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Wrist-worn devices hold great potential as a platform for mobile health (mHealth) applications because they comprise a familiar, convenient form factor and can embed sensors in proximity to the human body. Despite this potential, however, they are severely limited in battery life, storage, band-width, computing power, and screen size. In this paper, we describe the experience of the research and development team designing, implementing and evaluating Amulet - an open-hardware, open-software wrist-worn computing device - and its experience using Amulet to deploy mHealth apps in the field. In the past five years the team conducted 11 studies in the lab and in the field, involving 204 participants and collecting over 77,780 hours of sensor data. We describe the technical issues the team encountered and the lessons they learned, and conclude with a set of recommendations. We anticipate the experience described herein will be useful for the development of other research-oriented computing platforms. It should also be useful for researchers interested in developing and deploying mHealth applications, whether with the Amulet system or with other wearable platforms.

OBJECTIVES: The prevalence of obesity with sarcopenia is increasing in adults aged ≥65 years. This geriatric syndrome places individuals at risk for synergistic complications that leads to long-term functional decline. We ascertained the relationship between sarcopenic obesity and incident long-term impaired global cognitive function in a representative US population. DESIGN: A longitudinal, secondary data set analysis using the National Health and Aging Trends Survey. SETTING: Community-based older adults in the United States. PARTICIPANTS: Participants without baseline impaired cognitive function aged ≥65 years with grip strength and body mass index measures. METHODS: Sarcopenia was defined using the Foundation for the National Institutes of Health Sarcopenia Project grip strength cut points (men

Sarcopenia is the age-related loss of muscle mass and strength that is associated with adverse health outcomes. Resistance-based exercises are effective for mitigation and enhancement of strength; however, adherence is low and challenging to measure when patients are at home. In a single-arm, pilot study of seven older adults, we conducted a field-based usability study evaluating the feasibility and acceptability of using a system consisting of a Bluetooth-connected resistance exercise band and tablet-based app which together we call BandPass in completing four different home-based exercises. The system measured a total of 147 exercises by participants with a mean duration of 94±66 seconds, completing an average of 30±20 repetitions. Though not all patients completed each exercise type, patients were positive about use: patient activation measure: 80.7±14; system usability scale: 6.9±2.9; and confidence in use: 7.7±2.7. The BandPass system demonstrated its ability to collect data on exercise type, force during an exercise, and duration of exercise when older adults use it for monitoring exercise at home.

As the United States population ages, managing pathologies that largely affect older adults, including sarcopenia (i.e., loss of muscle mass and strength) represents a significant and growing clinical challenge. In addition to increased rates of sarcopenia with age, its incidence and impact increase after acute illness, increasing the risk of functional decline, institutionalization, or death. Resistance-based exercises promote muscle regeneration and strength and are an advised therapy for such patients. Yet, such therapeutic exercises are normally conducted either under direct clinical oversight or unsupervised by patients at home, where compliance rates are low. The presented device, BandPass, aims to create an integrated force data detection and acquisition system for monitoring and transmitting at-home exercise force data to patients and clinicians. A potentiometer-based sensor was integrated to a resistance exercise band through the use of custom designed electronics, which incorporated Bluetooth Low Energy (BLE) for wireless transmission to a mobile ‘app’. A protocol for calibrating the device was developed using a range of loads and validated in static benchtop and dynamic testing. Data from a pilot study with 7 older adults was also collected and analyzed to test the device. BandPass is 94% accurate with a coefficient of variation (CoV) of 4.9% and sensitivity of 150g. The pilot study recorded 147 exercises, allowing for analysis on patients’ exercise performances. BandPass was successfully able to measure force continuously over time during exercises, measure longitudinal compliance with exercises, and quantify force continuously over time. A mobile health (mHealth) force-sensing system allows for the remote monitoring of prescribed in-home resistance exercise band programs for at-risk older adults, bridging the gap between clinicians and patients.

Background Acute health care interventions for residents of skilled nursing facilities (SNFs) are often unwarranted, unwanted, and/or harmful. We describe a provider-focused care model to reduce unwarranted or unwanted acute health care utilization. Objective Assess the capability of the Reducing Avoidable Facility Transfers (RAFT) model to reduce unwanted and unwarranted acute health care utilization among residents in 3 rural SNFs between January 1, 2016 and June 30, 2017. Design Prospective cohort, pre/post study. Setting Three rural SNFs in collaboration with a geriatric practice in a tertiary academic medical center. Participants Post-acute care (PAC) and long-term care (LTC) residents of 3 rural SNFs. Intervention RAFT includes the following components: (1) a small team of providers who manage longitudinal care and after hours call; (2) elicitation of advance care plans and preferences regarding acute care; (3) standardized communication process engaging the provider at the identification of an acute care event; (4) a biweekly case review of all emergency department (ED) transfers. Measures ED and hospital utilization. Results RAFT demonstrated a 35% reduction in monthly ED transfers and a 30.5% reduction in monthly hospitalizations. These reductions were greatest for LTC residents. Conclusions/Implications The RAFT approach substantially reduced unwarranted ED and hospital utilization in this study. Results support replication and evaluation in a larger, more diverse setting and population.

Background Disparities in healthcare access and delivery, caused by transportation and health workforce difficulties, negatively impact individuals living in rural areas. These challenges are especially prominent in older adults. Design We systematically evaluated the feasibility, acceptability, and effectiveness in providing telemedicine (TMed), searching the English-language literature for studies (January 2012 to July 2018) in the following databases: Medline (PubMed); Cochrane Library (Wiley); Web of Science; CINAHL; EMBASE (Ovid); and PsycINFO (EBSCO). Participants Older adults (mean age = 65 years or older, and none were younger than 60 years). Interventions Interventions consisted of live, synchronous, two-way videoconferencing communication in nonhospital settings. All medical interventions were included. Measurements Quality assessment, using the Cochrane Collaboration's Risk-of-Bias Tool, was applied on all included articles, including a qualitative summary of all articles. Results Of 6616 citations, we reviewed the full text of 1173 articles, excluding 1047 that did not meet criteria. Of the 17 randomized controlled trials, the United States was the country with the most trials (6 [35%]), with cohort sizes ranging from 3 to 844 (median = 35) participants. Risk of bias among included studies varied from low to high. Our qualitative analysis suggests that TMed can improve health outcomes in older adults and that it could be used in this population. Conclusions TMed is feasible and acceptable in delivering care to older adults. Research should focus on well-designed randomized trials to overcome the high degree of bias observed in our synthesis. Clinicians should consider using TMed in routine practice to overcome barriers of distance and access to care. J Am Geriatr Soc 67:1737-1749, 2019.

