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In a case-control study with prevalence sampling, the authors explored the correlates for nocturia and their population-level impact. In 2003-2004, questionnaires were mailed to 6,000 subjects (aged 18-79 years) randomly identified from the Finnish Population Register (62.4% participated; 53.7% were female). Questionnaires contained items on medical conditions, medications, lifestyle, sociodemographic and reproductive factors, urinary symptoms, and snoring. Nocturia was defined as > or =2 voids/night. In age-adjusted analyses, factors associated with nocturia were entered into a multivariate model. Backward elimination was used to select variables for the final model, with adjustment for confounding. Although numerous correlates were identified, none affected > or =50% of nocturia cases of both sexes. The factors with the greatest impact at the population level were (urinary) urgency (attributable number/1,000 subjects (AN) = 24), benign prostatic hyperplasia (AN = 19), and snoring (AN = 16) for men and overweight and obesity (AN = 40), urgency (AN = 24), and snoring (AN = 17) for women. Moreover, correlates included prostate cancer and antidepressant use for men, coronary artery disease and diabetes for women, and restless legs syndrome and obesity for both sexes. Although several correlates were identified, none accounted for a substantial proportion of the population burden, highlighting the multifactorial etiology of nocturia. [ABSTRACT FROM AUTHOR]

Background: Nocturia (waking from sleep at night to void) and chronic insomnia frequently co-exist in older adults, contributing synergistically to sleep disturbance. Treatments typically target either nocturia or insomnia rather than simultaneously addressing shared mechanisms for these disorders., Methods: We conducted a multisite feasibility study to: (1) test and refine a protocol for recruitment, randomization, and assessment of older adults with co-existing nocturia and insomnia; and (2) examine preliminary changes in outcome measures to inform a future larger, multisite clinical trial. Participants were men and women aged 60 years and older recruited from outpatient clinics, reporting an average of two or more nocturia episodes per night over the past 4 weeks and meeting diagnostic criteria for chronic insomnia disorder. Participants were randomized to receive either integrated cognitive-behavioral therapy for insomnia and nocturia or a health education control program involving five weekly visits with a trained nurse practitioner interventionist. Outcomes (e.g., nocturia episodes) were measured 1-week post-treatment and 4-month post-randomization. Descriptive statistics examined the feasibility of outcomes to guide preparations for a future efficacy trial., Results: Of 245 adults screened, 55% were ineligible and 25% declined to participate. Sixty-one percent of 49 participants who provided informed consent were randomized. Of the 30 participants randomized (mean age = 70.6 years, 60% White), 14 were assigned to integrated cognitive-behavioral treatment and 16 to the control group. All randomized participants provided 4-month follow-up data. At 4 months, mean nightly nocturia episodes decreased by 0.9 (SD 1.0) in the integrated treatment group and by 0.2 (SD 1.2) in the control group compared with baseline., Discussion: Findings demonstrate the feasibility of recruiting, randomizing, and collecting outcome data from older adults (predominantly male) assigned to an integrated cognitive-behavioral therapy for coexisting insomnia and nocturia or a health education control program., (© 2024 The Author(s). Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Antiretroviral therapy has dramatically increased the lifespan of people living with HIV (PLWH), but advance care planning (ACP) and hospice services are underutilized in this population. The purpose of this study was to understand barriers and facilitators to ACP among this group. PLWH ( n = 25) were recruited from an HIV Clinic at a Veterans Affairs (VA) Medical Center in Atlanta, GA to represent a range of sociodemographic characteristics and experiences. Semi-structured interviews were analyzed using thematic analysis. More than half of participants (64%) indicated not engaging in ACP. We identified four key barriers to ACP: (1) a self-image among PLWH as "survivors" (and a reluctance to think about ACP); (2) a history of mistrust and mistreatment; (3) weak social ties and a desire to avoid disclosure of HIV status; and (4) a value for self-reliance. Findings have important implications for interventions to overcome these barriers., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: V.C. Marconi has received investigator-initiated research grants (to Emory University) and consultation fees from Eli Lilly, Bayer, Gilead Sciences, Merck, and ViiV. The other authors declare no conflicts of interest.

Importance: Natural language processing (NLP) has the potential to enable faster treatment access by reducing clinician response time and improving electronic health record (EHR) efficiency., Objective: To develop an NLP model that can accurately classify patient-initiated EHR messages and triage COVID-19 cases to reduce clinician response time and improve access to antiviral treatment., Design, Setting, and Participants: This retrospective cohort study assessed development of a novel NLP framework to classify patient-initiated EHR messages and subsequently evaluate the model's accuracy. Included patients sent messages via the EHR patient portal from 5 Atlanta, Georgia, hospitals between March 30 and September 1, 2022. Assessment of the model's accuracy consisted of manual review of message contents to confirm the classification label by a team of physicians, nurses, and medical students, followed by retrospective propensity score-matched clinical outcomes analysis., Exposure: Prescription of antiviral treatment for COVID-19., Main Outcomes and Measures: The 2 primary outcomes were (1) physician-validated evaluation of the NLP model's message classification accuracy and (2) analysis of the model's potential clinical effect via increased patient access to treatment. The model classified messages into COVID-19-other (pertaining to COVID-19 but not reporting a positive test), COVID-19-positive (reporting a positive at-home COVID-19 test result), and non-COVID-19 (not pertaining to COVID-19)., Results: Among 10 172 patients whose messages were included in analyses, the mean (SD) age was 58 (17) years; 6509 patients (64.0%) were women and 3663 (36.0%) were men. In terms of race and ethnicity, 2544 patients (25.0%) were African American or Black, 20 (0.2%) were American Indian or Alaska Native, 1508 (14.8%) were Asian, 28 (0.3%) were Native Hawaiian or other Pacific Islander, 5980 (58.8%) were White, 91 (0.9%) were more than 1 race or ethnicity, and 1 (0.01%) chose not to answer. The NLP model had high accuracy and sensitivity, with a macro F1 score of 94% and sensitivity of 85% for COVID-19-other, 96% for COVID-19-positive, and 100% for non-COVID-19 messages. Among the 3048 patient-generated messages reporting positive SARS-CoV-2 test results, 2982 (97.8%) were not documented in structured EHR data. Mean (SD) message response time for COVID-19-positive patients who received treatment (364.10 [784.47] minutes) was faster than for those who did not (490.38 [1132.14] minutes; P = .03). Likelihood of antiviral prescription was inversely correlated with message response time (odds ratio, 0.99 [95% CI, 0.98-1.00]; P = .003)., Conclusions and Relevance: In this cohort study of 2982 COVID-19-positive patients, a novel NLP model classified patient-initiated EHR messages reporting positive COVID-19 test results with high sensitivity. Furthermore, when responses to patient messages occurred faster, patients were more likely to receive antiviral medical prescription within the 5-day treatment window. Although additional analysis on the effect on clinical outcomes is needed, these findings represent a possible use case for integration of NLP algorithms into clinical care.

