Physical Activity and Different Concepts of Fall Risk Estimation in Older People--Results of the ActiFE-Ulm Study.

OBJECTIVES: To investigate the relationship between physical activity and two measures of fall incidence in an elderly population using person-years as well as hours walked as denominators and to compare these two approaches. DESIGN: Prospective cohort study with one-year follow-up of falls using fall calendars. Physical activity was defined as walking duration and recorded at baseline over one week using a thigh-worn uni-axial accelerometer (activPAL; PAL Technologies, Glasgow, Scotland). Average daily physical activity was extracted from these data and categorized in low (0-59 min), medium (60-119 min) and high (120 min and more) activity. SETTING: The ActiFE Ulm study located in Ulm and adjacent regions in Southern Germany. PARTICIPANTS: 1,214 community-dwelling older people (≥65 years, 56.4% men). MEASUREMENTS: Negative-binomial regression models were used to calculate fall rates and incidence rate ratios for each activity category each with using (1) person-years and (2) hours walked as denominators stratified by gender, age group, fall history, and walking speed. All analyses were adjusted either for gender, age, or both. RESULTS: No statistically significant association was seen between falls per person-year and average daily physical activity. However, when looking at falls per 100 hours walked, those who were low active sustained more falls per hours walked. The highest incidence rates of falls were seen in low-active persons with slow walking speed (0.57 (95% confidence interval (95% CI): 0.33 to 0.98) falls per 100 hours walked) or history of falls (0.60 (95% CI: 0.36 to 0.99) falls per 100 hours walked). CONCLUSION: Falls per hours walked is a relevant and sensitive outcome measure. It complements the concept of incidence per person years, and gives an additional perspective on falls in community-dwelling older people.

Serum Vitamin D Concentrations and Cognitive Function in a Population-Based Study among Older Adults in South Germany.

Our objective was to investigate the associations of vitamin D serum levels with dementia and cognitive function in specific domains in community dwelling older adults. Between 2009 and 2010, we conducted a cross-sectional study in 1,373 individuals (56% men) aged 65+ years in the "Activity and Function in the Elderly in Ulm" (ActiFE) study. Dementia was defined as a Mini-Mental State Examination (MMSE) score ≤ 24. The 25-OHD serum level [ng/mL] was measured by an electrochemilumineszenz immunoassay (ECLIA). Logistic regression models were used to calculate odds ratios (OR)s for cognitive domains (cut-point: 10th percentile) by serum 25-OHD concentrations (both continuously and by cut-point of 20 ng/ml for vitamin D deficiency). Mean age of the study population was 75.6 (SD 6.6) years.We identified 75 participants (43% women) with dementia. 25-OHD concentrations were significantly lower in the participants with dementia compared to persons with a MMSE score >24. We also observed an association of continuous 25-OHD serum concentrations with prevalence of dementia (crude OR 1.05, 95% confidence interval (CI), 1.01-1.08, p-value 0.009) per 1 ng/mL decrease, after adjustment the OR was 1.03, 95% CI, 0.995-1.08 (p-value 0.09). Although vitamin D deficiency was tentatively associated with severity of dementia measured by MMSE (OR 1.35, 95% CI, 0.84-2.19), the association was not statistically significant. However, deficits in specific cognitive domains such as executive functions, wordlist encoding, and visual memory (encoding and recall) were significantly associated with low vitamin D concentration. Our results suggest an association between vitamin D deficiency and cognitive function in specific domains in community dwelling older adults.

Objectively measured physical activity and vitamin D status in older people from Germany.

