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Karen L Caldwell,1 Shawn M Bergman,2 Scott R Collier,3 N Travis Triplett,3 Rebecca Quin,4 John Bergquist,5 Carl F Pieper6 1Department of Human Development and Psychological Counseling, 2Department of Psychology, 3Department of Health and Exercise Science, 4Department of Theatre and Dance, 5Department of Psychology, Appalachian State University, Boone, 6Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA Objective: To determine feasibility and estimate the effect of a 10-week tai chi chuan (TCC) intervention on anxiety and sleep quality in young adults. Participants: Seventy-five adults (18–40 years) from a predominately undergraduate mid-sized university. Methods: This was an assessor blinded, randomized feasibility trial, and participants were randomized into one of three groups: 10 weeks of TCC meeting 2 times per week, 10 weeks of TCC with a DVD of the curriculum, and control group receiving a handout on anxiety management. Anxiety and sleep quality were assessed 4 times: baseline, 4 weeks, 10 weeks (immediate post-intervention), and 2 months post-intervention. Retention was defined as a participant attending the baseline assessment and at least one other assessment. Adherence to the intervention was set a priori as attendance at 80% of the TCC classes. Results: Eighty-five percent of participants were retained during the intervention and 70% completed the 2 month follow-up assessments. To increase statistical power, the two TCC groups were combined in the analyses of anxiety and sleep quality measures. No significant changes in anxiety were found in the control group, while levels of anxiety decreased significantly over time in the two TCC groups. Sleep quality scores improved across time for all three groups, but adherent TCC participants reported greater improvement than control participants. Conclusion: TCC may be an effective nonpharmaceutical means of improving anxiety and poor sleep quality in young adults. Keywords: anxiety, sleep quality, tai chi chuan, randomized controlled trial, feasibility study

Objectives: Until recently, reports of physical activity in rheumatoid arthritis (RA) were limited to self-report methods and/or leisure-time physical activity. Our objectives were to assess, determine correlates of, and compare to well-matched controls both exercise and sedentary time in a typical clinical cohort of RA. Method: Persons with established RA (seropositive or radiographic erosions; n = 41) without diabetes or cardiovascular disease underwent assessments of traditional and disease-specific correlates of physical activity and 7 days of triaxial accelerometry. Twenty-seven age, gender, and body mass index (BMI)-matched controls were assessed. Results: For persons with RA, objectively measured median (25th-75th percentile) exercise time was 3 (1-11) min/day; only 10% (n = 4) of participants exercised for ≥ 30 min/day. Time spent in sedentary activities was 92% (89-95%). Exercise time was not related to pain but was inversely related to disease activity (r = -0.3, p < 0.05) and disability (r = -0.3, p < 0.05) and positively related to self-efficacy for endurance activity (r = 0.4, p < 0.05). Sedentary activity was related only to self-efficacy for endurance activity (r = -0.4, p < 0.05). When compared to matched controls, persons with RA exhibited poorer self-efficacy for physical activity but similar amounts of exercise and sedentary time. Conclusions: For persons with RA and without diabetes or cardiovascular disease, time spent in exercise was well below established guidelines and activity patterns were predominantly sedentary. For optimal care in RA, in addition to promoting exercise, clinicians should consider assessing sedentary behaviour and self-efficacy for exercise. Future interventions might determine whether increased self-efficacy can increase physical activity in RA. [ABSTRACT FROM AUTHOR]

Objective: Research has shown an association between depression and functional limitations in older adults. Our aim was to explore the latent traits of trajectories of limitations in mobility and instrumental activities of daily living (IADL) tasks in a sample of older adults diagnosed with major depression.Methods: Participants were 248 patients enrolled in a naturalistic depression treatment study. Mobility/IADL tasks included walking one-fourth mile, going up/down stairs, getting around the neighborhood, shopping, handling money, taking care of children, cleaning house, preparing meals and doing yardwork/gardening. Latent class trajectory analysis was used to identify classes of mobility/IADL function over a 4-year period. Class membership was then used to predict functional status over time.Results: Using time as the only predictor, three latent class trajectories were identified: (1) Patients with few mobility/IADL limitations (42%), (2) Patients with considerable mobility/IADL limitations (37%) and (3) Patients with basically no limitations (21%). The classes differed primarily in their initial functional status, with some immediate improvement followed by no further change for patients in Classes 1 and 2 and a stable course for patients in Class 3. In a repeated measures mixed model controlling for potential confounders, class was a significant predictor of functional status. The effect of baseline depression score, cognitive status, self-perceived health and sex on mobility/IADL score differed by class.Conclusions: These findings show systematic variability in functional status over time among older patients with major depression, indicating that a single trajectory may not reflect the pattern for all patients. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine the effects of primary care-based, multicomponent physical activity counseling (PAC) promoting physical activity (PA) guidelines on gait speed and related measures of PA and function in older veterans. DESIGN: Randomized controlled trial. SETTING: Veterans Affairs Medical Center of Durham, North Carolina. PARTICIPANTS: Three hundred ninety-eight male veterans aged 70 and older. INTERVENTION: Twelve months of usual care (UC) or multicomponent PAC consisting of baseline in-person and every other week and then monthly telephone counseling by a lifestyle counselor, one-time clinical endorsement of PA, monthly automated telephone messaging from the primary care provider, and quarterly tailored mailings of progress in PA. MEASUREMENTS: Gait speed (usual and rapid), self-reported PA, function, and disability at baseline and 3, 6, and 12 months. RESULTS: Although no between-group differences were noted for usual gait speed, rapid gait speed improved significantly more for the PAC group (1.56 +/- 0.41 m/s to 1.68 +/- 0.44 m/s) than with UC (1.57 +/- 0.40 m/sec to 1.59 +/- 0.42 m/sec, P=.04). Minutes of moderate/vigorous PA increased significantly in the PAC group (from 57.1 +/- 99.3 to 126.6 +/- 142.9 min/wk) but not in the UC group (from 60.2 +/- 116.1 to 69.6 +/- 116.1 min/wk, P<.001). Changes in other functional/disability outcomes were small. CONCLUSION: In this group of older male veterans, multicomponent PA significantly improved rapid gait and PA. Translation from increased PA to overall functioning was not observed. Integration with primary care was successful. [ABSTRACT FROM AUTHOR]

