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Background: Studies have demonstrated beneficial outcomes associated with timely surgical treatment of hip fracture. Subsequently, practice recommendations changed with 24–48 h as the recommended time for surgery from admission; however, recent data on timing of hip fracture surgery and how this impacts outcomes are lacking. Methods: This retrospective cohort study included patients who had a primary diagnosis of hip fracture and underwent a subsequent surgical repair within 3 days of admission (Premier Healthcare claims 2006–2021 data). The primary exposure of interest was time from hip fracture diagnosis to surgery (categorized as 0–1 day, 2 days, and 3 days). Outcomes included any major complication, mortality, and intensive care unit (ICU) admission. Mixed‐effects models measured the association between timing of surgery and outcomes. We report odds ratios (OR) and 95% confidence intervals. Results: Among 501,267 surgical hip fracture patients, 26.0%, 56.0%, and 18.1% of patients received surgery on days 0–1, 2, and 3, respectively. The median ages were 83, 84, and 84 years old, and there were 73.3%, 72.2%, and 68.8% female in each group respectively. Compared with repair on day 0–1, hip fracture surgical treatment on day 2 or day 3 was associated with increased odds of major complications (OR 1.06, 95% CI 1.03–1.08 and OR 1.17, 95% CI 1.13–1.2), mortality (OR 1.08, 95% CI 1.02–1.14 and OR 1.2, 95% CI 1.12–1.28), and ICU admission (OR 1.06, 95% CI 1.04–1.09 and OR 1.36, 95% CI 1.32–1.4) after adjusting major comorbidities; all p < 0.001. Conclusion: Despite the publication of society guidelines in 2015, most fracture patients still received surgery on day 2 or day 3 of admission and were associated with worse outcomes. Balancing optimization of clinical factors with timing of surgery can be challenging, and further research is needed. Nonetheless, our findings reiterate the importance of timely surgical intervention. [ABSTRACT FROM AUTHOR]

The study examines mortality rates after hip fractures among Black and White women in a northern California healthcare system. While Black women were more likely to have diabetes and higher comorbidity scores, overall mortality rates at 6 and 12 months post-fracture were similar between Black and White women. However, younger Black women aged 65-74 had higher mortality rates within 6 months post-fracture. The study highlights the need for further research on fracture outcomes among Black women in the Western United States to address potential disparities. [Extracted from the article]

Background: Hip fracture and depression are important public health issues among older adults, but how pre‐fracture depression impacts recovery after hip fracture is unknown, especially among males who often experience greater depression severity. Days at home (DAH), or the days spent outside a hospital or healthcare facility, is a novel, patient‐centered outcome that can capture meaningful aspects of fracture recovery. How pre‐fracture depression impacts DAH after fracture, and related sex differences, remains unclear. Methods: Participants included 63,618 Medicare fee‐for‐service beneficiaries aged 65+ years, with a hospitalization claim for hip fracture surgery between 2010 and 2017. The primary exposure was a diagnosis of depression at hospital admission, and the primary outcome was total DAH over 12 months post‐discharge. Longitudinal associations between pre‐fracture depression and the count of DAH among beneficiaries were estimated using Poisson regression models after adjustment for covariates; sex‐by‐depression interactions were also assessed. Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) reflecting relative differences were estimated from these models. Results: Overall, beneficiaries with depression were younger, White females, and spent 11 fewer average DAH compared to counterparts without depression when demographic factors (age and sex) (IRR = 0.91; 95% CI = 0.90, 0.92; p < 0.0001) and social determinants of health (race, Medicaid dual eligibility, and poverty) were adjusted for (IRR = 0.92; 95% CI = 0.91, 0.93; p < 0.0001), but this association attenuated after adjusting for medical complexities (IRR = 0.99; 95% CI = 0.98, 1.01; p = 0.41) and facility and geographical factors (IRR = 1.0037; 95% CI = 0.99, 1.02; p = 0.66). There was no evidence of effect modification by sex. Conclusions: The comorbidity burden of preexisting depression may impact DAH among both male and female Medicare beneficiaries with hip fracture. Results suggest a holistic health approach and secondary prevention of depressive symptoms after hip fracture. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusion Appropriate pain management can facilitate rehabilitation after a hip fracture as patients transition back to the community setting. Differences in opioid prescribing by race may exist during this critical transition period.We conducted a retrospective cohort study of older adult U.S. Medicare beneficiaries with a hip fracture to examine whether the receipt and dose of opioids differs between Black and White patients as they transitioned back to the community setting. We stratified beneficiaries by whether they received institutional post‐acute care (PAC). Outcomes were (1) receipt of an opioid and (2) opioid doses in the first 90 days in the community in milligram morphine equivalents (MMEs; also presented in mg oxycodone). We estimated relative rates and risk differences of opioid receipt and dose differences using Poisson and linear regression models, respectively, using the parametric g‐formula to standardize for age and sex.We identified 164,170 older adults with hip fracture (mean age = 82.7 years; 75% female; 72% with PAC; 46% with opioid use after fracture). Overall use of opioids in the community was similar between Black and white beneficiaries. Black beneficiaries had lower average doses in their first 90 days in both total cumulative doses (PAC group: 165 [95% CI −264 to −69] fewer MMEs [−248 mg oxycodone]; no PAC: 167 [95% CI −274 to −62] fewer MMEs [−251 mg oxycodone]) and average MME per days' supply of medication (PAC: −3.0 [−4.6 to −1.4] fewer MMEs per day [−4.5 mg oxycodone]; no PAC: −4.7 [−4.6 to −1.4] fewer MMEs per day [−7.1 mg oxycodone]). In secondary analyses, Asian beneficiaries experienced the greatest differences (e.g., 617–653 fewer cumulative mg oxycodone).Racial differences exist in pain management for Medicare beneficiaries after a hip fracture. Future work should examine whether these differences result in disparities in short‐ and long‐term health outcomes. [ABSTRACT FROM AUTHOR]

Background: Persistent inflammation is associated with adverse health outcomes, but its impact on mortality has not been investigated previously among hip fracture patients. This article aims to investigate the influence of changes in levels of cytokines in the 2 months after a hip fracture repair on 5‐year mortality. Methods: This is a prospective cohort study from the Baltimore Hip Studies (BHS) with 191 community‐dwelling older men and women (≥65 years) who had recently undergone surgical repair of an acute hip fracture, with recruitment from May 2006 to June 2011. Plasma interleukin‐6 (IL‐6), soluble tumor necrosis factor alpha receptor1 (sTNFα‐R1), and interleukin‐1 receptor agonist (IL‐1RA) were obtained within 22 days of admission and at 2 months. All‐cause mortality over 5 years was determined. Logistic regression analysis tested the associations between the cytokines' trajectories and mortality over 5 years, adjusted for covariates (age, sex, education, body mass index, lower extremity physical activities of daily living, and Charlson comorbidity index). Results: High levels of IL‐6 and sTNFα‐R1 at baseline with small or no decline at 2 months were associated with higher odds of 5‐year mortality compared with those with lower levels at baseline and greater decline at 2 months after adjustment for age, and other potential confounders (OR = 4.71, p = 0.01 for IL‐6; OR = 15.03, p = 0.002 for sTNFα‐R1). Similar results that failed to reach significance were found for IL‐1RA (OR = 2.40, p = 0.18). Those with higher levels of cytokines at baseline with greater decline did not have significantly greater mortality than the reference group, those with lower levels at baseline and greater decline. Conclusion: Persistent elevation of plasma IL‐6 and sTNFα‐R1 levels within the first 2 months after hospital admission in patients with hip fracture is associated with higher 5‐year mortality. These patients may benefit from enhanced care and earlier intensive interventions to reduce the risk of death. [ABSTRACT FROM AUTHOR]