BACKGROUND: Mobile health (mHealth) technologies comprise a multidisciplinary treatment strategy providing potential solutions for overcoming challenges of successfully delivering health promotion interventions in rural areas. We evaluated the potential of using technology in a high-risk population. METHODS: We conducted a convergent, parallel mixed-methods study using semi-structured interviews, focus groups, and self-reported questionnaires, using purposive sampling of 29 older adults, 4 community leaders and 7 clinicians in a rural setting. We developed codes informed by thematic analysis and assessed the quantitative data using descriptive statistics. RESULTS: All groups expressed that mHealth could improve health behaviors. Older adults were optimistic that mHealth could track health. Participants believed they could improve patient insight into health, motivating change and assuring accountability. Barriers to using technology were described, including infrastructure. CONCLUSIONS: Older rural adults with obesity expressed excitement about the use of mHealth technologies to improve their health, yet barriers to implementation exist.

Objective: A 5% change in weight is a significant predictor for frailty and obesity. We ascertained how self-reported weight change over the lifespan impacts rates of frailty in older adults. Methods: We identified 4,984 subjects ≥60 years with body composition measures from the National Health and Nutrition Examination Survey. An adapted version of Fried’s frailty criteria was used as the primary outcome. Self-reported weight was assessed at time current,1 and 10 years earlier and at age 25. Weight changes between each time point were categorized as ≥ 5%, ≤5% or neutral. Logistic regression assessed the impact of weight change on the outcome of frailty. Results: Among 4,984 participants, 56.5% were female, mean age was 71.1 years, and mean BMI was 28.2kg/m2. A weight loss of ≥ 5% had a higher association with frailty compared to current weight, age 25 (OR 2.94 [1.72,5.02]), 10 years ago (OR 1.68 [1.05,2.69]), and 1 year ago (OR 1.55 [1.02,2.36]). Weight gain in the last year was associated with increased rate of frailty (1.59 [1.09,2.32]). Conclusion: There is an association between frailty and reported weight loss over time while only weight gain in the last year has an association with frailty.

For persons with osteoarthritis (OA), nutrition education may facilitate weight and OA symptom management.The primary aim of this study was to determine preferred OA-related nutritional and weight management topics and their preferred delivery modality. The secondary aim was to determine whether there is a disconnect between what patients want to know about nutrition and OA management and what information health-care professionals (HCPs) are providing to patients.The Osteoarthritis Action Alliance surveyed individuals with OA to identify their preferences, categorized in 4 domains:Survey responses from 338 individuals with OA and 104 HCPs were included. The highest preference rankings in each domain were:There is disparity between the nutrition education content preferred by individuals with OA (which often lacks empirical support) and evidence-based topics being discussed by HCPs. HCPs must communicate evidence-based management of joint health and OA symptoms in patient-preferred formats. This study explored the information gap between what individuals with OA want to know and what HCPs believe they need to know.

Examination of speech datasets for detecting dementia, collected via various speech tasks, has revealed links between speech and cognitive abilities. However, the speech dataset available for this research is extremely limited because the collection process of speech and baseline data from patients with dementia in clinical settings is expensive. In this paper, we study the spontaneous speech dataset from a recent ADReSS challenge, a Cookie Theft Picture (CTP) dataset with balanced groups of participants in age, gender, and cognitive status. We explore state-of-the-art deep transfer learning techniques from image, audio, speech, and language domains. We envision that one advantage of transfer learning is to eliminate the design of handcrafted features based on the tasks and datasets. Transfer learning further mitigates the limited dementia-relevant speech data problem by inheriting knowledge from similar but much larger datasets. Specifically, we built a variety of transfer learning models using commonly employed MobileNet (image), YAMNet (audio), Mockingjay (speech), and BERT (text) models. Results indicated that the transfer learning models of text data showed significantly better performance than those of audio data. Performance gains of the text models may be due to the high similarity between the pre-training text dataset and the CTP text dataset. Our multi-modal transfer learning introduced a slight improvement in accuracy, demonstrating that audio and text data provide limited complementary information. Multi-task transfer learning resulted in limited improvements in classification and a negative impact in regression. By analyzing the meaning behind the Alzheimer's disease (AD)/non-AD labels and Mini-Mental State Examination (MMSE) scores, we observed that the inconsistency between labels and scores could limit the performance of the multi-task learning, especially when the outputs of the single-task models are highly consistent with the corresponding labels/scores. In sum, we conducted a large comparative analysis of varying transfer learning models focusing less on model customization but more on pre-trained models and pre-training datasets. We revealed insightful relations among models, data types, and data labels in this research area.

Background Older Latinos with HIV have been disproportionately affected by the epidemic and experience compounded health disparities that have deepened over time. These health disparities are largely related to lifestyle and are either preventable or amenable to early detection or intervention. Despite existing resources to deliver an intervention to reduce this compounded health disparity, there is little information on the effects of health promotion interventions on indices of cardiometabolic risk in midlife and older Latinos with HIV. The Happy Older Latinos are Active (HOLA) intervention is an innovative health promotion program that is uniquely tailored to meet the diverse needs and circumstances of older Latinos with HIV. The goal of this pilot study is to evaluate the feasibility and acceptability of HOLA among Latinos aged 50 and older with HIV. Methods/Design: HOLA, which is informed by Behavioral Activation and Social Learning theory is a community health worker (CHW)-led, multicomponent, health promotion intervention consisting of: (1) a social and physical activation session; (2) a moderately intense group walk led by a CHW for 45 minutes, 3x/week for 16 weeks; (3) pleasant events scheduling. The proposed pilot study will recruit and enroll 18 community dwelling Latinos with HIV aged 50+. Participants will be assessed at three time points (baseline, post intervention, and 3 months post intervention) on measures of cardiometabolic risk factors (waist circumference, dyslipidemia, hypertension, and glucose), psychosocial functioning, and health-related quality of life. Conclusions If HOLA can be delivered successfully by CHWs, then the scalability, accessibility, and potential for dissemination is increased. Additionally, the results of this pilot study have far reaching implications in regard to the health and welfare of other at-risk, under resourced populations. This pilot study will inform feasibility and identify modifications needed in the design of a larger hypothesis testing study.