BACKGROUND AND AIMS: Previous studies suggest that depression increases risk of falls, low bone mineral density, and fractures. Our aim was to evaluate whether depressive symptomatology alone predicts 5- year clinical fracture risk in older adults. METHODS: In this secondary analysis of a community-based, prospective cohort study including 4175 women and 1652 men in Canada, depressive symptomatology was assessed at baseline by the mental health inventory-5 (MHI-5) and the mental component score (MCS) of the short form 36 questionnaire (SF-36). Fracture events were assessed annually for five years; all reported incident fragility fractures were confirmed radiographically. RESULTS: Depressive symptomatology did not predict time to first fracture in men (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.45-1.65) or women (HR 1.09, 95% CI 0.86-1.39). Results were similar after controlling for potential confounders. Depressive symptoms were not significantly associated with baseline bone mineral density at the lumbar spine or femoral neck. Women with depressive symptoms were more likely to report falls in the previous month (odds ratio [OR] 1.52, 95% CI 1.12-2.06, p=0.01). This association did not achieve statistical significance in men (OR 1.71, 95% CI 0.96-3.04, p=0.07). CONCLUSION: In this large, community cohort, depressive symptomatology did not predict five-year risk of clinical fracture. Further research is needed to determine if individuals with major depressive disorder (MDD) are at higher fracture risk and whether neuroendocrine or hormonal dysregulation might contribute to such risk in MDD. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine the course of depressive symptoms in older patients with comorbid major depression and dysthymia. DESIGN: Secondary data analysis using both proportional hazards modeling and a repeated measures mixed model. SETTING: Clinical Research Center for the Study of Depression in Later Life conducted at Duke University. PARTICIPANTS: Two hundred fifty inpatients and outpatients age 60 and older with major depression enrolled in a naturalistic treatment study and followed up for 10 years. MEASUREMENTS: The Diagnostic Interview Schedule was used to confirm a clinical diagnosis of major depression and to identify patients with comorbid dysthymia at the time of study enrollment. Patients were administered the Montgomery-Asberg Depression Rating Scale (MADRS) every 3 months. For the proportional hazards models, partial remission was defined as a MADRS score <16 and full remission as a score <7. RESULTS: A total of 34.8% of the patients had comorbid major depression and dysthymia at baseline enrollment. Compared with those with major depression alone, they had longer time to both partial (median number of days = 175 versus 106) and full remission (median number of days = 433 versus 244) from major depression. In the repeated measures mixed model predicting MADRS score over 3 years of follow-up and controlling for the effects of potential confounders, the effect of having comorbid dysthymia was not consistent over time, with patients with both disorders having higher predicted scores after initial response. CONCLUSIONS: Older patients with comorbid major depression and dysthymia have a less favorable trajectory of recovery compared with those with major depression alone. [ABSTRACT FROM AUTHOR]

Objective: The fluid recommendation for adults aged 70+ years has been criticised on the basis of a low prevalence of dehydration in community-dwelling older adults. This study explores whether the low prevalence might reflect limitations of individual dehydration indices.Design: Cross-sectional data on plasma sodium, blood urea nitrogen (BUN), creatinine, glucose and potassium were used to classify 1,737 participants of the 1992 Established Populations for Epidemiologic Studies of the Elderly (EPESE) (70+ years) according to multiple dehydration indices. Associations between dehydration indices, health and functional status were evaluated.Results: Depending on the indicator used, the prevalence of dehydration ranged from 0.5% for hypotonic hypovolaemia only (plasma tonicity < 285 mOsm l(-1) with orthostatic hypotension) to 60% with dehydration defined as either plasma sodium >or=145 mEq l(-1), BUN/creatinine ratio >or=20, tonicity >or=295 mOsm l(-1), or hypotonic hypovolaemia. Elevated tonicity and BUN/creatinine ratio were respectively associated with chronic disease and functional impairment.Conclusions: The true prevalence of dehydration among community-dwelling adults may be low or high, depending on the indicator(s) used to define dehydration. Before we can pinpoint a generalisable prevalence of dehydration for community-dwelling seniors and draw conclusions about fluid recommendations, validation studies of dehydration indices and longitudinal studies of dehydration, health and functional status are needed. [ABSTRACT FROM AUTHOR]

Objective: In this study, we examined 204 older depressed individuals for up to 64 months to determine factors related to depression outcome. We hypothesized that both presence of vascular brain lesions seen on baseline magnetic resonance imaging (MRI) scans and lower baseline social support measures would be related to worse depression outcome.Method: At study entry, all subjects were at least 59 years old, had a diagnosis of major depression, and were free of other major psychiatric illness and primary neurological illness, including dementia and stroke. Depression was diagnosed via structured interview and clinical assessment by a geriatric psychiatrist who completed a Montgomery Asberg Depression Rating Scale (MADRS) to determine severity of depression. Subjects provided self-report data on social support variables and ability to perform basic and instrumental activities of daily living (ADL, IADL). All subjects agreed to have a baseline standardized MRI brain scan. Ratings of severity of hyperintensities were determined for the periventricular white matter, deep white matter, and subcortical gray matter by two readers who decided by consensus. Treatment was provided by geropsychiatrists following clinical guidelines. Using mixed models to analyze the data, we determined the effect of a variety of demographic, social and imaging variables on the trajectory of MADRS score, the outcome variable of interest.Results: MADRS scores decreased steadily over time. In a final HLM model, in which time since entry, a baseline time indicator, age, gender, education and Mini-mental State Examination score were controlled, subjective social support, instrumental ADL impairment, subcortical gray matter severity, and the interactions of time with social network and with subcortical gray matter lesions remained significantly associated with MADRS score.Conclusions: Both social and biological factors at baseline are associated with longitudinal depression severity in geriatric depression. [ABSTRACT FROM AUTHOR]