A retired oncologist describes the unexpected death of his wife, Claudia, who spent 25 years as head of the geriatrics service of a major VA hospital. The couple drew comfort in their orchestration of a "good death"; nevertheless they understood that her death was hastened by a number of missteps. In the 2 months following a hip fracture, a chain of complications that required five surgical interventions led to massive hemorrhage from necrotizing esophagitis. Claudia lacked resilience to recover from a sequence of traumas sustainable by a younger person—but even the most experienced geriatrician might not have identified or even suspected her risk. Despite multiple well‐controlled comorbidities Claudia was active and independent. She exercised daily and traveled extensively. She did not fit the profile of a frail or vulnerable person, according to assessing instruments in current use. According to the e‐prognosis calculator, her mortality risk was 10% lower than that of women her age. It is not surprising, nor deplorable, that after Claudia developed mild dysphagia, a gastroenterologist put off an EGD, awaiting a cardiac consult. That delay, however, proved fatal. Had the procedure been performed as soon as possible, it would have revealed esophagitis caused by a hiatal hernia, signaling need for different medications and prompt treatment. This might have prevented the terminal hemorrhage. The first important lesson from this case is that for an older patient with multiple comorbidities, even under control, delayed treatment is treatment denied. Current evaluation instruments are unable to spot critical resilience reductions in functional seniors. Inadequate pain management, premature discharge after surgery, and poor communication also contributed to the death. The second important lesson is that older patients, even when they are medical doctors, would benefit from a trained advocate to help them navigate the medical system. [ABSTRACT FROM AUTHOR]

BACKGROUND: Asian and Pacific Islander (Asian/PI) adults have lower hip fracture incidence than non-Hispanic White (NHW) adults, but data regarding Asian/PI subgroups are limited. We compared hip fracture incidence among older US Asian/PI and NHW populations, including ethnic subgroup differences. METHODS: Using observational data from a California healthcare system, we identified Asian/PI and NHW adults aged ≥50 years (2000-2019) and followed subjects to 2021 for hip fracture determined by principal/primary hospital diagnosis or by secondary hospital diagnosis with hip/femur procedure codes. Age-adjusted hip fracture incidence was calculated with 95% confidence intervals (CIs). Log-Poisson regression was used to determine fracture incidence rate ratios (IRRs, [CI]; NHW or Chinese as reference) adjusting for age and year. RESULTS: Among 215,359 Asian/PI and 776,839 NHW women, hip fracture incidence was 1.34 (1.28-1.40) and 2.97 (2.94-3.01) per 1000 person-years, respectively, with IRR 0.45 (0.43-0.47). Among 188,328 Asian/PI and 697,046 NHW men, hip fracture incidence was 0.62 (0.58-0.67) and 1.81 (1.78-1.84) per 1000 person-years, respectively, with IRR 0.34 (0.32-0.37). For the four largest Asian/PI subgroups, Filipina women (IRR 0.85 [0.75-0.96]) had lower, and Japanese (IRR 1.36 [1.20-1.54]) and South Asian (IRR 1.36 [1.07-1.72]) women had higher hip fracture incidence compared to Chinese women. Hip fracture incidence was only higher among South Asian (IRR 1.61 [1.21-2.14]) compared to Chinese men. CONCLUSION: Hip fracture incidence among US Asian/PI adults was 55% (women) and 66% (men) lower than NHW adults, but incidence varied by Asian/PI subgroup. The heterogeneity among Asian/PI adults highlights the importance of examining fracture risk by ethnic subgroup.

Background: Most fractures occur in women aged ≥80 years but competing mortality unrelated to fracture may limit the benefit of osteoporosis drug therapy for some women in late life. Our primary aim was to develop separate prediction models for non‐spine fracture (NSF) and mortality before fracture to identify subsets of women with varying fracture versus mortality risks. Methods: Separate prediction models were developed for NSF and mortality before NSF for 4895 women aged ≥80 years enrolled in the Study of Osteoporotic Fractures (SOF) or the Health Aging and Body Composition (HABC) study. Proportional hazards models modified to account for competing mortality were used to identify candidate risk factors for each outcome. Predictors associated with NSF or mortality (p < 0.2) were included in separate competing risk models to estimate the cumulative incidence of NSF and mortality before NSF during 5 years of follow‐up. This process was repeated to develop separate prediction models for hip fracture and mortality before hip fracture. Results: Significant predictors of NSF (race, total hip BMD, grip strength, prior fracture, falls, and use of selective serotonin reuptake inhibitors, benzodiazepines, or oral/transdermal estrogen) differed from predictors of mortality before NSF (age, walking speed, multimorbidity, weight change, shrinking, smoking, self‐rated health, dementia, and use of warfarin). Within nine subsets of women defined by tertiles of risk, 5‐year outcomes varied from 28% NSF and 8% mortality in the high‐risk NSF/low‐risk mortality subset, to 9% NSF and 22% mortality in the low‐risk NSF/high‐risk mortality subset. Similar results were seen for predictors of hip fracture and mortality before hip fracture. Conclusion: Considerable variation in 5‐year competing mortality risk is present among women in late life with similar 5‐year NSF risk. Both fracture risk and life expectancy should inform shared clinical decision‐making regarding initiation or continuation of osteoporosis drug therapy for women aged ≥80 years. [ABSTRACT FROM AUTHOR]

The article presents a study which described documented factors in multidisciplinary team (MDT) discussions of older adults referred for consideration of surgical versus non-operative management of hip fractures. Topics discussed include characteristics of hip fracture patients, factors impacting MDT decision and reliability, and limitations of the study.

Background: Little evidence exists about the comparative effects of first‐line antihypertensive medications (i.e., renin‐angiotensin‐aldosterone converting enzyme inhibitors (RAASi), amlodipine, or thiazide diuretics) in older adults with limited life expectancy. We compared the rates of injurious falls and short‐term cardiovascular events between different first‐line antihypertensive medication classes in adults receiving care in nursing homes (NH). Methods: This was a retrospective cohort of Medicare fee‐for‐service beneficiaries receiving care in NHs. Patients newly dispensed first‐line antihypertensive medications were identified using Part D claims (2015–2018) and linked with clinical assessments (i.e., Minimum Data Set). Fall‐related injuries (FRI), hip fractures, and major adverse cardiac events (MACE) outcomes were identified using hospitalization claims. Patients were followed from the date of antihypertensive dispensing until the occurrence of outcomes, death, disenrollment, or 6‐month follow‐up. Inverse‐probability‐of‐treatment‐weighted (IPTW) cause‐specific hazards regression models were used to compare outcomes between patients who were new users of RAASi, amlodipine, or thiazides. Results: Our cohort included 16,504 antihypertensive users (RAASi, n = 9574; amlodipine, n = 5049; thiazide, n = 1881). Mean age was 83.5 years (± 8.2), 70.6% were female, and 17.2% were non‐white race. During a mean follow‐up of 5.3 months, 326 patients (2.0%) experienced an injurious fall, 1590 (9.6%) experienced MACE, and 2123 patients (12.9%) died. The intention‐to‐treat IPTW hazard ratio (HR) for injurious falls for amlodipine (vs RAASi) use was 0.85 (95% confidence interval (CI) 0.66–1.08) and for thiazides (vs RAASi) was 1.22 (95% CI 0.88–1.66). The rates of MACE were similar between those taking anti‐hypertensive medications. Thiazides were discontinued more often than other classes; however, inferences were largely unchanged in as‐treated analyses. Subgroup analyses were generally consistent. Conclusions: Older adults with limited life expectancy experience similar rates of injurious falls and short‐term cardiovascular events after initiating any of the first‐line antihypertensive medications. [ABSTRACT FROM AUTHOR]

Background: Vitamin D deficiency has been linked to numerous health issues, including an increased risk of hip fractures. This meta‐analysis aimed to investigate the relationship between vitamin D deficiency and mortality in patients with hip fracture. To assess the impact of different levels of vitamin D deficiency on mortality in patients with hip fractures and examine the influence of potential confounding factors. Methods: A systematic search of PubMed, EMBASE, Scopus, and Cochrane Collaboration Library was conducted, resulting in nine eligible cohort studies (n = 4409). Patients with hip fractures were categorized based on their vitamin D levels as severe, moderate, or insufficient. Mortality was the primary outcome measure in this study. Subgroup analyses were performed according to the follow‐up time. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random‐effects model in Review Manager 5.4. Results: Nine studies, with a pool of 4409 patients, were included. Vitamin D insufficiency was significantly associated with increased mortality (OR 1.24, 95% CI 1.05–1.46; I2 = 4%). Severe deficiency also led to a significant increase in mortality (OR 2.08, 95% CI 1.09–3.97; I2 = 42%), whereas moderate deficiency did not show a significant effect (OR 1.06, 95% CI 0.79–1.44; I2 = 0%). Subgroup analysis revealed significant associations between vitamin D insufficiency and increased mortality at 1‐year (OR 1.37, 95% CI 1.06–1.77) and 2‐year follow‐ups (OR 1.78, 95% CI 1.01–3.15). After adjusting for potential confounders, no significant increase in the mortality rate was observed. Conclusions: This meta‐analysis suggests that vitamin D insufficiency and severe deficiency are associated with increased mortality in patients with hip fracture. However, after adjusting for confounding factors, this association was not statistically significant. Further research is necessary to understand the role of vitamin D deficiency in this population. [ABSTRACT FROM AUTHOR]