Background/objective: Understanding the effects of multimorbidity on motor and cognitive function is important for tailoring therapies. Individuals with diabetes mellitus (DM) have a greater risk of developing Parkinson's disease (PD). This study investigated if individuals with comorbid PD and DM experienced poorer functional ability compared to individuals with only PD or DM., Methods: A cross-sectional analysis of 424 individuals: healthy older adults (HOA), n = 170; PD without DM (PD-only), n = 162; DM without PD (DM-only), n = 56; and comorbid PD and DM (PD+DM), n = 36. Motor, motor-cognitive, cognitive, and psychosocial functions and PD motor symptoms were compared among groups using a two-way analyses of covariance with PD and DM as factors., Results: The PD-only and DM-only participants exhibited slower gait, worse balance, reduced strength, and less endurance. Motor-cognitive function was impaired in individuals with PD but not DM. DM-only participants exhibited impaired inhibition. Individuals with comorbid PD+DM had worse PD motor symptoms and exhibited impaired attention compared to the PD-only group., Conclusions: Having PD or DM was independently associated with poorer physical and mental quality of life, depression, and greater risk for loss of function. Both PD and DM have independent adverse effects on motor function. Comorbid PD+DM further impairs attention compared to the effect of PD-only, suggesting the importance of therapies focusing on attention. Understanding the functional ability levels for motor and cognitive domains will enhance the clinical care for PD, DM, and PD+DM.

We conducted a secondary data analysis to evaluate the association between annual foot exams and incident lower extremity amputations (LEA) among older veterans with diabetes during FY2007-FY2014. Older Veterans with at least one primary care provider visit each year (N = 664,162) and at least one foot exam each year (N = 72,892) and the overlap were identified from the 5 years prior to the study period of interest (FY2002-FY2006 (N = 71,122)). After excluding incident LEA related to cancer and trauma, 71,018 veterans (mean age +/- SD, % male) were included in the final cohort, which was followed from FY2007-FY2014 to evaluate the influence of subsequent annual foot exams and incident LEA. Consistent annual foot exams were protective for incident LEA in older veterans with diabetes, adjusted OR was 0.85 (97% CI: 0.74-0.96). Results indicate that adherence to annual foot exam guidelines can reduce incident LEA in older veterans with diabetes.

Introduction: Overactive bladder (OAB) and frailty are independently associated with patient burden. However, economic burden and treatment-taking behavior have not been well characterized among frail patients with OAB, which, given the varying safety and tolerability profiles of available treatments, is crucial., Objectives: To assess costs, health care resource utilization, treatment-taking behavior (persistence and adherence) to OAB medication in older, frail OAB patients., Methods: This was a retrospective cohort study using international business machines MarketScan Medicare Supplemental claims data. Eligible frail patients (per Claims-based Frailty Index score) initiating mirabegron were 1:2 propensity score matched (based on age, sex, and other characteristics) with those initiating antimuscarinics and were followed up to 1 year. All-cause, per-person, per-month costs, health care encounters, persistence (median days to discontinuation assessed using Kaplan-Meier methods) and adherence (≥80% of proportion of days covered at Day 365) were compared., Results: From 2527 patients with incident mirabegron (21%) or antimuscarinic (79%) dispensations, 516 incident mirabegron users (median age: 82 years, 64% female) were matched to 1032 incident antimuscarinic users (median age: 81 years, 62% female). Median cost was higher in mirabegron group ($1581 vs. $1197 per month); this was primarily driven by medication cost. There was no difference in medical encounters. Adherence (39.1% vs. 33.8%) and persistence (103 vs. 90 days) were higher in mirabegron users., Conclusions: Among frail older adults with OAB, mirabegron use was associated with higher costs and potential improvements in treatment-taking behaviors, particularly with respect to treatment adherence, versus those initiating antimuscarinics., (© 2022 The Authors. Neurourology and Urodynamics published by Wiley Periodicals LLC.)

Purpose: Perioperative pelvic floor muscle training can hasten recovery of bladder control and reduce severity of urinary incontinence following radical prostatectomy. Nevertheless, most men undergoing prostatectomy do not receive this training. The purpose of this trial was to test the effectiveness of interactive mobile telehealth (mHealth) to deliver an evidence-based perioperative behavioral training program for post-prostatectomy incontinence., Materials and Methods: This was a 3-site, 2-arm, randomized trial (2014-2019). Men with prostate cancer scheduled to undergo radical prostatectomy were randomized to a perioperative behavioral program (education, pelvic floor muscle training, progressive exercises, bladder control techniques) or a general prostate cancer education control condition, both delivered by mHealth for 1-4 weeks preoperatively and 8 weeks postoperatively. The primary outcome was time to continence following surgery measured by the ICIQ (International Consultation on Incontinence Questionnaire) Short-Form. Secondary outcomes measured at 6, 9 and 12 months included Urinary Incontinence Subscale of Expanded Prostate Cancer Index Composite; pad use; International Prostate Symptom Score QoL Question and Global Perception of Improvement., Results: A total of 245 men (ages 42-78 years; mean=61.7) were randomized. Survival analysis using the Kaplan-Meier estimate showed no statistically significant between-group differences in time to continence. Analyses at 6 months indicated no statistically significant between-group differences in ICIQ scores (mean=7.1 vs 7.0, p=0.7) or other secondary outcomes., Conclusions: mHealth delivery of a perioperative program to reduce post-prostatectomy incontinence was not more effective than an mHealth education program. More research is needed to assess whether perioperative mHealth programs can be a helpful addition to standard prostate cancer care.

