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Background Methods Results Conclusions Life‐space mobility captures the daily, enacted mobility of older adults. We determined cross‐sectional associations between life‐space mobility and cognitive impairment (CI) among community‐dwelling women in the 9th and 10th decades of life.A total of 1375 (mean age 88 years; 88% White) community‐dwelling women enrolled in a prospective cohort of older women. Life‐space score was calculated with range 0 (daily restriction to one's bedroom) to 120 (daily trips leaving town without assistance) and categorized (0–20, 21–40, 41–60, 61–80, 81–120). The primary outcome was adjudicated CI defined as mild cognitive impairment or dementia; scores on a 6‐test cognitive battery were secondary outcomes.Compared to women with life‐space scores of 81–120 and after adjustment for demographics and depressive symptoms, the odds of CI was 1.4‐fold (OR 1.36, 95% CI 0.91–2.03) higher for women with life‐space scores of 61–80, twofold (OR 1.98, 95% CI 1.33–2.94) higher for women with life‐space scores of 41–60, 2.6‐fold (OR 2.62, 95% CI 1.71–4.01) higher for women with life‐space scores of 21–40, and 2.7‐fold (OR 2.71, 95% CI 1.27–5.79) higher for women with life‐space scores of 0–20. The association of life‐space scores with adjudicated CI was primarily due to higher odds of dementia; the odds of dementia versus normal cognition was eightfold (OR 8.63, 95% CI 3.20–23.26) higher among women with life‐space scores of 0–20 compared to women with life‐space scores of 81–120. Lower life‐space scores were associated in a graded manner with lower mean scores on tests of delayed recall (California Verbal Learning Test‐II delayed recall) and language and executive function (phonemic fluency, category fluency, and Trails B). Life‐space score was not associated with scores on tests of attention and working memory (forward and backward digit span).Lower life‐space mobility is associated in a graded manner with CI among community‐dwelling White women in the 9th and 10th decades of life. [ABSTRACT FROM AUTHOR]

BACKGROUND: Persons with dementia (PWD) have high rates of polypharmacy. While previous studies have examined specific types of problematic medication use in PWD, we sought to characterize a broad spectrum of medication misuse and overuse among community-dwelling PWD. METHODS: We included community-dwelling adults aged ≥66 in the Health and Retirement Study from 2008 to 2018 linked to Medicare and classified as having dementia using a validated algorithm. Medication usage was ascertained over the 1-year prior to an HRS interview date. Potentially problematic medications were identified by: (1) medication overuse including over-aggressive treatment of diabetes/hypertension (e.g., insulin/sulfonylurea with hemoglobin A1c

Background: Spouses of persons living with dementia may face heightened psychosocial distress in the years immediately before and after their partner's death. We compared the psychosocial needs of spouses of partners with dementia with spouses of partners with non‐impaired cognition nearing and after the end of life, focusing on loneliness, depression, life satisfaction, and social isolation. Methods: We used nationally representative Health and Retirement Study married couples data (2006–2018), restricting to spouses 50+ years old. We included 2098 spouses with data on loneliness and depressive symptoms 2 years before and after the partner's death. We additionally examined a subset of spouses (N = 1113) with available data on life satisfaction and social isolation 2 years before their partner's death. Cognitive status of partners was classified as non‐impaired cognition, cognitive impairment not dementia (cognitive impairment), and dementia. We used multivariable logistic regression to determine: 1) the change in loneliness and depression for spouses pre‐ and post‐partner's death, and 2) life satisfaction and social isolation 2 years before the partner's death. Results: Spouses were on average 73 years old (SD: 10), 66% women, 7% Black, 7% Hispanic non‐White, 24% married to persons with cognitive impairment, and 19% married to partners with dementia. Before their partner's death, spouses married to partners with dementia experienced more loneliness (non‐impaired cognition: 8%, cognitive impairment: 16%, dementia: 21%, p‐value = 0.002) and depressive symptoms (non‐impaired cognition: 20%, cognitive impairment: 27%, dementia: 31%, p‐value < 0.001), and after death a similar prevalence of loneliness and depression across cognitive status. Before their partner's death, spouses of partners with dementia reported less life satisfaction (non‐impaired cognition: 74%, cognitive impairment: 68%; dementia: 64%, p‐value = 0.02) but were not more socially isolated. Conclusion: Results emphasize a need for clinical and policy approaches to expand support for the psychosocial needs of spouses of partners with dementia in the years before their partner's death rather than only bereavement. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions More than one‐fourth of older adults with cognitive impairment (CI) live alone; these individuals often lack support for medication management and face a high risk of adverse drug events. We characterized the frequency and types of high‐risk medications used by older adults with CI living alone and, for context, compared patterns with those in older adults with CI living with others.This was a cross‐sectional study of National Health and Aging Trends Study (NHATS) data and Medicare claims (2015–2017). We ascertained cognitive status from NHATS and medication use with Part D claims. We compared high‐risk medication use (those with adverse cognitive effects or low tolerance for misuse) among older adults with CI living alone versus living with others using logistic regression models adjusted for demographic/clinical factors.The unweighted sample included 1569 older adults with CI, of whom 491 (weighted national estimate, 31%) were living alone. In the living‐alone group, the mean age was 79.9 years and 66% were female, 64% reported managing medications on their own without difficulty, 14% reported managing medications on their own with difficulty, and 18% received total support with medication management. Older adults with CI living alone used a median of 5 medications (IQR, 3–8), 16% took ≥10 medications, and 46% took ≥1 high‐risk medication (anticholinergic/sedating: 24%; opioid: 13%; anticoagulant: 10%; sulfonylurea: 10%; insulin: 9%). Compared with those living with others, the use of high‐risk medications was similar (p > 0.05 for unadjusted/adjusted comparisons). Those living alone were more likely both to take at least one high‐risk medication and not receive help with medication management: 34% in those living alone versus 23% living with others (p < 0.05 for unadjusted/adjusted comparisons).Older adults with CI living alone use many medications; nearly half use high‐risk medications. Our findings can inform medication optimization interventions supporting this vulnerable population. [ABSTRACT FROM AUTHOR]

Background: Cognitive impairment is strongly associated with atrial fibrillation (AF). Rate and rhythm control are the two treatment strategies for AF and the effect of treatment strategy on risk of cognitive decline and frailty is not well established. We sought to determine how treatment strategy affects geriatric‐centered outcomes. Methods: The Systematic Assessment of Geriatric Elements‐AF (SAGE‐AF) was a prospective, observational, cohort study. Older adults with AF were prospectively enrolled between 2016 and 2018 and followed longitudinally for 2 years. In a non‐randomized fashion, participants were grouped by rate or rhythm control treatment strategy based on clinical treatment at enrollment. Baseline characteristics were compared. Longitudinal binary mixed models were used to compare treatment strategy with respect to change in cognitive function and frailty status. Cognitive function and frailty status were assessed with the Montreal Cognitive Assessment Battery and Fried frailty phenotype tools. Results: 972 participants (mean age = 75, SD = 6.8; 49% female, 87% non‐Hispanic white) completed baseline examination and 2‐year follow‐up. 408 (42%) were treated with rate control and 564 (58%) with rhythm control. The patient characteristics of the two groups were different at baseline. Participants in the rate control group were older, more likely to have persistent AF, prior stroke, be treated with warfarin and have baseline cognitive impairment. After adjusting for baseline differences, participants treated with rate control were 1.5 times more likely to be cognitively impaired over 2 years (adjusted OR: 1.47, 95% CI:1.12, 1.98) and had a greater decline in cognitive function (adjusted estimate: −0.59 (0.23), p < 0.01) in comparison to rhythm control. Frailty did not vary between the treatment strategies. Conclusions: Among those who had 2‐year follow‐up in non‐randomized observational cohort, the decision to rate control AF in older adults was associated with increased odds of decline in cognitive function but not frailty. [ABSTRACT FROM AUTHOR]

Introduction: Among older adults undergoing surgery, postoperative delirium is the most common complication. Cognitive impairment and dementia are major risk factors for postoperative delirium, yet they are frequently under‐recognized. It is well established that applying delirium preventive interventions to at‐risk individuals can reduce the likelihood of delirium by up to 40%. The aim of this study was to evaluate how often delirium preventive interventions are missing in patients at risk for delirium due to baseline cognitive impairment. Methods: We conducted a retrospective study using data from the observational study Perioperative Anesthesia Neurocognitive Disorder Assessment‐Geriatric (PANDA‐G) and clinical data from the University of California San Francisco delirium prevention bundle. Patients age 65+ received preoperative multidomain cognitive assessment as part of a research protocol prior to undergoing inpatient spine surgery at a single major academic institution. Results of the cognitive testing were not available to clinical teams. Using electronic medical records, we evaluated if patients who were cognitively impaired at baseline received delirium prevention orders, sleep orders, and avoidance of AGS Beers Criteria® potentially inappropriate medications. Results: Of the 245 patients included in the study, 42% were women. The mean [SD] age was 72 [5.2] years. Preoperative cognitive impairment was identified in 40% of participants (N = 98), and of these, 34% had postoperative delirium. Of patients with preoperative cognitive impairment, 45% did not receive delirium preventive orders, 43% received PIMs, and 49% were missing sleep orders. At least one of the three delirium preventive interventions was missing in 70% of the patients. Discussion: Undiagnosed preoperative cognitive impairment among older adults undergoing spine surgery is common. When cognitive test results were not available to clinicians, patients with baseline cognitive impairment frequently did not receive evidence‐based delirium preventive interventions. These findings highlight an opportunity to improve perioperative brain health care via preoperative cognitive assessment and clinical communication. [ABSTRACT FROM AUTHOR]