BACKGROUND: To analyse the seasonal relationship of objectively measured physical activity with vitamin D status in older persons from Southern Germany (latitude: 48.4°N). METHODS: Physical activity was assessed in 1193 community-dwelling individuals aged ≥65 years (58% men) over 1 week using a thigh-worn accelerometer. Furthermore, the 25-hydroxyvitamin D (25(OH)D) level was measured. Least-square means of 25(OH)D serum levels were calculated for quartiles of average daily walking duration stratified by season and adjusted for gender, age and body mass index. Participants with prescribed vitamin D supplements were excluded. RESULTS: Statistically significant linear associations between quartiles of walking duration with 25(OH)D serum levels were observed in all seasons but not in summer. Differences in 25(OH)D serum levels between the first and the last quartile were 3.42 ng/mL (p=0.002) in winter, 2.80 ng/mL (p=0.009) in spring, and 3.60 ng/mL (p<0.001) in the fall. The proportion of vitamin D insufficiency (<20 ng/mL) even in the highest quartile of walking duration was 45.3% in winter, 73.7% in spring, 17.4% in summer and 16.5% in the fall. CONCLUSIONS: Although a positive dose-response relationship was seen between walking duration and the 25(OH)D serum level for most seasons, vitamin D insufficiency was still very prevalent even in high-active persons during all seasons.

Predicting fatigue in older breast cancer patients receiving radiotherapy. A head-to-head comparison of established assessments.

OBJECTIVES: Because of substantial toxicities in older adults, chemotherapy is often omitted while the frequency of radiotherapy changes only minimally. In this study, we addressed the value of different assessments for predicting fatigue after radiotherapy in older breast cancer patients. PATIENTS AND METHODS: We included 74 women with primary breast cancer over the age of 65 years treated with radiotherapy (26 % with additional chemotherapy). Assessments were conducted before adjuvant treatment and after radiotherapy. The assessments included the Vulnerable Elders Survey (VES-13), the Karnofsky Performance Status (KPS), the EORTC Quality of Life assessment (EORTC-QLQ-C30), a cancer-specific comprehensive geriatric assessment (cancer-specific CGA), and the Fried frailty score. Multiple linear regression analyses were used to assess correlations with the FACIT-fatigue scale. RESULTS: Patients were on average 71 years old (range, 65-86 years). Most tumors (n=62) were classified as intermediate risk according to the St. Gallen consensus. The cancer-specific CGA was best associated with fatigue (p < 0.001, ß estimate = 1.75), followed by the Fried frailty score (for the score of 1 versus reference of 2 and higher: p = 0.035, ß estimate = - 5.74). There were no significant ceiling effects but there were substantial floor effects for the VES-13, KPS, and frailty score. CONCLUSION: The cancer-specific CGA and the Fried frailty score (driven mainly by the item "exhaustion") outperformed the other indices in predicting fatigue in a group of rather well-functioning older women with primary breast cancer.

Factors associated with fear of falling and associated activity restriction in community-dwelling older adults: a systematic review.

OBJECTIVE: Fear of falling (FOF) is an important threat to autonomy. Current interventions to reduce FOF have yielded conflicting results. A possible reason for this discrepancy could be its multicausality. Some risk factors may not have been identified and addressed in recent studies. The last systematic review included studies until 2006. METHODS: To identify additional risk factors for FOF and to test those mentioned previously, we conducted a systematic literature review. Studies examining FOF in community-dwelling older adults between 2006 and October 2013 were screened. RESULTS: Outcomes are summarized with respect to different constructs such as FOF, fall-related self-efficacy/balance confidence, and FOF-related activity restriction. Odds ratios and p values are reported. There is no clear pattern with regard to the different FOF-related constructs studied. The only parameters robustly associated across all constructs were female gender, performance-based and questionnaire-based physical function, the use of a walking aid, and, less robust, a history of falls and poor self-rated health. Conflicting results were identified for depression and anxiety, multiple drugs, and psychotropic drugs. Other potentially modifiable risk factors were only mentioned in one or two studies and warrant further investigation. Parameters with mainly negative results are also presented. CONCLUSION: Only few risk factors identified were robustly associated across all FOF-related constructs and should be included in future studies on FOF. Some newer factors have to be tested again in different cohorts. The comprehensive overview might assist in the conceptualization of future studies.