Background Resistance-based exercises effectively enhance muscle strength, which is especially important in older populations as it reduces the risk of disability. Our group developed a Bluetooth-enabled handle for resistance exercise bands that wirelessly transmits relative force data through low-energy Bluetooth to a local smartphone or similar device. We present a usability assessment that evaluates an exercise system featuring a novel Bluetooth-enabled resistance exercise band, ultimately intended to expand the accessibility of resistance training through technology-enhanced home-based exercise programs for older adults. Although our target population is older adults, we assess the user experience among younger adults as a convenient and meaningful starting point in the testing and development of our device. Methods There were 32 young adults participating in three exercise sessions with the exercise band, after which each completed an adapted version of the Usefulness, Satisfaction, and Ease (USE) questionnaire to characterize the exercise system's strengths and weaknesses in usability. Results Questionnaire data reflected a positive and consistent user experience, with all 20 items receiving mean scores greater than 5.0 on a seven-point Likert scale. There were no specific areas of significant weakness in the device's user experience. Conclusions The positive reception among young adults is a promising indication that the device can be successfully incorporated into exercise interventions and that the system can be further developed and tested for the target population of older adults.

In this Perspective Statement from The Obesity Society, the Clinical Committee discusses the use of weight loss supplements in the United States and the lack of regulatory oversight and rigorous testing of their efficacy and safety. A number of products and services claiming to promote weight loss are directly marketed to individuals with obesity and those wanting to lose weight. These products are not regulated as "drugs" by the Federal Drug Administration but, rather, are treated as dietary supplements if ingredients are "generally regarded as safe," requiring little or no testing to show efficacy or safety. Health care providers should be aware of the lack of evidence and deficiencies in regulatory oversight of dietary supplements marketed for weight loss. Regulatory authorities should protect consumers by ensuring accurate and safe marketing claims and preventing promotion of unproven and potentially unsafe products and claims.

The purpose of this study was to explore the relationships between self-reported hopelessness and risk factors for premature mortality in people with serious mental illness (SMI). Data were extracted from the 2014 Health Center Patient Survey (N = 5,592). Having a diagnosis of SMI was significantly associated with self-reported hopelessness. Hypertension or high blood pressure, congestive heart failure, and chronic obstructive pulmonary disorder were significantly associated with self-reported hopelessness. Higher levels of hopelessness were found to be significantly associated with increased alcohol consumption. Hopelessness may be an important dimension of health in people with SMI.

Older adults have been markedly impacted by the coronavirus disease 19 (COVID-19) pandemic. The American Geriatrics Society previously published a White Paper on Healthy Aging in 2018 that focused on a number of domains that are core to healthy aging in older adults: health promotion, injury prevention, and managing chronic conditions; cognitive health; physical health; mental health; and social health. The potentially devastating consequences of COVID-19 on health promotion are recognized. The purpose of this article is multifold. First, members of the Healthy Aging Special Interest Group will present the significant difficulties and obstacles faced by older adults during this unprecedented time. Second, we provide guidance to practicing geriatrics healthcare professionals overseeing the care of older adults. We provide a framework for clinical evaluation and screening related to the five aforementioned domains that uniquely impact older adults. Last, we provide strategies that could enhance healthy aging in the era of COVID-19.

Objective Dietary supplements and alternative therapies are commercialized as a panacea for obesity/weight gain as a result of the minimal regulatory requirements in demonstrating efficacy. These products may indirectly undermine the value of guideline-driven obesity treatments. Included in this study is a systematic review of the literature of purported dietary supplements and alternative therapies for weight loss. Methods A systematic review was conducted to evaluate the efficacy of dietary supplements and alternative therapies for weight loss in participants aged ≥18 years. Searches of Medline (PubMed), Cochrane Library, Web of Science, CINAHL, and Embase (Ovid) were conducted. Risk of bias and results were summarized qualitatively. Results Of the 20,504 citations retrieved in the database search, 1,743 full-text articles were reviewed, 315 of which were randomized controlled trials evaluating the efficacy of 14 purported dietary supplements, therapies, or a combination thereof. Risk of bias and sufficiency of data varied widely. Few studies (n = 52 [16.5%]) were classified as low risk and sufficient to support efficacy. Of these, only 16 (31%) noted significant pre/post intergroup differences in weight (range: 0.3-4.93 kg). Conclusions Dietary supplements and alternative therapies for weight loss have a limited high-quality evidence base of efficacy. Practitioners and patients should be aware of the scientific evidence of claims before recommending use.

Early detection of cognitive decline involved in Alzheimer's Disease and Related Dementias (ADRD) in older adults living alone is essential for developing, planning, and initiating interventions and support systems to improve users' everyday function and quality of life. In this paper, we explore the voice commands using a Voice-Assistant System (VAS), i.e., Amazon Alexa, from 40 older adults who were either Healthy Control (HC) participants or Mild Cognitive Impairment (MCI) participants, age 65 or older. We evaluated the data collected from voice commands, cognitive assessments, and interviews and surveys using a structured protocol. We extracted 163 unique command-relevant features from each participant's use of the VAS. We then built machine-learning models including 1-layer/2-layer neural networks, support vector machines, decision tree, and random forest, for classification and comparison with standard cognitive assessment scores, e.g., Montreal Cognitive Assessment (MoCA). Our classification models using fusion features achieved an accuracy of 68%, and our regression model resulted in a Root-Mean-Square Error (RMSE) score of 3.53. Our Decision Tree (DT) and Random Forest (RF) models using selected features achieved higher classification accuracy 80-90%. Finally, we analyzed the contribution of each feature set to the model output, thus revealing the commands and features most useful in inferring the participants' cognitive status. We found that features of overall performance, features of music-related commands, features of call-related commands, and features from Automatic Speech Recognition (ASR) were the top-four feature sets most impactful on inference accuracy. The results from this controlled study demonstrate the promise of future home-based cognitive assessments using Voice-Assistant Systems.