Background: Factors associated with functional status in elderly cancer survivors, in particular, comorbidity, have been inadequately studied.Methods: Of 4162 participants aged 65 and older enrolled in the Duke Established Populations for Epidemiologic Studies of the Elderly study in 1986, 376 of the participants self-reported a diagnosis of cancer. Participants were divided into 2 comorbidity groups and 4 cancer groups. Cancer groups included 132 participants diagnosed 0-4 years ago, 117 diagnosed 5-15 years ago, 127 diagnosed >15 years ago, and 3784 participants who had never been diagnosed with cancer. Comorbidity (self-reported stroke, diabetes, hypertension, and myocardial infarction) was classified as presence of 1 or no comorbidities (n = 3089) or 2 or more comorbidities (n = 1073). Function was assessed by Katz Activities of Daily Living, Rosow-Breslau, Nagi, and Instrumental Activities of Daily Living scales at the time of interview.Results: In a two-way analysis of covariance model of comorbidity and cancer group controlling for age, race, sex, education, marital status, depression, and cognitive status, duration of cancer survivorship does not influence most measures of function. In the subset of 376 cancer survivors, comorbidity significantly correlates with the functional status of these older cancer survivors (<0.02, for all 4 measures of function).Conclusions: In the older cancer survivor, regardless of duration following diagnosis, the presence of comorbidity rather than the history of cancer per se correlates with impaired functional status. [ABSTRACT FROM AUTHOR]

Background: As exercise is associated with favorable health outcomes, impaired older adults may benefit from specialized exercise interventions to achieve gains in function. The purpose of this study was to determine the added benefit of a spinal flexibility-plus-aerobic exercise intervention versus aerobic-only exercise on function among community-dwelling elders.Methods: We employed a randomized clinical trial consisting of 3 months of supervised exercise followed by 6 months of home-based exercise with telephone follow-up. A total of 210 impaired males and females over age 64 enrolled in this study. Of these, 134 were randomly assigned to either spinal flexibility-plus-aerobic exercise or aerobic-only exercise, with 116 individuals completing the study. Primary outcomes obtained at baseline, after 3 months of supervised exercise, and after 6 months of home-based exercise included: axial rotation, maximal oxygen uptake (VO2max); functional reach, timed-bed-mobility; and the Physical Function Scale (PhysFunction) of the Medical Outcomes Study SF-36.Results: Differences between the two interventions were minimal. Overall change scores for both groups combined indicated significant improvement for: axial rotation (p=.001), VO2max (p=.0001), and PhysFunction (p=.0016). Secondary improvements were noted for overall health (p=.0025) and reduced symptoms (p=.0008). Differences between groups were significant only for VO2max (p=.0014) at 3 months with the aerobic-only group improving twice as much in aerobic capacity as the spinal flexibility-plus-aerobic group. Repeated measures indicated both groups improved during the supervised portion of the intervention but tended to return toward baseline following the home-based portion of the trial.Conclusions: Gains in physical functioning and perceived overall health are obtained with moderate aerobic exercise. No differential improvements were noted for the spinal flexibility-plus-aerobic intervention. [ABSTRACT FROM AUTHOR]

The purpose of this study was to determine if there are racial differences in the occurrence of herpes zoster (shingles). The study population was the Duke Established Populations for Epidemiologic Studies of the Elderly, a probability sample of community-dwelling persons > 64 years old in North Carolina. Interviewers administered a comprehensive health survey to the participants that included questions about lifetime occurrence of shingles. Of the 3206 subjects, 316 (9.9%) had had zoster: 81 (4.5%) of 1754 blacks and 235 (16.1%) of 1452 whites had had shingles (P < .0001). After controlling for age, cancer, and demographic factors, blacks remained one-fourth as likely as whites (adjusted odds ratio 0.25, 95% confidence interval 0.18-0.35; P = .0001) to have experienced zoster. In summary, blacks had a significantly lower risk of developing herpes zoster than whites, a new finding in herpes zoster epidemiology. [ABSTRACT FROM AUTHOR]

Background: Determining the nature and rate of change in physical function among long-stay nursing home (NH) residents classified by cognitive performance is needed to inform judgments about prognosis and design of clinical trials to minimize functional decline.Methods: The study consisted of a longitudinal analysis using random coefficients models of 71,388 noncomatose residents aged 65 and older admitted in one of five states participating in the Health Care Financing Administration-sponsored National Case Mix and Quality Demonstration Project who stayed in the nursing home 1 year or longer. Linear effects of cognitive impairment on admission and over time on the trajectory of dependence in activities of daily living (ADLs) were estimated, adjusting for demographic status upon admission. Interaction terms were used to determine if subgroups of residents at the same cognitive level were at risk for a steeper than average rate of decline. Measures were derived from the NH Minimum Data Set (MDS+) ratings of each domain. Cognition was measured using the MDS-Cognitive Performance Scale. Physical function was determined by summing ADL dependence ratings of bathing, dressing, grooming, toileting, and eating (range 0 to 20). Demographics included age, gender, race, and marital status.Results: On average, ADL dependence worsened 0.84 points per year among these long-stay residents. Only cognition and marital status had clinically significant effects on ADL dependence. Married residents exhibited more ADL dependence than unmarried residents. Severity of cognitive impairment on admission and over time influenced severity of ADL dependence but not rate of decline. No interaction terms were clinically significant.Conclusions: Clinicians seeking to identify factors that accelerate ADL decline in long-stay NH residents must examine explanatory variables other than cognitive impairment and demographics. [ABSTRACT FROM AUTHOR]

Background: The evidence for an association between depression and mortality among community-dwelling elderly persons remains inconclusive, although it is well established for younger individuals. Extant studies suggest that this association weakens when adjusted for potential confounding factors, especially functional impairment. A cohort of elderly subjects followed for 3 years was analyzed to determine the association of depression and 3-year mortality, controlling for the major known risk factors for mortality in the elderly population.Methods: Information on depression (CES-D scores), mortality, demographics, body mass index, chronic disease, smoking history, cognitive impairment, functional impairment, self-rated health, and social support was obtained from a stratified probability-based sample of community-dwelling elderly persons, with equal distribution between African Americans and whites in the Piedmont of North Carolina. Descriptive statistics were calculated, and logistic regression was used for a series of models with progressively more control variables.Results: The unadjusted relative odds of mortality among depressed subjects at baseline was 1.98 over 3 years of follow-up. Inclusion of age, gender, and race into the model did not reduce the relative odds. When chronic disease and health habits, cognitive impairment, functional impairment, and social support were added to the model, the odds ratios for mortality with depression were 1.74, 1.69, 1.29, and 1.21, respectively. This decrease in odds ratios was not observed for other variables in the model when additional variables were added.Conclusions: The estimated odds of dying if depressed moved toward unity as other risk factors for mortality were controlled. Unlike other known risk factors for mortality in the elderly population, depression appears to be associated with mortality through a number of independent mechanisms, perhaps through complex feedback loops. [ABSTRACT FROM AUTHOR]