Insomnia in long-term care facilities: a comparison of seven European countries and Israel: the Services and Health for Elderly in Long TERm care study.

OBJECTIVES: To assess insomnia and its correlates as part of the Services and Health for Elderly in Long TERm care (SHELTER) study, funded by the 7th Framework Programme of the European Union. DESIGN: Cross-cultural investigation. SETTING: Long-term care facilities (LTCFs) in eight European countries (Czech Republic, France, Finland, Germany, England, the Netherlands, Italy) and one non-European country (Israel). PARTICIPANTS: Elderly residents (N = 4,156) of 57 LTCFs. MEASUREMENTS: Information on insomnia, age, sex, activities of daily living (ADLs), cognitive status, depression, major stressful life events, physical activity, fatigue, pain, and sleep medication use was extracted from the International Resident Assessment Instrument (interRAI)LTCF instrument. Rates of insomnia and its correlates were analyzed. Multivariate logistic regression was used to assess factors associated with insomnia, controlling for demographic variables. RESULTS: The prevalence of insomnia was 24% (range 13-30%), with significant differences between countries (P < .001). More insomnia complaints were reported in older than younger residents (P < .001). Higher rates of insomnia were associated with hypnosedatives and depression in all countries (P < .001) and with stressful life events, fatigue, and pain in most countries (P < .001). No associations were found between insomnia and ADLs, physical activity, or cognitive status. Age, depression, stressful life events, fatigue, pain and hypnosedatives were independent significant predictors of insomnia, controlling for all other variables and for country. CONCLUSION: Hypnosedatives and depression were strong predictors of insomnia beyond cultural differences. Overall, psychosocial variables were more strongly related to insomnia than functional and mental capacities.

Relationships between physical performance and knee and hip osteoarthritis: findings from the European Project on Osteoarthritis (EPOSA).

BACKGROUND: poor physical performance (PP) is known to be associated with disability, lower quality of life and higher mortality rates. Knee and hip osteoarthritis (OA) might be expected to contribute to poor PP, through joint pain and restricted range of movement. Both clinical and self-reported OA are often used for large-scale community and epidemiological studies. OBJECTIVE: to examine the relationships between hip and knee OA and PP in a large data set comprising cohorts from six European countries. METHODS: a total of 2,942 men and women aged 65-85 years from the Germany, Italy, Netherlands, Spain, Sweden and the UK were recruited. Assessment included an interview and clinical assessment for OA. PP was determined from walking speed, chair rises and balance (range 0-12); low PP was defined as a score of ≤9. RESULTS: the mean (SD) age was 74.2 (5.1) years. Rates of self-reported OA were much higher than clinical OA. Advanced age, female gender, lower educational attainment, abstinence from alcohol and higher body mass index were independently associated with low PP. Clinical knee OA, hip OA or both were associated with a higher risk of low PP; OR (95% CI) 2.93 (2.36, 3.64), 3.79 (2.49, 5.76) and 7.22 (3.63, 14.38), respectively, with relationships robust to adjustment for the confounders above as well as pain. CONCLUSION: lower limb OA at the hip and knee is associated with low PP, and for clinical diagnosis relationships are robust to adjustment for pain. Those at highest risk have clinical OA at both sites.

Multisite pain, pain frequency and pain severity are associated with depression in older adults: results from the ActiFE Ulm study.