Background Assessing functional ability is an important component of understanding healthy aging. Objective measures of functional ability include grip strength, gait speed, sit-to-stand time, and 6-min walk distance. Using samples from a weight loss clinical trial in older adults with obesity, we examined the association between changes in physical function and DNA-methylation-based biological age at baseline and 12 weeks in 16 individuals. Peripheral blood DNA methylation was measured (pre/post) with the Illumina HumanMethylationEPIC array and the Hannum, Horvath, and PhenoAge DNA methylation age clocks were used. Linear regression models adjusted for chronological age and sex tested the relationship between DNA methylation age and grip strength, gait speed, sit-to-stand, and 6-min walk. Results Participant mean weight loss was 4.6 kg, and DNA methylation age decreased 0.8, 1.1, and 0.5 years using the Hannum, Horvath, and PhenoAge DNA methylation clocks respectively. Mean grip strength increased 3.2 kg. Decreased Hannum methylation age was significantly associated with increased grip strength (β = −0.30, p = 0.04), and increased gait speed (β = 0.02, p = 0.05), in adjusted models. Similarly, decreased methylation age using the PhenoAge clock was associated with significantly increased gait speed (β = 0.02, p = 0.04). A decrease in Horvath DNA methylation age and increase in physical functional ability did not demonstrate a significant association. Conclusions The observed relationship between increased physical functional ability and decreased biological age using DNA methylation clocks demonstrate the potential utility of DNA methylation clocks to assess interventional approaches to improve health in older obese adults. Trial registration: National Institute on Aging (NIA), NCT03104192. Posted April 7, 2017, https://clinicaltrials.gov/ct2/show/NCT03104192

Introduction Obesity is highly prevalent in older adults aged 65 years or older. Different lifestyle interventions (diet, exercise, self-management) are available but benefits and harms have not been fully quantified comparing all available health promotion interventions. Special consideration must be given to functional outcomes and possible adverse effects (loss of muscle and bone mass, hypoglycaemia) of weight loss interventions in this age group. The objective of this study is to synthesise the evidence regarding the effects of different types and modalities of lifestyle interventions, or their combinations, on physical function and obesity-related outcomes such as body composition in older adults with obesity.Methods and analyses Six databases (Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Psychinfo and Web of Science) and two trial registries (Clinicaltrials.gov and the WHO International Clinical Trials Registry Platform) will be searched for randomised controlled trials of lifestyle interventions in older adults with obesity. Screening (title/abstract and full-text) and data extraction of references as well as assessment of risk of bias and rating of the certainty of evidence (Grading of Recommendations, Assessment, Development and Evaluation for network meta-analyses) will be performed by two reviewers independently. Frequentist random-effects network meta-analyses will be conducted to determine the pooled effects from each intervention.Ethics and dissemination We will submit our findings to peer-reviewed journals and present at national and international conferences as well as in scientific medical societies. Patient-targeted dissemination will involve local and national advocate groups.PROSPERO registration number CRD42019147286.

Objectives Pre-operative exercise may improve functional outcomes for lung cancer patients, but barriers associated with cost, resources, and burden make it challenging to deliver pre-operative exercise programs. The goal of this proof-of-concept study was to determine level of moderate-vigorous physical activity (MVPA) and change in aerobic capacity after participation in a home-based pre-operative exercise intervention. Materials and methods Eighteen patients scheduled for surgery for suspected stage I-III lung cancer received an exercise prescription from their surgeon and wore a commercially-available device that tracked their daily MVPA throughout the pre-operative period. Descriptive statistics were used to calculate adherence to the exercise prescription. A one-sample t-test was used to explore change in aerobic capacity from baseline to the day of surgery. Results Participants exhibited a mean of 20.4 (sd = 46.2) minutes of MVPA per day during the pre-operative period. On average, the sample met the goal of 30 min of MVPA on 16.4% of the days during the pre-operative period. The mean distance achieved at baseline for the 6-min walk test was 456.7 m (sd = 72.9), which increased to 471.1 m (sd = 88.4) on the day of surgery. This equates to a mean improvement of 13.8 m (sd = 37.0), but this difference was not statistically different from zero (p = 0.14). Eight of the 17 participants (47%) demonstrated a clinically significant improvement of 14 m or more. Conclusion A surgeon-delivered exercise prescription plus an activity tracker may promote clinically significant improvement in aerobic capacity and MVPA engagement among patients with lung cancer during the pre-operative period, but may need to be augmented with more contact with and support from practitioners over time to maximize benefits. Trial registration The study protocol was registered with ClinicalTrials.gov prior to initiating participant recruitment (NCT03162718).

Purpose Few evidence-based strategies are specifically tailored for disparity populations such as rural adults. Two-way video-conferencing using telemedicine can potentially surmount geographic barriers that impede participation in high-intensity treatment programs offering frequent visits to clinic facilities. We aimed to understand barriers and facilitators of implementing a telemedicine-delivered tertiary-care, rural academic weight-loss program for the management of obesity. Methods A single-arm study of a 16-week, weight-loss pilot evaluated barriers and facilitators to program participation and exploratory measures of program adoption and staff confidence in implementation and intervention delivery. A program was delivered using video-conferencing within an existing clinical infrastructure. Elements of Consolidated Framework for Implementation Research (CFIR) provided a basis for assessing intervention characteristics, inner and outer settings, and individual characteristics using surveys and semi-structured interviews. We evaluated elements of the RE-AIM model (reach, adoption) to assess staff barriers to success for future scalability. Findings There were 27 patients and 8 staff completing measures. Using CFIR, the intervention was valuable from a patient participant standpoint; staff equally had positive feelings about using telemedicine as useful for patient care. The RE-AIM framework demonstrated limited reach but willingness to adopt was above average. A significant barrier limiting sustainability was physical space for intervention delivery and privacy and dedicated resources for staff. Scheduling stressors were also a challenge in its implementation. Conclusions The need to engage staff, enhance organizational culture, and increase reach are major factors for rural health obesity clinics to enhance sustainability of using telemedicine for the management of obesity. Trial registration Clinicaltrials.gov NCT03309787. Registered on 16 October 2017.

