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Background: We previously reported that interventions to optimize medication use reduced adverse drug reactions (ADRs) by 21% and serious ADRs by 36% in older adults. With new evidence, we sought to update the systematic review and meta-analysis. Method: We searched OVID, Cochrane Library, ClinicalTrials.gov and Google Scholar from 30 April 2017–30 April 2023. Included studies had to be randomized controlled trials of older adults (mean age ≥65 years) taking medications that examined the outcome of ADRs. Two authors independently reviewed all citations, extracted relevant data, and assessed studies for potential bias. The outcomes were any and serious ADRs. We performed subgroup analyses by intervention type and setting. Random-effects models were used to combine the results from multiple studies and create summary estimates. Results: Six studies are new to the update, resulting in 19 total studies (15,675 participants). Interventions were pharmacist-led (10 studies), other healthcare professional-led (5 studies), technology based (3 studies), and educational (1 study). The interventions were implemented in various clinical settings, including hospitals, outpatient clinics, long-term care facilities/rehabilitation wards, and community pharmacies. In the pooled analysis, the intervention group participants were 19% less likely to experience an ADR (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.68–0.96) and 32% less likely to experience a serious ADR (OR 0.68, 95% CI 0.48–0.96). We also found that pharmacist-led interventions reduced the risk of any ADR by 35%, compared with 8% for other types of interventions. Conclusion: Interventions significantly and substantially reduced the risk of ADRs and serious ADRs in older adults. Future research should examine whether effectiveness of interventions vary across health care settings to identify those most likely to benefit. Implementation of successful interventions in health care systems may improve medication safety in older patients. [ABSTRACT FROM AUTHOR]

Hip fractures in geriatric patients are associated with substantial morbidity and mortality including postoperative delirium. Few data are available regarding preoperative identification of patients at risk of postoperative delirium before surgical repair of hip fracture. We used the Ultrabrief Two-Item Bedside Test, a proxy for delirium, to identify patients who are likely to have adverse outcomes postoperatively. This prospective pilot study included patients 65 years and older with an acute hip fracture. The questionnaire was administered preoperatively, and patients were followed up for 30 days postoperatively. We enrolled 30 patients, with a mean age of 78 years. The 12 patients with an abnormal test result had a significantly lower body mass index, a trend in descriptive statistics for pulmonary disease, and a higher ASA physical status. In addition, hospital stay following fracture repair was longer for patients with an abnormal test result, although not significantly (mean [SD]=8.8 [4.2] days vs 6.4 [2.0] days, median=8 vs 6 days, log-rank P=.052). A 2-item questionnaire could help identify patients who have sustained hip fracture who are likely to have a longer hospitalization. Future studies are needed to confirm these findings and determine whether interventions can reduce risk. [ABSTRACT FROM AUTHOR]

Osteoporosis and sarcopenia are prevalent in older adults. Trabecular bone score (TBS) is a novel method to evaluate bone microarchitecture, whereas grip strength and gait speed are simple methods to assess muscle strength and function. Few studies have linked the relationship between vitamin D levels (25OHD) with TBS, grip strength, and gait speed in healthy community dwelling adults. We sought to investigate this relationship in older women with osteoporosis and multiple comorbid conditions residing in long-term care (LTC) facilities. We analyzed baseline 25OHD, spine TBS, grip strength, and gait speed in 246 women with osteoporosis who were residents of LTC and enrolled in a randomized controlled clinical trial. On average, participants were 81.6 years old and had a BMI of 26.8 kg/m2. The correlation (r) of 25OHD with spine TBS, grip strength, and gait speed were (r = 0.15; p = 0.0208), (r = − 0.05; p = 0.4686), and (r = 0.19; p = 0.0041), respectively. Each 5 ng/dl increase in 25OHD was associated with an increase of 0.006 in spine TBS and 0.014 m/s in gait speed. After adjusting for covariates, each 5 ng/dl increase in 25OHD was associated with an increase of 0.004 in spine TBS (p = 0.0599) and 0.012 m/s in gait speed (p = 0.0144). In older women residing in LTC facilities, 25OHD was associated with spine TBS and gait speed. The strengths of the associations suggest there may be other factors with a more prominent role in bone microarchitecture, muscle strength, and physical function in this population. Our study found in older women who are residents of long-term care facilities, vitamin D level is associated with bone microarchitecture and mobility performance. • In older women, vitamin D is associated with bone architecture and gait speed. • We did not find association between vitamin D and grip strength in older women. • Factors other than vitamin D may have stronger impact on bone and muscle quality. [ABSTRACT FROM AUTHOR]

To determine the impact of an educational quality improvement initiative on the appropriateness of antibiotic prescribing restricted to uncomplicated cystitis in older noncatheterized nursing home residents. Quality improvement study with randomized assignment. Twenty-five nursing homes in United States were randomized to the intervention or usual care group by strata that included state, urban/rural status, bed size, and geographic separation. A 12-month trial of a low-intensity multifaceted antimicrobial stewardship intervention focused on uncomplicated cystitis in nursing home residents vs usual care. The outcome was the modified Medication Appropriateness Index as assessed by a blinded geriatric clinical pharmacist and consisted of an assessment of antibiotic effectiveness, dosage, drug-drug interactions, and duration. There were 75 cases (0.15/1000 resident days) in intervention and 92 (0.22/1000 resident days) in control groups with a probable cystitis per consensus guidelines. Compared with controls, there was a statistically nonsignificant 21% reduction in the risk of inappropriate antibiotic prescribing (nonzero Medication Appropriateness Index score rate 0.13 vs 0.21/1000 person days; adjusted incident rate ratio 0.79; 95% confidence interval 0.45‒1.38). There was a favorable comparison in inappropriateness of duration (77% vs 89% for intervention vs control groups, respectively; P =.0394). However, the intervention group had more problems with drug-drug interactions than the control group (8% vs 1%, respectively; P =.0463). Similarly, the intervention group had a nonsignificant trend toward more problems with dosage (primarily because of the lack of adjustment for decreased renal function) than the control group (32% vs 25%, respectively; P =.3170). Both groups had similar rates of problems with choice/effectiveness (44% vs 45%; P =.9417). The most common class of antibiotics prescribed inappropriately was quinolones (25% vs 23% for intervention versus control groups, respectively; P =.7057). A low-intensity intervention showed a trend toward improved appropriate antibiotic prescribing in nursing home residents with likely uncomplicated cystitis. Efforts to improve antibiotic prescribing in addition to the low-intensity intervention might include a consultant pharmacist in a nursing home to identify inappropriate prescribing practices. [ABSTRACT FROM AUTHOR]

Background The Figure-of-8-Walk test (F8WT) is a performance measure of the motor skill of walking. Unlike walking speed over a straight path, it captures curved path walking, which is essential to real-world activity, but meaningful cut-points have yet to be developed for the F8WT. Methods A secondary analysis of 421 community-dwelling older adults (mean age 80.7 ± 7.8), who participated in a community-based exercise clinical trial, was performed. Area under receiver operating characteristic curves (AUROCC) were calculated using baseline data, with F8WT performance discriminating different self-reported global mobility and balance dichotomies. Cut-points for the F8WT were chosen to optimize sensitivity and specificity. For validation, F8WT cut-points were applied to postintervention F8WT data. Participants were called monthly for 12 months after intervention completion to record self-reported incident falls, emergency department visits, and hospitalizations; risks of the outcomes were compared between those who performed well and poorly on the F8WT. Results F8WT performance times of ≤9.09 seconds and ≤9.27 seconds can discriminate those with excellent (sensitivity = 0.647; specificity = 0.654) and excellent/very good global mobility (sensitivity = 0.649; specificity = 0.648), respectively. A total number of steps ≤17 on the F8WT can discriminate those with excellent/very good/good global balance (sensitivity = 0.646; specificity = 0.608). Compared to those who performed poorly, those who performed well had a lower incidence of negative outcomes: F8WT time ≤9.09 seconds = 46%–59% lower; F8WT time ≤9.27 seconds = 46%–56% lower; F8WT steps ≤17 = 44%–50% lower. Conclusions Clinicians may consider these preliminary cut-points to aid in their clinical decision making, but further study is needed for definitive recommendations. [ABSTRACT FROM AUTHOR]

Objectives: With the emerging trends, more cluster randomized trials will be conducted in older adults, where facilities are randomized rather than individuals. Similarity of individuals from a facility (intraclass correlation coefficient/ICC) plays a critical role, but not readily available. We document ICCs for measures commonly used in community-dwelling older adults and discuss implications. Method: Secondary analysis of a range of baseline measures from the On the Move cluster randomized trial, whose ICCs were computed using a linear mixed model. Results: Self-reported disability measures related to facility characteristics and sense of community had the greatest ICCs (>0.10), while mobility performance measures had 0.05 to 0.10, and cognitive measure 0.11. Discussion: The ICCs for measures commonly used in older adults are of a sufficient magnitude to have a substantial impact on planned sample size of a study and credibility of results, and should be taken into consideration in study planning and data analysis. [ABSTRACT FROM AUTHOR]