Background: The prevalence of cognitive impairment in home health physical therapy (HHPT) is unknown. We sought to identify the prevalence of cognitive impairment, including cognitive impairment no dementia (CIND) and dementia, among older adults who used HHPT, and if cognitive impairment prevalence was higher among those with HHPT‐relevant characteristics. Methods: For our cross‐sectional analysis, we identified 963 fee‐for‐service Medicare beneficiaries with HHPT claims (>85 years old: 28.8%, women: 63.7%, non‐Hispanic White: 82.1%) in the 2014 and 2016 waves of the Health and Retirement Study (HRS) and used a validated algorithm to categorize cognitive status as normal, CIND, or dementia. We estimated the population prevalence and calculated age, gender, race/ethnicity adjusted odds ratio (aOR) of CIND and dementia for characteristics relevant to HHPT service delivery including depression, walking difficulty, fall history, incontinence, moderate‐vigorous physical activity (MVPA) ≤1x/week, and community‐initiated HHPT using multinomial logistic regression. Results: The population prevalence of cognitive impairment was 46.4% (CIND: 27.3%, dementia: 19.1%). The prevalence of cognitive impairment was greater among those with depression (46.7% vs. 39.5%), difficulty walking across the room (58.9% vs. 41.8%), fall history (49.1% vs. 42.9%), MVPA ≤1x/week (50.0% vs. 38.0%), and community‐initiated HHPT (55.2% vs. 40.2%). Compared to normal cognitive status, the odds of cognitive impairment were greater for those with MVPA≤1x/week (CIND: aOR = 1.57 [95% CI: 1.05–2.33], dementia: aOR = 2.55 [95% CI: 1.54–4.22]), depression (dementia: aOR = 1.99 [95% CI: 1.19–3.30]), difficulty walking across the room (dementia: aOR = 2.54 [95% CI: 1.40–4.60]), fall history (dementia: aOR = 1.85 [95% CI: 1.20–2.83]), and community‐initiated HHPT (dementia: aOR = 1.72 (95% CI: 1.13–2.61]). Conclusion: There is a high prevalence of CIND and dementia in HHPT, and no characteristics had a low prevalence of cognitive impairment. Physical therapists should be ready to identify cognitive impairment and adapt home health service delivery for this vulnerable population of older adults. [ABSTRACT FROM AUTHOR]

BACKGROUND: Guidelines recommend nursing home (NH) residents with cognitive impairment receive less intensive glycemic treatment and less frequent fingerstick monitoring. Our objective was to determine whether current practice aligns with guideline recommendations by examining fingerstick frequency in Veterans Affairs (VA) NH residents with diabetes across cognitive impairment levels. METHODS: We identified VA NH residents with diabetes aged ≥65 residing in VA NHs for >30 days between 2016 and 2019. Residents were grouped by cognitive impairment status based on the Cognitive Function Scale: cognitively intact, mild impairment, moderate impairment, and severe impairment. We also categorized residents into mutually exclusive glucose-lowering medication (GLM) categories: (1) no GLMs, (2) metformin only, (3) sulfonylureas/other GLMs (+/- metformin but no insulin), (4) long-acting insulin (+/- oral/other GLMs but no short-acting insulin), and (5) any short-acting insulin. Our outcome was mean daily fingersticks on day 31 of NH admission. RESULTS: Among 13,637 NH residents, mean age was 75 years and mean hemoglobin A1c was 7.0%. The percentage of NH residents on short-acting insulin varied by cognitive status from 22.7% in residents with severe cognitive impairment to 33.9% in residents who were cognitively intact. Mean daily fingersticks overall on day 31 was 1.50 (standard deviation = 1.73). There was a greater range in mean fingersticks across GLM categories compared to cognitive status. Fingersticks ranged widely across GLM categories from 0.39 per day (no GLMs) to 3.08 (short-acting insulin), while fingersticks ranged slightly across levels of cognitive impairment from 1.11 (severe cognitive impairment) to 1.59 (cognitively intact). CONCLUSION: NH residents receive frequent fingersticks regardless of level of cognitive impairment, suggesting that cognitive status is a minor consideration in monitoring decisions. Future studies should determine whether decreasing fingersticks in NH residents with moderate/severe cognitive impairment can reduce burdens without compromising safety.

INTRODUCTION: Growing evidence suggests that impairment in rest-activity rhythms may be a risk factor for cognitive decline and impairment in the aging population. However, previous studies included only a limited set of rest-activity metrics and produced mixed findings. We studied a comprehensive set of parametric and nonparametric characteristics of rest-activity rhythms in relation to mild cognitive impairment (MCI) and probable dementia in a cohort of older women. METHODS: The prospective analysis included 763 women enrolled in two ancillary studies of the Womens Health Initiative (WHI): the WHI Memory Study-Epidemiology of Cognitive Health Outcomes and Objective Physical Activity and Cardiovascular Health studies. The association between accelerometry-based rest-activity parameters and centrally adjudicated MCI and probable dementia were determined using Cox regression models adjusted for sociodemographic characteristics, lifestyle factors, and comorbidities. RESULTS: Overall, the results support a prospective association between weakened rest-activity rhythms (e.g., reduced amplitude and overall rhythmicity) and adverse cognitive outcomes. Specifically, reduced overall rhythmicity (pseudo F statistic), lower amplitude and activity level (amplitude/relative amplitude, mesor, and activity level during active periods of the day [M10]), and later activity timing (acrophase and midpoint of M10) were associated with a higher risk for MCI and probable dementia. Women with lower amplitude and mesor also exhibited faster cognitive decline over follow-up. CONCLUSION: Weakened rest-activity rhythms may be predictive markers for cognitive decline, MCI, and dementia among older women.

Background: The purpose of this study was determined whether cognitive impairment is associated with time taken to complete the electronic rapid fitness assessment (eRFA). We hypothesized that taking more time to complete the eRFA will indicate worsened cognitive function. Methods: We retrospectively identified patients who presented to the Memorial Sloan Kettering Cancer Center Geriatrics Service for preoperative evaluation and completed the eRFA as a part of their preoperative assessment from February 2015 to December 2020. Cognitive function was assessed using the Mini‐Cog©, which is a screening test for cognitive function status. Patients in this study underwent elective surgery and had a hospital length of stay ≥1 day. Time to complete the eRFA was automatically recorded by a web‐based tool; assistance with eRFA completion was self‐reported by the patient. In total, 2599 patients were included, of which 2387 had available Mini‐Cog© scores. Results: Overall, 50% of surveys were completed without assistance, 37% were completed with assistance, and 13% were completed by somebody else; Mini‐Cog© scores were lower, corresponding to worsened cognitive function status, in patients requiring assistance (median score respectively, 5 vs. 4 vs. 3; p‐value <0.0001; rates of cognitive impairment 7.5%, 22%, and 38%). Among patients who completed the questionnaire independently, greater cognitive impairment was associated with longer time to complete the eRFA (change in score per 5 min = −0.09; 95% CI −0.14, −0.03; p = 0.002). Conclusions: We found evidence that requirement for assistance in completing web‐based questionnaires, and time taken to complete a questionnaire, predict which patients benefit from more comprehensive cognitive function assessments. Future studies should further validate this finding in a more diverse population and establish optimal clinical pathways. [ABSTRACT FROM AUTHOR]

Background: The Successful Aging after Elective Surgery (SAGES) II Study was designed to examine the relationship between delirium and Alzheimer's disease and related dementias (AD/ADRD), by capturing novel fluid biomarkers, neuroimaging markers, and neurophysiological measurements. The goal of this paper is to provide the first complete description of the enrolled cohort, which details the baseline characteristics and data completion. We also describe the study modifications necessitated by the COVID‐19 pandemic, and lay the foundation for future work using this cohort. Methods: SAGES II is a prospective observational cohort study of community‐dwelling adults age 65 and older undergoing major non‐cardiac surgery. Participants were assessed preoperatively, throughout hospitalization, and at 1, 2, 6, 12, and 18 months following discharge to assess cognitive and physical functioning. Since participants were enrolled throughout the COVID‐19 pandemic, procedural modifications were designed to reduce missing data and allow for high data quality. Results: About 420 participants were enrolled with a mean (standard deviation) age of 73.4 (5.6) years, including 14% minority participants. Eighty‐eight percent of participants had either total knee or hip replacements; the most common surgery was total knee replacement with 210 participants (50%). Despite the challenges posed by the COVID‐19 pandemic, which required the use of novel procedures such as video assessments, there were minimal missing interviews during hospitalization and up to 1‐month follow‐up; nearly 90% of enrolled participants completed interviews through 6‐month follow‐up. Conclusion: While there are many longitudinal studies of older adults, this study is unique in measuring health outcomes following surgery, along with risk factors for delirium through the application of novel biomarkers—including fluid (plasma and cerebrospinal fluid), imaging, and electrophysiological markers. This paper is the first to describe the characteristics of this unique cohort and the data collected, enabling future work using this novel and important resource. [ABSTRACT FROM AUTHOR]

BackgroundNo studies have examined the longitudinal association between the persistence of pain and its relationship to cognitive problems in older adults. The objective of this study was to examine how the persistent of pain associates with cognitive performance, cognitive impairment, and subjective memory decline.MethodsAcross 10 biennial waves, 8515 adults ages 65 and over were assessed from the Health and Retirement Study (Mage  = 74.17, SD = 6.87, 59.2% female). At each wave, individuals were asked to report on pain presence, and if present, rate its intensity and interference with daily activities such as housework or chores. Using running frequencies or averages, we calculated the persistence of pain using these three pain measures. Cognition was assessed using cognitive performance and different cognitive impairment cutoffs. Incident subjective memory decline was additionally measured as new self-reported memory change in the last 2 years. General estimating equations examined concurrent associations between persistence of pain and cognitive variables, adjusting for demographics, depressive symptoms, and medical comorbidities.ResultsPersistence of pain presence was associated with an increased risk of cognitive impairment. Only persistence of pain interference, not pain intensity, was significantly associated with poorer cognitive performance or being classified as cognitively impaired. For every 2 years, persistence of pain interference was associated with 21% increased odds of cognitive impairment. Only one of three pain variables was related to incident subjective memory decline.ConclusionsPersistence of pain is associated with poorer cognitive performance in community-dwelling older adults, especially when involving ongoing interference in chores and work. Facilitating pain management might be important for helping to maintain later-life cognition and reduce dementia risk.