Background: Comorbidity is common in elderly persons. Its extent, correlates, and life-threatening impact in representative community residents are unclear.Methods: Self-reported information of physician-diagnosed coronary artery disease (CAD), cerebrovascular disease (CVD), diabetes, and cancer was obtained annually between 1986-87 and 1992-93, and hypertension was obtained triennially from the participants of the Duke Established Populations for Epidemiologic Studies of the Elderly, a stratified multistage sample of 4,126 Black and White community residents aged 65-100, living in a five-county area of North Carolina. Date of death was obtained from death certificates identified through search of the National Death Index. Statistical procedures included descriptive statistics, logistic regression, and survival analysis.Results: Of this sample, 57% reported hypertension, 20% diabetes, 15% CAD, 9% cancer, and 9% CVD; 29% reported none of these conditions, whereas 29% reported two or more. Demographic characteristics were not related to comorbidity with CVD or cancer. Increased education tended to be protective. The effect of age, gender, and race varied with condition. At baseline there was substantial comorbidity among hypertension, CAD, CVD, and diabetes, but not with cancer. Hypertension, CVD, and diabetes were risk factors for CAD, whereas diabetes was a risk factor for CVD. After controlling for demographic characteristics, all health conditions except hypertension were predictive of 6-year mortality, as was the presence of comorbidity.Conclusion: We found significant comorbidity in older persons who have hypertension, CAD, CVD, or diabetes; particular risk of developing comorbidity, particularly CAD, among those with hypertension, CVD, and diabetes; and risk of CVD in those with diabetes. With the exception of hypertension, these conditions, and comorbidity per se, are life-threatening. [ABSTRACT FROM AUTHOR]

Background: IL-6 is a multifunctional cytokine that has been shown to increase with age.Methods: Plasma IL-6 was measured by ELISA in 1,727 community-dwelling elderly subjects whose blood was drawn during the third in-person survey of the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE). Demographics, functional status (disability), and disease states were determined. Correlations of these factors with IL-6 were analyzed with Spearman's Rho while differences between groups were assessed by Wilcoxon test.Results: IL-6 levels were higher with age (p = .0001) even in this older population (> 70 years). There was a positive correlation between IL-6 and functional disability for each of the functional status measures (p = .0001), as well as a correlation between self-rated health and IL-6. Significantly higher median levels of IL-6 were found in subjects reporting prevalent cancer, heart attack, and high blood pressure, but not diabetes or arthritis. The association between age and functional status with high IL-6 remained when all other variables were controlled, in multivariable analysis.Conclusions: This association between increased plasma IL-6 levels and functional status suggests that dysregulation of IL-6 may be related to the functional disability seen with aging, and that IL-6 may be useful as a component of an overall marker of health. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study examines the relationship between the lack of private supplemental health insurance coverage and the development of disability among adults aged 65 and older. METHODS: Data are from the baseline and six follow-up waves of the Duke Established Populations for Epidemiologic Studies of the Elderly survey (N = 4,000). Discrete-time hazard models were used to estimate the impact of insurance coverage and other risk factors on the incidence of disability among those unimpaired at baseline. RESULTS: Controlling for education, income, and other potential confounders, the odds of developing disability were 35-49% higher among those without private coverage. Insurance coverage also statistically explained part of the increased risk of disability among low-income persons. DISCUSSION: The results indicate that changes in health insurance coverage as well as in individual behaviors may be needed to reduce disability generally and disability among the socioeconomically disadvantaged, in particular. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To test a brief, non-sectarian program of meditation training for effects on perceived stress and negative emotion, and to determine effects of practice frequency and test the moderating effects of neuroticism (emotional lability) on treatment outcome. DESIGN AND SETTING: The study used a single-group, open-label, pre-test post-test design conducted in the setting of a university medical center. PARTICIPANTS: Healthy adults (N=200) interested in learning meditation for stress-reduction were enrolled. One hundred thirty-three (76% females) completed at least 1 follow-up visit and were included in data analyses. INTERVENTION: Participants learned a simple mantra-based meditation technique in 4, 1-hour small-group meetings, with instructions to practice for 15-20 minutes twice daily. Instruction was based on a psychophysiological model of meditation practice and its expected effects on stress. OUTCOME MEASURES: Baseline and monthly follow-up measures of Profile of Mood States; Perceived Stress Scale; State-Trait Anxiety Inventory (STAI); and Brief Symptom Inventory (BSI). Practice frequency was indexed by monthly retrospective ratings. Neuroticism was evaluated as a potential moderator of treatment effects. RESULTS: All 4 outcome measures improved significantly after instruction, with reductions from baseline that ranged from 14% (STAI) to 36% (BSI). More frequent practice was associated with better outcome. Higher baseline neuroticism scores were associated with greater improvement. CONCLUSIONS: Preliminary evidence suggests that even brief instruction in a simple meditation technique can improve negative mood and perceived stress in healthy adults, which could yield long-term health benefits. Frequency of practice does affect outcome. Those most likely to experience negative emotions may benefit the most from the intervention. [ABSTRACT FROM AUTHOR]