Background: Assessing confidence in walking in older adults is important, as mobility is a critical aspect of independence and function, and self-report provides complementary information to performance-based measures. The modified Gait Efficacy Scale (mGES) is a self-report measure used to examine confidence in walking.Research Question: What are the psychometric properties of the mGES at the item level? Are there opportunities for improvement?Methods: We performed a secondary analysis of baseline data from a cluster randomized trial of 424 community-dwelling older adults and reliability data from 123 participants. We fitted a graded response model to dissect the mGES to the item and individual response level and examined opportunities to improve and possible shorten the mGES. We examined psychometric characteristics such as internal consistency, test-retest reliability and construct validity with respect to other relevant measures.Results: Mobility tasks such as navigating stairs and curbs with separate items for going up and down largely provide the same information on confidence, with downward direction providing slightly more. It may be reasonable to consider removal of walking 1/2 mile, stepping down and/or stair tasks with railings items due to little or duplicate information contributed compared to other items. The shortened scales proposed by removing the above items had similar psychometric properties to mGES.Significance: The mGES has good psychometric properties, but can be potentially shortened to substantially reduce responder burden. The upward direction curb and stairs items can be removed to result in a 7-item scale with virtually no loss of desirable psychometrics. An alternative 3-item version, level surface walking, stepping down curb and climbing up stairs without a railing items, entails only a minimal loss in psychometric properties. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Insomnia, especially difficulty maintaining sleep, is prevalent among older adults and increases the incidence of falls and fractures. Moreover, the drugs used to treat it exacerbate the risk. Yet current therapies fail to address one of its most common causes in older adults: nocturia and its primary contributor, nocturnal polyuria (NP), especially among the majority of individuals without lower urinary tract symptoms (LUTS). Therefore, we examined the factors associated with nocturia in two groups of such older women and the impact of nocturia on sleep. DESIGN: Secondary analysis of two observational studies of bladder function in carefully evaluated healthy older women. SETTING: Academic medical center. PARTICIPANTS: A total of 39 women without LUTS who had adequate fluid intake (ie, >1200 mL urine output/24 h recorded on their diary), normal videourodynamic testing, and normal daytime frequency (≤7 voids). MEASUREMENTS: Voided volumes and sleep duration obtained from subjects' 3‐day voiding diary, and sleep quality from the Center for Epidemiologic Studies Depression Scale. Nighttime excretion of more than 33% of 24‐hour urine volume was considered NP. RESULTS: Overall, 21 of these healthy subjects (54%) awakened at least once nightly to void, and 19 (90%) of them had NP. Compared with those without nocturia, participants with nocturia had shorter duration of the first uninterrupted sleep period (182 ± 100 vs 250 ± 60 min; P =.03), and they reported worse sleep quality. Two factors contributed independently to nocturia: (1) a larger proportion of 24‐hour urine output at night (43.4 ± 7.4% vs 25.4 ± 5.5%; P = <.001) and (2) smaller bladder capacity (484 ± 157 mL vs 608 ± 167 mL; P =.02). CONCLUSIONS: Nocturia, NP, and reduced bladder capacity are very common even in healthy older women without LUTS and are associated with impaired sleep. Thus applying currently available modalities to address both NP and reduced bladder capacity may effectively treat sleep disruption without incurring the complications of sedative‐hypnotics. J Am Geriatr Soc 67:2610–2614, 2019 [ABSTRACT FROM AUTHOR]

[Display omitted] • Exercise intervention targeting motor learning may improve balance in older adults. • Exercise intervention did not change postural control or prefrontal cortex activity. • There were no differences between treatment arms. Improving postural control in older adults is necessary for reducing fall risk, and prefrontal cortex activation may also play a role. We sought to examine the impact of exercise interventions on postural control and prefrontal cortex activation during standing balance tasks. We hypothesized that balance would improve and prefrontal control would be reduced. We assessed a subset of participants enrolled in a randomized trial of two exercise interventions. Both groups completed strength and endurance training and the experimental treatment arm included training on timing and coordination of stepping. Postural control and prefrontal cortex activation were measured during dual-task standing balance tasks before and after the intervention. Eighteen participants in the standard strengthening and mobility training arm and 16 in the timing and coordination training arm were included. We examined pre- to post-intervention changes within each study arm, and compared them between interventions. Results did not show any pre- to post-intervention changes on standing postural control nor prefrontal cortex activation in either arm. In addition, there were no differences between the two intervention arms in either balance or prefrontal activation. While exercise interventions can improve mobility, we do not demonstrate evidence of improved standing balance or prefrontal control in standing. [ABSTRACT FROM AUTHOR]

Body segment parameters (BSPs) such as segment mass, center of mass, and radius of gyration are required in many ergonomic tools and biomechanical models to estimate injury risk, and quantify muscle and joint contact forces. Currently, the full effects of age and obesity have not been taken into account when predicting BSPs. The goal of this study is to quantify the impact of body mass index (BMI) and age on BSPs, in order to provide more representative measures necessary for modeling inputs. A whole body dual energy X-ray absorptiometry (DXA) scan was collected for 280 working men and women with a wide range of BMI and aged 21 to 70 years. Established DXA processing methods were used to determine in-vivo estimates of the mass, center of mass, and radius of gyration for the upper arm, forearm, torso, thigh, and shank for males and females. Regression models were used to determine if age and BMI terms, as well as their interactions, were associated with these BSPs. The variability in BSPs explained by BMI alone ranged from 4 to 51%, and age explained an additional 3–19%. Thus, BMI and age are significant correlates of BSPs, and need to be taken into account when predicting certain BSPs in order to obtain accurate and representative results in biomechanical models. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To establish consensus recommendations for empirical treatment of uncomplicated cystitis with anti‐infectives in noncatheterized older nursing home residents to be implemented in the Improving Outcomes of UTI Management in Long‐Term Care Project (IOU) funded by the Agency for Healthcare Research and Quality. DESIGN: Two‐round modified Delphi survey. PARTICIPANTS: Expert panel of 19 clinical pharmacists. MEASUREMENTS: Comprehensive literature search and development/review/edit of draft survey by the investigative group (one geriatric clinical pharmacist, two geriatric medicine physicians, and one infectious disease physician). The expert panel members rated their agreement with each of 31 recommendations for drugs of choice, dosing medications at various levels of renal function, drug‐drug interactions to avoid, and duration of therapy by sex on a 5‐point Likert scale (1 = strongly disagree to 5 = strongly agree). Consensus agreement was defined as a lower 95% confidence limit of 4.0 or higher for the recommendation‐specific mean score. RESULTS: The response rate was 95% for the first round, and three recommendations achieved consensus (dosing for nitrofurantoin and trimethoprim/sulfamethoxazole in those without chronic kidney disease, and drug‐drug interaction between trimethoprim/sulfamethoxazole and warfarin). In the second round, 90% responded and reached consensus on an additional eight recommendations (two for nitrofurantoin or trimethoprim/sulfamethoxazole as initial drugs of choice, three for dosing ciprofloxacin, nitrofurantoin, and trimethoprim/sulfamethoxazole at various levels of chronic kidney disease, and three drug‐drug interactions to avoid: trimethoprim/sulfamethoxazole with phenytoin and ciprofloxacin with theophylline or with tizanidine). CONCLUSION: An expert panel of clinical pharmacists was able to reach consensus on a set of recommendations for the empirical treatment of cystitis with oral anti‐infective medications in older nursing home residents. The recommendations were incorporated into a treatment algorithm for uncomplicated cystitis in noncatheterized nursing home residents and used in educational materials for health professionals in an ongoing controlled intervention study. J Am Geriatr Soc 67:539–545, 2019. [ABSTRACT FROM AUTHOR]

Background We examined the relationship between global positioning system (GPS) indicators of community mobility and incident hospitalizations, emergency department (ED) visits, and falls over 1-year in community-dwelling older adults. Methods We performed a secondary analysis of a randomized trial investigating a physical therapy intervention to improve mobility in older adults. One hundred and forty-eight participants (mean age: 76.9 ± 6.2 years; 65% female) carried a GPS device following the postintervention visit. Over 1-year, new hospitalizations, falls, and ED visits were reported. GPS indicators of community mobility included the median area and compactness of the standard deviation ellipse (SDE), the median percentage of time spent outside of home (TOH), and median maximum distance from home. Generalized linear models assessed the association between 1-year risk of outcomes and GPS measures adjusted for age, race, gender, body mass index, comorbidity burden, and fall history. Results The mean ± standard deviation of the median SDE area was 4.4 ± 8.5 km2, median SDE compactness 0.7 ± 0.2, median percentage TOH 14.4 ± 12.0%, and median maximum distance from home was 38 ± 253 km. Each 5% increase in median percentage TOH was associated with a 24% lower risk of hospitalization (incident rate ratio = IRR = 0.76, 95%CI: 0.61–0.95; p  = .01). The association persisted after covariate adjustment (IRR = 0.78, 95%CI: 0.63–0.98; p  = .03). No significant associations appeared for any GPS indicators with incident falls or ED visits. Conclusions Increased TOH was associated with a lower risk of incident hospitalization over 1 year among community-dwelling older adults. Restricted community mobility may be an indicator of activity limitations related to future health outcomes, but further study is warranted. [ABSTRACT FROM AUTHOR]