Background: Frailty is an important geriatric syndrome predicting adverse health outcomes in older adults. However, the longitudinal characteristics of frailty components in post‐hip fracture patients are less understood. Adopting the Fried frailty definition, we examined the longitudinal trends and sex trajectory differences in frailty and its components over 1 year post‐fracture. Methods: Three hundred and twenty‐seven hip fracture patients (162 men and 165 women with mean age 80.1 and 81.5) from Baltimore Hip Studies 7th cohort with measurements at 22 days after admission, and months 2, 6, and 12 post‐fracture were analyzed. Frailty components included: grip strength, gait speed, weight, total energy expenditure, and exhaustion. Longitudinal analysis used mixed effect models. Results: At baseline, men were sicker with worse cognitive status, and had higher weight and grip strength, but lower total energy expenditure than women (p < 0.001). The prevalence of frailty was 31.5%, 30.2%, and 28.2% at months 2, 6, and 12 respectively, showing no longitudinal trends or sex differences. However, its components showed substantial recovery trends over the post‐fracture year after confounding adjustments, including increasing gait speed, reducing risk of exhaustion, and stabilized weight loss and energy expenditure over time. Particularly, while men's grip strength tended to remain stable over first year post surgery within patients, women's grip strength reduced significantly over time within patients. On average over time within patients, women were more active with higher energy expenditures but lower grip strength and weight than men. Conclusion: Significant recovery trends and sex differences were observed in frailty components during first year post‐fracture. Overall frailty status did not show those trends over months 2–12 since a summary measure might obscure changes in components. Therefore, frailty components provided important multi‐dimensional information on the complex recovery process of patients, indicating targets for intervention beyond the global binary measure of frailty. [ABSTRACT FROM AUTHOR]

Background: How psychological resilience influences postoperative outcomes remains poorly characterized. We tested the hypothesis that psychological resilience is associated with lower odds of death or new inability to walk independently and other outcomes at 60 days after hip fracture surgery. Methods: This was a pre‐planned secondary analysis of a multicenter randomized trial comparing spinal versus general anesthesia for hip fracture surgery. We analyzed data on 1360 adults aged 50 years or older who were hospitalized for hip fracture surgery at one of 46 US or Canadian hospitals and provided psychological resilience data preoperatively as measured via the Brief Resilience Scale. Major exclusions were the inability to walk without human assistance before fracture and contraindications to spinal anesthesia. Death or new inability to walk independently at 60 days after surgery was the primary outcome; death or new nursing home residence at 60 days and 60‐day mortality were secondary outcomes. Results: Greater psychological resilience was associated with lower odds of death or new inability to walk at day 60 (adjusted odds ratio [aOR] 0.77; 95% Confidence Interval [CI], 0.61 to 0.98; p = 0.03). We observed a similar association between psychological resilience and outcomes among patients who did not experience complications after surgery (aOR 0.72; CI 0.55 to 0.94, p = 0.02), but not those who had complications (aOR 1.00; CI 0.59 to 1.69, p = 0.99). Psychological resilience was associated with lower odds of 60‐day death or new nursing home residence (aOR 0.73; 95% CI 0.58 to 0.93; p < 0.001) but not with 60‐day mortality (aOR 0.92; 95% CI 0.56 to 1.49; p = 0.73). Conclusions: Psychological resilience is associated with better outcomes for older adults after hip fracture surgery, but largely among those who do not have postoperative complications. Future interventions may focus on improving psychological resilience preoperatively or providing support to patients with lower psychological resilience. [ABSTRACT FROM AUTHOR]

Background: Hip fractures are costly and common in older adults, but there is limited understanding of how treatment patterns and outcomes might differ between countries. Methods: We performed a retrospective serial cross‐sectional cohort study of adults aged ≥66 years hospitalized with hip fracture between 2011 and 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population‐representative administrative data. We examined mortality, hip fracture treatment approaches (total hip arthroplasty [THA], hemiarthroplasty [HA], internal fixation [IF], and nonoperative), and health system performance measures, including hospital length of stay (LOS), 30‐day readmission rates, and time‐to‐surgery. Results: The total number of hip fracture admissions between 2011 and 2018 ranged from 23,941 in Israel to 1,219,696 in the US. In 2018, 30‐day mortality varied from 3% (16% at 1 year) in Taiwan to 10% (27%) in the Netherlands. With regards to processes of care, the proportion of hip fractures treated with HA (range 23%–45%) and THA (0.2%–10%) differed widely across countries. For example, in 2018, THA was used to treat approximately 9% of patients in England and Israel but less than 1% in Taiwan. Overall, IF was the most common surgery performed in all countries (40%–60% of patients). IF was used in approximately 60% of patients in the US and Israel, but only 40% in England. In 2018, rates of nonoperative management ranged from 5% of patients in Taiwan to nearly 10% in England. Mean hospital LOS in 2018 ranged from 6.4 days (US) to 18.7 days (England). The 30‐day readmission rate in 2018 ranged from 8% (in Canada and the Netherlands) to nearly 18% in England. The mean days to surgery in 2018 ranged from 0.5 days (Israel) to 1.6 days (Canada). Conclusions: We observed substantial between‐country variation in mortality, surgical approaches, and health system performance measures. These findings underscore the need for further research to inform evidence‐based surgical approaches. [ABSTRACT FROM AUTHOR]

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: There is mixed evidence on whether living arrangements and social interactions are associated with poorer health outcomes after hip fracture repair. Distinct social profiles among male and female older adults may explain some of the differences. However, prior studies did not evaluate these differences by sex. This article aims to assess if the associations between living alone, social interaction, and physical performance differ by sex among hip fracture survivors. Methods: This prospective cohort study is part of the Baltimore Hip Studies seventh cohort, with 168 male and 171 female hip fracture patients assessed at baseline (≤22 days after hospitalization) and at 2, 6, and 12 months post admission. Living arrangements and interaction with children or siblings and others in the past 2 weeks were collected at all visits. Physical performance was measured in the follow‐up visits with the Short Physical Performance Battery (SPPB). Linear mixed models tested associations of living alone and social interaction with SPPB over time adjusted for age, education, comorbidities, physical functioning pre‐fracture, cognitive function, self‐rated health, and time. Results: For men only, living alone was associated with worse performance (0.7 points lower SPPB scores, p = 0.05). Higher social interaction was associated with 0.8 and 1.2 point higher SPPB scores for men and women, respectively (p < 0.05). Visiting with friends was significantly associated with better function among males, while visiting with children or siblings was associated with worse SPPB among females. Conclusions: Living arrangements and types of social interaction are differentially associated with physical function for older men and women. Screening for social isolation/integration and including interventions that promote social interaction and participation should be considered in healthcare programs for hip fracture survivors. [ABSTRACT FROM AUTHOR]

Background: Orthopedists and other clinicians assess recovery potential of hip fracture patients at 2 months post‐fracture for care planning. It is unclear if examining physical performance (e.g., balance, gait speed, chair stand) during this follow‐up visit can identify individuals at a risk of poor functional recovery, especially mobility, beyond available information from medical records and self‐report. Methods: Data came from 162 patients with hip fracture enrolled in the Baltimore Hip Studies‐7th cohort. Predictors of mobility status (ability to walk 1 block at 12 months post‐fracture) were the Short Physical Performance Battery (SPPB) comprising balance, walking and chair rise tasks at 2 months; baseline medical chart information (sex, age, American Society of Anesthesiologist physical status rating, type of fracture and surgery, and comorbidities); and self‐reported information about the physical function (ability to walk 10 feet and 1 block at pre‐fracture and at 2 months post‐fracture). Prediction models of 12‐month mobility status were built using two methods: (1) logistic regression with least absolute shrinkage and selection operator (LASSO) regularization, and (2) classification and regression trees (CART). Area under ROC curves (AUROC) assessed discrimination. Results: The participants had a median age of 82 years, and 49.3% (n = 80) were men. Two‐month SPPB and gait speed were selected as predictors of 12‐month mobility by both methods. Compared with an analytic model with medical chart and self‐reported information, the model that additionally included physical performance measures had significantly better discrimination for 12‐month mobility (AUROC 0.82 vs. 0.88, p = 0.004). Conclusion: Assessing SPPB and gait speed at 2 months after a hip fracture in addition to information from medical records and self‐report significantly improves prediction of 12‐month mobility. This finding has important implications in providing tailored clinical care to patients at a greater risk of being functionally dependent who would not otherwise be identified using regularly measured clinical markers. [ABSTRACT FROM AUTHOR]