This study evaluated the use of walking speed as an indicator of function and health status in acutely ill, hospitalized, older male veterans. Hospital inpatients in a Department of Veterans Affairs (VA) study of Geriatric Evaluation and Management (GEM) (n = 1,388, age 74.2 +/- 5.7, 98% male) were followed for 1 year. The results indicate that each 0.10 m/s reduction in baseline walking speed was associated with poorer health status (36-item short from [SF-36] beta = 4.5 [95% confidence interval (CI) 2.8 to 6.1], poorer physical functioning (beta = 2.1 [6.9 to 14.8], more disabilities (beta = 0.63 [0.53 to 0.73], additional rehabilitation visits (2.0 [1.4 to 2.5]), increased medical-surgical visits (2.8 [1.9 to 3.7]), longer hospital stays (2.2 [1.4 to 2.9]), and higher costs ($1,334 [$869 to $1,798]). In addition, each 0.10 m/s/yr increase in walking speed resulted in improved health status (SF-36 beta = 8.4 [6.0 to 10.7]), improved physical function (beta = 2.9 [2.5 to 3.3]), fewer basic disabilities (0.30 [0.2 to 0.4]), fewer instrumental disabilities (0.7 [0.6 to 0.8]), fewer hospitalization days (2.3 [1.3 to 3.3]), and 1-year cost reductions of $1,188 [-$65 to $2,442]. Walking speed is useful for the functional assessment of acutely ill, hospitalized older adults. Measurement of walking speed over time may help predict those who will need and use more health-related services. [ABSTRACT FROM AUTHOR]

Background: Predicting individual weight loss (WL) responses to lifestyle interventions is challenging but might help practitioners and clinicians select the most promising approach for each individual., Objective: The primary aim of this study was to develop machine learning (ML) models to predict individual WL responses using only variables known before starting the intervention. In addition, we used ML to identify pre-intervention variables influencing the individual WL response., Methods: We used 12-mo data from the comprehensive assessment of long-term effects of reducing intake of energy (CALERIE TM ) phase 2 study, which aimed to analyze the long-term effects of caloric restriction on human longevity. On the basis of the data from 130 subjects in the intervention group, we developed classification models to predict binary ("Success" and "No/low success") or multiclass ("High success," "Medium success," and "Low/no success") WL outcomes. Additionally, regression models were developed to predict individual weight change (percent). Models were evaluated on the basis of accuracy, sensitivity, specificity (classification models), and root mean squared error (RMSE; regression models)., Results: Best classification models used 20-40 predictors and achieved 89%-97% accuracy, 91%-100% sensitivity, and 56%-86% specificity for binary classification. For multiclass classification, accuracy (69%) and sensitivity (50%) tended to be lower. The best regression performance was obtained with 36 variables with an RMSE of 2.84%. Among the 21 variables predicting individual weight change most consistently, we identified 2 novel predictors, namely orgasm satisfaction and sexual behavior/experience. Other common predictors have previously been associated with WL (16) or are already used in traditional prediction models (3)., Conclusions: The prediction models could be implemented by practitioners and clinicians to support the decision of whether lifestyle interventions are sufficient or more aggressive interventions are needed for a given individual, thereby supporting better, faster, data-driven, and unbiased decisions. The CALERIE TM phase 2 study was registered at clinicaltrials.gov as NCT00427193., Competing Interests: Conflict of interest The authors report no conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: Caloric restriction (CR) is known to enhance insulin sensitivity and reduce the risk of metabolic disorders; however, its molecular mechanisms are not fully understood. This study aims to elucidate specific proteins and pathways responsible for these benefits., Methods: We examined adipose tissue from participants in the Comprehensive Assessment of Long-term Effects of Reducing Intake of Energy Phase 2 (CALERIE 2) study, comparing proteomic profiles from individuals after 12 and 24 months of CR with baseline and an ad libitum group. Biochemical and cell-specific physiological approaches complemented these analyses., Results: Our data revealed that CR upregulates prostacyclin synthase (PTGIS) in adipose tissue, an enzyme crucial for producing prostacyclin (PGI2). PGI2 improves the ability of insulin to stimulate the tether-containing UBX domain for GLUT4 (TUG) cleavage pathway, which is essential for glucose uptake regulation. Additionally, iloprost, a PGI2 analog, was shown to increase insulin receptor density on cell membranes, increasing glucose uptake in human adipocytes. CR also reduces carbonylation of GLUT4, a modification that is detrimental to GLUT4 function., Conclusions: CR enhances insulin sensitivity by promoting PTGIS expression and stimulating the TUG cleavage pathway, leading to increased GLUT4 translocation to the cell surface and decreased GLUT4 carbonylation. These findings shed light on the complex molecular mechanisms through which CR favorably impacts insulin sensitivity and metabolic health., (© 2024 The Obesity Society.)

Caloric restriction (CR) slows biological aging and prolongs healthy lifespan in model organisms. Findings from CALERIE-2 ™ - the first ever randomized, controlled trial of long-term CR in healthy, non-obese humans - broadly supports a similar pattern of effects in humans. To expand our understanding of the molecular pathways and biological processes underpinning CR effects in humans, we generated a series of genomic datasets from stored biospecimens collected from n=218 participants during the trial. These data constitute the first publicly-accessible genomic data resource for a randomized controlled trial of an intervention targeting the biology of aging. Datasets include whole-genome SNP genotypes, and three-timepoint-longitudinal DNA methylation, mRNA, and small RNA datasets generated from blood, skeletal muscle, and adipose tissue samples (total sample n=2327). The CALERIE Genomic Data Resource described in this article is available from the Aging Research Biobank. This mult-itissue, multi-omic, longitudinal data resource has great potential to advance translational geroscience., Competing Interests: Conflict of Interest. DWB and DLC are listed as inventors of the Duke University and University of Otago invention DunedinPACE, which is licensed to TruDiagnostic. DWB is consulting CSO and SAB chair of BellSant and serves on the SAB of the Hooke Clinic.