Background Older adults with obesity residing in rural areas have reduced access to weight management programs. We determined the feasibility, acceptability and preliminary outcomes of an integrated technology-based health promotion intervention in rural-living, older adults using remote monitoring and synchronous video-based technology. Methods A 6-month, non-randomized, non-blinded, single-arm study was conducted from October 2018 to May 2020 at a community-based aging center of adults aged ≥65 years with a body mass index (BMI) ≥30 kg/m2. Weekly dietitian visits focusing on behavior therapy and caloric restriction and twice-weekly physical therapist-led group strength, flexibility and balance training classes were delivered using video-conferencing to participants in their homes. Participants used a Fitbit Alta HR for remote monitoring with data feedback provided by the interventionists. An aerobic activity prescription was provided and monitored. Results Mean age was 72.9±3.9 years (82% female). Baseline anthropometric measures of weight, BMI, and waist circumference were 97.8±16.3 kg, 36.5±5.2 kg/m2, and 115.5±13.0 cm, respectively. A total of 142 participants were screened (n=27 ineligible), and 53 consented. There were nine dropouts (17%). Overall satisfaction with the trial (4.7+ 0.6, scale: 1 (low) to 5 (high)) and with Fitbit (4.2+ 0.9) were high. Fitbit was worn an average of 81.7±19.3% of intervention days. In completers, mean weight loss was 4.6±3.5 kg or 4.7±3.5% (pp=0.005) but no differences were observed in gait speed or grip strength. Subjective measures of late-life function improved (3.4±4.7 points, p Conclusions A technology-based obesity intervention is feasible and acceptable to older adults with obesity and may lead to weight loss and improved physical function. Clinical trial registration Registered on Clinicaltrials.gov #NCT03104205. Registered on April 7, 2017. First participant enrolled on October 1st, 2018.

Rural communities need access to effective interventions that can prevent functional decline among a growing population of older adults. We describe the conceptual framework and rationale for a multicomponent intervention (“Mind, Mood, Mobility”) delivered by Area Agency on Aging staff for rural older adults at risk for functional decline due to early impairments in cognition, mood, or mobility. Our proposed model utilizes primary care to identify at-risk older adults, combines evidence-based interventions that address multiple risk factors simultaneously, and leverages a community-based aging services workforce for intervention delivery.

The growing population of older adults (age ≥65 years) is expected to lead to higher rates of cardiovascular disease. The expansion of digital health (encompassing telehealth, telemedicine, mobile health, and remote patient monitoring), Internet access, and cellular technologies provides an opportunity to enhance patient care and improve health outcomes-opportunities that are particularly relevant during the current coronavirus disease-2019 pandemic. Insufficient dexterity, visual impairment, and cognitive dysfunction, found commonly in older adults should be taken into consideration in the development and utilization of existing technologies. If not implemented strategically and appropriately, these can lead to inequities propagating digital divides among older adults, across disease severities and socioeconomic distributions. A systematic approach, therefore, is needed to study and implement digital health strategies in older adults. This review will focus on current knowledge of the benefits, barriers, and use of digital health in older adults for cardiovascular disease management.

Objective The purpose of this study was to explore the feasibility, acceptability and perceived utility of the provision of a wearable fitness device and an exercise prescription from a surgeon, prior to surgery for lung cancer. Methods A single-arm, pre-post feasibility study was conducted with 30 participants scheduled for surgery to treat stage I, II or III lung cancer. Participants were given a Garmin Vivoactive HR device and a prescription for 150 min of moderately to vigorous exercise per week. Participants completed assessments on four occasions and completed a semi-structured interview on two occasions. Descriptive statistics were used to assess the feasibility and acceptability of study procedures, including synchronising the Garmin device and engaging in study assessments. Results Seventy-nine per cent of enrolled participants completed the pre-operative study activities. Seventy-one per cent of enrolled participants successfully synchronised their device during the pre-operative period. Data were transmitted from the device to the study team for an average of 70% of the pre-operative days. Conclusion This pilot study demonstrated the feasibility and acceptability of a pre-operative exercise program for patients scheduled to undergo surgery for lung cancer. Trial registration The study protocol was registered with ClinicalTrials.gov prior to the initiation of participant recruitment (NCT03162718).

Background Older persons with obesity aged 65+ residing in rural areas have reduced access to weight management programs due to geographic isolation. The ability to integrate technology into health promotion interventions shows a potential to reach this underserved population. Methods A 12-week pilot in 28 older rural adults with obesity (body mass index [BMI] ≥ 30 kg/m2) was conducted at a community aging center. The intervention consisted of individualized, weekly dietitian visits focusing on behavior therapy and caloric restriction with twice weekly physical therapist-led group strengthening training classes in a community-based aging center. All participants were provided a Fitbit Flex 2. An aerobic activity prescription outside the strength training classes was provided. Results Mean age was 72.9 ± 5.3 years (82% female). Baseline BMI was 37.1 kg/m2, and waist circumference was 120.0 ± 33.0 cm. Mean weight loss (pre/post) was 4.6 ± 3.2 kg (4.9 ± 3.4%; p < .001). Of the 40 eligible participants, 33 (75%) enrolled, and the completion rate was high (84.8%). Objective measures of physical function improved at follow-up: 6-minute walk test improved: 35.7 ± 41.2 m (p < .001); gait speed improved: 0.10 ± 0.24 m/s (p = .04); and five-times sit-to-stand improved by 2.1 seconds (p < .001). Subjective measures of late-life function improved (5.2 ± 7.1 points, p = .003), as did Patient-Reported Outcome Measurement Information Systems mental and physical health scores (5.0 ± 5.7 and 4.4 ± 5.0, both p < .001). Participants wore their Fitbit 93.9% of all intervention days, and were overall satisfied with the trial (4.5/5.0, 1–5 low–high) and with Fitbit (4.0/5.0). Conclusions A multicomponent obesity intervention incorporating a wearable device is feasible and acceptable to older adults with obesity, and potentially holds promise in enhancing health.