Background: An increased risk of fracture has been reported in older adults taking hypnotics. However, few studies have reported the comparative safety of hypnotics with different mechanisms of action. We examined the risk of fracture in older adults initiating suvorexant compared to those initiating Z‐drugs. Methods: We conducted a retrospective cohort study using a claims database within a longevity improvement and fair evidence (LIFE) study in Japan (1.5 million beneficiaries). People aged ≥65 years were included in this study. Exposure was defined as the initiation of either suvorexant or Z‐drugs (eszopiclone, zolpidem, or zopiclone). The evaluated outcomes were hip fracture and all‐cause fracture requiring hospitalization. We used inverse probability of treatment weights to adjust for confounding and followed the incidence of the outcome for three different periods: 30, 90, and 365 days. Cox proportional hazards models were fitted to the weighted population to estimate hazard ratios (HRs). Sensitivity analyses were performed with narrowed outcome definitions and inverse probability of censoring weights. Results: We identified 16,148 suvorexant new users and 54,327 Z‐drugs new users. During the 30‐day follow‐up, 21 (16.6 events per 1000 person‐years) and 53 hip fractures (12.2 events per 1000 person‐years) were identified among suvorexant and Z‐drugs new users, respectively (HR: 1.01, 95% confidence interval [CI]: 0.58–1.76). The analysis for all‐cause fracture showed an HR of 1.03 (95% CI: 0.78–1.36). Extended follow‐up (90 and 365 days) showed similar results for both outcomes. Sensitivity analyses showed consistent results except for an increased risk of all‐cause fracture requiring surgery (HR: 1.41, 95% CI: 0.87–2.29) during the 30‐day follow‐up. Conclusions: This is the first study to show that suvorexant has a generally comparable risk of fracture as compared to Z‐drugs. Further research is needed to investigate the potential short‐term increased risk of all‐cause fracture requiring surgery among suvorexant initiators. [ABSTRACT FROM AUTHOR]

ObjectivesTo determine the association between weight trajectory, health status, and mortality in older women.DesignCohort study.SettingStudy of Osteoporotic Fractures.ParticipantsOlder community-dwelling women (age: baseline (1986-88), mean 68, range 65-81; Year 20 (2006-08), mean 88, range 83-102 (N = 1,323)).MeasurementsBody weight measured repeatedly over 20 years (mean 8 times). Logistic and Cox proportional hazard models were used to evaluate whether 20-year weight trajectory measures were associated with hip fracture, falls, physical performance, and mortality.ResultsIn models adjusted for age, clinic, calcium use, Year 20 weight, walking speed, comorbidity score, smoking, self-reported health, and walking for exercise, women with moderate weight loss (>9.0 kg) over 20 years had a 74% greater risk of death (hazard ratio (HR) = 1.74, 95% confidence interval (CI) = 1.37-2.20) in the 5 years after the Year 20 visit than those with no weight loss and more than twice the risk of hip fracture (HR = 2.56, 95% CI = 1.39-4.70). They were 3.6 times (odds ratio (OR) = 3.60, 95% CI = 1.86-6.95) as likely to have poor physical function at the Year 20 visit as women with no weight loss but no greater risk of 2 or more falls in the 1.5 years after the Year 20 visit. Weight variability and abrupt weight decline were not associated with adverse health oucomes (falls, fractures, mortality), but those in the highest quartile of variability were 2.3 times (OR = 2.26, 95% CI = 1.34-3.80) as likely to have poor physical function scores.ConclusionIn women surviving past 80 years of age, moderate weight loss over 20 years was associated with greater risk of hip fracture, poor physical function, and mortality but not of falls. Future work should separate voluntary from involuntary weight loss.

Background: Community‐dwelling older adults experiencing hip fracture often fail to achieve adequate walking capacity following surgery and rehabilitation. Effects of psychological factors on post‐fracture walking capacity are poorly understood. Accordingly, this paper investigates effects of psychological resilience on observed walking capacity measures in older adults following hip fracture, controlling for important covariates. Methods: Data were drawn from the Community Ambulation Project, a clinical trial of 210 community‐dwelling adults aged ≥60 years who experienced a minimal trauma hip fracture and were randomized to one of two 16‐week home‐based physical therapist‐guided interventions. Psychological resilience was measured at study baseline using the 6‐item Brief Resilience Scale (BRS); scores were classified into groups in order to distinguish levels of self‐reported resilience. Walking capacity was assessed at study baseline and 16 weeks later using 4‐Meter Gait Speed (4MGS), 50‐Foot Walk Test (50FWT), and 6‐Minute Walk Distance (SMWD). In multivariate analyses of covariance in which 16‐week follow‐up values of each walking measure were outcomes, covariates included clinical trial arm, gender, age, and baseline values of: walking measure corresponding to the outcome; body mass index; depressive symptom severity; degree of psychological optimism; cognitive status; informal caregiver need; and days from hospital admission to randomization. Results: Increases between baseline and 16 weeks later in mean gait speed in meters/sec (m/s) and walking distance in meters (m) in 4MGS, 50FWT and SMWD were 0.06 m/s (p = 0.061), 0.11 m/s (p < 0.01), and 25.5 m (p = 0.056) greater, respectively, in the most resilient BRS group compared to the least resilient BRS group. Conclusion: Higher levels of psychological resilience were associated with greater walking speed and distance. Psychological resilience represents a potentially clinically important pathway and intervention target, toward the goal of improving walking capacity among older adults known to have substantial residual disability following hip fracture. [ABSTRACT FROM AUTHOR]

Background: Long‐term functional limitations are common after hip fractures. Exercise may alleviate these negative consequences but there is no consensus on an optimal training program. The objective was to study the effects of a 12‐month home‐based supervised, progressive exercise program on functioning, physical performance, and physical activity. Methods: Secondary analysis of a randomized controlled trial targeting patients with surgical repair of a hip fracture, aged ≥60 years, Mini‐Mental State Examination (MMSE) score of ≥12. The participants were randomized into Exercise (n = 61) or Usual care (n = 60). Assessments at baseline, 3, 6, and 12 months included Lawton's Instrumental Activities of Daily Living (IADL), Short Physical Performance Battery (SPPB), handgrip strength, and self‐reported frequency of sessions of leisure‐time physical activity. Analyzed using mixed‐effects models. Results: Participants' (n = 121) mean age was 81 years (SD 7), and 75% were women. The mean IADL score at baseline was 17.1 (SD 4.5) in the exercise group, and 17.4 (5.1) in the usual care group. The mean SPPB scores were 3.9 (1.6) and 4.2 (1.8), and handgrip strength was 17.7 (8.9) kg and 20.8 (8.0) kg, respectively. The age‐ and sex‐adjusted mean changes in IADL over 12 months were 3.7 (95% CI 2.8–4.7) in the exercise and 2.0 (1.0–3.0) in the usual care group (between‐group difference, p = 0.016); changes in SPPB 4.3 (3.6–4.9) and 2.1 (1.5–2.7) (p < 0.001); and changes in handgrip strength 1.2 kg (0.3–2.0) and 1.0 kg (−1.9 to −0.2) (p < 0.001), respectively. We found no between‐group differences in changes in the frequency of leisure‐time activity sessions. Conclusion: A 12‐month home‐based supervised, progressive exercise program improved functioning and physical performance more than usual care among patients with hip fractures. However, the training did not increase leisure‐time physical activity. [ABSTRACT FROM AUTHOR]

