Associations of sex, Alzheimer's disease and related dementias, and days alive and at home among older Medicare beneficiaries recovering from hip fracture.

BACKGROUND: Males constitute 25% of older adults who experience hip fractures in the United States; a concerning upward trend given poorer health and outcomes among male survivors. Male sex is associated with worse cognitive performance after hip fracture, impacting participation in rehabilitation and long-term outcomes especially for those with Alzheimer's disease or related dementias (ADRD). However, little research has evaluated whether sex differences in post-fracture recovery are greater among those living with ADRD. METHODS: Data were drawn from 2010 to 2017 Medicare fee-for-service beneficiaries aged 65 years and older who survived hospitalization for hip fracture (n = 69,581). The primary outcome was days alive and at home (DAAH), a validated patient-centered claims-based outcome calculated as 365 days from fracture minus days in hospital, nursing home, rehabilitation facility, emergency department, or time after death. Multivariable Poisson regressions with an interaction term between sex and ADRD status were to model the association between DAAH and ADRD in the 12 months post hip fracture, adjusting for demographics, injury severity, chronic disease burden, and hospital-level fixed effects. RESULTS: Compared to females, males were younger and had more comorbidities at the time of fracture. Among survivors, males with ADRD spent a mean of 160.7 DAAH compared to 228.4 for males without ADRD, 177.8 for females with ADRD, and 248.0 for females without ADRD. In adjusted analyses, males without ADRD spent 8.2% fewer DAAH compared to females (rate ratio [RR] = 0.92, 95% CI 0.92-0.92). This relative sex difference increased significantly when comparing those living with ADRD, with males spending an additional 3.3% fewer DAAH (interaction RR = 0.96, 95% CI 0.96-0.97). CONCLUSIONS: Males spend fewer DAAH after hip fracture than females, and this difference increases modestly for males living with ADRD compared to females. This suggests that cognitive impairment may be a small but significant contributor to sex-based differences observed during hip fracture recovery.

Advance Care Planning and Communication Skills Improve after an Interprofessional Team Simulation with Standardized Patients.

Background: Improving rates of advance care planning (ACP) and advance directive completion is a recognized goal of health care in the United States. No prior study has examined the efficacy of standardized patient (SP)-based student interprofessional ACP trainings. Objectives: The present study aims to evaluate an interprofessional approach to ACP education using SP encounters. Design: We designed a pre-post evaluation of an innovative interprofessional ACP training curriculum using multimodal adult learning techniques to test the effects of completing ACP discussions with SPs. Three surveys (pre-training T1, post-training T2, and post-clinical encounter T3) evaluated student knowledge, Communication Self-Efficacy (CSES), ACP self-efficacy, and interprofessional teamwork (using SPICE-R2). Setting/Subjects: Students from the schools of medicine, nursing, and social work attended three training modules and two SP encounters focused on ACP. Measurements/Results: During academic year 2018-2019, 36 students participated in the training at University of Maryland. Results demonstrated statistically significant improvements in ACP self-efficacy, M T1 = 2.9 (standard deviation [SD]T1 = 0.61) compared with M T3 = 3.9 (SDT3 = 0.51), p < 0.001, and CSES, M T1 = 4.6 (SDT1 = 1.35) versus M T3 = 7.3 (SDT3 = 0.51), p < 0.001, from T1 to T3. There was a medium-to-large improvement in knowledge from an average score of 4.3 (SD = 1.0) at T1 to an average score of 5.5 (SD = 1.4) at T2, p = 0.005, d = 0.67. Conclusions: Our interprofessional training module and SP encounter was successful in improving medical, social work, and nursing students' self-reported communication skills and knowledge regarding ACP.

Differential misclassification of cognitive impairment by sex among hip fracture patients.