Objectives: To establish the prevalence of sarcopenia in a long‐term care population, assess agreement among different consensus sarcopenia diagnostic criteria, and examine agreement of a self‐reported questionnaire with consensus guidelines. Design: Cross‐sectional secondary analysis. Setting: Long‐term care communities in the greater Pittsburgh, Pennsylvania, area. Participants: Women aged 65 and older (mean 83.6) undergoing eligibility screening for a fracture reduction trial (N = 141). Measurements: We measured appendicular lean muscle mass using dual‐energy X‐ray absorptiometry. Hand grip strength and usual gait speed were also evaluated. Sarcopenia status was determined according to European Working Group on Sarcopenia in Older People (EWGSOP) and the Foundation for the National Institutes of Health (FNIH) Sarcopenia Project criteria and the SARC‐F questionnaire. Results: Eleven participants were sarcopenic (7.8%) according to the EWGSOP criteria, six (4.3%) according to FNIH conservative cut‐point guidelines, and 32.6% (n = 46) according to FNIH intermediate cut‐points. Only 2 of 141 participants met criteria for sarcopenia according to all three guidelines. Sarcopenia was identified in 30 (21.3%) participants according to the SARC‐F questionnaire. Sensitivity of the SARC‐F with consensus panel definitions ranged from 18.2% to 33.3%. Specificity ranged from 78.7% to 81.1%. Conclusion: Current consensus criteria from the EWGSOP and FNIH Sarcopenia Project do not agree and have little overlap in older female long‐term care residents. The SARC‐F questionnaire is a simple tool that could be implemented in long‐term care, but it has low sensitivity compared with current consensus guidelines in the identification of sarcopenic individuals. [ABSTRACT FROM AUTHOR]

Objectives To determine whether proinflammatory biomarkers are associated with frailty assessed according to functional status, mobility, mental health, and falls over 24 months. Design Secondary analysis of a 2-year double-blind clinical trial for osteoporosis. Setting Nursing homes and assisted living facilities. Participants Women aged 65 and older with osteoporosis in long-term care ( LTC) (N = 178). Measurements Baseline serum concentrations of proinflammatory cytokines and soluble receptors (high sensitivity C-reactive protein (hs- CRP), tumor necrosis factor alpha ( TNF α) and its two receptors ( TNF α-R1 and TNF α-R2), interleukin-6 ( IL-6), soluble IL-6 receptor ( sIL-6R), IL-10), functional status assessed according to activities of daily living, the Nursing Home Physical Performance Test, gait speed, cognitive status, mental health, and falls. Results At baseline, older age was moderately associated with higher serum concentrations of hs- CRP (correlation coefficient ( r) = 0.22), TNF α-R1 ( r = 0.36), TNF α-R2 ( r = 0.34), and IL-10 ( r = 0.16) (all P < .05). Frail participants had significantly higher hs- CRP, TNF α-R1, TNF α-R2, IL-6, and IL-6- sR levels (all P < .05) than those nonfrail participants. Higher baseline hs- CRP and IL-6 levels were associated with worse physical performance and gait speed at 12 months independent of age, zoledronic acid use, and comorbidity (| r| = 0.25-0.30; all P < .05). Inflammatory markers were not significantly associated with incident falls. Conclusions Higher proinflammatory biomarker levels are associated with frailty and poorer function and mobility in older women residing in LTC facilities. [ABSTRACT FROM AUTHOR]

Objective The authors compared the effects of a standard strength and endurance intervention with a standard plus timing and coordination training intervention on community mobility measured using global positioning systems (GPS) among community-dwelling older adults in this secondary analysis of a randomized controlled trial. Methods Participants were randomized to a standard or a standard plus timing and coordination training program. Community mobility was measured using the Life Space Assessment (LSA) and GPS indicators of community mobility at baseline, as well as at 12 (immediately after the intervention), 24, and 36 weeks. Linear mixed models were used for analysis. Results There were 166 participants with GPS data at baseline, including 81 in the standard plus group and 85 in the standard group. The groups did not differ in participant characteristics or GPS measures at baseline. There were no significant within-group changes in GPS indicators of community mobility or LSA score over time, nor between-group differences of the same. Conclusion There were no significant changes in community mobility with either intervention or between-intervention differences. These findings suggest that interventions targeting physical function alone may not be sufficient to improve community mobility or participation in older adults. Future research should focus on the development of multifaceted interventions targeted to improve real-world participation. Impact The studied interventions did not significantly change community mobility measured using GPS-derived community mobility measures or self-report measures in older adults, suggesting that more comprehensive interventions may be needed to target improvements in community mobility. [ABSTRACT FROM AUTHOR]

Objectives To examine the effect of self-reported daytime sleepiness on performance-based balance measures and self-reported balance confidence in community-dwelling older adults. Design Cross-sectional secondary analysis of an observational cohort study designed to develop and refine measures of balance and mobility in community-dwelling older adults. Setting Community. Participants Older adults (aged 78.2 ± 5.9) (n = 120). Measurements The performance-based gait and balance measures included gait speed, double support time, and step width. Narrow walk, obstacle walk, and timed standing balance were also assessed. The Activities-Specific Balance Confidence Scale was included as a self-reported measure. Daytime sleepiness was defined as an Epworth Sleepiness Scale score of 9 or greater. Body mass index, fall-related comorbidities, and use of central nervous system ( CNS) medications were considered as covariates. Results Forty-five percent of participants reported daytime sleepiness. Participants reporting daytime sleepiness differed significantly from those without in gait speed (adjusted difference (standard error ( SE)) −0.09 (0.04) m/s, P = .03), step width (adjusted difference ( SE) 0.02 (0.01), P = .03), and self-reported balance confidence (adjusted difference ( SE) −1.02 (0.38), P = .01) even after adjusting for covariates. Two-way analysis of variance of CNS medication use and daytime sleepiness showed no significant interaction effects. Conclusion Self-reported daytime sleepiness is associated with slower gait speed and poor balance confidence in community-dwelling older adults. Subjective sleep assessment should be considered when assessing balance and implementing interventions for improving balance in older adults. Further study is needed to examine the role of CNS medication use. [ABSTRACT FROM AUTHOR]

Background Group exercise programs for older adults often exclude the timing and coordination of movement. Stakeholder involvement in the research process is strongly encouraged and improves the relevance and adoption of findings. We describe stakeholder involvement in the design of a clinical trial of a group-based exercise program that incorporates timing and coordination of movement into the exercises. Methods The study was a cluster randomized, single-blind intervention trial to compare the effects on function, disability and mobility of a standard group exercise program and the “ On the Move ” group exercise program in older adults residing in independent living facilities and senior apartment buildings, and attending community centers. Exercise classes were twice weekly for 12 weeks delivered by study exercise leaders and facility activity staff personnel. Outcomes The primary outcomes function, disability and mobility were assessed at baseline and post-intervention. Function and disability were assessed using the Late Life Function and Disability Instrument, and mobility using the Six-Minute Walk Test and gait speed. Stakeholders Patient and provider stakeholders had significant input into the study aims, design, sample, intervention, outcomes and operational considerations. Summary A community-based exercise program to improve walking can be developed to address both investigator identified missing components in current exercise to improve walking and stakeholder defined needs and interest for the activity program. Involvement of stakeholders substantially improves the relevance of research questions, increases the transparency of research activities and may accelerate the adoption of research into practice. [ABSTRACT FROM AUTHOR]

Objective to examine whether psychomotor speed predicts individual and combined disorders in cognition, mobility and mood and if white matter hyperintensities explain these associations. Design and setting longitudinal; Cardiovascular Health Study. Subjects 5,888 participants (57.6% women, 15.7% black, 75.1 (5.5), mean years (SD)). Methods psychomotor speed (Digit Symbol Substitution Test (DSST)) and small vessel disease (white matter hyperintensities (WMH)) were measured in 1992-94. Global cognition (Modified Mini-Mental State (3MS) examination), mobility (gait speed (GS)) and mood (Center for Epidemiologic Studies Depression (CES-D) scale) were measured annually over 5 years and classified as clinical, subclinical or no disorders based on established values (3MS: 80 and 85 points; GS: 0.6 and 1.0 m/s; CES-D: 10 and 5 points). Analyses were adjusted for demographics, baseline status, education, diabetes, hypertension, ankle--arm index. Results among those with no disorder in cognition, mobility and mood (N = 619) in 1992-94, being in the lowest DSST quartile compared to the highest was associated with nearly twice the odds of developing 1+ clinical or subclinical disorders (N = 413) during follow-up. Associations were stronger for incident clinical disorders in cognition (OR: 8.44, p < 0.01) or mobility (OR: 9.09, p < 0.05) than for mood (OR: 1.88, p < 0.10). Results were similar after adjustment for WMH. Conclusions slower psychomotor speed may serve as a biomarker of risk of clinical disorders of cognition, mobility and mood. While in part attributable to vascular brain disease, other potentially modifiable contributors may be present. Further studying the causes of psychomotor slowing with ageing might provide novel insights into age-related brain disorders. [ABSTRACT FROM AUTHOR]