Background: Several international study groups adopted appendicular skeletal muscle mass (ASM) index adjusted by (1) height squared, (2) weight, and (3) body mass index (BMI) in the diagnosis of sarcopenia. However, different prevalence rates of sarcopenia by each index and clinical implications were not well known. The purpose of this study was to compare the differences in (1) the percentage of sarcopenia in hip fracture patients and (2) the relative mortality rate according to the sarcopenia criteria of three ASM indices. Methods: Between January 2009 and December 2020, 1003 older adult hip fracture patients at a tertiary institution were eligible and retrospectively reviewed for this study. Based on the ASM measured on dual‐energy X‐ray absorptiometry, three indices were calculated, and sarcopenia was diagnosed. The proportion of sarcopenia was evaluated according to each index. One, two, and five‐year mortality rates were compared between each sarcopenia group and a normal musculature group, based on ASM criteria. Results: The proportion of sarcopenia patients differed according to three ASM indices. The proportion of sarcopenic patients by ASM/height2 index was higher than those of the other two indices in both male and female hip fracture patients. In male patients, 61% were sarcopenic by ASM/height2 index, 37% by ASM/weight index, and 44% by ASM/BMI index. In female patients, 26%, 11%, and 14% were sarcopenic, respectively. Among the three indices, only ASM/height2 had significant correlations with all 1‐, 2‐, and 5‐year mortality rates. Conclusions and Implications: The prevalence of sarcopenia in hip fracture patients differed substantially according to ASM indices. Sarcopenic hip fracture patients had a higher mortality rate than those with normal musculature. The 1‐year, 2‐year, and 5‐year mortality rates were discriminated by ASM/height2 criteria in both men and women. Future prospective studies in a larger cohort are warranted. [ABSTRACT FROM AUTHOR]

Background: Mortality rates among men are double that of women in the first 2 years after hip fracture and may be related to more infections. Research has only examined differences in short‐term mortality after hip fracture. Thus, the objective was to determine if long‐term all‐cause mortality and infection‐specific mortality rates are higher in men compared to women. Methods: Data come from a prospective cohort study (Baltimore Hip Studies 7th [BHS‐7]) with up to 10.2 years of follow‐up (2006–2018). The participants were selected from eight acute care hospitals in the 25‐hospital BHS network. Enrolled women were frequency‐matched (1:1) to men on timing of admission for hip fracture that yielded an analytic sample size of 300 participants (155 women, 145 men). Associations between sex and mortality were analyzed using Cox proportional hazard models and cause‐specific Cox models adjusted for age, cognition, body mass index, pre‐fracture lower extremity activities of daily living limitation, depressive symptoms, and comorbidity. Results: Participants had a mean age of 80 years, 48% (n = 145) were men and the median follow‐up was 4.9 (interquartile range = 2.3–8.7) years. Over the follow‐up period after hospital admission for hip fracture, 237 (79.0%) participants died of all causes (132 men and 105 women) and 38 (12.7%) died of infection‐specific causes (25 men and 13 women). Men had significantly higher rates of all‐cause mortality [hazard ratio (HR) = 2.31(95% confidence interval [CI] 2.02–2.59)] and infection‐specific mortality (HR = 4.43, CI 2.07–9.51) compared to women. Conclusions: Men had a two‐fold higher rate of all‐cause mortality and four‐fold higher rate of infection‐specific mortality compared to women over a follow‐up period of up to 10.2 years. Findings suggest that interventions to prevent and treat infections, tailored by sex, may be needed to narrow significant differences in long‐term mortality rates between men and women after hip fracture. [ABSTRACT FROM AUTHOR]

Background: Potentially disruptive medical, surgical, and social events—such as pneumonia, hip fracture, and widowhood—may accelerate the trajectory of decline and impact caregiving needs in older adults, especially among people with dementia (PWD). Prior research has focused primarily on nursing home residents with dementia. We sought to assess the incidence of potentially disruptive events in community‐dwelling people with and without dementia. Methods: Retrospective cohort study of participants aged 65+ enrolled in the Health and Retirement Study between 2010 and 2018 (n = 9346), including a subset who were married–partnered at baseline (n = 5105). Dementia was defined with a previously validated algorithm. We calculated age‐adjusted and gender‐stratified incidence per 1000 person‐years and incidence rate ratios of: 1) hospitalization for pneumonia, 2) hip fracture, and 3) widowhood in people with and without dementia. Results: PWD (n = 596) were older (mean age 84 vs. 75) and a higher proportion were female (67% vs. 57%) than people without dementia (PWoD) (n = 8750). Age‐adjusted incidence rates (per 1000 person‐years) of pneumonia were higher in PWD (113.1; 95% CI 94.3, 131.9) compared to PWoD (62.1; 95% CI 54.7, 69.5), as were hip fractures (12.3; 95% CI 9.1, 15.6 for PWD compared to 8.1; 95% CI 6.9, 9.2 in PWoD). Point estimates of widowhood incidence were slightly higher for PWD (25.3; 95% CI 20.1, 30.5) compared to PWoD (21.9; 95% CI 20.3, 23.5), but differences were not statistically significant. The association of dementia with hip fracture—but not pneumonia or widowhood—was modified by gender (male incidence rate ratio [IRR] 2.24, 95% CI 1.34, 3.75 versus female IRR 1.31 95% CI 0.92,1.86); interaction term p = 0.02). Conclusions: Compared to PWoD, community‐dwelling PWD had higher rates of pneumonia and hip fracture, but not widowhood. Knowing how often PWD experience these events can aid in anticipatory guidance and care planning for this growing population. [ABSTRACT FROM AUTHOR]

Background: Hip fracture often represents a major transition in patients' health, with a 1‐year mortality rate between 25% and 30% and a challenging recovery course. Caring for hip fracture patients presents opportunities for goals of care discussions that include prognostic information and guidance about functional dependence. Methods: We conducted qualitative, semi‐structured interviews with 23 attending physicians involved with the care of hip fracture patients, including orthopedic surgeons, anesthesiologists, internists, and geriatricians, across 13 health systems in the United States and Canada. Questions addressed knowledge and interpretation of prognosis, discussing prognosis and goals of care, and timing and prioritization of surgery. Interviews were analyzed using a constructivist grounded theory approach to identify themes and develop a coding taxonomy. Results: Physicians agreed that hip fracture had a considerable 1‐year mortality, felt that it was important to discuss prognostic outcomes and the recovery process, wanted to elucidate patients' priorities, and often promoted timely surgery. Physicians perceived challenges when discussing mortality data with new patients in an acute setting. They more easily discussed outcomes related to functional dependence and quality of life. Some physicians used iterative communication as a strategy to have in‐depth conversations in a busy perioperative setting. Conclusion: Providing timely, compassionate care for hip fracture patients is challenging. There are opportunities to study iterative communication to encourage dialogue at key points of patient care to better discuss prognosis and recovery and bolster coordinated multidisciplinary care that focuses on patients' goals and values. [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]

The article discusses research which investigated the prevalence of idiopathic normal pressure hydrocephalus (iNPH) in patients with hip fractures. The study compared three major symptoms of iNPH, demographic data and risk factors in patients suspected of having iNPH and those who were not. It evaluated radiological characteristics of iNPH using Evans' index (EI), disproportionately enlarged subarachnoid-space hydrocephalus (DESH) and callosal angle (CA).

ObjectivesTo compare the ability of the commonly used Women's Health Initiative (WHI) and Cardiovascular Health Study (CHS) frailty phenotypes to predict falls, hip fracture, and death in WHI Clinical Trial participants aged 65 and older.DesignLongitudinal cohort study.SettingWHI Clinical Trial.ParticipantsParticipants with data for WHI and CHS frailty phenotypes (N = 3,558).MeasurementsFrailty was operationally defined in the CHS as the presence of three or more of weight loss, poor energy, weakness, slowness, and low physical activity. WHI operationalized frailty similarly but with the RAND-36 physical function scale substituted for slowness and weakness (RAND-36 physical function scale score 78 = 0 points). Frailty was defined as a summary score of 3 or greater, prefrailty as a score of 2 or 1, and nonfrailty as a score of 0. Outcomes were modeled using Cox regression. Harrell C-statistics were compared for models containing alternative instruments.ResultsApproximately 5% of participants were frail based on the CHS or WHI phenotype. The WHI frailty phenotype was associated with higher rates of falls (hazard ratio (HR) = 1.48, P = .003), hip fracture (HR = 1.87, P = .04), and death (HR = 2.32, P < .001). Comparable HRs in CHS-phenotype frail women were 1.32 (P = .04), 1.08 (P = .83), and 1.91 (P < .001), respectively. Harrell C-statistics revealed marked but insignificant differences in predicting abilities between CHS and WHI phenotype models (P > .50 for all).ConclusionThe WHI phenotype, which does not require direct measurements of physical performance, might offer a practical advantage for epidemiological and clinical needs.