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. [ABSTRACT FROM AUTHOR]

Background: The timely detection of Alzheimer's disease and other related dementias (ADRD) is suboptimal. Digital data already stored in electronic health records (EHR) offer opportunities for enhancing the timely detection of ADRD by facilitating the development of passive digital markers (PDMs). We conducted a systematic evidence review to identify studies that describe the development, performance, and validity of EHR‐based PDMs for ADRD. Methods: We searched the literature published from January 2000 to August 2022 and reviewed cross‐sectional, retrospective, or prospective observational studies with a patient population of 18 years or older, published in English that collected and interpreted original data, included EHR as a source of digital data, and had the primary purpose of supporting ADRD care. We extracted relevant data from the included studies with guidance from the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies checklist and used the US Preventive Services Task Force criteria to appraise each study. Results: We included and appraised 19 studies. Four studies were considered to have a fair quality, and none was considered to have a good quality. The functionality of the PDMs varied from detecting mild cognitive impairment, Alzheimer's disease or ADRD, to forecasting stages of ADRD. Only seven studies used a valid reference diagnostic method. Nine PDMs used only structured EHR data, and five studies provided complete information on the race and ethnicity of its population. The number of features included in the PDMs ranges from 10 to 853, and the PMDs used a variety of statistical and machine learning algorithms with various time‐at‐risk windows. The area under the curve (AUC) for the PDMs varied from 0.67 to 0.97. Conclusion: Although we noted heterogeneity in the PDMs development and performance, there is evidence that these PDMs have the potential to detect ADRD at earlier stages. [ABSTRACT FROM AUTHOR]

Background: The Institute for Healthcare Improvement's 4‐Ms framework of care for older adults recommends a multidisciplinary assessment of a patient's Medications, Mentation, Mobility, and What Matters Most. Electronic health record (EHR) systems were developed prior to this emphasis on the 4‐Ms. We sought to understand how healthcare providers across the healthcare system perceive their EHRs and to identify any current best practices and ideas for improvement regarding integration of the 4‐Ms. Methods: Anonymous survey of healthcare providers who care for older adults. The survey aimed to evaluate efficiency, error tolerance, and satisfaction (usefulness and likeability). The survey was distributed through organizational list serves that focus on the care of older adults and through social media. Results: Sixty‐six respondents from all geographic segments of the U.S. (n = 62) and non‐U.S. practices (n = 4) responded. Most (82%) were physicians. Respondents used a range of EHRs and 82% had >5 years of experience with their current EHR. Over half of respondents agreed that their EHR had easy to find contact information (56%) and advance directives. Finding a patient's prior cognitive status (26% agreement), goals of care (24%), functional status (14%), and multidisciplinary geriatric assessments (27%) was more difficult. Only 3% were satisfied with how their EHR handles geriatric syndromes. In free text responses, respondents (79%) described three areas that the EHR assists in the care of older adults: screening tied to actions or orders; advance care planning, and medication alerts or review. Common suggestions on how to improve the EHR included incorporating geriatric assessments in notes, establishing a unified place to review the 4‐Ms, and creating age‐specific best practice alerts. Conclusions: The majority of healthcare providers were not satisfied with how their EHR handles multidisciplinary geriatric assessment and geriatric care. EHR modifications would aide in reporting, communicating, and tracking the 4‐Ms in EHRs. [ABSTRACT FROM AUTHOR]

Background: Polypharmacy is common in older adults with cognitive impairment and multiple chronic conditions, increasing risks of adverse drug events, hospitalization, and death. Deprescribing, the process of reducing or stopping potentially inappropriate medications, may improve outcomes. The OPTIMIZE pragmatic trial examined whether educating and activating patients, family members and clinicians about deprescribing reduces number of chronic medications and potentially inappropriate medications. Acceptability and challenges of intervention delivery in cognitively impaired older adults are not well understood. Methods: We explored mechanisms of intervention implementation through post hoc qualitative interviews and surveys with stakeholder groups of 15 patients, 7 caregivers, and 28 clinicians. We assessed the context in which the intervention was delivered, its implementation, and mechanisms of impact. Results: Acceptance of the intervention was affected by contextual factors including cognition, prior knowledge of deprescribing, communication, and time constraints. All stakeholder groups endorsed the acceptability, importance, and delivery of the intervention. Positive mechanisms of impact included patients scheduling specific appointments to discuss deprescribing and providers being prompted to consider deprescribing. Recollection of intervention materials was inconsistent but most likely shortly after intervention delivery. Short visit times remained the largest provider barrier to deprescribing. Conclusions: Our work identifies key learnings in intervention delivery that can guide future scaling of deprescribing interventions in this population. We highlight the critical roles of timing and repetition in intervention delivery to cognitively impaired populations and the barrier posed by short consultation times. The acceptability of the intervention to patients and family members highlights the potential to incorporate deprescribing education into routine clinical practice and expand proven interventions to other vulnerable populations. [ABSTRACT FROM AUTHOR]

Background: The Successful Aging after Elective Surgery (SAGES) II study was designed to increase knowledge of the pathophysiology and linkages between delirium and dementia. We examine novel biomarkers potentially associated with delirium, including inflammation, Alzheimer's disease (AD) pathology and neurodegeneration, neuroimaging markers, and neurophysiologic markers. The goal of this paper is to describe the study design and methods for the SAGES II study. Methods: The SAGES II study is a 5‐year prospective observational study of 400–420 community dwelling persons, aged 65 years and older, assessed prior to scheduled surgery and followed daily throughout hospitalization to observe for development of delirium and other clinical outcomes. Delirium is measured with the Confusion Assessment Method (CAM), long form, after cognitive testing. Cognitive function is measured with a detailed neuropsychologic test battery, summarized as a weighted composite, the General Cognitive Performance (GCP) score. Other key measures include magnetic resonance imaging (MRI), transcranial magnetic stimulation (TMS)/electroencephalography (EEG), and Amyloid positron emission tomography (PET) imaging. We describe the eligibility criteria, enrollment flow, timing of assessments, and variables collected at baseline and during repeated assessments at 1, 2, 6, 12, and 18 months. Results: This study describes the hospital and surgery‐related variables, delirium, long‐term cognitive decline, clinical outcomes, and novel biomarkers. In inter‐rater reliability assessments, the CAM ratings (weighted kappa = 0.91, 95% confidence interval, CI = 0.74–1.0) in 50 paired assessments and GCP ratings (weighted kappa = 0.99, 95% CI 0.94–1.0) in 25 paired assessments. We describe procedures for data quality assurance and Covid‐19 adaptations. Conclusions: This complex study presents an innovative effort to advance our understanding of the inter‐relationship between delirium and dementia via novel biomarkers, collected in the context of major surgery in older adults. Strengths include the integration of MRI, TMS/EEG, PET modalities, and high‐quality longitudinal data. [ABSTRACT FROM AUTHOR]

Background: Although patient participation in treatment decisions is important for preference‐concordant care delivery, it is largely unknown how cognitive impairment influences treatment preferences. We investigated whether treatment preferences for the care of serious illness differ between adults with and without cognitive impairment in hypothetical clinical scenarios. Methods: Data from the 2018 Health and Retirement Study were used. The sample included 1291 self‐respondents (201 respondents with cognitive impairment, and 1090 with normal cognition). We examined treatment preferences for life‐extending, limited, and comfort care options in two hypothetical clinical scenarios where the respondent imagines a patient with (1) good physical health with severe cognitive impairment consistent with dementia; and (2) with physical impairment due to a heart attack, but normal cognition. Respondents specified whether they were unsure, or if they would want or not want each treatment option. Linear probability models were used to compare treatment preferences by cognitive status. Results: Respondents with cognitive impairment were more likely to report that they were unsure about treatment options across both clinical scenarios compared to those with normal cognition. For the limited treatment option, cognitive impairment was associated with a lower rate of expressing a treatment preference by 7.3 (p = 0.070) and 8.5 (p = 0.035) percentage points for dementia and heart attack scenarios, respectively. Among those who articulated preferences, cognitive impairment was associated with a higher rate of preference for life‐extending treatment in both dementia (30.1% vs. 20.0%, p = 0.044) and heart attack scenarios (30.0% vs. 20.2%, p = 0.033). Conclusions: Compared to those with normal cognition, cognitive impairment was associated with greater uncertainty about treatment preferences and higher rates of aggressive care preferences among those who specified preferences. Further research should assess whether preferences for aggressive care become more common as cognition declines in order to improve preference‐concordant care delivery for patients with cognitive impairment. [ABSTRACT FROM AUTHOR]

ObjectivesTo determine prevalence of, and outcomes associated with, a positive screen for cognitive impairment in older adults in jail.DesignCombined data from cross-sectional (n=185 participants) and longitudinal (n=125 participants) studies.SettingUrban county jail.ParticipantsIndividuals in jail aged 55 and older (N = 310; mean age 59, range 55-80). Inclusion of individuals aged 55 and older is justified because the criminal justice system defines "geriatric prisoners" as those aged 55 and older.MeasurementsBaseline and follow-up assessments of health, psychosocial factors, and cognitive status (using the Montreal Cognitive Assessment (MoCA)); 6-month acute care use and repeat arrest assessed in those followed longitudinally.ResultsParticipants were of low socioeconomic status (85% annual income

Background: Atrial fibrillation (AF) treatment includes anticoagulation for high stroke risk individuals and either rate or rhythm control strategies. We aimed to investigate the impact of age, geriatric factors, and medical comorbidities on choice of rhythm versus rate control strategy in older adults. Methods: Patients with AF aged ≥65 years with CHA2DS2VASc score ≥2 and eligible for anticoagulation were recruited for the Systematic Assessment of Geriatric Elements‐AF (SAGE‐AF) prospective cohort study. An interview that included measures of HRQoL, cognitive function, vision, hearing, and frailty was performed. The association between these elements and AF treatment strategy was examined by multivariable logistic regression models. Results: One thousand two hundred forty‐four participants (mean age 76 years; 49% female; 85% non‐Hispanic white) were enrolled. Rate and rhythm control were used in 534 and 710 participants, respectively. Compared to participants <75 years, those ≥75 were more likely to be treated with a rate control strategy (age 75–84 adjusted odds ratio [aOR] 1.37 [95% CI 0.99, 1.88]; age 85+ aOR = 2.05, 95% CI 1.30, 3.21). Those treated with a rate control strategy were more likely to have cognitive impairment (aOR = 1.50, 95% CI 1.13, 1.99), and peripheral vascular disease (PVD) (aOR = 1.82, 95% CI 1.22, 2.72) but less likely to have visual impairment (aOR 0.73 [0.55, 0.98]), congestive heart failure (CHF; aOR 0.68 [0.49, 0.94]) or receive anticoagulation (aOR 0.53, 95% CI 0.36, 0.78). Conclusion: Older age, cognitive impairment, and PVD were associated with use of rate control strategy. Visual impairment, CHF, and anticoagulation use were associated with a rhythm control strategy. There was no difference in HRQoL between the rate and rhythm control groups. This study suggests that certain geriatric elements may be associated with AF treatment strategies. Further study is needed to evaluate how these decisions affect outcomes. [ABSTRACT FROM AUTHOR]