Gait variability is a marker of gait performance and future mobility status in older adults. Reliability of gait variability has been examined mainly in community dwelling older adults who are likely to fluctuate over time. The purpose of this study was to compare test-retest reliability and determine minimal detectable change (MDC) of spatial and temporal gait variability in younger and older adults. Forty younger (mean age=26.6 ± 6.0 years) and 46 older adults (mean age=78.1 ± 6.2 years) were included in the study. Gait characteristics were measured twice, approximately 1 week apart, using a computerized walkway (GaitMat II). Participants completed 4 passes on the GaitMat II at their self-selected walking speed. Test-retest reliability was calculated using Intra-class correlation coefficients (ICCs(2,1)), 95% limits of agreement (95% LoA) in conjunction with Bland-Altman plots, relative limits of agreement (LoA%) and standard error of measurement (SEM). The MDC at 90% and 95% level were also calculated. ICCs of gait variability ranged 0.26-0.65 in younger and 0.28-0.74 in older adults. The LoA% and SEM were consistently higher (i.e. less reliable) for all gait variables in older compared to younger adults except SEM for step width. The MDC was consistently larger for all gait variables in older compared to younger adults except step width. ICCs were of limited utility due to restricted ranges in younger adults. Based on absolute reliability measures and MDC, younger had greater test-retest reliability and smaller MDC of spatial and temporal gait variability compared to older adults. [ABSTRACT FROM AUTHOR]

Background: Functional independence with aging is an important goal for individuals and society. Simple prognostic indicators can inform health promotion and care planning, but evidence is limited by heterogeneity in measures of function.Methods: We performed a pooled analysis of data from seven studies of 27,220 community-dwelling older adults aged 65 or older with baseline gait speed, followed for disability and mortality. Outcomes were incident inability or dependence on another person in bathing or dressing; and difficulty walking ¼ - ½ mile or climbing 10 steps within 3 years.Results: Participants with faster baseline gait had lower rates of incident disability. In subgroups (defined by 0.2 m/s-wide intervals from <0.4 to ≥ 1.4 m/s) with increasingly greater gait speed, 3-year rates of bathing or dressing dependence trended from 10% to 1% in men, and from 15% to 1% in women, while mobility difficulty trended from 47% to 4% in men and 40% to 6% in women. The age-adjusted relative risk ratio per 0.1 m/s greater speed for bathing or dressing dependence in men was 0.68 (0.57-0.81) and in women: 0.74 (0.66-0.82); for mobility difficulty, men: 0.75 (0.68-0.82), women: 0.73 (0.67-0.80). Results were similar for combined disability and mortality. Effects were largely consistent across subgroups based on age, gender, race, body mass index, prior hospitalization, and selected chronic conditions. In the presence of multiple other risk factors for disability, gait speed significantly increased the area under the receiver operator characteristic curve.Conclusion: In older adults, gait speed predicts 3 year incidence of bathing or dressing dependence, mobility difficulty, and a composite outcome of disability and mortality. [ABSTRACT FROM AUTHOR]

Background: Despite wide-spread use of antihypertensives in older adults, the literature is unclear about their association with incident recurrent falls over time.Methods: Health, Aging and Body Composition study participants (n = 2,948) who were well functioning at baseline (1997) were followed to Year 7 (2004). The main outcome was recurrent falls (≥2) in the ensuing 12 months. Antihypertensive use was examined as: (a) any versus none, (b) long- versus short-term (≥2 vs <2 years), and by (c) summated standardized daily dose (SDD; 1 = maximum recommended daily dose for one antihypertensive), and (d) subclass.Results: Controlling for potential demographic, health status/behavior and access to care confounders, we found no increase in risk of recurrent falls in antihypertensive users compared to nonusers (adjusted odds ratio [AOR] = 1.13; 95% CI = 0.88-1.46), or those taking higher SDDs or for longer durations. Only those using a loop diuretic were found to have a modest increased risk of recurrent falls (AOR = 1.50; 95% CI = 1.11-2.03).Conclusions: Antihypertensive use overall was not statistically significantly associated with recurrent falls after adjusting for important confounders. Loop diuretic use may be associated with recurrent falls and needs further study. [ABSTRACT FROM AUTHOR]

Objectives To determine whether a clinical surveillance system could be used to detect drug-associated hypoglycemia events and determine their incidence in nursing home ( NH) residents. Design Retrospective cohort. Setting Four NHs in western Pennsylvania. Participants Any resident of the four NHs who had a computer-generated alert detecting potential drug-associated hypoglycemia over a 6-month period were included. Measurements Descriptive statistics were used to summarize all variables, including the frequency and distribution of alert type according to glucose threshold. Analyses were conducted according to numbers of alerts and residents. The medications associated with the drug-associated hypoglycemia alerts were identified, and frequency of their inclusion in alerts was calculated. Additional calculations included time to drug-associated hypoglycemic event alert from date of admission and frequency of events associated with postacute, short-stay (≤35 days) admissions. Results Seven hundred seventy-two alerts involving 141 residents were detected. Ninety (63.8%) residents had a glucose level of 55 mg/dL or less, and 42 (29.8%) had a glucose level of 40 mg/dL or less. Insulin orders were associated with 762 (98.7%) alerts. Overall incidence of drug-associated hypoglycemia events was 9.5 per 1,000 resident-days. Conclusion Hypoglycemia can be detected using a clinical surveillance system. This evaluation found a high incidence of drug-associated hypoglycemia in a general NH population. Future studies are needed to determine the potential benefits of use of a surveillance system in real-time detection and management of hypoglycemia in NHs. [ABSTRACT FROM AUTHOR]

Objectives To examine the association between statin use and objectively assessed decline in gait speed in community-dwelling older adults. Design Longitudinal cohort study. Setting Health, Aging and Body Composition (Health ABC) Study. Participants Two thousand five participants aged 70-79 at baseline with medication and gait speed data at 1998-99, 1999-2000, 2001-02, and 2002-03. Measurements The independent variables were any statin use and their standardized daily doses (low, moderate, high) and lipophilicity. The primary outcome measure was decline in gait speed of 0.1 m/s or more in the following year of statin use. Multivariable generalized estimating equations were used, adjusting for demographic characteristics, health-related behaviors, health status, and access to health care. Results Statin use increased from 16.2% in 1998-99 to 25.6% in 2002-03. The overall proportions of those with decline in gait speed of 0.1 m/s or more increased from 22.2% in 1998 to 23.9% in 2003. Statin use was not associated with decline in gait speed of 0.1 m/s or more (adjusted odds ratio ( AOR) = 0.90, 95% confidence interval ( CI) = 0.77-1.06). Similar nonsignificant trends were also seen with the use of hydrophilic or lipophilic statins. Users of low-dose statins were found to have a 22% lower risk of decline in gait speed than nonusers ( AOR = 0.78, 95% CI = 0.61-0.99), which was mainly driven by the results from 1999-2000 follow-up. Conclusion These results suggest that statin use did not increase decline in gait speed in community-dwelling older adults. [ABSTRACT FROM AUTHOR]

Objectives To examine the relationship between serum biomarkers and self-reported pain intensity and pain-related function, in addition to the contribution of magnetic resonance imaging ( MRI) findings of lumbar spine degenerative changes, in older adults with chronic low back pain. Design Single-center cross-sectional cohort study. Setting Academic medical center. Participants Individuals aged 60 and older with axial low back pain without radiculopathy or previously diagnosed osteoarthritis of the knee or hip or pain outside the low back that is more severe than the back pain (n = 43). Measurements To examine pain-related impairment, pain was measured on a pain thermometer and the McGill Pain Questionnaire Short Form was administered. To examine pain-related function or activity limitation, the Roland Morris Disability Questionnaire, Short Physical Performance Battery ( SPPB), and repetitive trunk rotation were used. Single plasma samples were obtained before and after physical performance tests and analyzed for inflammatory markers (E-selectin and regulated on activation, normal T cell expressed and secreted ( RANTES)), inhibitors of catabolic enzymes (tissue inhibitor of metalloproteinases-1 ( TIMP-1)), markers of matrix turnover (C- telopeptide of type II collagen ( CTX- II) and aggrecan chondroitin sulfate 846 ( CS846)), and stress biomarkers (neuropeptide Y ( NPY)). Conventional nongadolinium lumbar MRI was performed and analyzed quantitatively and clinically. Results Composite MRI measurements did not show significant correlation with pain or pain-related function. Basal levels and changes in serum biomarkers in response to activity, particularly NPY and RANTES, demonstrated associations with pain and pain-related function in addition to the explanatory power of MRI-based results. Conclusion Serum biomarkers may be a metric for assessment of active disease in older adults, in whom imaging changes are ubiquitous. In addition, changing levels of biomarkers in response to activity suggests that they may be useful as metrics to measure treatment responses in future studies and may reflect potential targets for use in designing personalized treatment for older adults with low back pain. [ABSTRACT FROM AUTHOR]