Objectives: Estimate incidence of and risks for SARS-CoV-2 infection among nursing home staff in the state of Georgia during the 2020-2021 Winter COVID-19 Surge in the United States., Design: Serial survey and serologic testing at 2 time points with 3-month interval exposure assessment., Setting and Participants: Fourteen nursing homes in the state of Georgia; 203 contracted or employed staff members from those 14 participating nursing homes who were seronegative at the first time point and provided a serology specimen at second time point, at which time they reported no COVID-19 vaccination or only very recent vaccination (≤4 weeks)., Methods: Interval infection was defined as seroconversion to antibody presence for both nucleocapsid protein and spike protein. We estimated adjusted odds ratios (aORs) and 95% CIs by job type, using multivariable logistic regression, accounting for community-based risks including interval community incidence and interval change in resident infections per bed., Results: Among 203 eligible staff, 72 (35.5%) had evidence of interval infection. In multivariable analysis among unvaccinated staff, staff SARS-CoV-2 infection-induced seroconversion was significantly higher among nurses and certified nursing assistants accounting for race and interval infection incidence in both the community and facility (aOR 5.3, 95% CI 1.0-28.4). This risk persisted but was attenuated when using the full study cohort including those with very recent vaccination., Conclusions and Implications: Midway through the first year of the pandemic, job type continues to be associated with increased risk for infection despite enhanced infection prevention efforts including routine screening of staff. These results suggest that mitigation strategies prior to vaccination did not eliminate occupational risk for infection and emphasize critical need to maximize vaccine utilization to eliminate excess risk among front-line providers., (Copyright © 2022 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: The number of people living with dementia is growing and most patients go years without receiving a specific diagnosis or support services, leading to suboptimal care, negative impacts on the quality of life, and increased costs of care. To address these gaps, the State of Georgia Department of Human Services collaborated with academic and community partners to create the Georgia Memory Net (GMN)., Design: GMN is a hub and spoke model partnered with Emory University's Cognitive Neurology Clinic and Emory Goizueta Alzheimer's Disease Research Center to provide training and support for best practices in diagnosis and management to Memory Assessment Clinics (MACs) throughout the state., Setting: Communities across the State of Georgia., Participants: GMN is a mix of academic and community providers, hospital systems, state and community agencies. Patients and families are evaluated at the MACs and connected to community services., Intervention: A dedicated clinic workflow: primary care providers (PCPs) identify a memory problem and refer to the MACs for diagnostic evaluation; meeting with a community services educator, and development of a care plan. The patient is reconnected with the PCP for continuity of care., Measurements: Initial metrics include numbers of unique patients, total patient visits, and referrals to state agency partners for community services., Results: GMN established five MACs across Georgia with annual state funding. Partners at Emory University provided initial training; refined patient workflows for best practices; and provide ongoing support, guidance, and continuing education for MAC teams. Local PCPs and community services partners demonstrated strong engagement with the new model., Conclusions: GMN is an innovative care model to improve access to accurate and timely diagnosis in patients with memory loss. GMN may help improve the quality of life for patients and families through preventive and early care., (© 2022 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Background: Remaining current on the latest advances in the peer-reviewed literature is a basic tenant of medical education and evidence-based practice. We updated an important prior publication (Vaughan, et al.) identifying landmark articles in geriatric medicine by considering the influence of altmetrics and updating the list with notable articles published between 2012 and 2019., Methods: Articles were identified by searching Web of Science and Scopus for highly cited articles clinically relevant to geriatrics or gerontology and by searching the Altmetric Explorer database for relevant articles with high altmetric scores. The results of the literature search were screened and evaluated using a bibliometric score consisting of an adjusted journal impact factor, citation count, and altmetric score., Results: The top 12 notable articles in geriatrics were selected by a consensus panel and ranked using an expert opinion survey. This process reinforces the concept of combining subjective and objective measures to identify notable articles to be used for the education of healthcare professionals in geriatrics principles of care for older adults., Conclusions: While our update was performed approximately 9 years after the initial identification of landmark articles, we propose that future updates are conducted at an interval of every 5 years by the governance of a national professional society., (© 2022 The American Geriatrics Society.)

Aims: While behavior-based pelvic floor muscle exercise therapy is an effective treatment for overactive bladder in Parkinson's disease (PD) patients, cognitive function may be a predictor of rehabilitation outcomes., Methods: In a planned exploratory analysis, participants who had a Montreal Cognitive Assessment (MoCA) with a score ≥18 who were randomized in a clinical trial to behavioral treatment were classified by perceived improvement (Benefit vs. No Benefit) as reported on a validated Satisfaction and Benefit Questionnaire. General cognition (MoCA), motor procedural learning (Serial reaction time task), verbal memory (Buschke delayed recall), spatial memory (Nonverbal/Spatial selective reminding test), and working memory (Wisconsin card sorting task) were compared between the two groups using Wilcoxon rank-sum test., Results: Of the 26 participants randomized to behavioral treatment (70% male, mean age 71 ± 6.1 years), 22 participants (85%) reported Benefit and four reported No Benefit. General cognition, motor procedural learning, verbal memory, spatial memory, and working memory did not differ between these groups. While the difference between the time to complete the final practiced series and the random series of the Serial Reaction Time Task (SRTT) was statistically similar between the groups, the Benefit group performed the random sequence more quickly (567.0 ± 136.5 ms) compared to the No Benefit group (959.4 ± 443.0 ms; p = 0.03) and trended toward faster performance in the final practiced series., Conclusions: Perceived benefit from behavioral treatment for overactive bladder was not associated with measures of baseline cognition other than faster completion of the SRTT. This is noteworthy because many behavior-based therapy studies exclude participants with mild cognitive impairment. Additional studies may evaluate if domain-specific cognitive function, particularly the assessment of implicit memory, could lead to individualized behavioral therapy recommendations., (© 2022 Wiley Periodicals LLC. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Background and Objectives: Despite the prevalence of published opinions about the use of professional academic writers to help disseminate the results of clinical research, particularly opinions about the use of ghost writers, very little information has been published on the possible roles for professional writers within academic medical departments or the mechanisms by which these departments can hire and compensate such writers. To begin addressing this lack of information, the Association of Departments of Family Medicine hosted an online discussion and a subsequent webinar in which we obtained input from three departments of family medicine in the United States regarding their use of academic writers. This discussion revealed three basic models by which academic writers have benefitted these departments: (1) grant writing support, (2) research and academic support for clinical faculty, and (3) departmental communication support. Drawing on specific examples from these institutions, the purpose of this paper is to describe the key support activities, advantages, disadvantages, and funding opportunities for each model for other departments to consider and adapt.

Background: Historically, older adults have been excluded from trials evaluating hepatitis C virus (HCV) treatment, in part, due to the adverse effects associated with previous regimens. Veterans are at high risk of HCV infection. Ledipasvir/sofosbuvir (LED/SOF) is a once daily antiviral regimen with demonstrated efficacy and tolerability among the younger population. We examined the tolerability and effectiveness of LED/SOF in Veterans age ≥65 years versus those <65 years who were treated at the Atlanta VA Health Care System (AVAHCS)., Methods: Using the VA Clinical Case Registry, all persons who filled a LED/SOF prescription at the AVAHCS from January 1, 2015, through March 31, 2016, were identified. The electronic medical records were reviewed to identify basic demographic information: comorbidities; polypharmacy; and outcomes. Sustained virologic response (SVR) was defined as an undetectable HCV RNA, at least 12 weeks after completing treatment. Descriptive statistics were employed using SAS v9.2., Results: We identified 345 Veterans who filled LED/SOF during the study period; 94 were excluded due to exposure to ribavirin and IFN containing regimens; 97 (38.6%) were ≥65 years. Veterans were predominantly black (57%) and male (97%). Cancer was more prevalent among older Veterans (p = 0.047) as was polypharmacy (p = 0.001). Treatment completion rates between older and younger Veterans were not significantly different (99 vs. 95%, respectively; p = 0.16), but significantly more older Veterans achieved SVR (98 vs. 91%; p = 0.03)., Conclusions: LED/SOF was a well-tolerated and effective regimen in an older Veteran population despite their multiple comorbidities and polypharmacy presence., (© 2021 The American Geriatrics Society.)

Objectives: To estimate prior severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection among skilled nursing facility (SNF) staff in the state of Georgia and to identify risk factors for seropositivity as of fall 2020., Design: Baseline survey and seroprevalence of the ongoing longitudinal Coronavirus 2019 (COVID-19) Prevention in Nursing Homes study., Setting: The study included 14 SNFs in the state of Georgia., Participants: In total, 792 SNF staff employed or contracted with participating SNFs were included in this study. The analysis included 749 participants with SARS-CoV-2 serostatus results who provided age, sex, and complete survey information., Methods: We estimated unadjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) for potential risk factors and SARS-CoV-2 serostatus. We estimated adjusted ORs using a logistic regression model including age, sex, community case rate, SNF resident infection rate, working at other facilities, and job role., Results: Staff working in high-infection SNFs were twice as likely (unadjusted OR, 2.08; 95% CI, 1.45-3.00) to be seropositive as those in low-infection SNFs. Certified nursing assistants and nurses were 3 times more likely to be seropositive than administrative, pharmacy, or nonresident care staff: unadjusted OR, 2.93 (95% CI, 1.58-5.78) and unadjusted OR, 3.08 (95% CI, 1.66-6.07). Logistic regression yielded similar adjusted ORs., Conclusions: Working at high-infection SNFs was a risk factor for SARS-CoV-2 seropositivity. Even after accounting for resident infections, certified nursing assistants and nurses had a 3-fold higher risk of SARS-CoV-2 seropositivity than nonclinical staff. This knowledge can guide prioritized implementation of safer ways for caregivers to provide necessary care to SNF residents., (© The Author(s) 2021.)