The term “obesity” is associated with societal stigma and discrimination. Eight individual semi-structured interviews and five focus groups with 29 community-dwelling, rural older adults with obesity, seven primary care clinicians, and four rural community leaders were completed using purposive and snowball sampling. Clinicians perceived that older adults are less affected by obesity stigma than younger adults, yet this was not observed by community leaders; however, older participants with obesity reported that they often felt ashamed and/or stigmatized because of their weight. There was also a disconnect between clinician and older adult understanding of obesity. For older adults with obesity, the word “obesity” was associated with negative connotations. Just as physiological aspects of obesity persist into older adulthood, so do psychological aspects, such as perceptions of stigma. The use of the word “obesity” in medical settings may hinder communication between clinician and older participants. Heightened awareness may change the dialogue around obesity.

OBJECTIVE: Recognizing the adverse outcomes that occur to obese adults over the age of 65 with loss of muscle mass or strength, or sarcopenia is important. We will review the definitions of Sarcopenic Obesity, and attempt to link the epidemiological data with the molecular pathways. Upon understanding the model of sarcopenic obesity, we will discuss targeted interventions and further challenges to address this geriatrics syndrome. KEY FINDINGS: As our understanding of this syndrome is growing, more data is emerging to help define Sarcopenic Obesity across different populations. We now have a better understanding of biological pathways in aging such as changes in body composition, sex-specific hormones, pro-inflammatory markers, and myocellular mechanisms. We will review a comprehensive model that shows the interactions between the different pathways leading to sarcopenic obesity. Such a model will explain the promising interventions in place and invite future ones. CONCLUSION: Sarcopenic Obesity is an important geriatric syndrome with significant clinical and healthcare implications. Further research is needed to harmonize definitions, clarifying mechanisms contributing to syndrome and use evidence-based interventions to target biological mechanisms in both research and clinical settings.

Older adults with obesity are at a high risk of decline, particularly in rural areas. Our study objective was to gain insights into how a potential Mobile Health Obesity Wellness Intervention (MOWI) in rural older adults with obesity, consisting of nutrition and exercise sessions, could be helpful to improve physical function. A qualitative methods study was conducted in a rural community, community-based aging center. Four community leaders, 7 clinicians and 29 patient participants underwent focus groups and semi-structured interviews. All participants had a favorable view of MOWI and saw its potential to improve health and create accountability. Participants noted that MOWI could overcome geographic barriers and provided feedback about components that could improve implementation. There was expressed enthusiasm over its potential to improve health. The use of technology in older adults with obesity in rural areas has considerable promise. There is potential that this intervention could potentially extend to distant areas in rural America that can surmount accessibility barriers. If successful, this intervention could potentially alter healthcare delivery by enhancing health promotion in a remote, geographically constrained communities. MOWI has the potential to reach older adults with obesity using novel methods in geographically isolated regions.

This study was a 12-week feasibility weight-loss intervention consisting of caloric restriction and aerobic/resistance exercise in older adults with obesity (body mass index ≥ 30kg/m(2)) in a geographically isolated area. Primary outcomes assessed weight and physical function. Mean age was 71.0±5.1years (67% female). Individuals completed 100% of all assessments, attended 88% of the physical therapy classes and 89% of the nutrition sessions. Level of satisfaction (5-point Likert) was high (5.0, 1 – low; 5 - high). Weight decreased from 93.7±9.7 to 89.4±4.0kg (p

UNSTRUCTURED Digital therapeutics can overcome many of the barriers to translation of evidence-based treatment for substance use, mental health, and other behavioral health conditions. Delivered via nearly ubiquitous platforms such as the web, smartphone applications, text messaging, and videoconferencing, digital therapeutics can transcend the time and geographic boundaries of traditional clinical settings so that individuals can access care when and where they need it. There is strong empirical support for digital therapeutic approaches for behavioral health, yet implementation science with regard to scaling use of digital therapeutics for behavioral health is still in its early stages. In this paper, we summarize the proceedings of a day-long workshop, “Implementation Science and Digital Therapeutics,” sponsored and hosted by the Center for Technology and Behavioral Health at Dartmouth College. The Center for Technology and Behavioral Health is an interdisciplinary P30 Center of Excellence funded by the National Institute on Drug Abuse, with the mission of promoting state-of-the-technology and state-of-the-science for the development, evaluation, and sustainable implementation of digital therapeutic approaches for substance use and related conditions. Workshop presentations were grounded in current models of implementation science. Directions and opportunities for collaborative implementation science research to promote broad adoption of digital therapeutics for behavioral health are offered.

OBJECTIVE: Body composition changes with aging can increase rates of obesity, frailty and impact function. Measuring adiposity using body fat (%BF) or central adiposity using waist circumference (WC) have greater diagnostic accuracy than traditional measures such as body mass index (BMI). DESIGN: This is an observational study SETTING: This study focused on older community-dwelling participants PARTICIPANTS: We identified individuals age ≥ 60 years old using the 1999–2004 cross-sectional National Health and Nutrition Survey (NHANES). INTERVENTION: The primary analysis evaluated the association between frailty and %BF or WC. Frailty was the primary predictor (robust=referent) and %BF and WC were considered continuous outcomes. Multiple imputation analyses accounted for missing characteristics. MEASUREMENT: Dual energy x-ray absorptiometry was used to assess %BF and WC was objectively measured. Frailty was defined using an adapted version of Fried’s criteria that was self-reported: (low BMI

We implemented a transitional care management service led by a nurse care manager. An interdisciplinary team developed a workflow using a Plan-Do-Study-Act cycle for contacting patients. Of the 146 (97.9%) eligible patients, 143 (97.9%) had a phone call within 48 hours. There were 84 of 120 (70.0%) and 117 of 120 (97.5%) attendance rates of those attending visits within 7 and 14 days. A care manager-led workflow was successfully and easily implemented within a primary care practice.