BACKGROUND: Males have worse outcomes after hip fracture than female counterparts. Cognitive impairment (CI) also increases the risk of poor recovery from hip fracture; however, CI is under-recognized. Patient sex may contribute to this under-recognition through differential misclassification. The objective of this study was to measure under-recognition and differential misclassification of CI by patient sex. METHODS: A cross-sectional analysis of baseline data from an observational cohort study of community-dwelling hip fracture patients aged 65 and older (n = 339; females = 171, males = 168) recruited from eight hospitals in the greater Baltimore, MD area within 15 days of hospitalization for surgical repair with cognitive testing within 22 days of admission. Indication of Alzheimer's disease or related dementias and/or delirium as a postoperative complication in the medical record was considered evidence of documented CI. Observed CI was measured with the Modified Mini-Mental State Examination (3MS, ≤78). Source of cognitive impairment identification (SCI) was defined as: "3MS Only," "Hospital Record Only," "Both," "No CI" was compared between males and females using logistic regression. RESULTS: Males had more comorbidities and worse physical status upon admission, but otherwise had similar hospital experiences. SCI distribution was 12.7% "3MS Only" (n = 42), 11.5% "Hospital Record Only" (n = 38), 9.4% "Both" (n = 31), and "No CI" (n = 219). Males were more likely to be identified with CI using the "3MS Only" and "Both," and females were more likely to have no indication of CI. CONCLUSION: There were sex differences in the documentation of CI versus observed impairment. Males had more CI using direct testing. This may be contributing to sex differences in recovery outcomes after hip fracture. Results support the implementation of cognitive testing in hip fracture patients to reduce the impact of differential misclassification by patient sex.

Four Square Step Test Performance in Hip Fracture Patients.

BACKGROUND AND PURPOSE: Preventing subsequent falls in persons recovering from hip fracture is paramount. The Four Square Step Test (FSST) is a fast, easy measure of dynamic balance, with times more than 15 seconds previously associated with multiple fall risk in older adults. This study investigates among hip fracture patients (1) FSST performance, and how (2) unique population characteristics (such as fracture side) and (3) cognition impact FSST performance. METHODS: Patients with hip fracture (n = 40) 60 years and older came from an ancillary study to a larger randomized controlled trial testing two 16-week in-home physical therapy interventions after completion of usual care rehabilitation. Baseline measurers included: FSST, demographics, fracture characteristics, Modified Mini-Mental State Examination (3MS), Hooper Visual Organization Test (HVOT), and Trails Making Tests (TMT) A and B. RESULTS: Of 40 patients with hip fracture, 13 did not complete the FSST at baseline and were significantly older (P = .040) and performed worse on cognitive tests (3MS, HVOT, TMT-B; P < .05). Mean FSST time was 24.3 ± 13.1 seconds for the other 27, of whom 7 finished in less than 15 seconds. A significant 3-way interaction was observed, such that those with left-side pertrochanteric fractures who performed poorly on the HVOT did significantly worse on the FSST (P < .01, R2 = 0.93). DISCUSSION: Almost one-third of patients with hip fracture could not perform the FSST after completing usual care rehabilitation. Inability to perform the FSST was not random, as those without the FSST were physically and cognitively worse than those who did perform the FSST. Among those who could attempt the FSST, few performed well. Cognitive ability related to spatial orientation and fracture characteristics such as fracture side and fracture type has a synergistic effect on FSST performance. CONCLUSIONS: This is one of the first studies to assess the FSST in a population with hip fracture. At 4 months after hip fracture, most patients cannot perform the FSST in less than 15 seconds. Fracture side and fracture type appear important to FSST performance, as does cognition. More work needs to be done longitudinally to study the FSST in patients with hip fracture.

An interprofessional training to improve advance care planning skills among medicine, nursing, and social work students.

Suboptimal training for healthcare students is a recognized barrier to successful completion of advance care planning (ACP) with patients and families. Our study sought to enhance ACP knowledge and communication skills for interprofessional healthcare students. During academic year 2017-2018, 46 students (19-medicine, 16-nursing, and 11-social work), received three training modules delivered by interprofessional faculty. Students subsequently observed a clinical ACP encounter attended by a patient and their family, a clinical social worker, and an internal medicine resident. Three surveys (pre-training T1, post-training T2, and post-clinical encounter T3) evaluated change in student knowledge, communication self-efficacy, ACP self-efficacy, and interprofessional teamwork (using SPICE-R). A randomized waitlist approach was used to test the effects of the clinical ACP training. Student attendance and engagement were high. Relative to baseline, all outcomes differed at all data collection intervals (p < 0.05), except for the SPICE-R from T2 to T3 (p > 0.05). ACP self-efficacy scores declined at T2 before improving at T3. Communication self-efficacy was lower at T2 but improved at T3. Teamwork improved with a medium-large effect (ES = 0.75) at T2 and a large effect (ES = 1.00) at T3. Participant knowledge of ACP improved overall (p < 0.001) as well as for each discipline (p < 0.05). Preliminary findings indicate the interprofessional training experience enhanced student communication skills, ACP knowledge, and appreciation for team-based care. T2 findings demonstrate decrease in communication and ACP self-efficacy, perhaps suggesting students initially underestimated ACP complexity and overestimated their ability to communicate about ACP. T3 findings further suggest that students ultimately benefited from the training experience with meaningful improvements on all key outcomes.