Context: Hypogonadism may be caused by Cushing syndrome (CS) and may intensify its adverse consequences., Objective: To determine the frequency of male hypogonadism before and after curative surgery for CS, and its cause., Design: Post-hoc analyses of prospective cohort studies., Setting: Clinical research center., Patients: Men with ACTH-dependent CS. Cohort 1 (C1) (n=8, age 32.5±12 y; studied 1985-1989); Cohort 2 (C2) (n=44, 42.7 ± 15.1 y; studied 1989-2021)., Interventions: C1: Every 20-minute blood sampling for 24h before and 1-40 months after surgical cure. Three subjects underwent GnRH stimulation tests pre- and post-surgery. C2: Hormone measurements at baseline and 6 and 12 months (M) post-cure., Main Outcome Measures: C1: LH, FSH, LH pulse frequency and LH response to GnRH. C2: LH, FSH, testosterone (T), free T, fT4, T3, TSH and UFC levels and frequency of hypogonadism pre- and post-surgery., Results: C1: mean LH and LH pulse frequency increased after surgery (p < 0.05) without changes in LH pulse amplitude, mean FSH, or peak gonadotropin response to GnRH. C2: 82% had baseline hypogonadism (total T 205 ± 28 ng/dL). Thyroid hormone levels varied inversely with UFC and cortisol. LH, total and free T, and SHBG increased at 6M and 12M post surgery, but hypogonadism persisted in 51% at 6M and in 26% at 12M., Conclusion: Hypogonadism in men with CS is widely prevalent but reversible in ∼75% of patients one year after surgical cure and appears to be mediated through suppression of hypothalamic GnRH secretion, and modulated by thyroid hormones., (Published by Oxford University Press on behalf of the Endocrine Society 2024.)

Background: Central nervous system (CNS) medication use is common among older adults, yet the impact of hospitalizations on use remains unclear. This study details CNS medication use, discontinuations, and user profiles during hospitalization periods., Methods: Retrospective cohort study using electronic health records on patients ≥65 years, from three hospitals (2018-2020), and prescribed a CNS medication around hospitalization (90 days prior to 90 days after). Latent class transitions analysis (LCTA) examined profiles of CNS medication class users across four time points (90 days prior, admission, discharge, 90 days after hospitalization)., Results: Among 4666 patients (mean age 74.3 ± 9.3 years; 63% female; 70% White; mean length of stay 4.6 ± 5.6 days (median 3.0 [2.0, 6.0]), the most commonly prescribed CNS medications were antidepressants (56%) and opioids (49%). Overall, 74% (n = 3446) of patients were persistent users of a CNS medication across all four time points; 7% (n = 388) had discontinuations during hospitalization, but of these, 64% (216/388) had new starts or restarts within 90 days after hospitalization. LCTA identified three profile groups: (1) low CNS medication users, 54%-60% of patients; (2) mental health medication users, 30%-36%; and (3) acute/chronic pain medication users, 9%-10%. Probability of staying in same group across the four time points was high (0.88-1.00). Transitioning to the low CNS medication use group was highest from admission to discharge (probability of 9% for pain medication users, 5% for mental health medication users). Female gender increased (OR 2.4, 95% CI 1.3-4.3), while chronic kidney disease lowered (OR 0.5, 0.2-0.9) the odds of transitioning to the low CNS medication use profile between admission and discharge., Conclusions: CNS medication use stays consistent around hospitalization, with discontinuation more likely between admission and discharge, especially among pain medication users. Further research on patient outcomes is needed to understand the benefits and harms of hospital deprescribing, particularly for medications requiring gradual tapering., (© 2024 The American Geriatrics Society.)

Objective: To compare a remotely supervised weight loss and exercise intervention to lifestyle counseling for effects on cardiovascular disease risk, disease activity, and patient-reported outcomes in older patients with rheumatoid arthritis (RA) and overweight/obesity., Methods: Twenty older (60-80 years), previously sedentary participants with seropositive RA and overweight/obesity were randomized to 16 weeks of either Supervised Weight loss and Exercise Training (SWET) or Counseling Health As Treatment (CHAT). The SWET group completed aerobic training (150 minutes/week moderate-to-vigorous intensity), resistance training (two days/week), and a hypocaloric diet (7% weight loss goal). The CHAT control group completed two lifestyle counseling sessions followed by monthly check-ins. The primary outcome was a composite metabolic syndrome z-score (MSSc) derived from fasting glucose, triglycerides, high density lipoprotein-cholesterol, minimal waist circumference, and mean arterial pressure. Secondary outcomes included RA disease activity and patient-reported outcomes., Results: Both groups improved MSSc (absolute change -1.67 ± 0.64 in SWET; -1.34 ± 1.30 in CHAT; P < 0.01 for both groups) with no between-group difference. Compared with CHAT, SWET significantly improved body weight, fat mass, Disease Activity Score-28 C-reactive protein, and patient-reported physical health, physical function, mental health, and fatigue (P < 0.04 for all between-group comparisons). Based on canonical correlations for fat mass, cardiorespiratory fitness, and leg strength, component-specific effects were strongest for (1) weight loss improving MSSc, physical health, and mental health; (2) aerobic training improving physical function and fatigue; and (3) resistance training improving Disease Activity Score-28 C-reactive protein., Conclusion: In older patients with RA and overweight/obesity, 16 weeks of remotely supervised weight loss, aerobic training, and resistance training improve cardiometabolic health, patient-reported outcomes, and disease activity. Less intensive lifestyle counseling similarly improves cardiovascular disease risk profiles, suggesting an important role for integrative interventions in the routine clinical care of this at-risk RA population., (© 2023 The Authors. ACR Open Rheumatology published by Wiley Periodicals LLC on behalf of American College of Rheumatology.)

Purpose: Cardiac rehabilitation (CR) is endorsed for coronary artery disease (CAD), but studies report inconsistent findings regarding efficacy. The objective of this study was to determine whether confounding factors, potentially contributing to these heterogeneous findings, impact the effect of CR on all-cause readmission and mortality., Methods: Patients (n = 2641) with CAD, CR eligible, and physically able were identified. Electronic medical records were inspected individually for each patient to extract demographic, clinical characteristic, readmission, and mortality information. Patients (n = 214) attended ≥1 CR session (CR group). Survival was considered free from: all-cause readmission; or composite outcome of all-cause readmission or death. Cox proportional hazards models, adjusting for demographics, comorbidities, and discharge criteria, were used to determine HR with 95% CI and to compare 180-d survival rates between the CR and no-CR groups., Results: During 180 d of follow-up, 12.1% and 18.7% of the CR and non-CR patients were readmitted to the hospital. There was one death (0.5%) in the CR group, while 98 deaths (4.0%) occurred in the non-CR group. After adjustment for age, sex, race, depression, anxiety, dyslipidemia, hypertension, obesity, smoking, type 2 diabetes, and discharge criteria, the final model revealed a significant 42.7% reduction in readmission or mortality risk for patients who attended CR (HR = 0.57: 95% CI, 0.33-0.98; P = .043)., Conclusions: Regardless of demographic characteristics, comorbidities, and cardiovascular discharge criteria, the risk of 180-d all-cause readmission or death was markedly decreased in patients who attended CR compared with those who did not., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc.)