Background: Kidney cancer is the fastest‐growing cancer diagnosis in the developed world. About 16% of new cases are stage IV, which has a low five‐year survival rate. Many patients with metastatic renal cell carcinoma (mRCC) are older and may have mild cognitive impairment or dementia (MCI/D). Given prior reports of patients with dementia initiating less cancer therapy and the importance of oral anticancer agents (OAAs) in mRCC treatment, we investigated the prevalence of preexisting MCI/D in patients with mRCC and their OAA use. Methods: SEER‐Medicare patients were analyzed who were ≥65 years, diagnosed with mRCC between 2007 and 2015, and had Medicare part D coverage. Patterns and predictors of (a) OAA utilization within the 12 months following mRCC diagnosis and (b) adherence (percent of days covered [PDC] ≥ 80%) during the first 90 days following treatment initiation were assessed. Results: Of the 2792 eligible patients, 268 had preexisting MCI/D, and 907 initiated OAA treatment within 12 months of mRCC diagnosis. Patients with preexisting MCI/D were less likely to begin an OAA than those without MCI/D (fully‐adjusted HR 0.53, 95% CI 0.38–0.76). Among OAA initiators, a preexisting MCI/D diagnosis did not alter the likelihood that a person would be adherent (adjusted RR 0.84, 95% CI 0.55–1.28). Conclusions: Patients with preexisting MCI/D were half as likely to start an OAA during the year following mRCC diagnosis than patients without comorbid MCI/D. The 90‐day adherence of OAA initiators was not significantly different between those with and without preexisting MCI/D. In light of this, clinicians should assess mRCC patients for cognitive impairment and take steps to optimize OAA utilization by those with MCI/D. [ABSTRACT FROM AUTHOR]

Objectives: Physical frailty becomes a robust risk factor in patients with heart failure (HF) and coexistence of physical and psychological frailty is likely to be a prognostic indicator. This study aimed to analyze the prognosis of coexistence of these two factors in patients with HF. Methods: This study was a secondary analysis of a multicenter prospective cohort study (FLAGSHIP). We analyzed data from 2502 patients with HF from the FLAGSHIP study in Japan. We divided the patients into four physical frailty categories using a frailty score ranging from 0 to 14 (<4: I, 4–8: II, 9–12: III, and 14: IV, the score 13 does not exist in calculation). The higher category indicates more severe physical frailty. Psychological frailty was defined as the presence of cognitive decline and/or depressive symptoms. The study outcome was a 2‐year composite outcome of rehospitalization for HF or all‐cause mortality after hospital discharge. Results: During the 3734.7 person‐year follow‐up, 774 patients experienced the composite outcome. After adjusting for confounders, physical and psychological frailty were independently associated with adverse outcomes. Using physical frailty category I, without psychological frailty as the reference, adjusted hazard ratios for adverse outcomes were 1.29 [95% confidence interval (CI) 0.86–1.92] for category I with psychological frailty, 0.99 (95% CI 0.71–1.37) for category II without psychological frailty, 1.61 (95% CI 1.16–2.23) for category II with psychological frailty, 1.56 (95% CI 1.14–2.15) for category III without psychological frailty, 1.62 (95% CI 1.20–2.20) for category III with psychological frailty, 1.50 (95% CI 1.05–2.14) for category IV without psychological frailty, and 2.16 (95% CI 1.59–2.94) for category IV with psychological frailty, respectively. Conclusions: Combined assessment of physical and psychological frailty leads to more detailed risk stratification of patients with HF. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background/objectives: Despite a high prevalence and association with poor outcomes, screening to identify cognitive impairment (CI) in the emergency department (ED) is uncommon. Identification of high‐risk subsets of older adults is a critical challenge to expanding screening programs. We developed and evaluated an automated screening tool to identify a subset of patients at high risk for CI. Methods: In this secondary analysis of existing data collected for a randomized control trial, we developed machine‐learning models to identify patients at higher risk of CI using only variables available in electronic health record (EHR). We used records from 1736 community‐dwelling adults age > 59 being discharged from three EDs. Potential CI was determined based on the Blessed Orientation Memory Concentration (BOMC) test, administered in the ED. A nested cross‐validation framework was used to evaluate machine‐learning algorithms, comparing area under the receiver‐operator curve (AUC) as the primary metric of performance. Results: Based on BOMC scores, 121 of 1736 (7%) participants screened positive for potential CI at the time of their ED visit. The best performing algorithm, an XGBoost model, predicted BOMC positivity with an AUC of 0.72. With a classification threshold of 0.4, this model had a sensitivity of 0.73, a specificity of 0.64, a negative predictive value of 0.97, and a positive predictive value of 0.13. In a hypothetical ED with 200 older adult visits per week, the use of this model would lead to a decrease in the in‐person screening burden from 200 to 77 individuals in order to detect 10 of 14 patients who would fail a BOMC. Conclusion: This study demonstrates that an algorithm based on EHR data can define a subset of patients at higher risk for CI. Incorporating such an algorithm into a screening workflow could allow screening efforts and resources to be focused where they have the most impact. See related editorial by Hirshon in this issue. [ABSTRACT FROM AUTHOR]

Background: Hearing loss is highly prevalent among older adults with cognitive impairment and may exacerbate neuropsychiatric symptoms and affect interactions with others. Although audiometry is the gold standard for measuring hearing, it is not always used in research or clinical settings focused on the care of individuals with cognitive impairment. Subjective assessments of hearing, both self‐ and proxy‐rated, are widespread but may not adequately capture the presence of hearing loss as compared to audiometry. This study investigates the concordance between subjective and objective hearing assessments among older adults with and without cognitive impairment and evaluates factors associated with concordance. Methods: Participants were a subset of the Atherosclerosis Risk in Communities Neurocognitive Study (ARIC‐NCS), a prospective cohort study representing four US communities with adjudicated cognitive diagnoses and audiometric data, totaling 3326 self‐rated and 520 proxy‐rated hearing assessments. Sensitivity and specificity were calculated, and multivariable logistic regression estimated the magnitude of the association between the concordance of hearing assessments and variables of interest. Results: Sensitivity and specificity for self‐rated hearing status were 71.2% and 85.9% among cognitively normal older adults, 61.1% and 84.9% among persons with MCI, and 52.6% and 81.2% among persons with dementia, respectively. For proxy‐rated hearing, sensitivity and specificity were 65.7% and 83.3% for persons with MCI and 73.3% and 60.3% for persons with dementia, respectively. Female sex was positively associated with concordance for self‐rated hearing assessments. Conclusions: The low sensitivity of self‐ and proxy‐rated hearing assessments compared to audiometry suggests that hearing loss among older adults with cognitive impairment may go underreported and unaddressed in subjective assessments. Clinicians and researchers should recognize the limitations of using self‐ and proxy‐rated hearing assessments as measures of hearing status and incorporate objective audiometric evaluation whenever possible. See related editorial by Chodosh & Blustein in this issue. [ABSTRACT FROM AUTHOR]

Background: Cognitive impairment and behavioral changes associated with Alzheimer's disease and related dementias (ADRDs) can impair safe firearm handling ability, an issue that can be challenging for ADRD caregivers to address. In this qualitative analysis, we sought to explore behavioral disruptions that raise concerns about firearm access in dementia and how caregivers react and respond. Methods: Secondary qualitative analysis using data from semi‐structured, one‐on‐one interviews originally conducted as part of a study to develop firearm safety educational materials for ADRD caregivers. Interviewees were English‐speaking adults (≥18 years) from three stakeholder groups: ADRD caregivers (professional or informal), medical professionals (geriatricians, neurologists), and firearm professionals (retailers, range employees, instructors). For secondary analysis, transcripts of interviews were recoded and analyzed after an inductive‐deductive thematic analysis process. Results: Among 24 participants, 17 (70%) were female and 20 (83%) white; 13 (54%) had personal or professional experience with ADRD caregiving; and 5 (21%) had a firearm affiliation. Major themes were: (1) behavioral disturbances that make caregivers concerned about firearm access; (2) caregiver emotional responses to and difficulties associated with these disturbances; and (3) caregiver actions (planned or actual) to limit firearms access. Conclusion: Various behavioral disturbances and emotional burdens can trigger ADRD caregiver concern about firearms access, but strategies exist for restricting or safeguarding firearms in the home. Study findings suggest a need for caregiver support on this topic, including counseling by healthcare providers, advance planning for older firearm owners, and development of community resources. [ABSTRACT FROM AUTHOR]

Background: This study examined the risk of mortality in older adults with newly detected cognitive impairment or dementia. Methods: Data from the Australian cohort of the ASPirin in Reducing Events in the Elderly (ASPREE) trial were examined. The ASPREE clinical trial compared daily low‐dose aspirin to a placebo and involved 16,703 individuals aged 70 years and over, who were without major cognitive impairment, physical disability, or cardiovascular disease at recruitment. During the trial, evidence of cognitive impairment, based on cognitive testing and medical record information, triggered dementia adjudication of participants using DSM‐IV criteria. Cox proportional hazard models were used to compare mortality rates across the dementia, trigger‐only, and no‐trigger groups. Results: Over a median 4.7‐year follow‐up period, 806 participants triggered dementia adjudication, with 485 (60.2%) judged to have dementia. Following recruitment, mortality risks were 32.9, 33.6, and 10.8 events per 1000 person‐years in the dementia, trigger‐no‐dementia, and no‐trigger groups, respectively. In the fully adjusted model, mortality risks remained higher in the dementia and trigger‐no‐dementia groups, with hazard ratios of 1.7 (95% CI: 1.3–2.1) and 1.9 (95% CI: 1.5–2.6), respectively. There was no discernible difference between the dementia and trigger‐no‐dementia groups in mortality rates following recruitment, or following a dementia trigger. These two groups were more likely to die from sepsis, respiratory disease, and dementia, but less likely to die from cancer than the no‐trigger group, χ2 = 161.5, p < 0.001. Conclusion: ASPREE participants who triggered for a dementia evaluation experienced a substantially higher mortality rate than those who remained cognitively intact. The increase was indistinguishable among persons who met DSM‐IV criteria for dementia vs. those who triggered for a dementia evaluation but failed to meet DSM‐IV criteria. Future work should investigate whether earlier detection of cognitive decline can be used to identify and prevent early mortality. [ABSTRACT FROM AUTHOR]