Mobile health (mHealth) interventions hold the promise of augmenting existing health promotion interventions. Older adults present unique challenges in advancing new models of health promotion using technology including sensory limitations and less experience with mHealth, underscoring the need for specialized usability testing. We use an open-source mHealth device as a case example for its integration in a newly designed health services intervention. We performed a convergent, parallel mixed-methods study including semi-structured interviews, focus groups, and questionnaires, using purposive sampling of 29 older adults, 4 community leaders and 7 clinicians in a rural setting We transcribed the data, developed codes informed by thematic analysis using inductive and deductive methods, and assessed the quantitative data using descriptive statistics. Our results suggest the importance of end-users in user-centered design of mHealth devices and that aesthetics are critically important. The prototype could potentially be feasibly integrated within health behavior interventions. Centralized dashboards were desired by all participants and ecological momentary assessment could be an important part of monitoring. Concerns of mHealth, including the prototype device, include the device's accuracy, its intrusiveness in daily life and privacy. Formative evaluations are critically important prior to deploying large-scale interventions.

Objective: To compare estimates of the prevalence of mobility and physical function limitations by race and ethnicity using data from the Medical Expenditure Panel Survey (MEPS). Method: The sample comprised of 28,854 adults aged ≥60 from the MEPS (2004-2013). Physical function (limitations in basic and instrumental activities of daily living [ADL/IADL]) and mobility limitations were assessed by self-report. Results: Non-Hispanic Whites (NHWs) represented the majority of the sample followed by non-Hispanic Blacks (NHBs), Hispanic and non-Hispanic Other (Other). For mobility limitation, NHBs had the highest prevalence followed by NHWs and Hispanics (33.3%, 28.6%, and 26.2%, respectively). Multivariable logistic regression analyses were performed for the primary outcome of mobility limitation. In the adjusted model, Hispanics had lower odds of mobility limitations (prevalence odds ratio [POR]: 0.78; 95% confidence interval [CI] = [0.67,0.91]) compared with NHWs. For ADL limitations, NHBs had higher odds of having ADLs (POR: 1.87; 95% CI = [1.44, 2.44]) when compared with NHWs. Conclusion: This article evaluated the influence of race and ethnicity, on the prevalence of mobility and functional limitations that are not always consistent with expected racial and ethnic differences.

Aiming to assess the association between measures of obesity and outcomes in coronary artery disease (CAD) patients. We included consecutive patients referred to cardiac rehabilitation because of prior CAD events, who were classified using BMI groups and sex-specific tertiles of waist-to-hip ratio (WHR). Follow-up was ascertained using a population-based, record linkage system that consists of complete data on all residents. A major cardiovascular event (MACE) was defined as the composite outcome including acute coronary syndromes, coronary revascularization, ventricular arrhythmias, stroke or death from any cause. The association between obesity measures and MACE was assessed using cox proportional hazards models adjusted for potential confounders. The cohort included 1529 patients (74% men) mean age ± SD 63.1±12.5 years, 40% were obese by BMI. Eighty-eight percent of men and 57% of women were classified as having central obesity by WHR. Median follow-up was 5.7 years and 415 patients had a MACE event. After adjustment, a high WHR tertile was a significant predictor for MACE in women (HR=1.85 [95% Cl: 1.16, 2.94]; p=0.01), but not in men (HR=0.92 [95%CI: 0.69, 1.22]; p=0.54). This relationship in women persisted after further adjustment for BMI (HR=1.75 [95%CI: 1.07, 2.87]; p=0.03). Obesity by BMI was not associated with MACE in either men (HR=1.07 [95%CI: 0.76, 1.51]; p=0.69) or women (HR=0.98 [95%CI: 0.62, 1.56]; p=0.95). In conclusion WHR is associated with a higher risk of MACE among women with CAD but not in men. There was no obesity paradox when assessing obesity by BMI and MACE in CAD patients when including non-fatal events.

Obesity in older adults affects not only morbidity and mortality but, importantly, quality of life and the risk of institutionalization. Weight loss interventions can effectively lead to improved physical function. Diet-alone interventions can detrimentally affect muscle and bone physiology and, without interventions to affect these elements, can lead to adverse outcomes. Understanding social and nutritional issues facing older adults is of utmost importance to primary care providers. This article will also discuss the insufficient evidence related to pharmacotherapy as well as providing an overview of using physiologic rather than chronologic age for identifying suitable candidates for bariatric surgery.

Background: Obesity in combination with sarcopenia (age-related loss of muscle mass, strength or function) is increasing in adults aged ≥65 years which places individuals at risk for functional decline and worse health. We ascertained the relationship between sarcopenic obesity and self-reported health in a representative US population. Methods: We identified participants ≥65 years with grip strength and body mass index (BMI) measures from the baseline wave of the National Health and Aging Trends Survey. Sarcopenia was defined using the Sarcopenia Definitions and Outcomes Consortium grip strength cut-points (males

As health indicators such as life expectancy have improved for many older adults, some older adults experience a disproportionate amount of preventable disease, death, and disability. The causes of health disparities among older adults are multidimensional in that disparities are due to multiple, interacting factors such as socioeconomic status, disability status, geographic location, and race/ethnicity. Achieving health equity in late-life requires innovative strategies to address interconnected environmental, sociocultural, behavioral and biological factors that impede opportunities to achieve optimal health and quality of life. This symposium will present state-of-the-art innovations and strategies employed among socially disadvantaged racial, ethnic, and other population groups, and communities. We will discuss innovations in the workforce enhancements with older adult peer support specialists and community health workers, community engagement techniques in program design, and digital solutions aimed at addressing multiple dimensions of health in older adults.

