A Community-Based Collaborative Care Model to Improve Functional Health in Underserved Community-Dwelling Older Adults.

OBJECTIVE: Examine the effects of a 6-month health multidimensional intervention on physical function, bone density, and mood in a diverse sample of community-dwelling older adults at risk for frailty and excess disability. METHOD: A quasi-experimental, pre- post-program design was implemented. Adults aged 55 years and older ( n = 337, 60% African American) participated in the intervention and received assessments at baseline, 6 months, and 12 months. RESULTS: Physical function was maintained during the intervention for both African American and White elders but declined at 12 months for both groups ( p < .0001). Symptoms of depression improved during the intervention ( M = 0.65 ± 0.07, M = 0.15 ± 0.04, M = 0.68 ± 0.07, p < .001, respectively) but worsened at 12 months ( M = 0.68 ± 0.07, p < .001). Bone density scores remained stable from baseline (distal: -1.62 ± 1.17, proximal: -2.73 ± 1.85) to 12 months (distal: -1.72 ± 1.21, proximal: -3.11 ± 1.85, ps > .05) for both groups. DISCUSSION: Program findings may serve as a basis for the development of a randomized, controlled study to provide empirical evidence of intervention efficacy. Such findings may help inform the development of community-based programs to identify vulnerable older adults and provide vital preventative care to decrease frailty and excess disability.

Differential Prescribing of Antimuscarinic Agents in Older Adults with Cognitive Impairment.

BACKGROUND: Oral oxybutynin has been associated with the development of cognitive impairment. OBJECTIVE: The objective of this study was to describe the use of oral oxybutynin versus other antimuscarinics (e.g., tolterodine, darifenacin, solifenacin, trospium, fesoterodine, transdermal oxybutynin) in older adults with documented cognitive impairment. METHODS: This is a population-based retrospective analysis of antimuscarinic new users aged ≥ 66 years from January 2008 to December 2011 (n = 42,886) using a 5% random sample of Medicare claims linked with Part D data. Cognitive impairment was defined as a diagnosis of mild cognitive impairment, dementia, use of antidementia medication, and memory loss/drug-induced cognitive conditions in the year prior to the initial antimuscarinic claim. We used multivariable generalized linear models to assess indicators of cognitive impairment associated with initiation of oral oxybutynin versus other antimuscarinics after adjusting for comorbid conditions. RESULTS: In total, 33% received oral oxybutynin as initial therapy. Cognitive impairment was documented in 10,259 (23.9%) patients prior to antimuscarinic therapy. Patients with cognitive impairment were 5% more likely to initiate another antimuscarinic versus oral oxybutynin (relative risk [RR] 1.05; 95% confidence interval [CI] 1.03-1.06). The proportion of patients with cognitive impairment initiated on oral oxybutynin increased from 24.1% in 2008 to 41.1% in 2011. The total cost of oral oxybutynin, in $US, year 2011 values, decreased by 10.5%, whereas the total cost of other antimuscarinics increased by 50.3% from 2008 to 2011. CONCLUSION: Our findings suggest opportunities for quality improvement of antimuscarinic prescribing in older adults, but this may be hampered by cost and formulary restrictions.

Cognitive Dysfunction, Medication Management, and the Risk of Readmission in Hospital Inpatients.

OBJECTIVES: To determine whether cognitive dysfunction, in particular impaired executive function, may be a risk factor for early readmission in older adults independently managing their medications. DESIGN: Prospective observational study. SETTING: Tertiary hospital. PARTICIPANTS: Individuals aged 65 years and older discharged to home from the medicine service of a tertiary hospital (N = 452). MEASUREMENTS: Participants underwent a cognitive assessment including the Short Blessed Test (SBT), the executive function component of the Montreal Cognitive Assessment, and the Trail-Making Test Part B (TMT-B). Hospital use and demographic data were obtained. A logistic regression model was used to fit the likelihood of readmission on the basis of participant characteristics, medication management, and cognitive performance. Likelihood of hospital readmission within 30 days was determined. RESULTS: For participants managing medications themselves, adjusted 30-day odds of readmission increased 13% on average with each point decrease in SBT score (P = .003) and 9% on average with each 0.01 decrease in TMT-B score (P = .02). For participants who were independent in medication management with more than seven medications, the odds of 30-day readmission increased 16% on average with each point decrease in SBT score (P = .01) and 15% on average with each 0.01 decrease in TMT-B score (P = .03). CONCLUSION: Cognitive dysfunction, particularly executive dysfunction, is a risk factor for readmission in individuals managing their own medications. This risk is greater in individuals taking more than seven medications. The interaction of cognitive function, medication management, and number of medications may enhance risk-stratification efforts to identify individuals at risk of early readmission.