Declaration of Interest: The authors have no conflicts of interest to declare.

Objective: To evaluate tamsulosin (α-blocker therapy) for male overactive bladder (OAB) and to examine if indicators of concomitant benign prostatic hyperplasia are associated with OAB symptom improvement., Materials and Methods: This was a planned, exploratory analysis of a 4-week, α-blocker (tamsulosin 0.4 mg) run-in phase of the Male Overactive Bladder Trial in Veterans (MOTIVE). Participants with urinary urgency and urinary frequency (> 8 voids/24 hours) completed bladder diaries, answered symptom questionnaires (AUA-7 SI), and had post-void residual and noninvasive uroflowmetry measurement., Results: A total of 116 male Veterans aged 42-88 years with OAB participated. There were statistically significant reductions in voiding frequency (11.3 > 10.0 voids/24 hours, P < .0001), urgency scores (mean 2.5-2.2 points, P < .0001), and nightly nocturia (2.1 > 1.8, P < .001). Only baseline AUA-7 SI total and voiding subscale categories (mild, moderate, severe) were associated with significant reduction in AUA-7 SI total score. For continuous variables, only AUA-7 SI baseline total score was associated with AUA-7 SI storage symptom changes. No other baseline measures were associated with changes in urgency, frequency, or nocturia., Conclusion: Initiation of short course tamsulosin therapy in men was associated with statistical reduction in OAB symptoms. Baseline post-void residual, uroflow rate, and the voiding symptom subscore of the AUA-7 SI were not predictive of OAB symptom improvement with tamsulosin. These findings merits further exploration., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Cultural mistrust of government with regard to health issues has pressed the need to engage trusted community leaders with influence and reach in disproportionately affected communities to ensure that essential public health activities related to COVID-19 occur among populations experiencing disproportionate impact from the pandemic. In April of 2020, a Georgia-based integrated academic health care system created a Community Outreach and Health Disparities Collaborative to unite trusted community leaders from faith-based, civic, and health-sector organizations to work with the health system and Emory University to develop tailored approaches and mobilize support within the context of the communities' cultural and individual needs to reduce the burden of COVID-19. We describe the framework used to join health care and academic collaborators with community partners to mobilize efforts to address the disproportionate impact of COVID-19 on racial, ethnic, and socioeconomic minority groups. The framework outlines a series of steps taken that led to a community-driven collaboration designed to engage local influential community leaders as partners in improving access to care for disproportionately affected communities, collaborations that could be replicated by other large health care systems. This framework can also be applied to other chronic diseases or future public health emergencies to improve communication, education, and health care access for communities experiencing disproportionate impact.

Purpose: The goal of this study was to determine if the US adult population with nocturia (waking from sleep at night to void) can easily take medications (desmopressin acetate) approved by the US Food and Drug Administration for nocturia. The study examined: (1) the prevalence of comorbid conditions, laboratory abnormalities, and concomitant medications that increase risk of desmopressin use; and (2) whether these factors are associated with age or nocturia frequency., Methods: Using a cross-sectional analysis of four US National Health and Nutrition Examination Survey (NHANES) waves (2005-2012), a total of 4111 participants aged ≥50 years who reported ≥2 nightly episodes of nocturia were identified. The main outcome was frequency of contraindications and drug interactions as described in US Food and Drug Administration-approved prescribing information. These prescribing concerns were matched to examination findings, medical conditions, concomitant medications, and laboratory results of NHANES participants. The associations between prescribing concerns and nocturia severity and age groups were examined., Findings: The mean participant age was 65.7 years (95% CI, 65.3-66.1), and 45.5% were male. Desmopressin prescribing concerns were present in 80.5% (95% CI, 78.0-82.9) of those ≥50 years of age with nocturia; 50.0% (95% CI, 47.0-53.0) had contraindications, and 41.6% (95% CI, 39.3-44.0) took a concomitant drug that could increase risk of low serum sodium. Desmopressin contraindications were higher with older age (P < 0.001) and present in 73.2% (95% CI, 69.3-77.1) of those ≥80 years of age., Implications: Using NHANES data, this study showed that older US adults with nocturia have a high prevalence of medical conditions, concomitant medications, and baseline laboratory abnormalities that likely increase the risk of potentially severe adverse side effects from desmopressin use. A medication designed and approved for a clinical symptom that is most common in older adults could not be taken by most of the older adults with the symptom., (Published by Elsevier Inc.)

Urinary incontinence (UI) is a highly prevalent condition, burdening older adults and their informal caregivers. This study explored the development and feasibility of a 6-week evidence-based, educational/skill building program delivered via tablet-personal computer aimed at developing informal caregiver UI knowledge; and enhancing informal caregiver skill set in prompted voiding and toileting strategies. Caregivers also received individualized weekly coaching sessions from a nurse expert. Feasibility and preliminary efficacy were tested in three caregiver/care-recipient dyads. Recruitment of eligible participants through community-based resources was a challenge to feasibility. Most caregivers found the technology acceptable, but adherence to prompted voiding was inconsistent. All caregivers rated the intervention highly, reported improvements in their care-recipient's urine leakage, found access to a UI expert beneficial, and would recommend it to a friend. The results suggest that the tablet-facilitated intervention was feasible and acceptable to informal caregivers and showed promise for improving both caregiver and care recipient outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Frailty is a risk factor for adverse postoperative outcomes. We aimed to test the performance of a prospectively validated frailty measure, the Risk Analysis Index (RAI) in patients who underwent vascular surgery and delineate the additive impact of procedure complexity on surgical outcomes., Methods: We queried the 2007-2013 American College of Surgeons National Surgical Quality Improvement Program database to identify 6 major elective vascular procedure categories (carotid revascularization, abdominal aortic aneurysm [AAA] repair, suprainguinal revascularization, infrainguinal revascularization, thoracic aortic aneurysm [TAA] repair, and thoracoabdominal aortic aneurysm [TAAA] repair). We trained and tested logistic regression models for 30-day mortality, major complications, and prolonged length of stay (LOS). The first model, "RAI," used the RAI alone; "RAI-Procedure (RAI-P)" included procedure category (e.g., AAA repair) and procedure approach (e.g., endovascular); "RAI-Procedure Complexity (RAI-PC)" added outpatient versus inpatient surgery, general anesthesia use, work relative value units (RVUs), and operative time., Results: The RAI model was a good predictor of mortality for vascular procedures overall (C-statistic: 0.72). The C-statistic increased with the RAI-P (0.78), which further improved minimally, with the RAI-PC (0.79). When stratified by procedure category, the RAI predicted mortality well for infrainguinal (0.79) and suprainguinal (0.74) procedures, moderately well for AAA repairs (0.69) and carotid revascularizations (0.70), and poorly for TAAs (0.62) and TAAAs (0.54). For carotid, infrainguinal, and suprainguinal procedures, procedure complexity (RAI-PC) had little impact on model discrimination for mortality, did improve discrimination for AAAs (0.84), TAAs (0.73), and TAAAs (0.80). Although the RAI model was not a good predictor for major complications or LOS, discrimination improved for both with the RAI-PC model., Conclusions: Frailty as measured by the RAI was a good predictor of mortality overall after vascular surgery procedures. Although the RAI was not a strong predictor of major complications or prolonged LOS, the models improved with the addition of procedure characteristics like procedure category and approach., (Published by Elsevier Inc.)