BACKGROUND: there is ample literature showing pain and depression are related. However, different dimensions of pain have been used in former studies. OBJECTIVE: the objective of the study was to compare the strength of the association of different pain dimensions with depression in older adults. METHODS: assessments including evaluation of pain (severity, frequency, chronicity, quality, pain medication, painful body sites) and depression (measured by the Hospital Anxiety and Depression Scale) were performed in an observational study in community dwelling older adults (sample mean age 76, n = 1130) in Germany. The associations of different dimension of pain with depression were assessed using descriptive and multivariate methods. RESULTS: the number of painful body areas was most significantly associated with self-reported late life depression (OR 1.20, CI 1.11-1.31). Pain severity and frequency (OR 1.12, CI 1.01-1.23 and OR 1.18, CI 1.01-1.37) were also associated with depression; quality and duration were not. Except for severity (OR 1.12, CI 1.02-1.24) associations of pain dimensions were strongly reduced when controlling for relevant confounders and gender was an effect modifier. CONCLUSIONS: multisite pain, pain severity and frequency were the best predictors of late life depression. Clinicians should be especially aware of depressive disorders when older patients are complaining of pain in multiple areas across the body.

Treatment of pain in European nursing homes: results from the Services and Health for Elderly in Long TERm Care (SHELTER) study.

OBJECTIVE: To identify pharmacological and nonpharmacological pain management approaches and associated factors in nursing home residents across Europe. SETTING, PARTICIPANTS, AND MEASUREMENTS: Cross-sectional study with 4156 residents who were assessed using the interRAI instrument for Long Term Care Facilities (interRAI LTCF), including pharmacological and nonpharmacological pain management modalities. Those reporting pain were included in the analyses (n = 1900). A deeper analysis was performed for the subsample of residents who reported "current pain," defined as pain at least 1 day within the past 3 days (n = 838), and those who reported "current pain of moderate to severe intensity" (n = 590). RESULTS: Up to 24% of residents who reported pain did not receive any pain medication and up to 11% received it only PRN (as-needed basis), independent of current pain-intensity levels; 61% did not receive any nonpharmacological treatment and 21% received neither pharmacological nor nonpharmacological pain modalities. Considerable differences could be demonstrated across European countries. Factors positively associated with pharmacological pain management were being of female gender, reporting cancer, and having moderate or severe pain. High turnover rates of regular staff and low-to-moderate physicians' availability were negatively associated. Factors positively associated with nonpharmacological treatment were fractures and need of assistance in activities of daily living. Dementia, large nursing home facilities, above-average and high turnover rates of nursing staff, a low physicians' availability, and severe pain intensity were negatively associated. CONCLUSION: Despite some advances in recent years, pain treatment in European nursing home residents remains to be suboptimal and requires further improvement.

Seasonality of vitamin D status in older people in Southern Germany: implications for assessment.

BACKGROUND: from a clinical and public health perspective, it is important to understand the influence of seasonality on the serum vitamin D level to adequately assess and interpret an individual measurement. Therefore, the aim of this study was to analyse the effects of seasonal conditions on 25-hydroxyvitamin D (25(OH)D) serum levels in a population-based cohort of older people. METHODS: between March 2009 and April 2010 the 25(OH)D serum level was assessed in 1,418 community-dwelling individuals living in Germany aged ≥65 years (56.7% men) with no subscribed vitamin D supplementation. Least-square means of monthly 25(OH)D serum levels with 95% confidence intervals (CI) were estimated, adjusted for gender, age and body mass index. Additionally, the proportion of vitamin deficiency (<20 ng/ml), insufficiency (20-<30 ng/ml) and sufficiency (30 ng/ml or higher) were estimated for each month. Finally, mean values of daily total global solar radiation and daylight were calculated for each month. RESULTS: the minimum 25(OH)D serum level was observed in March with 15.4 ng/ml (SD = 6.56 ng/ml) and the maximum in August with 25.6 ng/ml (SD = 6.59 ng/ml). Compared with daylight and global solar radiation the progression over the year was similar but delayed by ∼2 months. The proportion of vitamin D deficiency, insufficiency and sufficiency were 78.8, 19.2 and 1.9% in March and 16.1, 63.4 and 20.5% in August, respectively. CONCLUSION: vitamin D insufficiency was very common in this cohort and showed a strong seasonal effect with lowest values in March.