The Nursing Home Falls Self-Efficacy Scale: development and testing.

We examined a brief measure of falls self-efficacy in nursing home residents participating in a pilot randomized controlled trial to study the effects of hip protectors on the prevention of fractures (N = 116, mean age 82 ± 8, 72% female). Internal consistency reliability was acceptable with Cronbach's alpha of .79. Factor analysis supported two factors representing self-efficacy expectations and outcome expectancy. Contrasted groups comparisons and construct validity were examined. We found lower falls self-efficacy in participants who needed help with mobility, in people with lower executive function, and in participants who reported fear of falling. Scores were not associated with prospective falls or adherence with hip protector use. The findings of this study provide preliminary support for the reliability and validity of the scale for future research.

Adherence to hip protectors and implications for U.S. long-term care settings.

OBJECTIVES: Determine nursing home characteristics related to adherence to use of a hip protector (HP) to prevent fracture; also describe adherence and related resident characteristics. DESIGN: A multicenter, randomized controlled trial of a HP in which adherence to wearing the HP was monitored by research staff 3 times a week for up to 21 months; data were collected by interviews and chart review. SETTING: Thirty-five nursing homes in Boston, St. Louis, and Baltimore. PARTICIPANTS: A total of 797 eligible residents, 633 (79%) of whom passed the run-in period, 397 (63%) of whom remained in the study until the end of follow-up. INTERVENTION: Residents wore a single HP on their right or left side. MEASUREMENTS: In addition to regular monitoring of adherence, data were collected regarding facility characteristics, staffing, policies and procedures, perception of HPs and related experience, and research staff ratings of environmental and overall quality; and also resident demographic characteristics, and function, health, and psychosocial status. RESULTS: Facility characteristics related to more adherence were not being chain-affiliated; less Medicaid case-mix; fewer residents wearing HPs; more paraprofessional staff training; more rotating workers; and having administrators who were less involved in meetings. CONCLUSION: Efforts to increase adherence to the use of HPs should focus on facilities with more Medicaid case-mix to reduce disparities in care, and those that have less of a culture of training. Staff may need support to increase adherence, and when adherence cannot be maintained, HP use should be targeted to those who remain adherent.

Vitamin D deficiency is associated with worse cognitive performance and lower bone density in older African Americans.

BACKGROUND: Vitamin D deficiency is common in older adults and is more prevalent among persons with darker pigmented skin. The detrimental effects of vitamin D deficiency on the bone are widely known; however, recent data suggest that vitamin D deficiency may contribute to other disorders, including low mood, cognitive impairment, and impaired mobility. OBJECTIVE: The purpose of this study was to determine whether nonskeletal diseases such as depression, cognitive impairment, and physical disability, which have been associated with vitamin D deficiency, are more commonly seen in older African Americans. DESIGN: In a cross-sectional study of 60 older adults (30 African Americans and 30 European Americans), vitamin D status, cognitive performance, physical performance, and bone mineral density (BMD) were assessed. Differences between groups and differences between those with vitamin D deficiency and those with normal vitamin D levels were tested. RESULTS: African Americans had a lower mean 25-hydroxyvitamin D level (17.98 ng/ml; SD, 6.9) compared to European Americans (25.20 ng/ml; SD, 7.0; p < .0001). Participants with vitamin D deficiency performed worse on a measure of cognitive performance, the Short Blessed Test (10.87 vs 6.31; p = .016); the Physical Performance Test (PPT) (27.00 vs 28.96; p = .039); and had lower BMD (0.823 vs 0.914; p = .005) and t scores (-1.29 vs -0.72; p = .008) of the hip. Among African Americans, vitamin D deficiency was associated with worse cognitive performance and lower BMD of the hip. CONCLUSIONS: Vitamin D deficiency in older African Americans was associated with worse cognitive performance and lower BMD of the hip.

Osteoporotic fractures: a brain or bone disease?

Osteoporosis is a skeletal disorder that predisposes individuals to increased risk of fracture. However, most osteoporotic fractures occur in women who do not meet criteria for osteoporosis. Hence, bone density, by itself, is a relatively poor predictor of fracture. Age and age-related factors are now recognized as increasingly important in determining fracture risk. Osteoporotic fractures are associated with increased disability and mortality, suggesting that osteoporosis may be a clinical manifestation of an underlying disease process affecting multiple systems. The systems affected, the musculo-skeletal system and the central nervous system, are shared in many respects with the frailty syndrome. Vitamin D deficiency is a major contributor to the frailty syndrome, osteoporosis, and osteoporotic fractures. Its effects are mediated by the development of cerebrovascular disease, postural instability, muscle weakness, and bone fragility. Thus, osteoporotic fractures result from both a bone and brain disease.