Background. Meaningful change criteria help determine if function has improved or declined, but their magnitudes may vary across clinically relevant subgroups. We estimate meaningful decline in four common measures of physical performance in subgroups of older adults based on initial performance, demographics, chronic conditions, and health status. Methods. We used baseline (Year 1) and Year 4 data from the Health, Aging and Body Composition (Health ABC) study, a well-functioning cohort at baseline of white and black men and women (age 70–79), to evaluate the magnitude of meaningful decline in performance (6 m gait speed, 400-m walk time (400MWT), Short Physical Performance Battery, and Health ABC Physical Performance Battery (PPB), based on self-reported perceived mobility anchors (climbing 10 steps and walking ¼ mile). Estimates were stratified by initial performance, demographics, health status, chronic conditions, and body mass index, and compared across strata. Results. For all four measures, small and substantial decline estimates were generally consistent among subgroups based on initial performance, demographics, health status, and chronic conditions. The only exception was for 400MWT, where men had greater estimates than women. For PPB, small change was 0.12 points, and substantial change was 0.22 points. Conclusions. Estimates of small and substantial meaningful decline resemble those previously reported for gait speed, 400MWT, and SPPB. Magnitudes of meaningful performance decline appear to be generally consistent across strata of initial performance, demographics, health status, body mass index, and chronic conditions. [ABSTRACT FROM PUBLISHER]

Objectives. Both diabetes mellitus (DM) and osteoporosis are very common in older adults who reside in long-term care (LTC) facilities. Nevertheless, few studies have examined the relationship between diabetes and bone quality in this population. The purpose of this study is to determine if bone mineral density (BMD) or trabecular bone score (TBS) is a better measure of bone quality and skeletal health, in LTC residents with and without a history of DM. Methodology. In this longitudinal cohort study, we examined baseline BMD (lumbar spine, total hip, and femoral neck), TBS, DM, and functional status in 511 LTC residents who were enrolled in two ongoing randomized placebo-controlled osteoporosis clinical trials. Results. On average, participants were older than 80 years and majority were prefrail or frail. Women with DM had greater lumbar spine BMD (1.106 vs 1.017, adjusted difference ± standard error = 0.084 ± 0.023 g/cm2, p = 0.0003) and femoral neck BMD (0.695 vs 0.651, 0.027 ± 0.013 g/cm2, p = 0.0463), but lesser lumbar spine TBS (1.211 vs 1.266, −0.036 ± 0.016, p = 0.0299) compared to women without DM. Total hip BMD was also higher based on descriptive statistics (0.780 vs 0.734, p = 0.6255) in diabetic women, although the difference was not statistically significant. Men had similar but attenuated findings. Conclusions. Among LTC residents, those with DM have greater BMD but lower bone quality measured by TBS. TBS should be considered in assessing older patients with DM. However, further studies are required to confirm the findings with respect to fractures. [ABSTRACT FROM AUTHOR]

Abstract: Stair negotiation is a key marker for independence among older adults; however, clinically meaningful change has not been established. Our objective was to establish the values of clinically meaningful change in stair negotiation time using distribution- and anchor-based approaches. Study participants were 371 community residing older adults (age≥70) in the Einstein Aging Study with time to ascend and descend 3 steps measured at baseline and at one-year follow-up. Anchor-based estimates were obtained using functional decline (defined as one-point increment in disability score) and change in self-reported walking ability over the one-year follow-up period. Small, moderate, and large meaningful change estimates were 0.28, 0.71, and 1.15s for stair ascent time (0.31, 0.78, and 1.25s for stair descent time) using the distribution-based approach of effect size. The estimates of meaningful decline range from 0.47 to 0.53s for stair ascent time (0.33–0.53s for stair descent time) using the anchor-based approach. The estimates of meaningful improvement were smaller (0.13–0.18s for stair ascent, 0.06–0.15 for stair descent) compared to those for decline. Based on general consistency between distribution- and anchor-based approaches, preliminary criteria suggested for stair negotiation time is 0.5s for meaningful decline and 0.2s for meaningful improvement. [Copyright &y& Elsevier]

Objectives To examine screening strategies for osteoporosis and fractures for treatment of long-term care residents. Design Cross-sectional analysis to examine screening strategies for treatment. Setting Assisted living and skilled care facilities. Participants Two hundred two frail women aged 65 and older (mean 85), excluding those receiving bisphosphonates. Measurements Clinical fractures of the hip or spine (Clin Fx); Clin Fx or bone mineral density ( BMD); Clin Fx, BMD, or vertebral fractures ( VF) assessed according to dual-energy X-ray absorptiometry-based vertebral fracture assessments; fracture risk algorithm using femoral neck BMD ( FRAX- FN); fracture risk algorithm using body mass index ( FRAX- BMI); or Clin Fx or heel ultrasound (heel US). Results Treatment eligibility ranged from 17% (Clin Fx) to 98% ( FRAX- BMI). VFs were found in 47%, 74% of which were silent. Criteria with Clin Fx, BMD, or VF identified 73% of study participants for treatment. FRAX- FN suggested treatment in 81% but would have missed approximately 10% of individuals with silent VFs. Clin Fx or heel US suggested that 39% of participants were eligible for treatment. Conclusion Long-term care residents eligible for osteoporosis treatment ranged from fewer than 20% to roughly all residents depending on screening criteria. VFs are common and identify a subset of residents missed by conventional BMD scans or FRAX- FN. A reasonable clinical approach could consider treatment for those with Clin Fx of the hip or spine, radiological evidence of a VF, or osteoporosis according to BMD classification. Prospective studies are needed to determine optimal screening strategies for treatment in this cohort. [ABSTRACT FROM AUTHOR]

Background. Aging in humans is characterized by a progressive loss of muscle mass and strength known as sarcopenia. Although considered to be a normal aspect of aging, the loss of strength can have significant effects on the health, functioning, and independence of elderly individuals. Although these aspects of sarcopenia have been well studied, the molecular mechanisms leading to its development are still unclear. The nematode Caenorhabditis elegans might be a novel animal model for sarcopenia as worms experience sarcopenia during aging and mutations affecting the daf-2/insulin-like signaling pathway are able to delay this process. Methods. Via the use of RNA interference, we screened a total of 43 genes, most of which have been shown to be required for the enhanced longevity of daf-2 mutants, to assess for the effects of these genes on muscle function and worm mobility during aging. Results. We identified 17 novel genes that are essential for the delay in the onset of sarcopenia in daf-2 mutants. The identified genes include splicing factors, vacuolar sorting proteins, transcription factors, and metabolic enzymes. Using a transgenic strain that only responds to RNA interference in the body wall muscle, we also found that most of the identified genes act in muscle to prevent the onset of sarcopenia. Conclusions. Our results demonstrate that at least in worms, specific genetic pathways that modify the development of sarcopenia can be identified. Interestingly, almost all the identified genes also have a known human homolog, and hence, our findings may offer significant leads toward the identification of genes involved in sarcopenia in people. [ABSTRACT FROM PUBLISHER]

Abstract: Background: Everyday ambulation requires navigation of variable terrain, transitions from wide to narrow pathways, and avoiding obstacles. While the effect of age on the transition to a narrow path has been examined briefly, little is known about the impact of fear of falling on gait during the transition to a narrow path. The purpose was to examine the effect of age and fear of falling on gait during transition to a narrow path. Methods: In 31 young, mean age=25.3 years, and 30 older adults, mean age=79.6 years, step length, step time, step width and gait speed were examined during usual and transition to narrow pathway using an instrumented walkway. Findings: During the transition to narrow walk condition, fearful older adults compared to young had a wider step width (0.06m vs 0.04m) prior to the narrow path and took shorter steps (0.53m vs 0.72m; p <0.001). Compared to non-fearful older adults, fearful older adults walked slower and took shorter steps during narrow path walking (gait speed: 1.1m/s vs 0.82m/s; p =0.01; step length: 0.60m vs 0.47m; p =0.03). In young and non-fearful older adults narrow path gait was similar to usual gait. Whereas older adults who were fearful, walked slower (0.82m/s vs 0.91m/s; p =0.001) and took shorter steps (0.44m vs 0.53m; p =0.004) during narrow path walking compared to usual walking. Interpretation: Changes in gait characteristics with transitioning to a narrow pathway were greater for fear of falling than for age. [Copyright &y& Elsevier]