ObjectivesTo develop a prediction index for 1-year mortality after hip fracture in older adults that includes predictors from a wide range of domains.DesignRetrospective cohort study.SettingsHealth and Retirement Study (HRS).ParticipantsHRS participants who experienced hip fracture between 1992 and 2010 as identified according to Medicare claims data (N = 857).MeasurementsOutcome measure was death within 1 year of hip fracture. Predictor measures were participant demographic characteristics, socioeconomic status, social support, health, geriatric symptoms, and function. Variables independently associated with 1-year mortality were identified, and best-subsets regression was used to identify the final model. The selected variables were weighted to create a risk index. The index was internally validated using bootstrapping to estimate model optimism.ResultsMean age at time of hip fracture was 84, and 76% of the participants were women. There were 235 deaths (27%) during the 1-year follow up. Five predictors of mortality were included in the final model: aged 90 and older (2 points), male sex (2 points), congestive heart failure (2 points), difficulty preparing meals (2 points), and not being able to drive (1 point). The point scores of the index were associated with 1-year mortality, with 0 points predicting 10% risk and 7 to 9 points predicting 66% risk. The c-statistic for the final model was 0.73, with an estimated optimism penalty of 0.01, indicating very little evidence of overfitting.ConclusionThe prognostic index combines demographic, comorbidity, and function variables and can be used to differentiate between individuals at low and high risk of 1-year mortality after hip fracture.

Improving the quality of medication use and medication safety are important priorities for prescribers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2020. We selected high‐quality studies that moved the field of research forward and were not merely replication studies. The chosen articles cover domains related to deprescribing, medication safety, and optimizing medication use. The first study, a noninferiority randomized clinical trial in England, evaluated whether antihypertensive medication reduction is possible without significant changes in systolic blood pressure control or adverse events over the 12‐week follow‐up (domain: deprescribing). The second study, a prospective cohort study of women at Kaiser Permanente Southern, California, examined the association between bisphosphonate use and atypical femur fracture (domain: medication safety). The third study examined the effectiveness and safety of a multifaceted antimicrobial stewardship and quality improvement initiative in reducing unnecessary antimicrobial use for unlikely cystitis cases in noncatheterized residents in 25 nursing homes across the United States (domain: optimizing medication use). Lastly, the fourth study, a population‐based cohort study in the United Kingdom, examined the association of tramadol use with risk of hip fracture (domain: medication safety). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens. [ABSTRACT FROM AUTHOR]

ObjectiveTo evaluate the associations between definitions of sarcopenia and clinical outcomes and the ability of the definitions to discriminate those with a high likelihood of having these outcomes from those with a low likelihood.DesignOsteoporotic Fractures in Men Study.SettingSix clinical centers.ParticipantsCommunity-dwelling men aged 65 and older (N = 5,934).MeasurementsSarcopenia definitions from the International Working Group, European Working Group on Sarcopenia in Older Persons, Foundation for the National Institutes of Health Sarcopenia Project, Baumgartner, and Newman were evaluated. Recurrent falls were defined as two or more self-reported falls in the year after baseline (n = 694, 11.9%). Incident hip fractures (n = 207, 3.5%) and deaths (n = 2,003, 34.1%) were confirmed according to central review of medical records over 9.8 years. Self-reported functional limitations were assessed at baseline and 4.6 years later. Logistic regression or proportional hazards models were used to estimate associations between sarcopenia and falls, hip fractures, and death. The discriminative ability of the sarcopenia definitions (vs reference models) for these outcomes was evaluated using area under the receiver operating characteristic curve or C-statistics. Referent models included age alone for falls, functional limitations and mortality, and age and bone mineral density for hip fractures.ResultsThe association between sarcopenia according to the various definitions and risk of falls, functional limitations, and hip fractures was variable; all definitions were associated with greater risk of death, but none of the definitions materially changed discrimination based on the AUC and C-statistic when compared with reference models (change ≤1% in all models).ConclusionSarcopenia definitions as currently constructed did not consistently improve prediction of clinical outcomes in relatively healthy older men.

ObjectivesTo establish the prevalence and correlates of disability during the 2 years before hip fracture.DesignData from participants who experienced hip fracture in the Health and Retirement Study (HRS) with hip fracture identified using linked Medicare claims. Each participant was interviewed at varying time points in the 2 years before hip fracture. Disability was defined as self-report of the need for assistance in any activity of daily living (walking across the room, eating, bathing, dressing, using the toilet, transferring). Based on the timing between interview and hip fracture, prevalence of disability was calculated in the cohort as a whole over the 2 years before hip fracture and in subgroups defined according to demographic and clinical characteristics.SettingThe HRS is a nationally representative longitudinal study (1992-2010).ParticipantsHRS participants aged ≥65 with hip fracture (mean age at fracture 84, 77% female).ResultsThe adjusted prevalence of disability was 20% (95% confidence interval (CI) = 14-25%) 2 years before hip fracture, with little change until approximately 10 months before fracture, when it started to rise, reaching 44% (95% CI = 33-55%) in the month before hip fracture. The prevalence of disability was highest in the last month before fracture for persons aged 85 and older (53%) and for those with dementia (60%).ConclusionCare models for hip fracture need to consider not only the acute medical and surgical needs, but also the high level of need for supportive care and caregiver assistance that chronically disabled individuals require.

BACKGROUND: There are few studies demonstrating how kidney function affects the risk of developing delirium in older adult surgical patients administered opioids. This study determined whether baseline kidney function influences the relationship between morphine equivalent dose and the development of delirium on postoperative day (POD) 2 in patients with hip fracture. METHODS: This retrospective study analyzed emergency department (ED) estimated glomerular filtration rate (eGFR), perioperative serum creatinine, intravenous morphine equivalents, and POD2 delirium assessment by the Confusion Assessment Method in 652 patients aged 65 years or older without preoperative delirium. ED eGFR was used to divide subjects into groups by presence or absence of chronic kidney disease (CKD), and associations of opioid dose with POD2 delirium were compared using multivariable logistic regression. RESULTS: POD2 delirium incidence was 29.8% (N = 194). Intraoperative and postanesthesia care unit (PACU) morphine equivalent dosage as well as ED eGFR were similar comparing patients with and without POD2 delirium. Age, American Society of Anesthesiologists status, and dementia were associated with delirium on POD2. The odds of POD2 delirium increased significantly with increase of intraoperative opioid in patients with CKD (odds ratio = 1.6; 95% confidence interval = 1.2–2.2), but not in patients without CKD (P‐interaction =.04). PACU or POD1 opioid doses were not associated with POD2 delirium after covariate adjustment. CONCLUSION: This study suggests that incremental increases in intraoperative opioids combined with CKD increase odds of POD2 delirium after hip fracture repair, compared with patients without CKD. [ABSTRACT FROM AUTHOR]

Background: Falls and interpersonal violence pose significant threats to older adults, leading to injuries, hospitalizations, and emergency department (ED) visits. This study investigates the demographics and injury patterns in older adults (aged 60 and above) who sought ED care due to assaults, comparing them with those who experienced falls to gain a deeper understanding of older adult abuse patterns., Method: This study utilizes data from the National Electronic Injury Surveillance System (NEISS) All Injury Program (2005-2019) to examine injuries among older adults aged 60 years and above. Participants were categorized into two groups: older adult abuse and injuries due to falls. The differences between the groups by demographics, injury locations, patterns, and temporal trends were analyzed using statistical methods accounting for the weighted stratified nature of the data. Cosinor analysis and Joinpoint regression were used for temporal analysis., Results: Over 15 years, there were an estimated 307,237 ED visits for older adult abuse and 39,477,217 for falls. Older adults experiencing abuse were younger and had lower hospital admission rates compared to fall patients. Injuries associated with abuse included contusions/abrasions, penetrating injuries, and fractures to the head/neck, fingers, toes, ribs, and lower extremities. In contrast, fall patients had higher admission rates, with more fractures, including cervical spine and hip fractures. Temporal patterns showed a higher rate of assaults during the summer, whereas abuse demonstrated bimodal peaks in the summer and fall., Conclusions: Injuries associated with abuse such as facial, upper trunk, and upper extremity fractures should raise suspicion even in the absence of severe symptoms. These findings emphasize the importance of early identification to connect older adults with support resources, as patients experiencing abuse often get discharged from the ED., (© 2024 The American Geriatrics Society.)