The Hip Impact Protection Project: design and methods.

BACKGROUND: Nearly 340,000 hip fractures occur each year in the U.S. With current demographic trends, the number of hip fractures is expected to double at least in the next 40 years. PURPOSE: The Hip Impact Protection Project (HIP PRO) was designed to investigate the efficacy and safety of hip protectors in an elderly nursing home population. This paper describes the innovative clustered matched-pair research design used in HIP PRO to overcome the inherent limitations of clustered randomization. METHODS: Three clinical centers recruited 37 nursing homes to participate in HIP PRO. They were randomized so that the participating residents in that home received hip protectors for either the right or left hip. Informed consent was obtained from either the resident or the resident's responsible party. The target sample size was 580 residents with replacement if they dropped out, had a hip fracture, or died. One of the advantages of the HIP PRO study design was that each resident was his/her own case and control, eliminating imbalances, and there was no confusion over which residents wore pads (or on which hip). LIMITATIONS: Generalizability of the findings may be limited. Adherence was higher in this study than in other studies because of: (1) the use of a run-in period, (2) staff incentives, and (3) the frequency of adherence assessments. The use of a single pad is not analogous to pad use in the real world and may have caused unanticipated changes in behavior. Fall assessment was not feasible, limiting the ability to analyze fractures as a function of falls. Finally, hip protector designs continue to evolve so that the results generated using this pad may not be applicable to other pad designs. However, information about factors related to adherence will be useful for future studies. CONCLUSIONS: The clustered matched-pair study design avoided the major problem with previous cluster-randomized investigations of this question - unbalanced risk factors between the experimental group and the control group. Because each resident served as his/her own control, the effects of unbalanced risk factors on treatment effect were virtually eliminated. In addition, the use of frequent adherence assessments allowed us to study the effect of various demographic and environmental factors on adherence, which was vital for the assessment of efficacy.

Hormone therapy and stroke.

Available biochemical and clinical data are sufficiently compelling to recommend low dose or transdermal hormone therapy for the management of menopausal symptoms when possible. Women initiating low dose or transdermal hormone therapy are not at increased risk of cardiovascular disease, stroke, venous thrombotic disease, and breast cancer. Evidence suggests that these outcomes are favorably affected by low-dose hormone therapy and persist with continuation of therapy.

The role of postoperative neurocognitive dysfunction on quality of life for postmenopausal women 6 months after cardiac surgery.

BACKGROUND: Women are prone to neurological complications after cardiac surgery. We have previously reported that treatment perioperatively with the neuroprotectant steroid 17beta-estradiol did not improve neurocognitive end-points 4 to 6 wk after surgery for elderly women. In this study, we evaluated the influence of early postoperative neurocognitive dysfunction on quality of life in postmenopausal women undergoing cardiac surgery and whether it is impacted by perioperative 17beta-estradiol treatment. METHODS: One hundred seventy-four postmenopausal women randomly received 17beta-estradiol or placebo in a double-blind manner beginning the day before surgery and continued until the fifth postoperative day. The patients underwent psychometric testing using a standard battery before surgery and again 4 to 6 wk and 6 mo postoperatively. Quality of life was assessed at baseline and 6 mo after surgery with the SF-36 questionnaire and the Lawton instrumental activities of daily living scale. RESULTS: Complete data were available from 108 women of whom 13% demonstrated postoperative neurocognitive dysfunction. Based on multiple logistic regression analysis, a neurocognitive deficit 4 to 6 wk after surgery was an independent predictor of a lower SF-36 physical component score (P = 0.004) and lower Lawton instrumental activities of daily living scale 6 mo postoperatively (P = 0.026). Treatment with 17beta-estradiol (P = 0.003) and smoking status (P = 0.015) were predictors of worse SF-36 mental health component rating. Preoperative lower scores were independently associated with low quality of life postoperatively for all measurements. CONCLUSIONS: Postoperative neurocognitive dysfunction is associated with impaired quality of life in women after cardiac surgery. Perioperative treatment with 17beta-estradiol provides no benefits to postoperative quality of life. The relationship between low preoperative and postoperative self-rated health status suggests that some aspects of quality of life in postmenopausal women are not amenable to improvements with cardiac surgery.