European project on osteoarthritis: design of a six-cohort study on the personal and societal burden of osteoarthritis in an older European population.

BACKGROUND: Osteoarthritis (OA), the most common form of arthritis, is a major contributor to functional impairment and loss of independence in older persons. The European Project on OSteoArthritis (EPOSA) is a collaborative study involving six European cohort studies on ageing. This project focuses on the personal and societal burden and its determinants of osteoarthritis. This paper describes the design of the project, and presents some descriptive analyses on selected variables across countries. METHODS/DESIGN: EPOSA is an observational study including pre-harmonized data from European cohort studies (Germany, Italy, the Netherlands, Spain, Sweden and the United Kingdom) on older community-dwelling persons aged 65 to 85 years. In total, 2942 persons were included in the baseline study with a mean age of 74.2 years (SD 5.1), just over half were women (51,9%). The baseline assessment was conducted by a face-to-face interview followed by a clinical examination. Measures included physical, cognitive, psychological and social functioning, lifestyle behaviour, physical environment, wellbeing and care utilisation. The clinical examination included anthropometry, muscle strength, physical performance and OA exam. A follow-up assessment was performed 12-18 months after baseline. DISCUSSION: The EPOSA study is the first population-based study including a clinical examination of OA, using pre-harmonized data across European countries. The EPOSA study provides a unique opportunity to study the determinants and consequences of OA in general populations of older persons, including both care-seeking and non care-seeking persons.

Pain characteristics and pain control in European nursing homes: cross-sectional and longitudinal results from the Services and Health for Elderly in Long TERm care (SHELTER) study.

OBJECTIVE AND DESIGN: Few studies have compared cross-national characteristics of residents with pain in European long term care facilities. The SHELTER project, a cross-national European study on nursing home residents, provides the opportunity to examine this issue. The present study aimed to evaluate key figures about pain and compare them with seven European countries and Israel. SETTING, PARTICIPANTS, AND MEASUREMENTS: A total of 3926 nursing home residents were assessed by the interRAI instrument for Long Term Care Facilities (interRAI LTCF). Prevalence of pain, frequency, intensity, consistency, and control were estimated and compared cross-nationally. Correlates between patient-related characteristics and inadequate pain management were tested using bivariate and multivariate logistic regression models. RESULTS: Overall, 1900 (48.4%) residents suffered from pain. Pain prevalence varied significantly among countries, ranging from 19.8% in Israel to 73.0% in Finland. Pain was positively associated with female gender, fractures, falls, pressure ulcers, sleeping disorders, unstable health conditions, cancer, depression, and number of drugs. It was negatively associated with dementia. In a multivariate logistic regression model, all associations remained except for sleeping disorders. Clinical correlations varied considerably among countries. Although in 88.1% of cases, pain was self-rated by the residents as sufficiently controlled, in only 56.8% of cases was pain intensity self-rated as absent or mild. Pain control and intensity improved within 1 year. CONCLUSION: Pain prevalence is high and varies considerably across Europe. Although most residents considered pain as adequately controlled, a closer look confirmed that many still suffer from high pain intensities. Analyzing the reasons behind these differences may help to improve pain management.

Association of objectively measured physical activity with established and novel cardiovascular biomarkers in elderly subjects: every step counts.