Background: Physical activity is associated with lower risk of dementia and cognitive impairment, but existing randomized controlled trials have shown conflicting results. As cognitive decline occurs decades before the onset of dementia, physical activity interventions initiated in late life may have missed the potential window for prevention. An ideal trial of physical activity initiated from midlife and lasts till incident dementia and cognitive impairment in late life is not feasible. We aimed to estimate the effectiveness of a hypothetical physical activity intervention initiated from midlife on reducing dementia and cognitive impairment by emulating target trials using observational data., Methods: The Health and Retirement Study was used to emulate target trials among noninstitutionalized participants aged 45 to 65 years with normal cognition who were physically inactive in the previous 2 years. Cognitive status was determined based on Langa-Weir classification of cognitive function (including immediate and delayed word recall tests, serial sevens subtraction, counting backward). Individuals were categorized as initiating physical activity or not, based on the self-reported physical activity. Intention-to-treat and per-protocol analysis were conducted with pooled logistic regression models with inverse-probability of treatment and censoring weights to estimate risk ratios (RRs), and 95% confidence intervals (95% CIs) were calculated with 200 sets of bootstrapping., Results: Among 1505 participants (average age 57.6 ± 4.8 years, 67% women, 76.5% White), 72 cases of dementia and 409 cases of cognitive impairment occurred. After 12 years of follow-up, physical activity reduced dementia (RR = 0.70, 95% CI: 0.43, 0.99) for intention-to-treat analysis, and reduced dementia (RR = 0.51, 95% CI: 0.19, 0.99) and cognitive impairment (RR = 0.77, 95% CI: 0.61, 0.92) for per-protocol analysis. No significant reduction was found among older adults., Conclusions: Physical activity initiated during midlife may reduce dementia and cognitive impairment in late life, which highlights the importance of preventing cognitive outcomes at an earlier stage of life., (© 2024 The American Geriatrics Society.)

Background/Objective: Poor air quality is implicated as a risk factor for cognitive impairment and dementia. Few studies have examined these associations longitudinally in well‐characterized population‐based cohorts with standardized annual assessment of both mild cognitive impairment (MCI) and dementia. We investigated the association between estimated ambient fine particulate matter (PM2.5) and risk of incident MCI and dementia in a post‐industrial region known for historically poor air quality. Setting/Participants: Adults aged 65+ years in a population‐based cohort (n = 1572). Measurements: Census tract level PM2.5 from Environmental Protection Agency (EPA) air quality monitors; Clinical Dementia Rating (CDR)®. Design: We estimated ambient PM2.5 exposure (μg/m3, single‐year and 5‐year averages) by geocoding participants' residential addresses to census tracts with daily EPA PM2.5 measurements from 2002 to 2014. Using Bayesian spatial regression modeling adjusted for age, sex, education, smoking history, and household income, we examined the association between estimated PM2.5 exposure and risk of incident MCI (CDR = 0.5) and incident dementia (CDR ≥ 1.0). Results: Modeling estimated single‐year exposure, each 1 μg/m3 higher ambient PM2.5 was associated with 67% higher adjusted risk of incident dementia (hazard ratio [HR] = 1.669, 95% credible interval [CI]: 1.298, 2.136) and 75% higher adjusted risk of incident MCI (HR = 1.746, 95% CI: 1.518, 2.032). Estimates were higher when modeling 5‐year ambient PM2.5 exposure for incident dementia (HR = 2.082, 95% CI: 1.528, 3.015) and incident MCI (HR = 3.419, 95% CI: 2.806, 4.164). Conclusions: Higher estimated ambient PM2.5 was associated with higher risk of incident MCI and dementia, particularly when considering longer‐term exposure, and independent of demographic characteristics and smoking history. Targeting poor air quality may be a reasonable population‐wide intervention to reduce the risk of cognitive impairment in older adults, particularly in regions exceeding current recommendations for safe exposure to PM2.5. [ABSTRACT FROM AUTHOR]

Importance: The impact of pre‐existing cognitive dysfunction on outcomes after transcatheter aortic valve replacement (TAVR) remains unclear. Objective: To study the association between dementia and post‐TAVR outcomes. Design: Cohort study with propensity‐score matching was conducted using the Nationwide Inpatient Sample. Exposures: History of dementia at the time of undergoing TAVR. Main outcomes: All‐cause in‐hospital mortality, stroke, bleeding requiring transfusion, acute kidney injury, post‐procedural vascular complications, post‐procedural pacemaker implantation, length of stay, in‐hospital delirium, and discharge disposition in patients with and without dementia undergoing TAVR. Results: Of 57,805 patients undergoing TAVR, 2910 (5.0%) had a diagnosis of dementia. Propensity‐score matching yielded 2895 matched pairs of patients. TAVR was associated with an increased risk of bleeding requiring transfusion (14.7% vs 8.6%, odd ratio (OR) 1.82 [95% confidence interval (CI) 1.26–2.63]; p < 0.01), discharge to a rehabilitation facility (45.8% vs 31.6%, OR 2.27 [95% CI 1.67–3.08]; p < 0.001), in‐hospital delirium (7.4% vs 3.6%, OR 2.13 [95% CI 1.26–3.61]; p < 0.01), increased length of stay (6.75 ± 0.07 days vs 6.11 ± 0.06 days, slope = 1.11 [95% CI 1.03–1.19]; p < 0.01), but comparable in‐hospital mortality (2.1% vs 2.6%, OR 1.26 [95% CI 0.57–2.79]; p = 0.57] in patients with dementia compared with patients without dementia. Conclusions and relevance: This study found that patients with dementia undergoing TAVR had a longer hospital stay as well as higher rates of discharge to a rehabilitation facility and in‐hospital delirium, which may indicate debility and functional decline during hospitalization; however, in‐hospital mortality and other outcomes were comparable between the two groups. TAVR candidates should be subjected to a comprehensive geriatric and cognitive assessment to help risk‐stratify them for potential post‐procedural functional decline. Prospective studies aimed at standardizing cognitive scoring and evaluating the post‐procedural quality of life are needed. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES Trauma survivors with chronic post‐traumatic stress disorder (PTSD) have been found to have cognitive impairment. But little is known about these outcomes among Latino and Asians who comprise more than 80% of the U.S. immigrant population. They also experience disparities in PTSD and dementia care albeit increased exposure to trauma. This study aimed to (1) examine the association between trauma exposures and PTSD with cognitive impairment in a sample of Latino and Asian older adults; and (2) assess whether sleep quality attenuated the PTSD‐cognitive impairment association. DESIGN Cross‐sectional secondary analysis of baseline data from the Positive Minds‐Strong Bodies randomized controlled trial on disability prevention. SETTING Community‐based organizations serving minority or immigrant older adults in Massachusetts, New York, Florida, or Puerto Rico. PARTICIPANTS Hispanic/Latino and Asian/Pacific Islander adults aged 60 or older eligible per randomized controlled trial screening for elevated mood symptoms and minor‐to‐moderate physical dysfunction (n = 134 and n = 86, respectively). MEASUREMENTS Neuropsychiatric measures were cognitive impairment (Mini Montreal Cognitive Assessment (MoCA)), PTSD (Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual‐5), trauma exposure (Brief Trauma Questionnaire), depression (Patient Health Questionnaire‐9), generalized anxiety (Generalized Anxiety Disorder Scale‐7), and daytime sleepiness (Epworth Sleepiness Scale). RESULTS: Mean age was 72.8 years and 77.5 years for the Latino and Asian groups, respectively. The Asian group was 100% immigrant, whereas 70.2% (n = 92) of the Latino group was foreign‐born. In unadjusted models, higher Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual‐5 scores were associated with decreased odds of normal cognitive functioning (MoCA ≥25) in the Asian group (odds ratio (95% confidence interval) =.93 (.87,.99)), but not the Latino group (odds ratio (95% confidence interval) =.99 (.95, 1.05)). This association remained significant after adjusting for covariates. Daytime sleepiness did not moderate the association between PTSD and cognitive functioning in the Asian group. CONCLUSION: Higher PTSD symptoms were associated with cognitive impairment in Asian, but not Latino, older adults. Clinicians serving older Asians should integrate trauma and cognitive screening to ensure this growing, underserved population receives appropriate evidence‐based treatments. [ABSTRACT FROM AUTHOR]

ObjectivesTo investigate the relationship between periodontal disease and cognitive decline.DesignAnalysis of a prospective cohort study.SettingThe Health, Aging and Body Composition (Health ABC) Study.ParticipantsOne thousand fifty-three participants who were administered the Modified Mini-Mental State Examination (3MS) at Year 1 (baseline) and Year 3 and had participated in a comprehensive periodontal examination at Year 2.MeasurementsThe prospective association between a range of oral health parameters and cognitive function was examined. Decline in 3MS score from Year 3 to 5 was investigated in 947 (89.9%) participants. Covariates included age, sex, education, race, cardiovascular disease and risk, and depressive symptoms.ResultsMost indicators of adverse oral health at Year 2 were associated with cognitive impairment based on averaged 3MS scores less than 80 for Years 1 and 3, but education and race substantially confounded these associations. Higher gingival index, a measure of gingival inflammation, at Year 2 remained independently associated with this definition of cognitive impairment and, in fully adjusted analyses, was also an independent predictor of a more-than-5-point cognitive decline from Year 3 to 5.ConclusionPeriodontitis may be a risk factor for cognitive decline. Gingivitis is reversible, and periodontitis to some degree is preventable and controllable when manifest. Therefore, further research is needed to clarify potential underlying mechanisms and oral health interventions that might ameliorate cognitive decline.

