Comparing different methods of gait speed estimation using wearable sensors in individuals with varying levels of mobility impairments.

Wearable sensors, such as inertial measurement units (IMU), provide the ability to quantify gait parameters outside of traditional gait laboratory settings. Walking speed has been shown to be associated with morbidity and mortality. Therefore, the ability of a clinician to easily and inexpensively measure gait speed within their clinic or patients' home setting can improve patient management and care. This study highlights multiple methods used to estimate patient walking speeds based only on IMU data and minimal anthropometric data, and identifies the algorithm appearing to be the most robust; one relying on identifying swing phases of gait first.Clinical relevance- Providing a clinician with a simple, inexpensive and reliable protocol for measuring patients' gait speed and other parameters could offer prevention and individualized care.

Risk of pneumonia in new users of cholinesterase inhibitors for dementia.

OBJECTIVES: To compare the risk of pneumonia in older adults receiving donepezil, galantamine, or rivastigmine for dementia. DESIGN: Retrospective cohort study. SETTING: Nationally representative 5% sample of Medicare databases. PARTICIPANTS: Medicare beneficiaries aged 65 and older who newly initiated cholinesterase inhibitor therapy between 2006 and 2009. MEASUREMENTS: Pneumonia, defined as the presence of a diagnosis code for pneumonia as the primary diagnosis on an inpatient claim or on an emergency department claim followed by dispensing of appropriate antibiotics. Cox proportional hazards models were used to estimate the risk of pneumonia. Subgroup analyses and sensitivity analyses were conducted using alternative pneumonia definitions and adjustments using high-dimensional propensity scores to test the robustness of the results. RESULTS: The mean age of 35,570 new users of cholinesterase inhibitors (30,174 users of donepezil, 1,176 users of galantamine, 4,220 users of rivastigmine) was 82; 75% were women, and 82% were white. The cumulative incidence of pneumonia was 51.9 per 1,000 person-years. The risk of pneumonia for rivastigmine users was 24% lower than that of donepezil users (hazard ratio (HR)=0.75, 95% confidence interval (CI)=0.60-0.93). Risk in galantamine users (HR=0.87, 95% CI=0.62-1.23) was not significantly different from risk in donepezil users. Results of subgroup and sensitivity analyses were similar to the primary results. CONCLUSION: The risk of pneumonia was lower in individuals receiving rivastigmine than in those receiving donepezil. Additional studies are needed to confirm the findings of pneumonia risk between the oral and transdermal forms of rivastigmine and in users of galantamine.

An educational intervention to improve internal medicine interns' awareness of hazards of hospitalization in acutely ill older adults.

Hospitalized older adults are susceptible to complications termed "hazards of hospitalization" (HOH), which collectively result in poor patient outcomes. Previous research has shown that residents are not aware of their patients' risk factors for HOH. This study investigated the effect of an educational intervention to increase internal medicine interns' knowledge and self-efficacy of HOH and to improve their care of hospitalized older adults as measured by their documentation of HOH. Targeted learners were internal medicine interns on their geriatrics rotation at a large academic hospital in 2011 to 2012. The intervention covered 10 specific HOH: delirium, pressure ulcers, urinary incontinence and retention, functional decline, falls, suboptimal prescribing, dehydration and malnutrition, infection, depression, and inappropriate interventions. Knowledge and self-efficacy were measured before and after training. HOH documentation rates of interns who did and did not complete the training were compared over a preset 8-week period. Forty-two of 43 eligible interns completed the curriculum. After training, knowledge was significantly greater (approximately 1 more correct question out of 3, P < .001). Self-reported confidence in managing each hazard also significantly increased (13 questions on two 5-point Likert scales, P < .001). Trained interns had significantly more-frequent documentation of patients' activities of daily living, gait, and plan for functional decline prevention than interns who were not trained (P < .05). Conversely, documentation of instrumental activities of daily living was more frequent among interns who were not trained (P < .01). Implementation of an educational intervention was successful in improving educational and behavior change outcomes regarding HOH.

Predicting nursing home placement among home- and community-based services program participants.