Telomere shortening is associated with age and risk of medical comorbidity. We assessed the relationship between measures of adiposity, leukocyte telomere length, and mortality and whether it is modified by age. Subjects with dual-energy X-ray absorptiometry measures were identified using the National Health and Nutrition Examination Survey 1999–2002. Obesity was categorized using two body fat definitions (BF1%: men ⩾25%; females ⩾35%; BF2% ⩾28% and ⩾38%, respectively), body mass index (BMI) and waist circumference (WC; men ⩾102 cm; females ⩾88 cm). Telomere length relative to standard reference DNA (T/S ratio) was assessed using quantitative PCR. Weighted multivariable regression models evaluated the association of telomere length with adiposity, both continuously and categorically (low/normal BF%, low/high WC and standard BMI categories). Differences in telomere length by age and adiposity were ascertained and subsequent models were stratified by age. Proportional hazard models assessed the risk of mortality by adiposity status. A telomere by adiposity interaction was tested in the entire cohort and by age category (

Purpose To ascertain whether rural status impacts self-reported health and whether the effect of rural status on self-reported health differs by obesity status. Methods We identified 22,307 subjects aged ≥60 from the Medical Expenditure Panel Survey 2004-2013. Body mass index (BMI) was categorized as underweight, normal, overweight, or obese. Physical and mental component scores of the Short Form-12 assessed self-reported health status. Rural/urban status was defined using metropolitan statistical area. Weighted regression models ascertained the relative contribution of predictors (including rural and BMI) on each subscale. Findings Mean age was 70.7 years. Rural settings had higher proportions classified as obese (30.7 vs 27.6%; P < .001), and rural residents had lower physical health status (41.7 ± 0.3) than urban (43.4 ± 0.1; P < .001). Obese or underweight persons had lower physical health status (39.5 ± 0.20 and 37.0 ± 0.82, respectively) than normal (44.7 ± 0.18) or overweight (44.6 ± 0.16) persons (P < .001). BMI category stratification was associated with differences in physical health between rural/urban by BMI. Individuals classified as underweight or obese had lower physical health compared to normal, while the differences were less pronounced for mental health. No differences in mental health existed between rural/urban status. A BMI * rural interaction was significant for physical but not mental health. Conclusions Rural residents report lower self-reported physical health status compared to urban residents, particularly older adults who are obese or underweight. No interaction was observed between BMI and rural status.

PURPOSE OF REVIEW: Obesity in the older adult is a burgeoning health epidemic that leads to increased morbidity, disability and institutionalization. This review presents a brief overview of geriatric-specific consequences of obesity by highlighting the risks and benefits of intentional weight loss. RECENT FINDINGS: Intentional weight loss reduces the extent of adiposity-related illnesses yet the approach in older adults is fraught with challenges. Interventions combining caloric restriction and physical exercise (aerobic and resistance), maximize fat loss and minimize loss of muscle and bone. Interventions are also effective at improving physical function, reducing medication burden, and improving symptomatic osteoarthritis in this population. Approaches can mitigate the risks of isolated caloric restriction on muscle and bone in a safe and effective manner. SUMMARY: Effective weight loss strategies should be considered in older adults. While there are potential risks, practical clinical approaches can minimize the potential harms while maximizing their benefits.

BACKGROUND Sarcopenia, defined as the age-associated loss of muscle mass and strength, can be effectively mitigated through resistance-based physical activity. With compliance at approximately 40% for home-based exercise prescriptions, implementing a remote sensing system would help patients and clinicians to better understand treatment progress and increase compliance. The inclusion of end users in the development of mobile apps for remote-sensing systems can ensure that they are both user friendly and facilitate compliance. With advancements in natural language processing (NLP), there is potential for these methods to be used with data collected through the user-centered design process. OBJECTIVE This study aims to develop a mobile app for a novel device through a user-centered design process with both older adults and clinicians while exploring whether data collected through this process can be used in NLP and sentiment analysis METHODS Through a user-centered design process, we conducted semistructured interviews during the development of a geriatric-friendly Bluetooth-connected resistance exercise band app. We interviewed patients and clinicians at weeks 0, 5, and 10 of the app development. Each semistructured interview consisted of heuristic evaluations, cognitive walkthroughs, and observations. We used the Bing sentiment library for a sentiment analysis of interview transcripts and then applied NLP-based latent Dirichlet allocation (LDA) topic modeling to identify differences and similarities in patient and clinician participant interviews. Sentiment was defined as the sum of positive and negative words (each word with a +1 or −1 value). To assess utility, we used quantitative assessment questionnaires—System Usability Scale (SUS) and Usefulness, Satisfaction, and Ease of use (USE). Finally, we used multivariate linear models—adjusting for age, sex, subject group (clinician vs patient), and development—to explore the association between sentiment analysis and SUS and USE outcomes. RESULTS The mean age of the 22 participants was 68 (SD 14) years, and 17 (77%) were female. The overall mean SUS and USE scores were 66.4 (SD 13.6) and 41.3 (SD 15.2), respectively. Both patients and clinicians provided valuable insights into the needs of older adults when designing and building an app. The mean positive-negative sentiment per sentence was 0.19 (SD 0.21) and 0.47 (SD 0.21) for patient and clinician interviews, respectively. We found a positive association with positive sentiment in an interview and SUS score (ß=1.38; 95% CI 0.37 to 2.39; P=.01). There was no significant association between sentiment and the USE score. The LDA analysis found no overlap between patients and clinicians in the 8 identified topics. CONCLUSIONS Involving patients and clinicians allowed us to design and build an app that is user friendly for older adults while supporting compliance. This is the first analysis using NLP and usability questionnaires in the quantification of user-centered design of technology for older adults.

Sarcopenic obesity portends poor outcomes, yet it is under-recognized in practice. We collected baseline clinical data including data on body composition (total and segmental muscle mass and total body fat), grip strength, and 5-times sit-to-stand. We defined sarcopenia using cut-points for appendicular lean mass (ALM) and obesity using body-fat cut-points. A total of 599 clinic patients (78.5% female; mean age was 51.3 ± 14.2 years) had bioelectrical impedance analysis (BIA) data (83.8%). Mean body mass index (BMI) and waist circumference were 43.1 ± 8.9 kg/m2 and 132.3 ± 70.7 cm, respectively. All patients had elevated body fat. There were 284 (47.4%) individuals fulfilling criteria for ALM-defined sarcopenia. Sarcopenic obese persons had a lower BMI (38.2 ± 6.4 vs 47.6 ± 8.6; P 3; P = 0.009) than those without sarcopenic obesity. Grip strength was lower in those with sarcopenic obesity (25.1 ± 8.0 vs 30.5 ± 11.3 kg; P