OBJECTIVE: To analyse the relationship between objectively measured daily walking duration and cardiovascular biomarkers of inflammation, cardiac dysfunction and renal impairment. METHODS: Between March 2009 and April 2010, physical activity was assessed in 1253 community-dwelling individuals living in Germany aged ≥65 years (57% men) over 1 week using a thigh-worn accelerometer. C reactive protein (CRP), white blood cells (WBC), N-terminal pro-brain natriuretic peptide, high-sensitive troponin T (hsTnT), creatinine (Cr) and cystatin C (CysC) were also measured. Least-square means of daily walking duration were calculated for quartiles of each biomarker adjusted for sex, age, pre-existing cardiovascular disease and smoking status. RESULTS: After adjustment for covariates, statistically significant linear associations with walking duration were observed for WBC, hsTnT, Cr and CysC. CRP quartiles 1 and 2 showed no significant difference followed by a significant inverse dose-response relationship. A similar pattern, but less pronounced, was seen for N-terminal pro-brain natriuretic peptide. Mean differences between the first two quartiles of CRP and its fourth quartile were 17 min. Between categories 1 (more beneficial) and 4 of WBC, hsTnT, Cr and CysC the differences were 15, 12, 23 and 20 min, respectively. CONCLUSION: Increased walking duration is associated with a more favourable profile of cardiovascular biomarkers in elderly subjects.

Dietary antioxidants and dementia in a population-based case-control study among older people in South Germany.

Oxidative stress is believed to play a central role in the pathogenesis of Alzheimer's disease (AD), a neurodegenerative disease. Antioxidants may prevent the onset AD as high dietary intake of vitamin C and E were reported to be associated with lower risk of the disease. The objective of this study was to evaluate the serum levels of antioxidants in persons with mild dementia to test whether it is associated with lower levels of antioxidants in a cross-sectional study in the population of the "Activity and Function in the Ederly in Ulm" (ActiFE) study. Main exposure measures were vitamin C, vitamin E, ß-carotene, lycopene, and coenzyme Q10 as analyzed by HPLC. Main outcome measures were mild cognitive impairment among 74 mildly demented compared to 158 age- and gender-matched controls. We found that blood vitamin C and ß-carotene concentrations were significantly lower in demented than in control persons even after adjusting for school education, intake of dietary supplements, smoking habits, body mass index, and alcohol consumption (3rd versus 1st tertile: OR: 0.29, 95% CI, 0.09-0.96 and 0.13, 95% CI, 0.03-0.55, respectively). No associations were found for vitamin E, lycopene, and coenzyme Q10. Our findings suggest an association of vitamin C and ß-carotene with dementia. However this is limited to the cross-sectional character of our study and longitudinal data will give further insight into this association.

Prevalence and determinants of chronic kidney disease in community-dwelling elderly by various estimating equations.

BACKGROUND: Chronic kidney disease (CKD) represents a global public health problem. Few data exist in the elderly. The objective of the current study is to estimate the prevalence of CKD by means of various established and new equations and to identify the main determinants of CKD in elderly. METHODS: The ActiFE Ulm (Activity and Function in the Elderly in Ulm) study is a population-based cohort study in people of 65 years and older. Kidney function was assessed by means of estimated glomerular filtration rate (eGFR) based on two creatinine- (Cr-; MDRD, CKD-EPI) and one cystatin C - (CysC-) based method. The relationship between various potential risk factors and CKD was quantified using unconditional logistic regression. RESULTS: A total of 1471 subjects were in the final analysis (mean age 75.6 years, SD 6.56). Overall, prevalence of CKD (eGFR < 60 mL/min/1.73 m(2)) was 34.3% by MDRD, 33.0% by CKD-EPI, and 14.6% by the CysC-based eGFR. All eGFRs showed statistically significant correlations with C-reactive protein, uric acid, as well as with lipid values. In multivariable analysis age was clearly related to prevalence of CKD and the risks were highest with the CysC-based equation. Females had a higher risk for CKD stages 3-5 with MDRD (OR 1.63; 95% CI: 1.23-2.16) whereas the OR was 1.23 (95% CI 0.92-1.65) with the CKD-Epi and OR = 0.89 (95% CI 0.58-1.34) with the CysC-based equation after multivariable adjustment. Although the cystatin C based definition of CKD resulted in a lower prevalence compared to the creatinine based ones, other measures of renal damage such as albuminuria were more prevalent in those defined by CysC-eGFR. CONCLUSIONS: Prevalence of CKD is very variable based on the used estimating equation. More work is needed to evaluate the various estimating equations especially in elderly before we are able to assess the practical consequences of the observed differences.