BACKGROUND: Sorting tests detect cognitive decline in older adults who have a neurodegenerative disorder, such as Alzheimerʼs and Parkinsonʼs disease. Although equally effective at detecting impairment as other cognitive screens (e.g. Mini‐Mental State Examination (MMSE)), sorting tests are not commonly used in this context. This study examines the QuickSort, which is a new brief sorting test that is designed to screen older adults for cognitive impairment. DESIGN: Observational cohort study. SETTING: General community and inpatients, Australia. PARTICIPANTS: Older (≥60 years) community‐dwelling adults (n = 187) and inpatients referred for neuropsychological assessment (n = 78). A normative subsample (n = 115), screened for cognitive and psychological disorders, was formed from the community sample. MEASUREMENTS: Participants were administered the QuickSort, MMSE, Frontal Assessment Battery (FAB), and Depression Anxiety and Stress Scale‐21. The QuickSort requires people to sort nine stimuli by color, shape, and number, and to explain the basis for their correct sorts. Sorting (range = 0–12), Explanation (range = 0–6), and Total (range = 0–18) scores were calculated for the QuickSort. RESULTS: The Cognitively Healthy subsample completed the QuickSort within 2 minutes, 50% had errorless performance, and 95% had Total scores of 10 or greater. The likelihood of community‐dwelling older adults and inpatients (n = 260) being impaired on either the MMSE or FAB, or both, increased by a factor of 3.75 for QuickSort Total scores of less than 10 and reduced by a factor of 0.23 for scores of 10 or greater. CONCLUSION: The QuickSort provides a quick, reliable, and valid alternative to lengthier cognitive screens (e.g., MMSE and FAB) when screening older adults for cognitive impairment. The QuickSort performance of an older adult can be compared with a cognitively healthy normative sample and used to estimate the likelihood they will be impaired on either the MMSE or FAB, or both. Clinicians can also use evidence‐based modeling to customize the QuickSort for their setting. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVE: A driving skill program had positive effects on safe driving performance in older adults, even those with cognitive impairment. However, the long‐term effects of the program remain unclear. The purpose of this study was to examine whether such effects were maintained at 1 year after the intervention in older adults with cognitive impairment who had low driving skills. DESIGN: A secondary analysis of single‐blind randomized controlled trial. SETTING: Community setting in Japan. PARTICIPANTS: Community‐living adults, aged 65 years or older (n = 159), with mild cognitive impairment (MCI). INTERVENTION: The intervention group completed 10 classroom sessions of 1 hour and 10 on‐road sessions of 50 minutes, focusing on common problem areas of older drivers. The control group received one education class about safety driving. MEASUREMENTS: On‐road driving performance was assessed by certified driving school instructors in a driving school at preintervention and postintervention, and 1‐year follow‐up. RESULTS: A total of 159 community‐living older drivers participated in this study and were randomized to either an intervention group (n = 71) or a control group (n = 88). One year after the intervention, 104 of 159 community‐living older drivers completed the follow‐up assessment (intervention group, n = 58). Regarding the safe driving skill score, there was a significant group × time interaction (P <.01), indicating benefits of the intervention over time. Although the intervention group showed a significant decline in the safe driving skill score from postintervention (score = 38.9 ± 46.1) to 1‐year follow‐up (score = −0.3 ± 55.2), there was a significant difference between the groups at 1‐year follow‐up (control group score = −148.5 ± 46.4) (P <.05), and between preintervention (score = −132.0 ± 54.6) and 1‐year follow‐up in the intervention group (P <.05). CONCLUSION: The driving skill program maintained safe driving performance that had been improved by the intervention in older adults with MCI. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES: Motoric cognitive risk (MCR) syndrome is characterized by cognitive complaints and slow gait speed in the absence of dementia. Consistent evidence indicates that it predicts dementia and premature mortality. Less is known about its antecedents, particularly the role of psychological function. Purpose in life is an aspect of well‐being that reflects a goal‐oriented and ‐driven life that has been implicated in cognitive aging. We aimed to examine the cross‐sectional association between purpose in life and MCR and to test the hypothesis that purpose is associated with a lower risk of new cases of MCR over an up to 12‐year follow‐up. DESIGN: Cross‐sectional and longitudinal multi‐cohort design. SETTING: Health and Retirement Study (HRS) and the National Health and Aging Trends Study (NHATS). PARTICIPANTS: A total of 6,785 individuals from the HRS and 5,665 from the NHATS. MEASUREMENTS: Participants reported on their purpose in life and cognitive complaints and completed a walking speed assessment. Cognitive complaints and walking speed were assessed again up to 12 years later in HRS and up to 7 years later in NHATS. RESULTS: Higher purpose in life was associated with a 33% lower risk of MCR concurrently (meta‐analytic odds ratio =.75; 95% confidence interval [CI] =.62–.90; P =.002) and an about 26% lower risk of incident MCR longitudinally (meta‐analytic hazard ratio =.77; 95% CI =.70–.84; P <.001). These associations were significant in each sample, were independent of sociodemographic covariates, and persisted after controlling for personality and health‐related factors (depressive symptoms, physical activity, disease burden). CONCLUSION: Purpose in life is associated with a lower risk of incident MCR, an association that was replicated in two independent samples. Purpose is a malleable aspect of psychological function that is a promising target of intervention for healthier cognitive aging. [ABSTRACT FROM AUTHOR]

OBJECTIVE: This pilot study assessed feasibility of video‐enhanced care management for complex older veterans with suspected mild cognitive impairment (CI) and their care partners, compared with telephone delivery. DESIGN: Pilot randomized controlled trial. SETTING: Durham Veterans Affairs Health Care System. PARTICIPANTS: Participants were enrolled as dyads, consisting of veterans aged 65 years or older with complex medical conditions (Care Assessment Need score ≥90) and suspected mild CI (education‐adjusted Modified Telephone Interview for Cognitive Status score 20–31) and their care partners. INTERVENTION: The 12‐week care management intervention consisted of monthly calls from a study nurse covering medication management, cardiovascular disease risk reduction, physical activity, and sleep behaviors, delivered via video compared with telephone. MEASUREMENTS: Dyads completed baseline and follow‐up assessments to assess feasibility, acceptability, and usability. RESULTS: Forty veterans (mean (standard deviation (SD)) age = 72.4 (6.1) years; 100% male; 37.5% Black) and their care partners (mean (SD) age = 64.7 (10.8) years) were enrolled and randomized to telephone or video‐enhanced care management. About a third of veteran participants indicated familiarity with relevant technology (regular tablet use and/or experience with videoconferencing); 53.6% of internet users were comfortable or very comfortable using the internet. Overall, 43 (71.7%) care management calls were completed in the video arm and 52 (86.7%) were completed in the telephone arm. Usability of the video telehealth platform was rated higher for participants already familiar with technology used to deliver the intervention (mean (SD) System Usability Scale scores: 65.0 (17.0) vs 55.6 (19.6)). Veterans, care partners, and study nurses reported greater engagement, communication, and interaction in the video arm. CONCLUSION: Video‐delivered care management calls were feasible and preferred over telephone for some complex older adults with mild CI and their care partners. Future research should focus on understanding how to assess and incorporate patient and family preferences related to uptake and maintenance of video telehealth interventions. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES: Oral anticoagulation (OAC) is challenging in older patients with nonvalvular atrial fibrillation (NVAF) who are often frail and have cognitive impairment. We examined the characteristics of older NVAF patients associated with higher odds of physical and cognitive impairments. We also examined if these high‐risk patients have different OAC prescribing patterns and their satisfaction with treatment because it may impact optimal management of their NVAF. METHODS: The patients in the Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE‐AF study cohort 2016–2018) had NVAF, were aged 65 and older, and eligible for the receipt of OAC. Measures included frailty (Fried Frailty scale), cognitive impairment (Montreal Cognitive Assessment Battery), OAC prescribing and type (direct oral anticoagulant [DOAC] or vitamin K antagonist [VKA]), depressive symptoms (Patient Health Questionnaire‐9), bleeding, stroke risk, and treatment benefit (Anti‐Clot Treatment Scale). RESULTS: Patients (n = 1,244) were 49% female, aged 76 (standard deviation = 7) years. A total of 14% were frail, and 42% had cognitive impairment. Frailty and cognitive impairment co‐occurred in 9%. Odds of having both impairments versus none were higher with depression (odds ratio [OR] = 4.62; 95% confidence interval [CI] = 2.59–8.26), older age (OR = 1.56; 95% CI = 1.29–1.88), lower education (OR = 3.81; 95%CI = 2.13–6.81), race/ethnicity other than non‐Hispanic White (OR = 7.94; 95% CI = 4.34–14.55), bleeding risk (OR = 1.43; 95% CI = 1.12–1.81), and stroke risk (OR = 1.35; 95% CI = 1.13–1.62). OAC prescribing was not associated with CI and frailty status. Among patients taking OACs (85%), those with both impairments were more likely to take DOAC than VKA (OR = 1.69; 95% CI = 1.01–2.80). Having both impairments (OR = 1.87; 95% CI = 1.08–3.27) or cognitive impairment (OR = 1.56; 95% CI = 1.09–2.24) was associated with higher odds of reporting lower treatment benefit. CONCLUSION: In a large cohort of older NVAF patients, half were frail or cognitively impaired, and 9% had both impairments. We highlight the characteristics of patients who may benefit from cognitive and physical function screenings to maximize treatment and enhance prognosis. Finally, the co‐occurrence of impairment was associated with low perceived benefit of treatment that may impede optimal management. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Oral anticoagulants are the cornerstone of stroke prevention in high‐risk patients with atrial fibrillation (AF). Geriatric elements, such as cognitive impairment and frailty, commonly occur in these patients and are often cited as reasons for not prescribing oral anticoagulants. We sought to systematically assess geriatric impairments in patients with AF and determine whether they were associated with oral anticoagulant prescribing. DESIGN: Cross‐sectional analysis of baseline data from the ongoing Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE‐AF) prospective cohort study. SETTING: Multicenter study with site locations in Massachusetts and Georgia that recruited participants from cardiology, electrophysiology, and primary care clinics from 2016 to 2018. PARTICIPANTS: Participants with AF age 65 years or older, CHA2DS2‐VASc (congestive heart failure; hypertension; aged ≥75 y [doubled]; diabetes mellitus; prior stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65‐74; female sex) score of 2 or higher, and no oral anticoagulant contraindications (n = 1244). MEASUREMENTS: A six‐component geriatric assessment included validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Oral anticoagulant use was abstracted from the medical record. RESULTS: A total of 1244 participants (mean age = 76 y; 49% female; 85% white) were enrolled; 42% were cognitively impaired, 14% frail, 53% pre‐frail, 12% socially isolated, and 29% had depressive symptoms. Oral anticoagulants were prescribed to 86% of the cohort. Oral anticoagulant prescribing did not vary according to any of the geriatric elements (adjusted odds ratios [ORs] for oral anticoagulant prescribing and cognitive impairment: OR =.75; 95% confidence interval [CI] =.51‐1.09; frail OR =.69; 95% CI =.35‐1.36; social isolation OR =.90; 95% CI =.52‐1.54; depression OR =.79; 95% CI =.49‐1.27; visual impairment OR =.98; 95% CI =.65‐1.48; and hearing impairment OR = 1.05; 95% CI =.71‐1.54). CONCLUSION: Geriatric impairments, particularly cognitive impairment and frailty, were common in our cohort, but treatment with oral anticoagulants did not differ by impairment status. These geriatric impairments are commonly cited as reasons for not prescribing oral anticoagulants, suggesting that prescribers may either be unaware or deliberately ignoring the presence of these factors in clinical settings. J Am Geriatr Soc 68:147–154, 2019 [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES: Memory clinic patients commonly also have declined physical performance. This may be attributable to white matter injury, due to vascular damage or neurodegeneration. Quantifying white matter injury is made possible by new magnetic resonance imaging (MRI) techniques, including diffusion‐weighted imaging (DWI) of network connectivity. We investigated whether physical performance in memory clinic patients is related to white matter network connectivity. DESIGN: Observational cross‐sectional study. SETTING: Memory clinic. PARTICIPANTS: Patients referred to a memory clinic with vascular brain injury on MRI (n = 90; average age = 72 years; 60% male; 34% with diagnosis Alzheimer disease). MEASUREMENTS: We reconstructed structural brain networks from DWI with fiber tractography and used graph theory to calculate global efficiency, fractional anisotropy (FA), and mean diffusivity (MD) of the white matter, and nodal strength (mean FA or MD of all white matter tracts connected to a node). Assessment of physical performance included gait speed, chair stand time, and Short Physical Performance Battery (SPPB) score. RESULTS: Lower global efficiency, lower FA, and higher MD correlated with poorer gait speed, SPPB scores, and chair stand times (R range = 0.23‐0.42). Global efficiency and FA explained 5% to 16% of the variance in gait speed, chair stand times, and SPPB scores, independent of age and sex. Moreover, global efficiency and FA explained an additional 4% to 5% of variance on top of lacunar infarcts and white matter hyperintensities. Regional analyses showed that, in particular, the connectivity strength of prefrontal, occipital, striatal, and thalamic nodes correlated with gait speed. CONCLUSION: Poorer physical performance is related to disrupted white matter network connectivity in memory clinic patients with vascular brain injury. The associations of these network abnormalities are partially independent of visible vascular injury. J Am Geriatr Soc 67:1880–1887, 2019 [ABSTRACT FROM AUTHOR]