Background. Mobility often is tested under a low challenge condition (ie, over a straight, uncluttered path), which often fails to identify early mobility difficulty. Tests of walking during challenging conditions may uncover mobility difficulty that is not identified with usual gait testing. Objective. The purpose of this study was to determine whether gait during challenging conditions predicts decline in gait speed over 1 year in older people with apparently normal gait (ie, gait speed of ≥ 1.0 m/s). Design. This was a prospective cohort study. Methods. Seventy-one older adults (mean age=75.9 years) with a usual gait speed of ≥1.0 m/s participated. Gait was tested at baseline under 4 challenging conditions: (1) narrow walk (15 cm wide), (2) stepping over obstacles (15.24 cm [6 in] and 30.48 cm [12 in]), (3) simple walking while talking (WWT), and (4) complex WWT. Usual gait speed was recorded over a 4-m course at baseline and 1 year later. A 1-year change in gait speed was calculated, and participants were classified as declined (decreased ≥ 0.10 m/s, n=18), stable (changed <0.10 m/s, n=43), or improved (increased ≥0.10 m/s, n=10). Analysis of variance was used to compare challenging condition cost (usual -- challenging condition gait speed difference) among the 3 groups. Results. Participants who declined in the ensuing year had a greater narrow walk and obstacle walk cost than those who were stable or who improved in gait speed (narrow walk cost=0.43 versus 0.33 versus 0.22 m/s and obstacle walk cost=0.35 versus 0.26 versus 0.13 m/s). Simple and complex WWT cost did not differ among the groups. Limitations. The participants who declined in gait speed over time walked the fastest, and those who improved walked the slowest at baseline; thus, the potential contribution of regression to the mean to the findings should not be overlooked. Conclusions. In older adults with apparently normal gait, the assessment of gait during challenging conditions appears to uncover mobility difficulty that is not identified by usual gait testing. [ABSTRACT FROM AUTHOR]

Background. Definitive evidence that exercise interventions that improve gait also reduce disability is lacking. A task-oriented, motor sequence learning exercise intervention has been shown to reduce the energy cost of walking and improve gait speed, but whether the intervention also improves activity and participation has not been demonstrated. Objective. The objective of this study was to compare the impact of a task-oriented, motor sequence learning exercise (TO) intervention and the impact of an impairment-oriented, multi-component exercise (IO) intervention on activity and participation outcomes in older adults with mobility limitations. The mediating effects of a change in the energy cost of walking on changes in activity and participation also were determined. Design. This study was a single-blind, randomized controlled trial. Setting. The study was conducted in an ambulatory clinical research training center. Participants. The study participants were 47 older adults (mean age=77.2 years, SD=5.5) with slow and variable gait. Intervention. The intervention was a 12-week, physical therapist-guided program of TO or IO. Measurements. Measures of activity (gait speed over an instrumented walkway; daily physical activity measured with an accelerometer; confidence in walking determined with the Gait Efficacy Scale; and physical function determined with the total, basic lower-extremity, and advanced lower-extremity components of the Late-Life Function and Disability Instrument [Late-Life FDI]) and participation (disability limitation dimension and instrumental role [home and community task performance] domain components of the Late-Life FDI) were recorded before and after the intervention. The energy cost of walking was determined from the rate of oxygen consumption during self-paced treadmill walking at the physiological steady state standardized by walking speed. An adjusted comparison of activity and participation outcomes in the treatment arms was made by use of an analysis of covariance model, with baseline and change in energy cost of walking added to the model to test for mediation. Tests were used to determine the significance of the mediating effects. Results. Activity improved in TO but not in IO for confidence in walking (Gait Efficacy Scale; mean adjusted difference=9.8 [SD=3.5]) and physical function (Late-Life FDI basic lower-extremity component; mean adjusted difference=3.5 [SD=1.7]). Improvements in TO were marginally greater than those in IO for gait speed, physical activity, and total physical function. Participation improved marginally more in TO than in IO for disability limitations and instrumental role. Limitations. The older adults were randomized to the intervention group, but differences in baseline measures had to be accounted for in the analyses. Conclusions. A TO intervention that improved gait also led to improvements in some activity and participation outcomes in older adults with mobility limitations. [ABSTRACT FROM AUTHOR]

Objective. To examine the prevalence and correlates of non-opioid and opioid analgesic use and descriptively evaluate potential undertreatment in a sample of community-dwelling elders with symptomatic knee and/or hip osteoarthritis (OA). Design. Cross-sectional. Setting. Health, Aging, and Body Composition Study. Patients. Six hundred and fifty-two participants attending the year 6 visit (2002-03) with symptomatic knee and/or hip OA. Outcome Measures. Analgesic use was defined as taking ≥1 non-opioid and/or ≥1 opioid receptor agonist. Non-opioid and opioid doses were standardized across all agents by dividing the daily dose used by the minimum effective analgesic daily dose. Inadequate pain control was defined as severe/extreme OA pain in the past 30 days from a modified Western Ontario and McMaster Universities Osteoarthritis Index. Results. Just over half (51.4%) reported taking at least one non-opioid analgesic and approximately 10% was taking an opioid, most (88.5%) of whom also took a non-opioid. One in five participants (19.3%) had inadequate pain control, 39% of whom were using <1 standardized daily dose of either a non-opioid or opioid analgesic. In adjusted analyses, severe/extreme OA pain was significantly associated with both non-opioid (adjusted odds ratio [AOR] = 2.44; 95% confidence interval [95% CI] = 1.49-3.99) and opioid (AOR = 2.64; 95% CI = 1.26-5.53) use. Conclusions. Although older adults with severe/extreme knee and/or hip OA pain are more likely to take analgesics than those with less severe pain, a sizable proportion takes less than therapeutic doses and thus may be undertreated. Further research is needed to examine barriers to optimal analgesic use. [ABSTRACT FROM AUTHOR]

Introduction and Rationale: Influenza and pneumonia remain serious health concerns for long-term care (LTC) residents. Vaccination of LTC residents and health care workers are reasonable preventive strategies, although most facilities fall short of Healthy People 2010 goals. Improving immunization rates across multiple LTC facilities remains an elusive challenge. This quality improvement study sought to improve immunization rates across 6 LTC facilities and identify persistent barriers to better performance. Methods: In 2002, 6 facilities associated with the University of Pittsburgh Institute on Aging established a quality improvement network addressing immunization rates. The facilities were provided with a written educational toolkit and shared information through an e-mail distribution list. To help determine optimal program structure in future years, 3 of the facilities participated in a single half-day collaborative training session. Change in immunization rates from baseline to year 2 were compared between those participating in the collaborative training and those not participating. Barriers to improved performance were sought from all groups through focus group analysis. Results: Facilities participating in the single collaborative training program improved immunization rates modestly, whereas facilities not participating in the collaborative training saw decreases in immunization rates. Staff turnover was cited as a significant barrier to improved performance. Discussion: It may be possible to improve immunization rates in LTC facilities, at least modestly, using a collaborative training process. Staff turnover may be an important barrier to improved LTC immunization rates. [Copyright &y& Elsevier]

Background. Striatal dopamine activity declines with normal aging. Age-related striatal dopaminergic denervation (SDD) has been implicated in standing balance and unperturbed gait. The goal of this study was to analyze the association between the degree of SDD and the magnitude of an unexpected slip perturbation induced during gait. Methods. Fifty healthy participants aged 20–86 years old underwent dopamine transporter positron emission tomography to classify SDD severity as mild, moderate, or severe. Participants also walked on a floor that was unexpectedly contaminated with a glycerol solution for gait testing. The magnitude of a slip was quantified using the peak slip velocity (PSV), measured at the slipping foot. Data were analyzed for both fast (greater than 1.2 m/s) and slow walkers as gait speed correlated with slip severity. All data analyses were age adjusted. Results. Greater severity of dopaminergic denervation in the caudate nucleus was correlated with higher PSV (p < .01) but only in the fast speed walking group. The relationship between SDD in the putamen and slip severity was not statistically significant in fast and slow walkers. Conclusions. Age-related SDD may impact the ability to recover from large perturbations during walking in individuals who typically walk fast. This effect, prominent in the caudate nucleus, may implicate a role of cognitive frontostriatal pathways in the executive control of gait when balance is challenged by large perturbations. Finally, a cautious gait behavior present in slow walkers may explain the apparent lack of involvement of striatal dopaminergic pathways in postural responses to slips. [ABSTRACT FROM PUBLISHER]

To assess whether the Timed Up and Go (TUG) is superior to gait speed in predicting multiple geriatric outcomes. Prospective cohort study. Medicare health maintenance organization and Veterans Affairs primary care clinics. Adults aged 65 and older (N=457). Baseline gait speed and TUG were used to predict health decline according to EuroQol and Medical Outcomes Study 36-item Short Form Survey (SF-36) global health; functional decline according to National Health Interview Survey (NHIS) activities of daily living (ADLs) score and SF-36 physical function index; hospitalization; and any falls and multiple falls over 1 year. Mean age was 74, and 44% of participants were female. Odds ratios for all outcomes were equivalent for gait speed and TUG. Using area under the receiver operating characteristic curve of 0.7 or greater for acceptable predictive ability, gait speed and TUG each alone predicted decline in global health, new ADL difficulty, and falls, with no difference in predictive ability between performance measures. Neither performance measure predicted hospitalization, EuroQol decline, or physical function decline. As a continuous variable, TUG did not add predictive ability to gait speed for any outcome. Gait speed predicts most geriatric outcomes, including falls, as does TUG. The time taken to complete TUG may not add to information provided by gait speed, although its qualitative elements may have other utility. [ABSTRACT FROM AUTHOR]