Assessment of nursing home residents in Europe: the Services and Health for Elderly in Long TERm care (SHELTER) study.

BACKGROUND: Aims of the present study are the following: 1. to describe the rationale and methodology of the Services and Health for Elderly in Long TERm care (SHELTER) study, a project funded by the European Union, aimed at implementing the interRAI instrument for Long Term Care Facilities (interRAI LTCF) as a tool to assess and gather uniform information about nursing home (NH) residents across different health systems in European countries; 2. to present the results about the test-retest and inter-rater reliability of the interRAI LTCF instrument translated into the languages of participating countries; 3 to illustrate the characteristics of NH residents at study entry. METHODS: A 12 months prospective cohort study was conducted in 57 NH in 7 EU countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands) and 1 non EU country (Israel). Weighted kappa coefficients were used to evaluate the reliability of interRAI LTCF items. RESULTS: Mean age of 4156 residents entering the study was 83.4 ± 9.4 years, 73% were female. ADL disability and cognitive impairment was observed in 81.3% and 68.0% of residents, respectively. Clinical complexity of residents was confirmed by a high prevalence of behavioral symptoms (27.5% of residents), falls (18.6%), pressure ulcers (10.4%), pain (36.0%) and urinary incontinence (73.5%). Overall, 197 of the 198 the items tested met or exceeded standard cut-offs for acceptable test-retest and inter-rater reliability after translation into the target languages. CONCLUSION: The interRAI LTCF appears to be a reliable instrument. It enables the creation of databases that can be used to govern the provision of long-term care across different health systems in Europe, to answer relevant research and policy questions and to compare characteristics of NH residents across countries, languages and cultures.

A short easy test can detect ability for autonomous insulin injection by the elderly with diabetes mellitus.

OBJECTIVE: Elderly patients with diabetes often have difficulty with self-administering insulin. It was the aim of the present study to find a short, easy performance test, such as the Timed Test of Money Counting (TTMC), that identifies elderly patients with diabetes, in grade to undertake proper insulin injection autonomously and correctly. PATIENTS AND METHODS: A total of 73 insulin-dependent patients (age 77.3 ± 7.1 years, HbA1c 8.2% ± 2.0%) completed the TTMC as part of a comprehensive geriatric assessment before and 3 months after structured diabetes education. RESULTS: The TTMC showed a sensitivity of 69.2% for autonomous injection of insulin 3 months after diabetes education, if patients performed the test within a time duration of less than 46 seconds. Specificity is 70% and positive predictive value 78.7% in this case. STUDY IMPLICATION: The TTMC seems to be a suitable predictor for ability to inject insulin autonomously after receiving diabetes education. The expenditure of time is only about 5 minutes and it helps to identify patients with diabetes who are able to inject insulin themselves after diabetes education.

Association of pain with behavioral and psychiatric symptoms among nursing home residents with cognitive impairment: results from the SHELTER study.

The etiology of behavioral and psychiatric symptoms is generally considered to be multifactorial, and these symptoms often indicate a need for care or assistance, which may include the presence of uncontrolled pain. The aim of this cross-sectional study was to assess the association of pain with behavioral and psychiatric symptoms in a population of nursing home (NH) residents with cognitive impairment in Europe. Data are from the SHELTER project, which contains information on NH residents in 8 countries. Pain was defined as any type of physical pain or discomfort in any part of the body in the 3 days before the assessment. The mean age of 2822 cognitively impaired residents entering the study was 84.1 (standard deviation 9.1)years, and 2110 (74.8%) were women. Of the total sample, 538 residents (19.1%) presented with pain. After adjusting for potential confounders, pain was significantly and positively associated with socially inappropriate behavior (odds ratio [OR] 1.37; 95% confidence interval [CI] 1.04-1.80), resistance to care (OR 1.41; 95% CI 1.08-1.83), abnormal thought process (OR 1.48; 95% CI 1.16-1.90), and delusions (OR 1.48; 95% CI 1.07-2.03). A borderline inverse association was observed with wandering (OR 0.74; 95% CI 0.55-1.00). In conclusion, this cross-sectional study provides evidence from a large sample of frail elderly showing an association between pain and behavioral and psychiatric symptoms. Treatment models that put together assessment and treatment of pain and evaluate their effect on behavioral and psychiatric symptoms are needed.