Phenomenon : Balancing the demands of medical training and parenthood is challenging. We explored perceptions of programmatic support, parental leave, breastfeeding, and self-reported biggest challenges among a large cohort of physician mothers in a variety of medical specialties and across the stage of training when they had their first child. Our goal was to inform strategies to help improve the physician parent experience. Approach : This cross-sectional, observational survey study was performed using a convenience sample from an online physician-mom support group from January to February 2018. Descriptive statistics and bivariate analyses were used to report results and examine relationships between career stage at first child and outcome variables. Responses to the open-ended question, "What is your biggest challenge as a physician mom?" were qualitatively analyzed. Findings : The survey received 896 complete responses. The most common specialties were obstetrics and gynecology (25.3%), pediatrics (19.9%), internal medicine or medicine/pediatrics (17.1%), and family medicine (10.2%). The majority of participants (63.9%) had their first child during medical training, including medical school (14.3%), residency (35.8%) or fellowship (13.6%). Medical students were less likely to perceive programmatic support than residents or fellows (44.1% vs. 63.1% vs. 62.3%, respectively), and only 19.9% of participants who became parents during medical training reported having a clear and adequate parental leave policy. Nearly 70% of participants breastfed for six months or more, with no statistical differences across career stage. Most participants (57.6%) delayed child-bearing for one or more reasons, with 32.3% delaying to complete training. The most common codes applied to responses for 'biggest challenges as a physician mom' were insufficient time, lack of work-life balance, missing out, and over-expectation. Insights : Physician mothers, particularly those who had their first child during training, continue to struggle with support from training programs, finding work-life balance, and feelings of inadequacy. Interventions such as clear and adequate leave policies, program-sponsored or onsite childcare and improved programmatic support of breastfeeding and pumping may help to ameliorate the challenges described by our participants.

Objectives: The prevalence of hearing loss increases with age. Untreated hearing loss is associated with poorer communication abilities and negative health consequences, such as increased risk of dementia, increased odds of falling, and depression. Nonetheless, evidence is insufficient to support the benefits of universal hearing screening in asymptomatic older adults. The primary goal of the present study was to compare three hearing screening protocols that differed in their level of support by the primary care (PC) clinic and provider. The protocols varied in setting (in-clinic versus at-home screening) and in primary care provider (PCP) encouragement for hearing screening (yes versus no)., Design: We conducted a multisite, pragmatic clinical trial. A total of 660 adults aged 65 to 75 years; 64.1% female; 35.3% African American/Black completed the trial. Three hearing screening protocols were studied, with 220 patients enrolled in each protocol. All protocols included written educational materials about hearing loss and instructions on how to complete the self-administered telephone-based hearing screening but varied in the level of support provided in the clinic setting and by the provider. The protocols were as follows: (1) no provider encouragement to complete the hearing screening at home, (2) provider encouragement to complete the hearing screening at home, and (3) provider encouragement and clinical support to complete the hearing screening after the provider visit while in the clinic. Our primary outcome was the percentage of patients who completed the hearing screening within 60 days of a routine PC visit. Secondary outcomes following patient access of hearing healthcare were also considered and consisted of the percentage of patients who completed and failed the screening and who (1) scheduled, and (2) completed a diagnostic evaluation. For patients who completed the diagnostic evaluation, we also examined the percentage of those who received a hearing loss intervention plan by a hearing healthcare provider., Results: All patients who had provider encouragement and support to complete the screening in the clinic completed the screening (100%) versus 26.8% with encouragement to complete the screening at home. For patients who were offered hearing screening at home, completion rates were similar regardless of provider encouragement (26.8% with encouragement versus 22.7% without encouragement); adjusted odds ratio of 1.25 (95% confidence interval 0.80-1.94). Regarding the secondary outcomes, roughly half (38.9-57.1% depending on group) of all patients who failed the hearing screening scheduled and completed a formal diagnostic evaluation. The percentage of patients who completed a diagnostic evaluation and received a hearing loss intervention plan was 35.0% to 50.0% depending on the group. Rates of a hearing loss intervention plan by audiologists ranged from 28.6% to 47.5% and were higher compared with those by otolaryngology providers, which ranged from 15.0% to 20.8% among the groups., Conclusions: The results of the pragmatic clinical trial showed that offering provider encouragement and screening facilities in the PC clinic led to a significantly higher rate of adherence with hearing screening associated with a single encounter. However, provider encouragement did not improve the significantly lower rate of adherence with home-based hearing screening., Competing Interests: Dr. Francis reports serving on the Surgical Advisory Boards for Advanced Bionics and Med-El. No other author reports a conflict of interest outside of funding for the study., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