BACKGROUND Geriatric hip fracture patients are susceptible to the adverse effects of opioid‐induced analgesia. Fascia iliaca blocks (FIBs) have emerged as an analgesic technique for this population. There are limited data on a preoperative FIB's effect on perioperative opioid intake. We hypothesized that preoperative FIB would reduce perioperative opioid consumption, measured in morphine milliequivalents (MMEs). DESIGN This is a prospective observational study. SETTING A level 1 trauma center in California. PARTICIPANTS From March 2017 to December 2017, patients 65 years and older presenting with a hip fracture received a preoperative FIB and were prospectively observed. This cohort was compared with a historical control. INTERVENTION All prospectively enrolled patients were given FIBs. For a single‐shot FIB, a 30‐ to 40‐mL bolus of 0.25% bupivacaine with 1:200,000 epinephrine was injected. For a continuous FIB, a bolus of 10 to 20 mL of 0.2% bupivacaine was injected, followed by a continuous infusion of 0.2% bupivacaine at 6 mL/h ending on the morning of postoperative Day 1. RESULTS: A total of 725 patients were included in this study, with 92 in the prospectively collected cohort. The mean age of this cohort was 84.2 (standard deviation = 8.4) years, and 69.2% were female. Patients who received a preoperative FIB consumed less MME preoperatively, 18.0 (interquartile range = 6.0–44.5) versus 29.5 (interquartile range = 6.0–56.5) (P =.007), with no change in pain scores. No differences were found in postoperative opioid consumption between groups. There was no difference in MME or pain score in patients with dementia. Subgroup analysis based on fracture pattern (femoral neck and intertrochanteric) demonstrated a significant decrease in preoperative MME consumption in femoral neck fractures only, 12.0 (interquartile range = 5.0–24.0) versus 29.0 (interquartile range = 12.0–59.0) (P <.001). CONCLUSION: FIBs reduce preoperative opioid intake and have low rates of opioid‐related adverse events in geriatric hip fracture patients. LEVEL OF EVIDENCE The level of evidence was II. [ABSTRACT FROM AUTHOR]

BACKGROUND Many health systems are establishing geriatrics‐orthopedics (Geri‐Ortho) comanagement programs; however, there is paucity of published information on existing programs' variations in clinical operations, structure, and reported implementation challenges and perceived successes. OBJECTIVE Our objective was to obtain detailed information about the variety of existing Geri‐Ortho comanagement programs in the United States. DESIGN/PARTICPANTS We conducted a cross‐sectional survey of 44 existing Geri‐Ortho comanagement programs, with 23 (52%) of programs responding. MEASUREMENT Quantitative questions were used to assess operational, staffing, and financial structures; and qualitative questions were used to identify reported challenges and perceived successes of implementation. RESULTS: Programs self‐identified as urban (n = 23), academic (n = 20), or nonprofit (n = 22) and as having a level I trauma center (n = 17). Most programs (n = 18) were funded fully by the institution. Fourteen programs used geriatricians, and nine used medicine/hospitalists as the supporting clinical service, whereas approximately half (n = 11) used these services in a true comanagement model. Six universal themes were identified as necessary for program implementation. The most commonly described successes perceived by all respondents were improvements in clinical outcomes and better interdisciplinary relationships. Reported challenges included difficulty in interdisciplinary geriatrics education, difficulty in adherence to protocols, and lack of funding for staffing. CONCLUSIONS: There are diverse types of Geri‐Ortho comanagement programs in the United States, although universal elements exist. Many had similar challenges in implementation, and further studies are needed to determine which implementation elements are critical to clinical and financial outcomes. J Am Geriatr Soc 68:1714‐1719, 2020. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES For older adults with acute hip fracture, use of preoperative noninvasive cardiac testing may lead to delays in surgery, thereby contributing to worse outcomes. Our study objective was to evaluate the preoperative use of pharmacologic stress testing and transthoracic echocardiogram (TTE) in older adults hospitalized with hip fracture. DESIGN Retrospective chart review. SETTING Seven hospitals (three tertiary, four community) within a large health system. PARTICIPANTS Patients, aged 65 years and older, hospitalized with hip fracture (n = 1,079; mean age = 84.2 years; 75% female; 82% white; 36% married). MEASUREMENTS Data were extracted from electronic medical records. The study evaluated associations between patient factors as well as clinical outcomes (time to surgery [TTS], length of stay [LOS], and in‐hospital mortality) and the use of preoperative noninvasive cardiac testing (pharmacologic stress tests or TTE). Descriptive statistics were calculated. Cox regression was performed for both TTS and LOS (evaluated as time‐dependent variable); logistic regression was used for in‐hospital mortality. RESULTS: Although 34.3% (n = 370) had a preoperative TTE,.7% (n = 8) underwent a nuclear stress test and none had a dobutamine stress echocardiogram. Median TTS was 1.1 days (IQR [interquartile range] =.8‐1.8 days), median LOS was 5.3 days (IQR = 4.2‐7.2 days), and in‐hospital mortality was 3% (n = 32). Patients admitted to the medical service had 3.5 times greater odds of undergoing a TTE compared with those on the orthopedic service (P <.001). Community hospitals had almost three times greater odds of preoperative TTE than tertiary centers (P <.001). In multivariable analysis, preoperative TTE was significantly associated with increased TTS (P <.001). No difference in mortality was found between patients with and without a preoperative TTE. CONCLUSION: This study highlights the high rate of TTE in preoperative assessment of older adults with acute hip fracture. Given the association between TTE and longer TTS, further studies must clarify the role of preoperative TTE in this population. J Am Geriatr Soc 68:1690‐1697, 2020. See related Special Series On Orthogeriatrics by Wolfe et al. in this issue. [ABSTRACT FROM AUTHOR]

OBJECTIVES Acute hip fracture is common and leads to significant morbidity and mortality. Co‐management programs, such as American Geriatric Society (AGS) CoCare: Ortho®, that optimize perioperative care of older adults, have demonstrated improved outcomes. Yet there is substantial variation in hip fracture care nationally. Our objective was to describe the implementation of AGS CoCare: Ortho® across a large integrated health system. DESIGN Program implementation of four phases. SETTING Large integrated health system. PARTICIPANTS One tertiary and three community hospitals. MEASUREMENTS The first two phases were communication and system‐level planning. The communication phase consisted of getting health system leadership buy‐in, creating an interdisciplinary steering committee, and building a business model. The planning phase consisted of choosing process and outcome measures, ensuring accurate and timely data collection, and creating standardized order sets and physician documentation. RESULTS: The second two phases were hospital‐level planning and implementation. The planning phase consisted of identifying sites and developing the co‐management structure. The implementation phase consisted of identifying and engaging frontline staff, rolling out the program, optimizing workflow, and educating providers. CONCLUSION: The program was implemented at four diverse sites. Major lessons learned included the need for an engaged steering committee to oversee the program; the importance of standardizing order sets and documentation; the utilization of hospitalists as co‐managers; the benefit of developing and actively using a data dashboard; the challenge of ensuring wide uptake of education modules; and the need to take proactive steps to improve multidisciplinary communication. J Am Geriatr Soc 68:1706‐1713, 2020. [ABSTRACT FROM AUTHOR]