Objective: Symptomatic peripheral artery disease (PAD) impairs walking, but data on the impact of PAD on community mobility is limited. Life-space mobility measures the distance, frequency, and assistance needed as older adults move through geographic areas extending from their bedroom (life-space mobility score: 0) to beyond their town (life-space mobility score: 120). We evaluated the association of PAD with longitudinal life-space mobility trajectory., Methods: Participants were part of the University of Alabama at Birmingham Study of Aging, a longitudinal study of community-dwelling older adults who were observed from 2001 to 2009. We limited our analysis to those who survived at least 6 months (N = 981). PAD was based on self-report with verification by physician report and hospital records. Our primary outcome was life-space mobility score assessed every 6 months. A multilevel change model (mixed model) was used to determine the association between PAD and life-space mobility trajectory during a median 7.9 years of follow-up., Results: Participants had a mean age of 75.7 (standard deviation, 6.7) years; 50.5% were female, and 50.4% were African American. PAD prevalence was 10.1%, and 57.1% of participants with PAD died. In participants with both PAD and life-space restriction, defined as life-space mobility score <60, we observed the highest mortality (73.1%). In a multivariable adjusted mixed effects model, participants with PAD had a more rapid decline in life-space mobility by -1.1 (95% confidence interval [CI], -1.9 to -0.24) points per year compared with those without PAD. At 5-year follow-up, model-adjusted mean life-space mobility was 48.1 (95% CI, 43.5-52.7) and 52.4 (95% CI, 50.9-53.8) among those with and without PAD, respectively, corresponding to a restriction in independent life-space mobility at the level of one's neighborhood., Conclusions: Life-space mobility is a novel patient-centered measure of community mobility, and PAD is associated with significant life-space mobility decline among community-dwelling older adults. Further study is needed to mechanistically confirm these findings and to determine whether better recognition and treatment of PAD alter the trajectory of life-space mobility., (Published by Elsevier Inc.)

Purpose: Although nocturia is associated with various comorbidities, its impact on falls and fractures remains unclear. We performed a systematic review and meta-analysis to evaluate the association between nocturia and falls and fractures as a prognostic and as a causal risk factor., Materials and Methods: We searched PubMed®, Scopus®, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and abstracts of major urological meetings up to December 31, 2018. We conducted random effects meta-analyses of adjusted relative risks of falls and fractures. We applied the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach to rate the quality of evidence for nocturia as a prognostic and causal factor of falls and fractures., Results: Among 5,230 potential reports 9 observational longitudinal studies provided data on the association between nocturia and falls or fractures (1 for both, 4 for falls, 4 for fractures). Pooled estimates demonstrated a risk ratio of 1.20 (95% CI 1.05-1.37, I 2 =51.7%, annual risk difference 7.5% among the elderly) for association between nocturia and falls and 1.32 (95% CI 0.99-1.76, I 2 =57.5%, annual risk difference 1.2%) for association between nocturia and fractures. Subgroup analyses showed no significant effect modification by age, gender, followup time, nocturia case definition or risk of bias. We rated the quality of evidence for nocturia as a prognostic factor as moderate for falls and low for fractures, and as very low as a cause of falls/fractures., Conclusions: Nocturia is probably associated with an approximately 1.2-fold increased risk of falls and possibly an approximately 1.3-fold increased risk of fractures.

Purpose: Nocturia (waking from sleep at night to void) is a common cause of sleep disruption associated with increased comorbidity and impaired quality of life. However, its impact on mortality remains unclear. We performed a systematic review and meta-analysis to evaluate the association of nocturia with mortality as a prognostic factor and a causal risk factor., Materials and Methods: We searched PubMed®, Scopus®, CINAHL® (Cumulative Index of Nursing and Allied Health Literature) and major conference abstracts up to December 31, 2018. Random effects meta-analyses were done to address the adjusted RR of mortality in people with nocturia. Meta-regression was performed to explore potential determinants of heterogeneity, including the risk of bias. We applied the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) framework to rate the quality of evidence for nocturia as a prognostic risk factor for mortality and separately as a cause of mortality., Results: Of the 5,230 identified reports 11 observational studies proved eligible for inclusion. To assess nocturia 10 studies used symptom questionnaires and 1 used frequency-volume charts. Nocturia was defined as 2 or more episodes per night in 6 studies (55%) and as 3 or more episodes per night in 5 (45%). Pooled estimates demonstrated a RR of 1.27 (95% CI 1.16-1.40, I 2 =48%) with an absolute 1.6% and 4.0% 5-year mortality difference in individuals 60 and 75 years old, respectively. The pooled estimates of relative risk did not differ significantly across varying age, gender, followup, nocturia case definition, risk of bias or study region. We rated the quality of evidence for nocturia as a prognostic factor as moderate and as a cause of mortality as very low., Conclusions: Nocturia is probably associated with an approximately 1.3-fold increased risk of death.