Efficacy of a hip protector to prevent hip fracture in nursing home residents: the HIP PRO randomized controlled trial.

CONTEXT: Past studies of the efficacy of hip protectors to prevent hip fracture in nursing home residents have had conflicting results, possibly due to potential biases from clustered randomization designs and modest adherence to intervention. OBJECTIVE: To determine whether an energy-absorbing and energy-dispersing hip protector would reduce the risk of hip fracture when worn by nursing home residents. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, randomized controlled clinical trial in which 37 nursing homes were randomly assigned to having residents wear a 1-sided hip protector on the left or right hip. Participants were 1042 nursing home residents (mean [SD] aged 85 [7] years; 79% women) who consented and adhered to the hip protector use during a 2-week run-in period and were enrolled. Participating facilities were in greater Boston, Massachusetts, St Louis, Missouri, and Baltimore, Maryland from October 2002 to October 2004. Mean duration of participation for nursing home residents was 7.8 months. None were withdrawn because of adverse effects. INTERVENTION(S): Undergarments with a 1-sided hip protector made of a 0.32-cm outer layer of polyethylene (2.7 kg/m3) backed by a hard high-density polyethylene shield (0.95 cm) that was backed by 0.9 kg/m3 of 1.27-kg ethylene vinyl acetate foam. Each facility was visited 3 times per week to assess adherence and provide staff support. MAIN OUTCOME MEASURE: Adjudicated hip fracture occurrences on padded vs unpadded hips. RESULTS: After a 20-month follow-up (676 person-years of observation), the study was terminated due to a lack of efficacy. The incidence rate of hip fracture on protected vs unprotected hips did not differ (3.1%; 95% confidence interval [CI], 1.8%-4.4% vs 2.5%; 95% CI, 1.3%-3.7%; P = .70). For the 334 nursing home residents with greater than 80% adherence to hip protector use, the incidence rate of hip fracture on protected vs unprotected hips did not differ (5.3%; 95% CI, 2.6%-8.8% vs 3.5%; 95% CI, 1.3%-5.7%; P = .42). Overall adherence was 73.8%. CONCLUSIONS: In this clinical trial of an energy-absorbing/shunting hip protector conducted in US nursing homes, we were unable to detect a protective effect on the risk of hip fracture, despite good adherence to protocol. These results add to the increasing body of evidence that hip protectors, as currently designed, are not effective for preventing hip fracture among nursing home residents. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00058864.

Neurocognitive outcomes are not improved by 17beta-estradiol in postmenopausal women undergoing cardiac surgery.

BACKGROUND AND PURPOSE: Neurocognitive dysfunction is an important source of patient morbidity and mortality after cardiac surgery that may disproportionately affect postmenopausal women. 17beta-Estradiol limits the extent of ischemic neuronal injury in a variety of experimental models. The purpose of this study was to evaluate whether perioperative administration of 17beta-estradiol to postmenopausal women reduces the frequency of neurocognitive dysfunction after cardiac surgery. METHODS: One hundred seventy-four postmenopausal women not on estrogen replacement therapy who were undergoing primary coronary artery bypass graft surgery and/or valve surgery with cardiopulmonary bypass were prospectively randomized to receive in a double-blinded manner either 17beta-estradiol or placebo beginning the day before surgery and continuing for 5 days postoperatively. The patients were evaluated before and after surgery with the National Institutes of Health Stroke Scale and a psychometric test battery. RESULTS: There were no differences in the frequency of neurocognitive dysfunction (primary outcome) between patients randomized to perioperative 17beta-estradiol (n=86) and those randomized to placebo (n=88) 4 to 6 weeks after surgery (17beta-estradiol, 22.4% versus placebo, 21.4%, P=0.45). The mean scores on tests of psychomotor speed were worse in women in the 17beta-estradiol group than in the placebo group at the 4- to 6-week (P=0.005) postoperative testing sessions. CONCLUSIONS: Perioperative treatment with 17beta-estradiol did not result in improved neurocognitive outcomes in postmenopausal women undergoing cardiac surgery.

Circumstances of patient falls and injuries in 9 hospitals in a midwestern healthcare system.