Effects of Popular Diets without Specific Calorie Targets on Weight Loss Outcomes: Systematic Review of Findings from Clinical Trials.

The present review examined the evidence base for current popular diets, as listed in the 2016 U.S. News & World Report, on short-term (≤six months) and long-term (≥one year) weight loss outcomes in overweight and obese adults. For the present review, all diets in the 2016 U.S. News & World Report Rankings for "Best Weight-Loss Diets", which did not involve specific calorie targets, meal replacements, supplementation with commercial products, and/or were not categorized as "low-calorie" diets were examined. Of the 38 popular diets listed in the U.S. News & World Report, 20 met our pre-defined criteria. Literature searches were conducted through PubMed, Cochrane Library, and Web of Science using preset key terms to identify all relevant clinical trials for these 20 diets. A total of 16 articles were identified which reported findings of clinical trials for seven of these 20 diets: (1) Atkins; (2) Dietary Approaches to Stop Hypertension (DASH); (3) Glycemic-Index; (4) Mediterranean; (5) Ornish; (6) Paleolithic; and (7) Zone. Of the diets evaluated, the Atkins Diet showed the most evidence in producing clinically meaningful short-term (≤six months) and long-term (≥one-year) weight loss. Other popular diets may be equally or even more effective at producing weight loss, but this is unknown at the present time since there is a paucity of studies on these diets.

Successful aging: Advancing the science of physical independence in older adults.

The concept of 'successful aging' has long intrigued the scientific community. Despite this long-standing interest, a consensus definition has proven to be a difficult task, due to the inherent challenge involved in defining such a complex, multi-dimensional phenomenon. The lack of a clear set of defining characteristics for the construct of successful aging has made comparison of findings across studies difficult and has limited advances in aging research. A consensus on markers of successful aging is furthest developed is the domain of physical functioning. For example, walking speed appears to be an excellent surrogate marker of overall health and predicts the maintenance of physical independence, a cornerstone of successful aging. The purpose of the present article is to provide an overview and discussion of specific health conditions, behavioral factors, and biological mechanisms that mark declining mobility and physical function and promising interventions to counter these effects. With life expectancy continuing to increase in the United States and developed countries throughout the world, there is an increasing public health focus on the maintenance of physical independence among all older adults.

A systematic review of randomized controlled trials examining the effectiveness of saffron (Crocus sativus L.) on psychological and behavioral outcomes.

BACKGROUND: Throughout the past three decades, increased scientific attention has been given to examining saffron's (Crocus sativus L.) use as a potential therapeutic or preventive agent for a number of health conditions, including cancer, cardiovascular disease, and depression. OBJECTIVE: The purpose of this systematic review is to examine and categorize the current state of scientific evidence from randomized controlled trials (RCTs) regarding the efficacy of saffron on psychological/behavioral outcomes. SEARCH STRATEGY: Electronic and non-electronic systematic searches were conducted to identify all relevant human clinical research on saffron. The search strategy was extensive and was designed according to the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)." Reference lists of articles that met the inclusion criteria were searched. Only English language studies were reviewed. INCLUSION CRITERIA: Saffron trials in combination with other substances and saffron safety studies were considered, in accordance with the PRISMA statement. Included studies must have a control group. Included studies must measure a physiological and/or a behavioral outcome. DATA EXTRACTION AND ANALYSIS: The methodological quality of all included studies was independently evaluated by two reviewers using the Jadad score. Mean scores and P-values of measures were compared both inter- and intra-study for each parameter (i.e., depression). RESULTS: Twelve studies met our inclusion criteria. These studies examined the effects of saffron on psychological/behavioral outcomes of: major depressive disorder (n=6), premenstrual syndrome (n = 1), sexual dysfunction and infertility (n=4), and weight loss/snacking behaviors (n=1). The data from these studies support the efficacy of saffron as compared to placebo in improving the following conditions: depressive symptoms (compared to anti-depressants and placebo), premenstrual symptoms, and sexual dysfunction. In addition, saffron use was also effective in reducing excessive snacking behavior. CONCLUSION: Findings from initial clinical trials suggest that saffron may improve the symptoms and the effects of depression, premenstrual syndrome, sexual dysfunction and infertility, and excessive snacking behaviors. Larger multi-site clinical trials are needed to extend these preliminary findings.