Importance: First-line behavioral and drug therapies for overactive bladder (OAB) symptoms in men are effective but not usually curative., Objective: To determine whether combining behavioral and drug therapies improves outcomes compared with each therapy alone for OAB in men and to compare 3 sequences for implementing combined therapy., Design, Setting, and Participants: In this 3-site, 2-stage, 3-arm randomized clinical trial, participants were randomized to 6 weeks of behavioral therapy alone, drug therapy alone, or combined therapy followed by step-up to 6 weeks of combined therapy for all groups. Participants were recruited from 3 outpatient clinics and included community-dwelling men 40 years or older with urinary urgency and 9 or more voids per 24 hours. Data were collected from July 2010 to July 2015 and analyzed from April 2016 to September 2019., Interventions: Behavioral therapy consisted of pelvic floor muscle training with urge suppression strategies and delayed voiding. Drug therapy included an antimuscarinic (sustained-release tolterodine, 4 mg) plus an α-blocker (tamsulosin, 0.4 mg)., Main Outcomes and Measures: Seven-day bladder diaries completed before and after each 6-week treatment stage were used to calculate reduction in frequency of urination (primary outcome) and other symptoms (ie, urgency, urgency incontinence, and nocturia). Other secondary outcomes included validated patient global ratings of improvement and satisfaction, Overactive Bladder Questionnaire score, and International Prostate Symptom Score., Results: Of the 204 included men, 133 (65.2%) were white, and the mean (SD) age was 64.1 (11.1) years. A total of 21 men discontinued treatment and 183 completed treatment. Mean (SD) voids per 24 hours decreased significantly in all 3 groups from baseline to 6-week follow-up (behavioral therapy: 11.7 [2.4] vs 8.8 [2.1]; change, 2.9 [2.4]; percentage change, 24.7%; P < .001; drug therapy: 11.8 [2.5] vs 10.3 [2.7]; change, 1.5 [2.3]; percentage change, 12.7%; P < .001; combined therapy: 11.8 [2.4] vs 8.2 [2.3]; change, 3.6 [2.1]; percentage change, 30.5%; P < .001). Intention-to-treat analyses indicated that posttreatment mean (SD) voiding frequencies were significantly lower in those receiving combined therapy compared with drug therapy alone (8.2 [2.3] vs 10.3 [2.7]; P < .001) but not significantly lower compared with those receiving behavioral therapy alone (8.2 [2.3] vs 8.8 [2.1]; P = .19) and were lower for behavioral therapy alone compared with drug therapy alone (8.8 [2.1] vs 10.3 [2.7]; P < .001). At 12-week follow-up, after all groups had received combined therapy, improvements in mean (SD) voids per 24 hours were also greatest for those receiving initial combined therapy compared with baseline (behavioral therapy: 11.7 [2.4] vs 8.0 [2.2]; change, 3.7 [2.3]; percentage change, 31.6%; P < .001; drug therapy: 11.8 [2.5] vs 8.6 [2.3]; change, 3.2 [2.5]; percentage change, 27.1%; P < .001; combined therapy: 11.8 [2.4] vs 8.0 [2.2]; change, 3.8 [2.1]; percentage change, 32.2%; P < .001), but there were no statistically significant group differences on primary or secondary measures., Conclusions and Relevance: Combining behavioral and drug therapy yields greater improvements in OAB symptoms than drug therapy alone but not behavioral therapy alone. When using a stepped approach, it is reasonable to begin with behavioral therapy alone., Trial Registration: ClinicalTrials.gov identifier: NCT01175382.

Effective education necessitates a shared mental model of what and how learners should be taught. Students in various healthcare professions education programs learn together most effectively when programs have a shared mental model for education. Because healthcare professions education programs must satisfy their respective accreditation standards, the terminology of those standards reflects that body's shared mental model for education. Thus, interprofessional education (IPE) would be facilitated by common educational lexicon across accrediting bodies. In this study, the terminology used in the accreditation standards from several healthcare professions educational programs was measured. An analysis was conducted to illustrate whether terms used by accreditors were internally consistent and whether there was consistency across professions. Counts of learning outcomes terms used revealed little internal consistency within each set of standards. Additionally, the terms in the various standards documents used to describe educational outcomes were not consistent across accreditors. Individual healthcare professions educational programs find IPE difficult to implement and maintain for pre-professional students. This study suggests that these programs' learning outcomes, which are regulated by accreditation standards, probably conflict with implementation of IPE initiatives. Strategies to normalize learning outcomes language and develop shared mental models for IPE are needed.

Aim: Determine the efficacy of behavioral therapy for urinary symptoms in Parkinson's disease., Methods: Randomized trial of behavioral therapy compared with control condition among adults (aged 54-85 years, 74% male, 10% Black/ 83% White) with Parkinson's and greater than or equal to 4 incontinence episodes weekly. Behavioral therapy included pelvic floor muscle exercises, bladder training, fluid and constipation management. Both groups completed bladder diary self-monitoring. Outcomes included diary-derived incontinence and ICIQ-overactive bladder (OAB) score (range, 0-16) with bother and quality of life questionnaires (higher scores = worse outcomes)., Results: Fifty-three participants randomized and 47 reported 8-week outcomes including 26 behavioral therapy and 21 control. Behavioral vs control participants were similar with respect to age (71.0 ± 6.1 vs 69.7 ± 8.2 years), sex (70% vs 78% male), motor score, cognition, mean weekly incontinence episodes (13.9 ± 9.6 vs 15.1 ± 11.1) and OAB symptoms (8.9 ± 2.4 vs 8.3 ± 2.2). Weekly incontinence reduction was similar between behavioral (-6.2 ± 8.7) and control participants (-6.5 ± 13.8) (P = 0.89). After multiple imputation analysis, behavioral therapy participants reported statistically similar reduction in OAB symptoms compared to control (-3.1 ± 2.8 vs -1.9 ± 2.2, P = 0.19); however quality of life (-22.6 ± 19.1 vs -7.0 ± 18.4, P = 0.048) and bother (-12.6 ± 17.2 vs - 6.7 ± 8.8, P = 0.037) improved significantly more with behavioral therapy., Conclusion: Self-monitoring resulted in fewer urinary symptoms; however, only multicomponent behavioral therapy was associated with reduced bother and improved quality of life. Providers should consider behavioral therapy as initial treatment for urinary symptoms in Parkinson's disease., (© 2019 Wiley Periodicals, Inc.)

Background/objectives: To optimize health and well-being for all older people, we must collectively develop leaders to pioneer models of care, educate the healthcare workforce, advance research, and engage the community., Methods: The Emerging Leaders in Aging (ELIA) program was created to train a multiprofessional cadre of leaders focused on the health and well-being of older people. ELIA uses the social change curricular framework and addresses knowledge of self, community, and engagement with change. Program impact measured included scholar satisfaction, confidence related to curricular domains before and after the program, project progress, and scholar productivity., Results: Four cohorts of 65 scholars in seven health professions from 24 states were selected for the year-long 55-hour program. Overall satisfaction from members of the first three cohorts who have completed the program (n = 46) was 4.86 (scale = 1-5), and scholar confidence increased from 5.8 to 8.0 (scale = 1-9) (p < .001). These scholars reported 85 presentations, 63 publications, and 21 awards subsequent to training. All scholars described the importance of a program focused on early and mid-career leaders in health and aging., Discussion: The ELIA program leverages longitudinal, distance mentor communities, and project-based learning strategies. It has improved confidence and skills in emerging leaders who commit their efforts toward the care of older persons. Programs like ELIA are critical to preparing a healthcare workforce to optimize care for all as our health needs and expectations change with age. J Am Geriatr Soc 67:437-442, 2019., (© 2019 The American Geriatrics Society.)