BACKGROUND: Several states offer publicly funded-care management programs to prevent long-term care placement of high-risk Medicaid beneficiaries. Understanding participant risk factors and services that may prevent long-term care placement can facilitate efficient allocation of program resources. OBJECTIVES: To develop a practical prediction model to identify participants in a home- and community-based services program who are at highest risk for long-term nursing home placement, and to examine participant-level and program-level predictors of nursing home placement. STUDY DESIGN: In a retrospective observational study, we used deidentified data for participants in the Connecticut Home Care Program for Elders who completed an annual assessment survey between 2005 and 2010. METHODS: We analyzed data on patient characteristics, use of program services, and short-term facility admissions in the previous year. We used logistic regression models with random effects to predict nursing home placement. The main outcome measures were long-term nursing home placement within 180 days or 1 year of assessment. RESULTS: Among 10,975 study participants, 1249 (11.4%) had nursing home placement within 1 year of annual assessment. Risk factors included Alzheimer's disease (odds ratio [OR], 1.30; 95% CI, 1.18-1.43), money management dependency (OR, 1.33; 95% CI, 1.18-1.51), living alone (OR, 1.53; 95% CI, 1.31-1.80), and number of prior short-term skilled nursing facility stays (OR, 1.46; 95% CI, 1.31-1.62). Use of a personal care assistance service was associated with 46% lower odds of nursing home placement. The model C statistic was 0.76 in the validation cohort. CONCLUSIONS: A model using information from a home- and community-based service program had strong discrimination to predict risk of long-term nursing home placement and can be used to identify high-risk participants for targeted interventions.

Comparative cardiovascular safety of dementia medications: a cross-national study.

OBJECTIVES: To compare the cardiovascular safety of currently marketed dementia medications in new users in the United States and Denmark. DESIGN: Retrospective cohort study. SETTING: Nationally representative sample of Medicare beneficiaries from 2006 through 2009 and nationwide Danish administrative registries from 1997 through 2007. PARTICIPANTS: Individuals treated with a dementia medication aged 65 and older. MEASUREMENTS: Hospitalizations for myocardial infarction (MI), heart failure, and syncope or atrioventricular block in both cohorts; fatal or nonfatal MI and cardiac death in the Danish cohort; and all-cause mortality in sensitivity analyses. RESULTS: In 46,737 Medicare beneficiaries and 29,496 Danish participants, donepezil was the most frequently used medication. There were no substantial differences in the risk of MI or heart failure between participants using donepezil and those using other cholinesterase inhibitors (all hazard ratios (HR) crossing 1). In the Danish cohort, memantine was associated with fatal or nonfatal MI (HR = 1.33, 95% confidence interval (CI) = 1.08-1.63), cardiac death (HR = 1.31, 95% CI = 1.12-1.53), and a trend toward higher rates of hospitalization for MI (HR = 1.31, 95% CI = 0.98-1.76). Memantine was also associated with greater risk of all-cause mortality in the Medicare (HR = 1.20, 95% CI = 1.13-1.28) and Danish (HR = 1.83, 95% CI = 1.73-1.94) cohorts, suggesting that sicker individuals were selected for memantine therapy. CONCLUSION: Cholinesterase inhibitors have similar cardiovascular risk profiles. Associations between memantine and fatal outcomes in Denmark may be related, in part, to selection of sicker individuals for memantine therapy.

"I can do patient care on my own": autonomy and the manager role.

PURPOSE: An internal medicine (IM) residency program redesigned its second year, the Manager Year, to restore balance among autonomy, supervision, and clinical competence. This study examined the response of residents and some supervising attendings to this innovation. METHOD: In this qualitative study-part of a total program evaluation-two authors gathered data from 36 second-year resident-managers, 3 third-year residents, and 8 attendings through semistructured interviews between spring 2005 and spring 2007. All resident-managers in 2005-2006 and all but one in 2006-2007 were interviewed. From verbatim transcripts, two of the authors coded the responses into themes; then all four reviewed and revised these themes. RESULTS: Coding revealed that second-year residents associated four qualities with their experience as managers: ownership of patients, accountability to others, competence in patient management skills, and personal satisfaction. They described the manager role as being as being "on your own." They were accountable to fellow managers, attendings, and nursing staff at a different level from that of an intern. Without an intern to teach, they learned critical management skills to complete their work. They became adult learners around their own patient cases. CONCLUSIONS: Successful preparation of physicians for independent practice requires a careful balance between autonomy and supervision, increasing the former during the training program sequence. For resident-managers, the assignment as principle caregiver occurs at the interface between the two. Managers identify themselves as a great deal more autonomous while still valuing attending supervision and input from co-managers to meet responsibilities.

Cognitive and psychosocial aspects of caring for elderly patients with diabetes.

The population is aging in the United States as well as worldwide. The prevalence of diabetes increases with increasing age. To provide optimal care to older adults with diabetes, unique psychosocial barriers need to be considered by medical providers. Unlike in younger adults, cognitive dysfunction/dementia and depressive mood disorders are common coexisting conditions in older adults with diabetes. This article reviews recent literature on epidemiology and clinical implications of cognitive and psychosocial dysfunctions in older patients with diabetes. This article focuses on cognitive dysfunctions, dementia, depression, and other psychosocial stresses, and their implications in the care of older adults with diabetes.