High rates of maternal and neonatal morbidity and mortality in Kenya may be influenced by provider training and knowledge in emergency obstetric and neonatal care in addition to availability of supplies necessary for this care. While post-abortion care is a key aspect of life-saving maternal health care, no validated questionnaires have been published on provider clinical knowledge in this arena. Our aim was to determine provider knowledge of maternal-child health (MCH) emergencies (post-abortion care, pre-eclampsia, postpartum hemorrhage, neonatal resuscitation) and determine factors associated with clinical knowledge. Our secondary aim was to pilot a case-based questionnaire on post-abortion care. We conducted a cross-sectional survey of providers at health facilities in western Kenya providing maternity services. Providers estimated facility capacity through perceived availability of both general and specialized supplies. Providers reported training on the MCH topics and completed case-based questions to assess clinical knowledge. Knowledge was compared between topics using a linear mixed model. Multivariable models identified variables associated with scores by topic. 132 providers at 37 facilities were interviewed. All facilities had access to general supplies at least sometime while specialized supplies were available less frequently. While only 56.8% of providers reported training on post-abortion care, more than 80% reported training on pre-eclampsia, postpartum hemorrhage, and neonatal resuscitation. Providers' clinical knowledge across all topics was low (mean score of 63.3%), with significant differences in scores by topic area. Despite less formal training in the subject area, providers answered 71.6% (SD 16.7%) questions correctly on post-abortion care. Gaps in supply availability, training, and clinical knowledge on MCH emergencies exist. Increasing training on MCH topics may decrease pregnancy and postpartum complications. Further, validated tools to assess knowledge in post-abortion care should be created, particularly in sub-Saharan Africa where legal restrictions on abortion services exist and many abortions are performed in unsafe settings., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Hagey et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The risk of dysphagia increases with age, affecting up to 33% of adults over the age of 65. Older adults with dysphagia are at increased risk for negative physical health outcomes such as aspiration pneumonia and death. However, the relationship between dysphagia and psychosocial health is uncertain in this population., Objective: We aimed to assess the associations between dysphagia and psychosocial health among older adults (≥ 65) with self-reported dysphagia., Design: We performed a cross-sectional assessment of the National Health and Aging Trends Study (NHATS) conducted in 2019., Main Measures: Weighted logistic and linear regression models were used to assess the relationship between self-reported dysphagia and psychosocial health using established patient-reported outcome measures including those for depression, anxiety, and social isolation previously used in NHATS analyses, while adjusting for demographics, comorbid conditions, and risk factors for dysphagia identified by purposeful selection., Key Results: Among the 4041 adults in this cohort, almost half (40%) were between 70 and 74 years old, more than half were female (55%), and a significantly higher proportion were White, non-Hispanic respondents (78.1%, p < 0.01) compared with other races and ethnicities. There were 428 (10.5%) respondents reporting dysphagia symptoms within the previous month. In the multivariable model, dysphagia was associated with significantly increased odds of anxiety (OR 1.33 [1.06, 1.67]) and a significantly decreased sense of well-being (coefficient - 1.10 [- 1.66, - 0.54]), but no association was detected for social isolation., Conclusions: When accounting for factors associated with underlying physical health status, self-reported dysphagia is independently associated with negative psychosocial health and warrants attention by healthcare providers. Future studies should aim to identify causal factors and the extent to which interventions may mitigate these factors., (© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background and Objectives: Traumatic brain injuries (TBIs) are associated with increased risk of dementia, but whether lifetime TBI influences cognitive trajectories in later life is less clear. Cognitive interventions after TBI may improve cognitive trajectories and delay dementia. Because twins share many genes and environmental factors, we capitalize on the twin study design to examine the association between lifetime TBI and cognitive decline., Methods: Participants were members of the National Academy of Sciences-National Research Council's Twin Registry of male veterans of World War II with self or proxy-reported history of TBI and with up to 4 observations over 12 years of the modified Telephone Interview for Cognitive Status (TICS-m). We used linear random-effects mixed models to analyze the association between TBI and TICS-m in the full sample and among co-twins discordant for TBI. Additional TBI predictor variables included number of TBIs, severity (loss of consciousness [LOC]), and age of first TBI (age <25 vs 25+ years [older age TBI]). Models were adjusted for age (centered at 70 years), age-squared, education, wave, twin pair, lifestyle behaviors, and medical conditions., Results: Of 8,662 participants, 25% reported TBI. History of any TBI (β = -0.56, 95% CI -0.73 to -0.39), TBI with LOC (β = -0.51, 95% CI -0.71 to -0.31), and older age TBI (β = -0.66, 95% CI -0.90 to -0.42) were associated with lower TICS-m scores at 70 years. TBI with LOC (β = -0.03, 95% CI -0.05 to -0.001), more than one TBI (β = -0.05, 95% CI -0.09 to -0.002,), and older age TBI (β = -0.06, 95% CI -0.09 to -0.03) were associated with faster cognitive decline. Among monozygotic pairs discordant for TBI (589 pairs), history of any TBI (β = -0.55, 95% CI -0.91 to -0.19) and older age TBI (β = -0.74, 95% CI -1.22 to -0.26) were associated with lower TICS-m scores at 70 years. Those with more than one TBI (β = -0.13, 95% CI -0.23 to -0.03) and older age TBI (β = -0.07, 95% CI -0.13 to -0.002) showed greater cognitive decline compared with their co-twin without TBI., Discussion: These findings support an association of the effect of TBI on cognitive score and the rapidity of cognitive decline in later life. The results in monozygotic pairs, who share all genes and many exposures, particularly in early life, provide additional evidence of a causal relationship between TBI and poorer late-life cognitive outcomes., (© 2023 American Academy of Neurology.)

Many studies identified factors associated with vaccination intention and hesitancy, but factors associated with vaccination promptness and the effect of vaccination intention on vaccination promptness are unknown. This study identified factors associated with COVID-19 vaccination promptness and evaluated the role of vaccination intention on vaccination promptness in 1223 participants in a community-based longitudinal cohort study (June 2020 to December 2021). Participants answered questions regarding COVID-19 vaccination intention, vaccination status, and reasons for not receiving a vaccine. The association of baseline vaccine hesitancy with vaccination was assessed by the Kaplan-Meier survival analysis. Follow-up analyses tested the importance of other variables predicting vaccination using the Cox proportional hazards model. Older age was associated with shorter time to vaccination (HR = 1.76 [1.37-2.25] 85-year-old versus 65-year-old). Lower education levels (HR = 0.80 [0.69-0.92]), household incomes (HR = 0.84 [0.72-0.98]), and baseline vaccination intention of 'No' (HR = 0.16 [0.11-0.23]) were associated with longer times to vaccination. The most common reasons for not being vaccinated (N = 58) were vaccine safety concerns (n = 33), side effects (n = 28), and vaccine effectiveness (n = 25). Vaccination campaigns that target populations prone to hesitancy and address vaccine safety and effectiveness could be helpful in future vaccination rollouts.