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

Urinary symptoms worsen further the quality of life of persons already burdened by neurologic disease. Urinary symptoms frequently occur in the setting of neurologic diseases such as Parkinson disease and Parkinson-plus syndromes, multiple sclerosis, and stroke. Urinary incontinence is associated with increased caregiver burden and enhances the risk of institutionalization among those living with dementia. Nocturia is associated with impaired sleep and work productivity. Providing patient-centered care for urinary symptoms involves assessing patient and family goals for care and incorporating a multicomponent assessment and treatment plan to align treatment options with the goals for care. Lifestyle and behavioral therapies are available as first-line treatment for most urinary symptoms. Consideration of drug therapy should aim to minimize the potential for adverse drug events such as orthostatic hypotension when using α blockers for men with concomitant prostate enlargement or anticholinergic side effects with anticholinergic bladder relaxant therapy. Interventional therapies such as percutaneous nerve stimulation, cystoscopic botulinum toxin injection, and sacral neuromodulation are available for patients who do not have significant urinary retention at baseline. Containment strategies aim to prevent skin irritation and provide support. With a patient-centered approach, providers empower patients to control and contain urinary symptoms and, thus, maintain confidence and social engagement., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To identify patterns of prevalent chronic medical conditions among women with urinary incontinence (UI)., Materials and Methods: We combined cross-sectional data from the 2005-2006 to 2011-2012 US National Health and Nutrition Examination Surveys, and identified 3 800 women with UI and data on 12 chronic conditions. Types of UI included stress UI (SUI), urgency UI (UUI), and mixed stress and urgency UI (MUI). We categorized UI as mild, moderate or severe using validated measures. We performed a two-step cluster analysis to identify patterns between clusters for UI type and severity. We explored associations between clusters by UI subtype and severity, controlling for age, education, race/ethnicity, parity, hysterectomy status and adiposity in weighted regression analyses., Results: Eleven percent of women with UI had no chronic conditions. Among women with UI who had at least one additional condition, four distinct clusters were identified: (i) cardiovascular disease (CVD) risk-younger; (ii) asthma-predominant; (iii) CVD risk-older; and (iv) multiple chronic conditions (MCC). In comparison to women with UI and no chronic diseases, women in the CVD risk-younger (age 46.7 ± 15.8 years) cluster reported the highest rate of SUI and mild UI severity. In the asthma-predominant cluster (age 51.5 ± 10.2 years), women had more SUI and MUI and more moderate UI severity. Women in the CVD risk-older cluster (age 57.9 ± 13.4 years) had the highest rate of UUI, along with more severe UI. Women in the MCC cluster (age 61.0 ± 14.8 years) had the highest rates of MUI and the highest rate of moderate/severe UI., Conclusions: Women with UI rarely have no additional chronic conditions. Four patterns of chronic conditions emerged with differences by UI type and severity. Identification of women with mild UI and modifiable conditions may inform future prevention efforts., (Published 2018. This article is a U.S. Government work and is in the public domain in the USA.)

Background: Knowing how chronic kidney disease (CKD) patients talk about their encounters with providers (i.e., their discourse) can inform the important clinical goal of engaging patients in their chronic disease self-management. The aim of this study was to analyze patient discourse on ongoing CKD monitoring encounters for health communication strategies that motivate patient engagement., Methods: Passages regarding CKD monitoring from 6 focus group transcripts on self-management with a total of 30 participants age ≥ 70 years from the Atlanta Veterans Affairs Renal Clinic across three different CKD trajectories (stable, linear decline, and non-linear) were extracted. These passages were examined using three-stage critical discourse analysis (description, interpretation, explanation) for recurring patterns across groups., Results: Focus group participants were an average age of 75.1, 96.7% male, and 60% Black. Passages relating to CKD monitoring (n = 55) yielded predominantly negative communication themes. Perceived negative communication was characterized through a patient discourse of unequal exchange, whereby engaged patients would provide bodily fluids and time for appointments and continued to wait for meaningful, contextualized monitoring information from providers and/or disengaged providers who withheld that information. However, some encounters were depicted as helpful. Perceived positive communication was characterized by a patient discourse of kidney protection, whereby patients and providers collaborate in the mutual goal of preserving kidney function., Conclusions: Patient perceived an unequal exchange in CKD monitoring encounters. This perception appears rooted in a lack of easily understandable information. By accessing the positive discourse of protecting the kidneys (e.g., through eGFR level) vs. the discourse of damage (e.g., serum creatinine level), healthcare professionals can clarify the purpose of monitoring and in ways that motivate patient engagement in self-management. Patients being monitored for CKD progression may best be supported through messaging that conceptualizes monitoring as kidney protection and provides concrete contextualized information at each monitoring encounter.

Objectives: Safe and easily implemented treatment regimens are needed for the management of patients with type 2 diabetes mellitus (T2DM) in long-term care (LTC) and skilled nursing facilities., Design: This 6-month open-label randomized controlled trial compared the efficacy and safety of a DPP4 inhibitor (linagliptin) and basal insulin (glargine) in LTC residents with T2DM., Settings: Three LTC institutions affiliated with a community safety-net hospital, US Department of Veterans Affairs and Emory Healthcare System in Atlanta, Georgia., Participants: A total of 140 residents with T2DM treated with oral antidiabetic agents or low-dose insulin (≤0.1 U/kg/d), with fasting or premeal blood glucose (BG) > 180 mg/dL and/or HbA1c >7.5%., Intervention: Baseline antidiabetic therapy, except metformin, was discontinued on trial entry. Residents were treated with linagliptin 5 mg/d (n = 67) or glargine at a starting dose of 0.1 U/kg/d (n = 73). Both groups received supplemental rapid-acting insulin before meals for BG > 200 mg/dL., Measurements: Primary outcome was mean difference in daily BG between groups. Main secondary endpoints included differences in frequency of hypoglycemia, glycosylated hemoglobin (HbA1c), complications, emergency department visits, and hospital transfers., Results: Treatment with linagliptin resulted in no significant differences in mean daily BG (146 ± 34 mg/dL vs. 157 ± 36 mg/dL, P = .07) compared to glargine. Linagliptin treatment resulted in fewer mild hypoglycemic events <70 mg/dL (3% vs. 37%, P < .001), but there were no differences in BG < 54 mg/dL (P = .06) or <40 mg/dL (P = .05) compared to glargine. There were no significant between-group differences in HbA1c, length of stay, complications, emergency department visits, or hospitalizations., Conclusion: Treatment with linagliptin resulted in noninferior glycemic control and in significantly lower risk of hypoglycemia compared to insulin glargine in long-term care and skilled nursing facility residents with type 2 diabetes., (Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. All rights reserved.)

Aims: To compare the prevalence of urinary and bowel symptoms in a sample of adults with early Parkinson's disease (PD) and healthy controls (HC)., Methods: Data were obtained from the Michael J. Fox Parkinson's Progression Markers Initiative (PPMI). Prevalent bladder (urinary incontinence (UI) and nighttime voiding) and bowel (constipation and fecal incontinence (FI)) symptoms were defined as occurring at least sometimes when queried using the Scale for Outcomes in PD for Autonomic Symptoms., Results: The proportion of men (65% vs 64%) and the mean age (61.0 ± 9.7 vs 60.2 ± 11.2 years) was similar between early PD (n = 423) and HC (n = 195). UI and constipation were more prevalent among early PD versus HC (UI: 26.7% vs 8.2%, constipation: 32.4% vs 11.8%; P's < 0.0001). Prevalent nighttime voiding was high among both groups, but not significantly different (82.5% vs 84.1%, P = 0.62). FI was infrequent in both. The odds of UI and constipation were significantly higher in early PD even after adjustment for age, sex, cognition, and overactive bladder (UI model only), constipation (UI and constipation models only), depression, and anxiety medication usage (UI: OR: 4.39 [95% CI: 2.92, 5.87]; constipation: 3.34 [2.20, 4.42]; P's < 0.0001)., Conclusions: While constipation is known to precede PD diagnosis, these data suggest that the occurrence of UI is elevated in early PD compared to a well-matched HC population., (© 2017 Wiley Periodicals, Inc.)