Assessing Physical Activity in Inpatient Rehabilitation: validity, practicality, and sensitivity to change in the physical activity in inpatient rehabilitation assessment.

OBJECTIVE: To validate a novel assessment of inpatient physical activity. DESIGN: Prospective cohort study for the evaluation of a novel questionnaire for physical activity in geriatric inpatients. SETTING: German geriatric inpatient rehabilitation unit. PARTICIPANTS: Patients (N=96; 67 [72%] women; median age, 81y) with a variety of main underlying diagnoses, including musculoskeletal diseases, hip fracture, cardiovascular diseases, stroke, and others. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Ceiling and floor effects and administration time were measured. For criterion-related concurrent validity (convergent and discriminative), the Physical Activity in Inpatient Rehabilitation Assessment (PAIR) was administered in parallel to self-rated, proxy-rated, and performance-based measures of physical function at admission. Measurements were repeated at discharge and 4-month follow-up in the home environment, including a standard physical activity questionnaire to determine predictive validity. Spearman correlation coefficients were calculated to describe associations between parameters. Sensitivity to change was estimated using standardized response means (SRMs). RESULTS: Administration time of the PAIR ranged from less than 1 to 4 minutes. Ceiling effects occurred mainly at discharge (5%-14%), and floor effects (5%-11%), at admission. There were no missing values. Associations between convergent and predictive validity measures and functional measures (r=.43-.53, r=.49-.54, respectively) were clearly better when cognition was intact. Discriminative validity expressed as effect sizes ranged from .27 to 1.44. The SRM to describe sensitivity to change was .65 for the total score. CONCLUSIONS: The PAIR is the first validated questionnaire to assess physical activity in geriatric inpatients. It is practical and its validity and sensitivity to change are similar to existing physical activity questionnaires for community-dwelling older persons.

European Project on OSteoArthritis (EPOSA): methodological challenges in harmonization of existing data from five European population-based cohorts on aging.

BACKGROUND: The European Project on OSteoArthritis (EPOSA), here presented for the first time, is a collaborative study involving five European cohort studies on aging. This project focuses on the personal and societal burden and its determinants of osteoarthritis (OA). The aim of the current report is to describe the purpose of the project, the post harmonization of the cross-national data and methodological challenges related to the harmonization process METHODS: The study includes data from cohort studies in five European countries (Germany, Italy, the Netherlands, Spain and the United Kingdom) on older community-dwelling persons aged ≥ 59 years. The study design and main characteristics of the five cohort studies are described. Post harmonization algorithms are developed by finding a "common denominator" to merge the datasets and weights are calculated to adjust for differences in age and sex distribution across the datasets. RESULTS: A harmonized database was developed, consisting of merged data from all participating countries. In total, 10107 persons are included in the harmonized dataset with a mean age of 72.8 years (SD 6.1). The female/male ratio is 53.3/46.7%. Some variables were difficult to harmonize due to differences in wording and categories, differences in classifications and absence of data in some countries. The post harmonization algorithms are described in detail in harmonization guidelines attached to this paper. CONCLUSIONS: There was little evidence of agreement on the use of several core data collection instruments, in particular on the measurement of OA. The heterogeneity of OA definitions hampers comparing prevalence rates of OA, but other research questions can be investigated using high quality harmonized data. By publishing the harmonization guidelines, insight is given into (the interpretation of) all post harmonized data of the EPOSA study.