OBJECTIVE: Preventing hospital falls and injuries requires knowledge of fall and injury circumstances. Our objectives were to determine whether reported fall circumstances differ among hospitals and to identify predictors of fall-related injury. DESIGN: Retrospective cohort study. Adverse event data on falls were compared according to hospital characteristics. Logistic regression was used to determine adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for risk factors for fall-related injury. SETTING: Nine hospitals in a Midwestern healthcare system. PATIENTS: Inpatients who fell during 2001-2003. RESULTS: The 9 hospitals reported 8,974 falls that occurred in patient care areas, involving 7,082 patients; 7,082 falls were included in our analysis. Assisted falls (which accounted for 13.3% of falls in the academic hospital and 9.8% of falls in the nonacademic hospitals; P<.001) and serious fall-related injuries (which accounted for 3.7% of fall-related injuries in the academic hospital and 2.2% of fall-related injuries in the nonacademic hospitals; P<.001) differed by hospital type. In multivariate analysis for the academic hospital, increased age (aOR, 1.006 [95% CI, 1.000-1.012]), falls in locations other than patient rooms (aOR, 1.53 [95% CI, 1.03-2.27]), and unassisted falls (aOR, 1.70 [95% CI, 1.23-2.36]) were associated with increased injury risk. Altered mental status was associated with a decreased injury risk (aOR, 0.72 [95% CI, 0.58-0.89]). In multivariate analysis for the nonacademic hospitals, increased age (aOR, 1.007 [95% CI, 1.002-1.013]), falls in the bathroom (aOR, 1.46 [95% CI, 1.06-2.01]), and unassisted falls (aOR, 1.83 [95% CI, 1.37-2.43]) were associated with injury. Female sex (aOR, 0.83 [95% CI, 0.71-0.97]) was associated with a decreased risk of injury. CONCLUSION: Some fall characteristics differed by hospital type. Further research is necessary to determine whether differences reflect true differences or merely differences in reporting practices. Fall prevention programs should target falls involving older patients, unassisted falls, and falls that occur in the patient's bathroom and in patient care areas outside of the patient's room to reduce injuries.

Vitamin D deficiency is associated with low mood and worse cognitive performance in older adults.

BACKGROUND: Vitamin D deficiency is common in older adults and has been implicated in psychiatric and neurologic disorders. This study examined the relationship among vitamin D status, cognitive performance, mood, and physical performance in older adults. METHODS: A cross-sectional group of 80 participants, 40 with mild Alzheimer disease (AD) and 40 nondemented persons, were selected from a longitudinal study of memory and aging. Cognitive function was assessed using the Short Blessed Test (SBT), Mini-Mental State Exam (MMSE), Clinical Dementia Rating (CDR; a higher Sum of Boxes score indicates greater dementia severity), and a factor score from a neuropsychometric battery; mood was assessed using clinician's diagnosis and the depression symptoms inventory. The Physical Performance Test (PPT) was used to measure functional status. Serum 25-hydroxyvitamin D levels were measured for all participants. RESULTS: The mean vitamin D level in the total sample was 18.58 ng/mL (standard deviation: 7.59); 58% of the participants had abnormally low vitamin D levels defined as less than 20 ng/mL. After adjusting for age, race, gender, and season of vitamin D determination, vitamin D deficiency was associated with presence of an active mood disorder (odds ratio: 11.69, 95% confidence interval: 2.04-66.86; Wald chi(2) = 7.66, df = 2, p = 0.022). Using the same covariates in a linear regression model, vitamin D deficiency was associated with worse performance on the SBT (F = 5.22, df = [2, 77], p = 0.044) and higher CDR Sum of Box scores (F = 3.20, df = [2, 77], p = 0.047) in the vitamin D-deficient group. There was no difference in performance on the MMSE, PPT, or factor scores between the vitamin D groups. CONCLUSIONS: In a cross-section of older adults, vitamin D deficiency was associated with low mood and with impairment on two of four measures of cognitive performance.

Prevention of osteoporotic fractures in the elderly.

Osteoporosis is a common and preventable disorder of the older adult skeleton that predisposes an individual to an increased risk of fracture, a major cause of disability in older adults. Most patients with osteoporosis have an identifiable cause of bone loss. Factors contributing to osteoporotic fractures are more often associated with disordered neuromuscular function affecting postural stability than disordered skeletal integrity. Effective pharmacologic agents are available for the prevention and treatment of osteoporosis. Prevention of osteoporotic fractures in the elderly, particularly nonvertebral fractures, presents unique challenges. Fracture prevention requires identification and management of disorders that contribute to falls, the prevention of falls, and reduction of the impact force of falls. Thus, both pharmacological and nonpharmacological strategies need to be employed. The presence of multiple co-morbidities further complicates management of osteoporosis in the elderly population.