OBJECTIVES: We aimed to examine the associations between immigration‐related factors and prevalent and incident cognitive impairment (CI) and whether the associations varied by sex among US Chinese older adults. DESIGN: Two‐wave prospective study. SETTING: The greater Chicago area. PARTICIPANTS: Community‐dwelling adults aged 60 and older who self‐identified as Chinese, who were interviewed at two time points during 2011‐2013 (N = 3157) and 2013‐2015 (N = 2713). MEASUREMENTS: CI was assessed by the 30‐item Chinese Mini‐Mental State Examination (C‐MMSE). CI prevalence was determined by the percentage of respondents whose C‐MMSE score was below 18 at baseline (N = 3033), and CI incidence was determined by the percentage of the respondents whose score was 18 or above at baseline (N = 2443) but dropped below 18 at wave 2. Immigration‐related factors included age at migration, immigration reasons, and acculturation. RESULTS: The CI prevalence rate was 7.62% at baseline, and the incidence rate was 5.12% at wave 2. Women were more likely than men to have CI, consisting of 77.06% and 75.20% among persons with CI at the time points. None of the immigration‐related factors were related to CI prevalence and incidence. Older age, fewer years of education, and more instrumental activities of daily living limitations were risk factors of CI in the whole, male, and female samples. CONCLUSION: Older Chinese women were generally disadvantaged in cognition and overall health as compared with older Chinese men. Yet immigration experience does not link to CI for both men and women after equalizing the well‐established effects of age and education on cognition. Future research needs to investigate whether the risk of CI in late life is related to the biological and contextual factors earlier in the life course. Decreasing sex disparities in the risk of dementia may focus on reducing educational and health disparities in the early life stage. J Am Geriatr Soc 67:S513–S518, 2019. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Nondemented cognitive impairment (CI) presents opportunities for early interventions among individuals at risk for dementia. Identification of modifiable determinants is paramount to the development of effective clinical interventions. Metabolic syndrome (MetS) was theorized as a risk factor, but current research yields inconsistent findings. Few studies have examined the association between MetS and CI among US populations, and global results may be ungeneralizable. We investigated the MetS‐CI association among high socioeconomic, nondemented older US adults, examining the roles of sociodemographic, clinical, behavioral, and genetic factors. DESIGN: Cross‐sectional. SETTING: Cooper Clinic of Dallas, Texas: Cooper Center Longitudinal Study (2009‐2017). PARTICIPANTS: A total of 5200 dementia‐free older adult Cooper Clinic patients. MEASUREMENTS: CI was detected with a Montreal Cognitive Assessment (MoCA) score lower than 26. MetS was established based on National Cholesterol Education Program Adult Treatment Panel guidelines. Unadjusted and multivariable log‐binomial regression were used to assess the MetS‐CI association, with modification assessment by age, sex, education, cardiorespiratory fitness (CRF), and apolipoprotein‐ε4 carrier status (APOE‐ε4). RESULTS: MetS was not associated with CI when adjusting for age, sex, minority status, education, and marital status (prevalence ratio [PR] = 1.09; 95% confidence interval =.97‐1.23) or when additionally adjusting for body mass index, CRF, alcohol consumption, current smoking status, and APOE‐ε4 (PR = 1.07; 95% confidence interval = .80‐1.45). The association was not modified by age, sex, CRF, or APOE‐ε4 (P for interaction >.05). CONCLUSION: In contrast with some global and US studies, MetS and CI were not associated among our study population of nondemented older US adults. MetS may not be a suitable intervention target for poor cognitive outcomes among high socioeconomic older US adults, although separate MetS components may have different recommendations. Future studies should explore more diverse older US populations. If replicated, these findings would inform clinical efforts to reduce the burden of poor cognitive outcomes in the United States. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the differences in life expectancy with and without cognitive impairment (CI) by educational levels and sex in Brazil. Design: Longitudinal observational study. Setting: The sample was drawn from three waves (2000, 2006, and 2010) of the Health, Well‐Being, and Aging Study (Saúde, bem‐estar e envelhecimento; SABE) collected in São Paulo, Brazil. Participants: Adults aged 60 years and older (N = 2116). Measurements: Educational levels were estimated in the baseline wave (2000), cognition was assessed in all waves, and mortality data were obtained through the state and municipal mortality system in Brazil. Interpolation of Markov chain methods was used to estimate life expectancy with and without CI by education and sex. Results: Life expectancy without CI at the age of 60 years was 13.0 years among men with no education and 17.6 years among their counterparts with 8 years of schooling. On the other hand, life expectancy with CI was higher among men with no education than those with more education (3.2 and 0.6 years, respectively). Among 60‐year‐old women without education, life expectancy without CI reached 16.2 years, but it was considerably higher among more educated women (22.7 years). Life expectancy with CI reached 4.5 years among women aged 60 years with no education, vs 1.0 year among women with 8 years of schooling. Conclusions: Adults older than 60 years with no education live shorter lives and with longer periods of CI than those with education. Women in São Paulo live longer lives than men, but they live with CI for a greater number of years. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To evaluate relationships between frailty and cognition longitudinally in adults 50 years and older with breast cancer receiving chemotherapy. DESIGN: Secondary analysis of a prospective longitudinal observational study. SETTING: University of Rochester NCI Community Oncology Research Program community oncology clinics. PARTICIPANTS: Patients with breast cancer age 50 and older receiving adjuvant/neoadjuvant chemotherapy (n = 376) and age‐matched controls without cancer (n = 234). MEASUREMENTS: Frailty was assessed using a modified frailty score from self‐reported assessments (weakness, exhaustion, physical activity, and gait speed). Cognition was assessed by patient report (Functional Assessment of Cancer Therapy‐Cognition [FACT‐Cog]) and objective measures. Frailty and cognition were measured at three time points (prechemotherapy [A1], postchemotherapy [A2], and 6 months postchemotherapy [A3]; similar time interval for controls). Linear regression models evaluated associations between frailty and cognition adjusting for covariates. RESULTS: The average age was 59 years (standard deviation = 6.4 y). At baseline, patients with cancer had a higher mean frailty score (1.21 vs.73; P < .001) and lower mean FACT‐Cog score (158.4 vs 167.3; P < .001) compared with controls. Objective cognitive measures were not statistically different. Longitudinal decline in FACT‐Cog between A1 and A2 (P < .05) and between A1 and A3 (P < .01) was associated with increased frailty score in patients compared with controls. Longitudinal worsening in Controlled Oral Word Association (P < .05) and Trail‐Making Test (P < .01) were associated with an increase in frailty between A1 and A2 in patients compared with controls; longitudinal decline in the Delayed Match to Sample test was associated with an increase in frailty between A1 and A3 (P < .05) in patients compared with controls. This finding remained significant for a subset analysis of those aged 65 and older. CONCLUSION: In patients with breast cancer aged 50 and older, longitudinal decline in FACT‐Cog and objective measures of attention and memory were associated with increased frailty during treatment and up to 6 months posttreatment. Overall, our study suggests cognition and frailty are both important factors to assess in breast cancer patients. J Am Geriatr Soc 67:928–936, 2019. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES: Mind‐body exercise has positive effects on cognitive performance, according to clinical observation and experts' recommendations. However, its potential benefits for the cognitive function of aging adults are uncertain and still lack systematic estimations. Therefore, we conducted a systematic review and meta‐analysis to evaluate the overall efficacy and effectiveness of mind‐body exercises for cognitive performance in aging individuals with or without cognitive impairment. DESIGN: A systematic review and meta‐analysis. SETTING AND PARTICIPANTS: We searched related trials through June 2018 from four databases: Medline, Embase, PsycINFO (all via Ovid), and the Cochrane Library/Central Register of Controlled Trials. MEASUREMENTS: Methodological quality was assessed using the Cochrane Risk of Bias Tool. A meta‐analysis of comparative effects was performed using Review Manager v.5.3 software, and publication bias was examined using Egger's test. RESULTS: A total of 32 randomized controlled trials with 3624 participants were ultimately included in this meta‐analysis. The results revealed that mind‐body exercises as a whole had benefits in improving global cognition compared with that of the control group (mean difference [MD] = 0.92; 95% confidence interval [CI] = 0.33‐1.51; p =.002) and were more effective than control interventions in promoting cognitive flexibility (MD = −8.80; 95% CI = −15.22 to −2.38; p =.007), working memory (MD = 0.32; 95% CI = 0.01‐0.64; p =.05), verbal fluency (standardized mean difference [SMD] = 0.27; 95% CI = 0.09‐0.45; p =.003), and learning (SMD = 0.24; 95% CI = 0.10‐0.39; p =.001) on cognitively intact or impaired older adults. In dose‐subgroup analysis, only moderate exercise intensity (60‐120 min per week) significantly increased global cognition scores compared with those of the control group (MD = 1.15; 95% CI = 0.34‐1.97; p =.006). CONCLUSION: Mind‐body exercises, especially tai chi and dance mind‐body exercise, are beneficial for improving global cognition, cognitive flexibility, working memory, verbal fluency, and learning in cognitively intact or impaired older adults. Moderate intensity is recommended as the optimal dose for older adults. J Am Geriatr Soc 67:749–758, 2019. [ABSTRACT FROM AUTHOR]