Abstract: Background: The presence of a vertebral fracture identifies a patient who has clinical osteoporosis. However, approximately 2/3 to 3/4 of VFs are asymptomatic. Vertebral Fracture Assessment is a method derived from dual-energy X-ray absorptiometry (DXA) to assess vertebral fractures. The objectives of this study were 1) to determine the association between the degree of height loss in older men and women and the risk of a vertebral fracture, and 2) to determine if the knowledge of vertebral fractures will alter the classification of osteoporosis based on bone mineral density alone. Methods: 231 men and women over the age of 65 underwent DXA scan of their spine and hip (including bone mineral density and Vertebral Fracture Assessment), measurement of their height, and a questionnaire. Results: We found that height loss was significantly associated with a vertebral fracture (p=0.0160). The magnitude of the association translates to a 19% increase in odds for 1/2in. and 177% for 3in. Although 45% had osteoporosis by either bone mineral density or fracture criteria, 30% would have been misclassified if bone mineral density criteria were used alone. Conclusions: Height loss is an indicator for the presence of vertebral fractures. Bone mineral density criteria alone may misclassify older patients who have osteoporosis. [ABSTRACT FROM AUTHOR]

The article discusses a study which evaluated the relationship between gait speed and survival in geriatric patients, as well as determined the degree to which gait speed explains variability in survival after accounting for age and sex. The study's design, setting and participants are described. Main outcome measures include survival rates and life expectancy. The study found that survival increased across the full range of gait speeds based on the pooled analysis of individual data from 9 selected cohorts.

Objectives: The objectives of this study were to determine the prevalence of pain, describe its treatment, and determine factors associated with any pain in older residents assigned to a hospice specialty unit bed or receiving services from a hospice/palliative care/end-of-life special program in US nursing homes. Design: Cross-sectional study of data from the 2004 National Nursing Home Survey. Setting: The setting was 1174 US nursing homes. Participants: Participants were 303 sampled patients, 65 years or older, representing 33,413 individuals receiving hospice/palliative care. Measurements: Facility staff was asked if, in the past 7 days, the resident had reported or shown evidence of pain. Medication use data were derived from medication administration records. Information about demographics and health status was derived from Minimum Data Set records. Results: Cancer was the primary diagnosis in only 11.4% of residents. Overall 36.6% had any pain in the previous week. Among those with any pain, 86.4% received some analgesic; specifically, 65.5% received opioids, whereas 31.7% received acetaminophen. Those with any pain compared with those without pain had shorter lengths of stay in hospice/palliative care (mean 123 days versus 161 days, P < .01), were more likely to be incontinent of bowel (76.2%, versus 60.3%, P < 0.01) and bladder (84.5% versus 71.8%, P = 0.01). Conclusions: Pain symptoms were present in more than one third of older nursing home hospice/palliative care residents despite the use of opioids in two thirds of those who had reported or shown evidence of any pain. Additional future studies are needed to improve the management of pain in older residents receiving hospice/palliative care in US nursing homes. [Copyright &y& Elsevier]

OBJECTIVES: To assess the predictive value of five performance-based measures for the onset of difficulty in activities of daily living (ADLs). DESIGN: A prospective cohort study; home visits every 6 months for 18 months. SETTING: Community-based. PARTICIPANTS: Community-dwelling older adults, n=110, (mean age 80.3±7.0; range 67–98) who reported no difficulty in basic ADLs. MEASUREMENTS: The Short Physical Performance Battery (SPPB), gait speed, Berg Balance Scale (BBS), grip strength, and Timed Up and Go Test (TUG) were evaluated at baseline. Seven ADL items were assessed at baseline and 6, 12, and 18 months. The onset of ADL disability was self-report of difficulty in any of the seven ADL items. Logistic regression models were fitted for each of the physical performance measures to predict onset of ADL difficulty at 6, 12, and 18 months. RESULTS: After controlling for age, comorbid conditions, and sex, the BBS was the most consistent and best predictor for the onset of ADL difficulty over an 18-month period (6 months, c-statistic=0.725, (95% confidence interval (CI)=0.60–0.85; 12 months, c-statistic=0.840 95% CI=0.75, 0.93; 18 months, c-statistic=0.821, 95% CI=0.71, 0.93). The SPPB showed excellent predictive value for the onset of difficulty at 12 months. Ninety-five, 89, and 75 older adults completed the 6, 12, and 18-month follow-up visits, respectively. CONCLUSION: BBS, followed by SPPB, TUG, gait speed, and grip strength, were predictive of the onset of ADL difficulty over an 18-month period in community-dwelling older adults. Screening nondisabled older adults with simple performance tests could allow clinicians to identify those at risk for ADL difficulty and may help to detect early functional decline. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: In addition to bone mineral density (BMD), trabecular microstructure contributes to skeletal strength. Our goal was to examine changes in trabecular microstructure in women on therapy. Materials and methods: We followed 10 postmenopausal women receiving a bisphosphonate, risedronate (35 mg once weekly), over 12 months and examined trabecular microarchitecture with high resolution wrist MR images (hr-MRI). MRI parameters included bone volume/total volume (BV/TV), surface density (representing plates), curve density (representing rods), surface-to-curve ratio and erosion index (depicting deterioration). We assessed BMD of the spine, hip and radius and markers of bone turnover. Results: Women had been receiving bisphosphonate therapy for 43±9 months (mean±SD) prior to the first MRI. Indices of hr-MRI demonstrated improvement in surface-to-curve ratio (13.0%) and a decrease in erosion index (12.1%) consistent with less deterioration (both p <0.05). BMD of the spine, hip and radius and markers of bone turnover remained stable. Parameters of hr-MRI were associated with 1/3 distal radius BMD (correlation coefficient 0.71 to 0.86, p <0.05). Discussion: We conclude that hr-MRI of the radius demonstrates improvements in trabecular microstructure not appreciated by conventional BMD and provides additional information on parameters that contribute to structural integrity in patients on antiresorptive therapy. [Copyright &y& Elsevier]

Abstract: Objectives: Gait variability is an important indicator of impaired mobility in older adults; however, little is known about the meaning of change in gait variability over time. This study estimated clinically meaningful change in measures of gait variability using both distribution- and anchor-based approaches. Design: Community-based observational cohort study. Setting: Bronx County and the research center at Albert Einstein College of Medicine. Participants: Of 1148 participants in the Einstein Aging Study, 241 had quantitative gait assessments in two consecutive years between 2001 and 2005. Measurements: Gait variables were collected using a 12-foot instrumented walkway as participants walked at their normal walking speed. Gait variability was defined as the within-person standard deviation (SD) across steps in two 12-foot walks. Distribution-based meaningful change estimates used Cohen''s effect size (0.2 for small and 0.5 for moderate effects). Anchor-based estimates were obtained using dichotomous and ordinal self-reported walking ability ratings as anchors. Results: Distribution-based estimates for small and substantial changes of variability measures were: stance time 0.005 and 0.014s; swing time 0.003 and 0.009s; step length 0.24 and 0.61cm; and step width 0.03 and 0.08cm. Among those reporting no change in walking ability, measures of gait variability were stable over 1 year. Among those reporting a decline in walking, stance time and swing time variability increased. Among those reporting an improvement in walking, only step length variability improved. Conclusion: Preliminary criteria for meaningful change are 0.01s for stance time and swing time variability and 0.25cm for step length variability. These estimates may identify important changes over time in both clinical settings and research studies. [Copyright &y& Elsevier]

Background: Therapeutic activities to improve mobility often include walking practice and exercises to improve deficits in endurance, strength, and balance. Because walking may also be energy inefficient in people with decreased mobility, another approach is to reduce energy cost by improving timing and coordination (TC) of movement. [ABSTRACT FROM PUBLISHER]

Objectives: To describe the management of and satisfaction with laboratory testing, and desirability of laboratory health information technology in the nursing home setting. Design: Cross-sectional study using an Internet-based survey. Participants and Setting: National sample of 426 nurse practitioners and 308 physicians who practice in the nursing home setting. Measurements: Systems and processes available for ordering and reviewing laboratory tests, laboratory test result management satisfaction, self-reported delays in laboratory test result review, and desirability of computerized laboratory test result management features in the nursing home setting. Results: A total of 96 participants (48 physicians and 48 nurse practitioners) completed the survey, for an overall response rate of 13.1% (96/734). Of the survey participants, 77.1% had worked in the nursing home setting for more than 5 years. Over half of clinicians (52.1%) reported 3 or more recent delays in receiving laboratory test results. Only 43.8% were satisfied with their laboratory test results management. Satisfaction was associated with keeping a list of laboratory orders and availability of computerized laboratory test order entry. In the nursing home, 35.4% of participants reported the ability to electronically review laboratory test results, 12.5% and 10.4% respectively had computerized ordering of chemistry/hematology and microbiology/pathology tests. The following 3 features were rated most desirable in a computerized laboratory test result management system: showing abnormal results first, warning if a test result was missed, and allowing electronic acknowledgment of test results. Conclusion: Delays in receiving laboratory test results and dissatisfaction with the management of laboratory test result information are commonly reported among physicians and nurse practitioners working in nursing homes. Test result management satisfaction was associated with computerized order entry and keeping track of ordered laboratory tests, suggesting that implementation of certain health information technology could potentially improve quality of care. [Copyright &y& Elsevier]