Background: The definition of frailty, as modeled by the Fried criteria, has been limited primarily to the physical domain. The purpose of this study was to assess the additive value of cognitive function with existing frailty criteria to predict poor postoperative outcomes in a large multidisciplinary cohort of patients undergoing major operations., Study Design: A 4-level composite frailty scoring system was created via the combination of the Fried frailty score and the Emory Clock Draw Test to assess preoperative frailty and cognitive impairment, respectively. Overall survival was defined as months from date of operation to date of death or last follow-up., Results: This study included 330 patients undergoing major operations; mean age was 58 years and a total of 53 patient deaths occurred during 4-year follow-up. Among the robust cohort, 20 of 168 patients died (11.9%), and among those who were both physically frail and cognitively impaired, 11 of 26 patients died (42.3%). Multivariable analysis demonstrated the physically frail and cognitively impaired cohort to have a 3.92 higher risk of death (95% CI 1.66 to 9.26) compared with the cohort of robust patients (p = 0.002). Kaplan-Meier survival curves reveal an overall difference in long-term survival (log-rank p < 0.0001), driven mainly by the high risk of mortality among patients with both physical frailty and cognitive impairment., Conclusions: The use of a combined frailty and cognitive assessment score has a more powerful potential to predict adult patients at higher risk of overall survival than either measurement alone. The addition of cognitive assessment to physical frailty measure can lead to improved preoperative decision making and possibly early intervention, as well as more accurate patient counseling., (Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Falls remain a major geriatric problem, and the search for new solutions continues. We investigated how existing fall prevention technology was experienced within nursing home nurses' environment and workflow. Our NIH-funded study in an American nursing home was followed by a cultural learning exchange with a Dutch nursing home. We constructed two case reports from interview and observational data and compared the magnitude of falls, safety cultures, and technology characteristics and effectiveness. Falls were a high-magnitude problem at the US site, with a collectively vigilant safety culture attending to non-directional audible alarms; falls were a low-magnitude problem at the NL site which employed customizable, infrared sensors that directed text alerts to assigned staff members' mobile devices in patient-centered care culture. Across cases, 1) a coordinated communication system was essential in facilitating effective fall prevention alert response, and 2) nursing home safety culture is tightly associated with the chosen technological system., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To examine the association between long-term metformin therapy and serum vitamin B12 monitoring., Design: Retrospective cohort study., Setting: A single Veterans Affairs Medical Center (VAMC), 2002-2012., Participants: Veterans 50 years or older with either type 2 diabetes and long-term metformin therapy (n = 3,687) or without diabetes and no prescription for metformin (n = 13,258)., Measurements: We determined diabetes status from outpatient visits, and defined long-term metformin therapy as a prescription ≥500 mg/d for at least six consecutive months. We estimated the proportion of participants who received a serum B12 test and used multivariable logistic regression, stratified by age, to evaluate the association between metformin use and serum B12 testing., Results: Only 37% of older adults with diabetes receiving metformin were tested for vitamin B12 status after long-term metformin prescription. The mean B12 concentration was significantly lower in the metformin-exposed group (439.2 pg/dL) compared to those without diabetes (522.4 pg/dL) (P = .0015). About 7% of persons with diabetes receiving metformin were vitamin B12 deficient (<170 pg/dL) compared to 3% of persons without diabetes or metformin use (P = .0001). Depending on their age, metformin users were two to three times more likely not to receive vitamin B12 testing compared to those without metformin exposure, after adjusting for sex, race and ethnicity, body mass index, and number of years treated at the VAMC., Conclusion: Long-term metformin therapy is significantly associated with lower serum vitamin B12 concentration, yet those at risk are often not monitored for B12 deficiency. Because metformin is first line therapy for type 2 diabetes, clinical decision support should be considered to promote serum B12 monitoring among long-term metformin users for timely identification of the potential need for B12 replacement., (© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.)

Background and Objectives: Patients with CKD are asked to perform self-management tasks including dietary changes, adhering to medications, avoiding nephrotoxic drugs, and self-monitoring hypertension and diabetes. Given the effect of aging on functional capacity, self-management may be especially challenging for older patients. However, little is known about the specific challenges older adults face maintaining CKD self-management regimens., Design, Setting, Participants, & Measurements: We conducted an exploratory qualitative study designed to understand the relationship among factors facilitating or impeding CKD self-management in older adults. Six focus groups ( n =30) were held in August and September of 2014 with veterans≥70 years old with moderate-to-severe CKD receiving nephrology care at the Atlanta Veterans Affairs Medical Center. Grounded theory with a constant comparative method was used to collect, code, and analyze data., Results: Participants had a mean age (range) of 75.1 (70.1-90.7) years, 60% were black, and 96.7% were men. The central organizing concept that emerged from these data were managing complexity. Participants typically did not have just one chronic condition, CKD, but a number of commonly co-occurring conditions. Recommendations for CKD self-management therefore occurred within a complex regimen of recommendations for managing other diseases. Participants identified overtly discordant treatment recommendations across chronic conditions ( e.g., arthritis and CKD). Prioritization emerged as one effective strategy for managing complexity ( e.g. , focusing on BP control). Some patients arrived at the conclusion that they could group concordant recommendations to simplify their regimens ( e.g. , protein restriction for both gout and CKD)., Conclusions: Among older veterans with moderate-to-severe CKD, multimorbidity presents a major challenge for CKD self-management. Because virtually all older adults with CKD have multimorbidity, an integrated treatment approach that supports self-management across commonly occurring conditions may be necessary to meet the needs of these patients., (Copyright © 2017 by the American Society of Nephrology.)

Objectives: Chronic kidney disease (CKD) almost universally occurs in individuals with other medical problems. However, few studies have described CKD-related multimorbidity using a framework that identifies chronic conditions as concordant (having overlap in treatment goals) versus discordant (having opposing treatment recommendations) and unrelated (having no overlap, but contributing to complexity via different resource requirements)., Design: Retrospective cohort., Setting: Veterans Affairs (VA) Medical Centers., Participants: VA patients (n = 821,334) ages 18-100 years with at least one outpatient visit and incident CKD defined as an estimated glomerular filtration rate <60 mL/min/1.73 m 2 for at least 3 months between January 1, 2005 and December 31, 2008 after excluding prevalent CKD., Measurements: We determined the associations of number of chronic conditions (1, 2, 3, 4, 5, 6 or more) stratified by the presence of one or more discordant/unrelated conditions with mortality, hospitalizations and emergency department (ED) visits., Results: There were 381,187 deaths over 6.8 median years of follow-up. Higher risks of death, hospitalization and ED visits were associated with higher number of chronic conditions, among those with and without discordant/unrelated conditions. However, the magnitudes of the associations were consistently larger when at least one discordant/unrelated condition was present. For example, compared to patients with one concordant condition, patients with six or more concordant conditions had an age-, race- and sex-adjusted hazard ratio (HR) for mortality of 1.72 (95% CI 1.64-1.80) whereas those with six or more conditions, at least one of which was discordant/unrelated, had a HR of 2.05 (2.01-2.09) (P-interaction <0.001)., Conclusions: The presence of one or more discordant/unrelated conditions was associated with increased risk for adverse health outcomes, beyond the effect of multimorbidity., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)