Objectives: Improving function is an important outcome of postacute care in skilled nursing facilities (SNFs), but cognitive impairment can limit a resident's ability to improve during a postacute care stay. Our objective was to examine the association between residents' cognitive status on admission and change in self‐care and mobility during a Medicare‐covered SNF stay. Design: Retrospective analysis of Medicare beneficiaries who had a new SNF stay between January and June 2017. Setting: SNFs in the United States. Participants: Newly admitted residents with Medicare‐covered SNF stays between January and June 2017 (n = 246 395). Measurements: Residents' self‐care and mobility at SNF admission and discharge were determined using items from Section GG (eating, oral hygiene, toileting hygiene, sit to lying, lying to sitting, sit to stand, chair/bed transfer, and toilet transfer) of the Minimum Data Set. Residents were classified as cognitively intact, mildly impaired, moderately impaired, or severely impaired, according to the Cognitive Function Scale. Multivariable regression models controlling for residents' demographic and clinical characteristics and SNF fixed effects were used to identify residents whose discharge scores for self‐care and mobility were better or the same as expected according to their cognitive status on admission. Results: Residents who were cognitively impaired on admission had lower functional status on admission and were less likely to improve in self‐care and mobility compared with residents who were cognitively intact. Approximately 63% of residents who were cognitively intact had discharge scores for self‐care and mobility that were better or the same as expected compared with 45% of residents with severe cognitive impairment. Conclusions: Cognitive impairment is associated with poorer self‐care and mobility function among SNF residents. These findings have important implications for clinicians, who may need additional support when caring for residents with cognitive impairment to make the same improvements in functional status as residents who are cognitively intact. J Am Geriatr Soc 67:553–557, 2019. [ABSTRACT FROM AUTHOR]

Objectives: To review intervention programs that measure gait to investigate what features of the intervention may contribute to improving gait in older adults with cognitive impairment or dementia. Design: Systematic review using Medline, Cinahl, Scopus, PsychInfo, Amed, Embase, Web of Science, and PubMed for original research published in English between January 1, 2000, and July 23, 2018, to identify interventional controlled trials. Narrative synthesis was undertaken. Results: Of 6,379 citations, 36 articles met inclusion criteria. Interventions were categorized as medication or medical devices (8 studies), exercise (19 studies), and exercise plus cognitive training (9 studies). Antidementia medication may improve gait variability in people with Alzheimer's disease. Exercise programs focusing on strength and balance training, especially when combined with functional mobility training, improve gait in people with mild cognitive impairment or dementia. Exercise plus cognitive training programs combining strength and balance training, functional mobility training, and training on attention and executive function also improve gait. Conlusion: Physical and cognitive factors affect gait performance, and both should be addressed in intervention programs. Physical exercises including functional mobility training, especially walking, have better results than physical programs with only static, resistance, and flexibility training. Cognitive intervention should be concomitant with physical exercises rather than separate, with a focus on attention and executive function. Combining physical training with cognitive training in a functional context may assist older adults with cognitive impairment generalize from training to everyday activity. J Am Geriatr Soc 67:381–391, 2019. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether a multicomponent intervention improves care in hospitalized older adults with cognitive impairment. Design: One‐year retrospective chart review with propensity score matching on critical demographic and clinical variables was used to compare individauls with cognitive impairmenet on intervention and nonintervention units. Setting: Large tertiary medical center. Participants: All hospitalized individuals age 65 and older with cognitive impairment admitted to medicine who required constant or enhanced observation for behavioral and psychological symptoms. Intervention: Multicomponent intervention (geographic unit cohorting, multidisciplinary approach, patient engagement specialists (PES), staff education) or usual care. Measurements: In‐hospital mortality, length of stay, readmission, management of behavioral disturbances. Results: After propensity score matching, 476 of the 712 intervention visits were pair‐matched with 476 of the 558 usual care visits. Matching was successful in balancing baseline covariates between intervention and usual care units. Individuals admitted to the intervention unit had lower in‐hospital mortality (1.1% vs 2.9%, p=0.05) and shorter stays (5.0 vs 5.8 days, p=0.04). There was no difference in discharge home (p=0.90) or 30‐day readmission rates (p=0.44). Individuals on the intervention unit were less likely than those receivng usual care to have an order for constant (12.0% vs 45.8%, p<0.01) or enhanced (22.1% vs 79.6%, p<0.01) observation, to be taking benzodiazepines (26.3% vs 38.0%, p<0.01), to be taking nothing by mouth (29.6% vs 40.8%, p=0.01), to be on bedrest (17.0% vs 25.8%, p=0.01), to be taking antipsychotics (41.2% vs 54.0%, p<0.01), or to have restraints (3.2% vs 6.9%, p=.01). Conclusion: A multicomponent intervention of geographic cohorting, multidisciplinary approach, PES, and staff education may offer a new paradigm in the management of hospitalized older adults with cognitive impairment. [ABSTRACT FROM AUTHOR]

Older adults with cognitive impairment face many healthcare challenges, chief among them participating in medical decision‐making about their own health care. Advance care planning (ACP) is the process whereby individuals communicate their wishes for future care with their clinicians and surrogate decision‐makers while they are still able to do so. ACP has been shown to improve important outcomes for individuals with cognitive impairment, but rates of ACP for these individuals are low because of individual‐, clinician‐, and system‐related factors. Addressing ACP early in the illness trajectory can maximize the chances that people can participate meaningfully. This article recommends best practices for approaching ACP for older adults with cognitive impairment. The importance of providing anticipatory guidance and eliciting values to guide future care to create a shared framework between clinicians, individuals, and surrogate decision‐makers is emphasized. It is recommended that ACP be approached as an iterative process to continue to honor and support people's wishes as cognitive impairment progresses and increasingly threatens independence and function. The article describes effective strategies for assessing decision‐making capacity, identifying surrogate decision‐makers, and using structured communication tools for ACP. It also provides guidelines for documentation and billing. Finally, special considerations for individuals with advanced dementia are described, including the use of artificial hydration and nutrition, decisions about site of care, and the role of hospice care. [ABSTRACT FROM AUTHOR]

Objectives: To compare postoperative outcomes of individuals with and without cognitive impairment enrolled in the Perioperative Optimization of Senior Health (POSH) program at Duke University, a comanagement model involving surgery, anesthesia, and geriatrics. Design: Retrospective analysis of individuals enrolled in a quality improvement program. Setting: Tertiary academic center. Participants: Older adults undergoing surgery and referred to POSH (N = 157). Measurements: Cognitive impairment was defined as a score less than 25 out of 30 (adjusted for education) on the St. Louis University Mental Status (SLUMS) Examination. Median length of stay (LOS), mean number of postoperative complications, rates of postoperative delirium (POD, %), 30‐day readmissions (%), and discharge to home (%) were compared using bivariate analysis. Results: Seventy percent of participants met criteria for cognitive impairment (mean SLUMS score 20.3 for those with cognitive impairment and 27.7 for those without). Participants with and without cognitive impairment did not significantly differ in demographic characteristics, number of medications (including anticholinergics and benzodiazepines), or burden of comorbidities. Participants with and without cognitive impairment had similar LOS (P = .99), cumulative number of complications (P = .70), and 30‐day readmission (P = .20). POD was more common in those with cognitive impairment (31% vs 24%), but the difference was not significant (P = .34). Participants without cognitive impairment had higher rates of discharge to home (80.4% vs 65.1%, P = .05). Conclusion: Older adults with and without cognitive impairment referred to the POSH program fared similarly on most postoperative outcomes. Individuals with cognitive impairment may benefit from perioperative geriatric comanagement. Questions remain regarding the validity of available measures of cognition in the preoperative period. [ABSTRACT FROM AUTHOR]