Abstract: Chronic low back pain (CLBP) in older adults may be disabling and therapeutically challenging, largely because of the inefficacy and/or morbidity associated with traditional pain treatment. We conducted a randomized controlled trial in 200 men and women⩾age 65 with CLBP to evaluate the efficacy of percutaneous electrical nerve stimulation (PENS) with and without general conditioning and aerobic exercise (GCAE), for reducing pain and improving physical function. Participants were randomized to receive (1) PENS, (2) control-PENS (brief electrical stimulation to control for treatment expectancy), (3) PENS+GCAE, or (4) control-PENS+GCAE, twice a week for 6 weeks. All four groups experienced significantly reduced pain (range −2.3 to −4.1 on the McGill Pain Questionnaire short form), improved self-reported disability (range −2.1 to −3.0 on Roland scale) and improved gait velocity (0.04–0.07m/s), sustained at 6 months. The GCAE groups experienced significantly fewer fear avoidance beliefs immediately post-intervention and at 6 months than non-GCAE groups. There were no significant side effects. Since brief electrical stimulation (i.e., control-PENS) facilitated comparably reduced pain and improved function at 6 months as compared with PENS, the exact dose of electrical stimulation required for analgesia cannot be determined. GCAE was more effective than PENS alone in reducing fear avoidance beliefs, but not in reducing pain or in improving physical function. [Copyright &y& Elsevier]

Many diagnostic tests may be available to identify a particular disease. Diagnostic performance can be potentially improved by combining. “Either” and “both” positive strategies for combining tests have been discussed in the literature, where a gain in diagnostic performance is measured by a ratio of positive (negative) likelihood ratio of the combined test to that of an individual test. Normal theory and bootstrap confidence intervals are constructed for gains in likelihood ratios. The performance (coverage probability, width) of the two methods are compared via simulation. All confidence intervals perform satisfactorily for large samples, while bootstrap performs better in smaller samples in terms of coverage and width. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the influence of androgen deprivation therapy (ADT) in men with nonmetastatic prostate cancer. Methods: We conducted a 2-year controlled, prospective study. Twenty-three men on 6 months or longer of ADT (chronic), 12 men on less than 6 months of ADT (acute), and 13 men not on ADT (healthy controls or prostate cancer patients not on ADT) were studied. We used validated, objective tests for physical and visual-motor function and dual X-ray absorptiometry for body composition at baseline and at 24 months. Results: We found the baseline percentage of body fat increased and baseline percentage of lean mass decreased with duration of ADT (P <0.002 across groups for both). After 24 months, men on chronic ADT had significant declines in lean body mass percentage (P = 0.058) and increases in body fat percentage (P = 0.029). Men on acute ADT had smaller but still significant differences in body composition at baseline and similar trends at 24 months. At baseline, men on chronic ADT had longer chair rise times than men on no ADT (P = 0.073) or acute ADT (P = 0.035). Four-meter walk velocities at 24 months were slower in men on acute (P = 0.006) and chronic ADT (P <0.001). Conclusions: Declines in lean body mass and increases in body fat percentage over 2 years are observed in men on ADT. Lower body physical function performance is reduced in men on chronic ADT. Changes in body composition and physical function should be considered in men on long-term ADT. [Copyright &y& Elsevier]

OBJECTIVES: To estimate the relationship between 1-year improvement in measures of health and physical function and 8-year survival. DESIGN: Prospective cohort study. SETTING: Medicare health maintenance organization and Veterans Affairs primary care programs. PARTICIPANTS: Persons aged 65 and older (N=439). MEASUREMENTS: Six measures of health and function assessed at baseline and quarterly over 1 year. Participants were classified as improved at 1 year, transiently improved, or never improved for each measure using a priori definitions of meaningful change: gait speed (usual walking pace over 4 m), 0.1 m/s; Short Physical Performance Battery, 1 point; Medical Outcomes Study 36-item Short Form Health Survey physical function, 10 points; EuroQol, 0.1 point; National Health Interview activity of daily living scale, 2 points; and global health change, two levels or reaching the ceiling. Mortality was ascertained from the National Death Index. Covariates included demographics, comorbidity, cognitive function, and hospitalization. RESULTS: Of the six measures, only improved gait speed was associated with survival. Mortality after 8 years was 31.6%, 41.2%, and 49.3% for those with improved, transiently improved, and never improved gait speed, respectively. The survival benefit for improvement at 1 year persisted after adjustment for covariates (hazard ratio=0.42, 95% confidence interval=0.29–0.61, P<.001) and was consistent across subgroups based on age, sex, ethnicity, initial gait speed, healthcare system, and hospitalization. CONCLUSION: Improvement in usual gait speed predicts a substantial reduction in mortality. Because gait speed is easily measured, clinically interpretable, and potentially modifiable, it may be a useful “vital sign” for older adults. Further research is needed to determine whether interventions to improve gait speed affect survival. [ABSTRACT FROM AUTHOR]

Objectives: To have health care professionals in nursing homes identify organizational-level and individual-level modifiable barriers to medication error reporting. Design: Nominal group technique sessions to identify potential barriers, followed by development and administration of a 20-item cross-sectional mailed survey. Participants and Setting: Representatives of 4 professions (physicians, pharmacists, advanced practitioners, and nurses) from 4 independently owned, nonprofit nursing homes that had an average bed size of 150, were affiliated with an academic medical center, and were located in urban and suburban areas. Measurements: Barriers identified in the nominal group technique sessions were used to design a 20-item survey. Survey respondents used 5-point Likert scales to score factors in terms of their likelihood of posing a barrier (“very unlikely” to “very likely”) and their modifiability (“not modifiable” to “very modifiable”). Immediate action factors were identified as factors with mean scores of <3.0 on the likelihood and modifiability scales, and represent barriers that should be addressed to increase medication error reporting frequency. Results: In 4 nominal group technique sessions, 28 professionals identified factors to include in the survey. The survey was mailed to all 154 professionals in the 4 nursing homes, and 104 (67.5%) responded. Response rates by facility ranged from 55.8% to 92.9%, and rates by profession ranged from 52.0% for physicians to 100.0% for pharmacists. Most respondents (75.0%) were women. Respondents had worked for a mean of 9.8 years in nursing homes and 5.4 years in their current facility. Of 20 survey items, 14 (70%) had scores that categorized them as immediate action factors, 9 (64%) of which were organizational barriers. Of these factors, the 3 considered most modifiable were (1) lack of a readily available medication error reporting system or forms, (2) lack of information on how to report a medication error, and (3) lack of feedback to the reporter or rest of the facility on medication errors that have been reported. Conclusions: The study results provide a broad-based perspective of the barriers to medication error reporting in the nursing home setting. Efforts to improve medication error reporting frequency should focus on organizational-level rather than individual-level interventions. [Copyright &y& Elsevier]

Unlabelled: The dopaminergic system of the basal ganglia has been implicated in the integration of sensory information important for balance based on studies in patients with Parkinson's disease. Striatal dopaminergic activity decreases with normal aging.Objective: To investigate the relationship between regional striatal dopaminergic denervation and sensory information integration important for balance in middle-aged and older adults.Methods: Community-dwelling subjects (N=35; age 41-83) with no clinical diagnoses of conditions affecting balance underwent dynamic posturography testing (Sensory Organization Test/SOT) and C-11-beta-CFT dopamine transporter positron emission tomography.Results: Reduced ventral striatal dopamine was significantly correlated with increased anterior-posterior sway in three SOT conditions. Specifically, during quiet standing (SOT Conditions #1, 2) and when repeatedly to sway-referenced visual environments (SOT Condition #3, Trial #3), pre-synaptic dopaminergic denervation in the anteroventral striatum explained over 20-25% of the variability in sway magnitude above and beyond that explained by age (pConclusions: The SOT Condition #3 findings suggest that, in normal aging, the central ability to inhibit balance destabilizing vision-related postural control processes depends at least partially on striatal dopaminergic pathways. In contrast, striatal dopaminergic denervation does not appear to impair the ability to disengage destabilizing proprioceptive inputs and to trigger the vestibular control system during challenging sensory perturbations (SOT Conditions #4-6). Finally, quiet standing results (SOT Conditions #1, 2) justify the need to further investigate the impact of striatal dopaminergic denervation on the ability to tune muscle tone in healthy adults. [ABSTRACT FROM AUTHOR]