorsed lifetime depressed mood or anhedonia in the 2001-2002 National Epidemiological Survey on Alcohol and Related Condition (302 Asian Americans; 8602 Whites; 2266 Blacks; 2254 Hispanics). Proportions and types of lifetime mental health service use across depressive symptom subtypes were assessed and compared across the racial and ethnic categories., Results: A four class model of depressive subtypes was examined across race and ethnicity ("mild," "cognitive," "psychosomatic," and "severe"). Asian Americans, blacks, and Hispanics with "severe" subtype of depression had significantly lower odds of mental health service use compared to whites with "severe" subtype of depression. While Asian Americans did not have higher proportion of "psychosomatic" subtype than other race and ethnic groups, Asian Americans with "cognitive" subtype of depression significantly underused mental health services compared to Asian Americans with "psychosomatic" subtype of depression (Odds ratio:0.34, 95% Confidence interval:0.13,0.91)., Limitation: We were unable to account for heterogeneity of the subethnic group compositions based on country of origin and other socio-demographic factors., Conclusions: A targeted outreach intervention to raise awareness among Asian Americans, blacks, and Hispanics with "severe" subtype and Asian Americans with "cognitive" subtype of depression may reduce disparity in mental health service utilization across racial and ethnic groups., (Published by Elsevier B.V.)

Aims: To classify the different types of anemia among moderately to severely disabled women living in the community and examine the relationship between types of anemia and mortality., Methods: We studied anemia in 688 women, >or=65 years, in the Women's Health and Aging Study I, a population based study of moderately to severely disabled older women living in the community in Baltimore, Maryland. Anemia was defined by World Health Organization criteria. Causes of anemia were classified as due to nutritional deficiencies (iron, folate, and B12 deficiencies), anemia of chronic inflammation, anemia with renal disease, and unexplained anemia., Results: 147 of 688 (21.4%) women were anemic (hemoglobin <12 g/dL). Of the 147 anemic women, 22 (15.0%) had anemia due to nutritional causes, 45 (30.6%) had anemia due to chronic inflammation, 29 (19.7%) had anemia and renal disease, and 51 (34.7%) had unexplained anemia. The proportions of those who died over five years among non-anemic women and women with anemia due to nutritional causes, chronic inflammation, renal disease, and unexplained anemia were 26.1%, 18.2%, 38.6%, 64.3%, and 33.3%, respectively (p<0.0001). Compared with non-anemic women, those with anemia and renal disease (HR 1.99, 95% CI 1.18-3.35, p=0.009) and anemia of chronic inflammation (HR 1.69, 95% CI 1.00-2.84, p=0.05) had higher risk of death., Conclusions: Anemia is common among moderately to severely disabled older women living in the community, and about one-third of the anemia is unexplained. Anemia with renal disease and anemia of chronic inflammation are associated with a higher mortality.

Background: Dehydroepiandrosterone sulfate (DHEAS) is an endogenously produced sex steroid that has been hypothesized to have anti-aging effects. Low DHEAS levels are associated with mortality in older men, but the relationship between DHEAS levels and mortality in women is not clearly defined., Methods: The relationship between serum DHEAS level and 5-year mortality was analyzed in a cohort of 539 disabled women aged 65-100 years enrolled in the Women's Health and Aging Study I (WHAS I). Using Cox proportional hazard models, we calculated multivariate-adjusted mortality risks by DHEAS quartiles and by DHEAS continuously, allowing for a nonlinear relationship. We also examined cause-specific mortality., Results: We found a U-shaped relationship between DHEAS level and mortality. After adjusting for multiple covariates, women in the top and bottom DHEAS quartiles had a more than 2-fold higher 5-year mortality than did those in the middle quartiles (hazard ratio, 2.15; 95% confidence interval [CI], 1.17-3.98 for the top quartile and 2.05; 95% CI, 1.27-3.32 for the bottom quartile, each compared to the third quartile). Women with higher DHEAS levels tended to have greater cancer mortality, whereas those with lower DHEAS tended to have greater cardiovascular mortality., Conclusion: Disabled older women with either low or high levels of DHEAS are at greater risk for death than are those with intermediate levels. More research is needed to determine if targeted dehydroepiandrosterone supplementation would provide clinical benefit to disabled older women.