OBJECTIVES Patients undergoing hip fracture surgery have a 10 times increased risk of stroke compared with the general population. We aimed to evaluate the association between the CHA2DS2‐VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, previous stroke/TIA [transient ischemic attack]/systemic embolism (2 points), vascular disease, age 65‐74 years, and female sex) score and the risk of stroke, thromboembolism, and all‐cause mortality in patients with hip fracture with or without atrial fibrillation (AF). DESIGN Nationwide prospective cohort study. SETTING Danish hospitals. PARTICIPANTS Subjects were all incident hip fracture patients in Denmark age 65 years and older with surgical repair procedures between 2004 and 2016 (n = 78,096). Participants were identified using the Danish Multidisciplinary Hip Fracture Registry. MEASUREMENTS We calculated incidence rates, cumulative incidences, and hazard ratios (HRs) with 95% confidence intervals (CIs) by CHA2DS2‐VASc score, stratified on AF history. RESULTS: The cumulative incidence of ischemic stroke 1 year after hip fracture increased with ascending CHA2DS2‐VASc score, and it was 1.9% for patients with a score of 1 and 8.6% for patients with a score above 5 in the AF group. Corresponding incidences in the non‐AF group were 1.6% and 7.6%. Compared with a CHA2DS2‐VASc score of 1, adjusted HRs were 5.53 (95% CI = 1.37‐22.24) among AF patients and 4.91 (95% CI = 3.40‐7.10) among non‐AF patients with a score above 5. A dose‐response–like association was observed for all cardiovascular outcomes. All‐cause mortality risks and HRs were substantially higher for all CHA2DS2‐VASc scores above 1 in both the AF group and the non‐AF group. CONCLUSION: Among patients with hip fracture, a higher CHA2DS2‐VASc score was associated with increased risk of stroke, thromboembolism, and death. This finding applied both to patients with and without AF. Patients with high CHA2DS2‐VASc scores had almost similar absolute risks for cardiovascular outcomes, irrespective of AF. J Am Geriatr Soc 68:1698‐1705, 2020. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Although peripheral nerve blocks are associated with improved pain control and end outcomes among older adults with hip fracture, their current utilization among US hip fracture patients is not well understood. We characterized contemporary use of peripheral nerve blocks after hip fracture over time and identified predictors of nerve block receipt. DESIGN: Retrospective cohort study of claims data from one large national private US insurer. SETTING: US acute care hospitals. PARTICIPANTS: A total of 94 985 adults aged 50 years and older hospitalized for a femoral neck, intertrochanteric, or subtrochanteric fracture; 409 263 adults aged 50 years and older hospitalized for elective hip or knee arthroplasty between 2004 and 2016. MEASUREMENTS: Receipt of a peripheral nerve block for pain control, based on Current Procedural Terminology codes in physician service claims. RESULTS: Overall, 2874 hip fracture patients (3.0%; 95% confidence interval [CI] = 2.9‐3.1) received a nerve block for pain control, and the percentage receiving a block increased from.4% in 2004‐2006 (95% CI =.3%‐.6%) to 4.6% in 2013‐2016 (95% CI = 4.4%‐4.8%; P <.001). The adjusted odds of receiving a nerve block was lower for patients with vs without dementia (odds ratio [OR] =.88; 95% CI =.80‐.98; P =.02) and among patients aged 75 to 84 vs 64 years or younger (OR =.86; 95% CI =.74‐1.00; P =.02). The odds of nerve block receipt did not vary according to race, ethnicity, fracture location, or most other common comorbidities. Compared with patients with hip fracture, the adjusted odds of nerve block receipt were 2 times higher among patients undergoing elective hip replacement and more than 30 times higher among patients undergoing elective knee replacement. CONCLUSION: Although use of peripheral nerve blocks for pain control after hip fracture has increased over time, fewer than 5 of every 100 patients hospitalized with hip fracture currently receive a peripheral nerve block, suggesting possible underuse. J Am Geriatr Soc 68:835–840, 2020 See related Editorial by Ellen F. Binder [ABSTRACT FROM AUTHOR]

ObjectivesTo evaluate the association between chronic kidney disease and incident hip fracture using serum cystatin-C as a biomarker of renal function calculated without reference to muscle mass.DesignCase-control study nested within a prospective study.SettingThe Women's Health Initiative Observational Study conducted at 40 U.S. clinical centers.ParticipantsFrom 93,676 women aged 50 to 79 followed for an average of 7 years, 397 incident hip fracture cases and 397 matched controls were studied.MeasurementsCystatin-C levels were measured on baseline serum using a particle-enhanced immunonepholometric assay. Estimated glomerular filtration rates (eGFR(cys-c)) were calculated using a validated equation and categorized into three groups (>or=90.0 mL/min per 1.73 m(2), 60.0-89.9 mL/min per 1.73 m(2), and

ObjectivesTo define frailty using simple indicators; to identify risk factors for frailty as targets for prevention; and to investigate the predictive validity of this frailty classification for death, hospitalization, hip fracture, and activity of daily living (ADL) disability.DesignProspective study, the Women's Health Initiative Observational Study.SettingForty U.S. clinical centers.ParticipantsForty thousand six hundred fifty-seven women aged 65 to 79 at baseline.MeasurementsComponents of frailty included self-reported muscle weakness/impaired walking, exhaustion, low physical activity, and unintended weight loss between baseline and 3 years of follow-up. Death, hip fractures, ADL disability, and hospitalizations were ascertained during an average of 5.9 years of follow-up.ResultsBaseline frailty was classified in 16.3% of participants, and incident frailty at 3-years was 14.8%. Older age, chronic conditions, smoking, and depressive symptom score were positively associated with incident frailty, whereas income, moderate alcohol use, living alone, and self-reported health were inversely associated. Being underweight, overweight, or obese all carried significantly higher risk of frailty than normal weight. Baseline frailty independently predicted risk of death (hazard ratio (HR)=1.71, 95% confidence interval (CI)=1.48-1.97), hip fracture (HR=1.57, 95% CI=1.11-2.20), ADL disability (odds ratio (OR)=3.15, 95% CI=2.47-4.02), and hospitalizations (OR=1.95, 95% CI=1.72-2.22) after adjustment for demographic characteristics, health behaviors, disability, and comorbid conditions.ConclusionThese results support the robustness of the concept of frailty as a geriatric syndrome that predicts several poor outcomes in older women. Underweight, obesity, smoking, and depressive symptoms are strongly associated with the development of frailty and represent important targets for prevention.

ObjectivesTo describe differences in osteoporosis risk factors and rates of fracture and antiresorptive therapy use in women who did and did not participate in an osteoporosis screening program.SettingGroup Health Cooperative, a health maintenance organization in western Washington state.ParticipantsA total of 9,268 women (aged 60-80) who were not using any antiresorptive therapy were invited to participate in an osteoporosis screening program. This study compares the 35% who participated with the 65% who did not.DesignThis observational cohort study of women invited to participate in a randomized, controlled trial of an osteoporosis screening program provided all participants with personalized feedback on their risk of osteoporosis. Some participants also received bone density testing. Automated administrative data were used to examine differences between participants and nonparticipants in fracture outcomes and medication initiation before and after invitation.ResultsBaseline fracture rates did not differ between participants and nonparticipants. After age adjustment, nonparticipants had a higher hip fracture rate (14.1 vs 8.3 per 1,000) and a lower rate of initiating any antiresorptive therapy (10.3 vs 17.9 per 100) than participants after an average of 28 to 29 months of follow-up.ConclusionParticipants had reduced hip fracture rates and increased initiation of antiresorptive therapy compared with nonparticipants. It was not possible to determine whether participating in the screening program, unmeasured confounding, or selection bias accounted for differences in hip fracture or therapy initiation rates. These results suggest that women who do not participate in osteoporosis screening should be pursued to identify individuals who could benefit from primary and secondary osteoporosis prevention.

OBJECTIVES: To determine predictors of new activities of daily living (ADLs) disability and worsened mobility disability and secondarily increased daily care hours received, in previously independent hip fracture patients. DESIGN: Retrospective cohort study. SETTING: Academic hospital with ambulatory follow‐up. PARTICIPANTS: Community‐dwelling adults 65 years or older independent in ADLs undergoing hip fracture surgery in 2015 (n = 184). MEASUREMENTS: Baseline, 3‐ and 6‐month ADLs, mobility, and daily care hours received were ascertained by telephone survey and chart review. Comorbidities, medications, and characteristics of hospitalization were extracted from patient charts. Models for each outcome used logistic regression with a backward elimination strategy, adjusting a priori for age, sex, and race. RESULTS: Predictors of new ADL disability at 3 months were dementia (odds ratio [OR] = 11.81; P = .001) and in‐hospital delirium (OR = 4.20; P = .002), and at 6 months were age (OR = 1.04; P = .014), dementia (OR = 9.91; P = .001), in‐hospital delirium (OR = 3.00; P = .031) and preadmission opiates (OR = 7.72; P = .003). Predictors of worsened mobility at 3 months were in‐hospital delirium (OR = 4.48; P = .001) and number of medications (OR = 1.13; P = .003), and at 6 months were age (OR = 1.06; P = .001), preadmission opiates (OR = 7.23; P = .005), in‐hospital delirium (OR = 3.10; P = .019), and number of medications (OR = 1.13; P = .013). Predictors of increased daily care hours received at 3 and 6 months were age (3 months: OR = 1.07; P = .014; 6 months: OR = 1.06; P = .017) and number of medications (3 months: OR = 1.13; P = .004; 6 months: OR = 1.22; P = .013). The proportion of patients with ADL disability and care hours received did not change from 3 to 6 months, yet there were significant improvements in mobility. CONCLUSION: Age, dementia, in‐hospital delirium, number of medications, and preadmission opiate use were predictors of poor outcomes in independent older adults following hip fracture. Further investigation is needed to identify factors associated with improved mobility measures from 3 to 6 months to ultimately optimize recovery. [ABSTRACT FROM AUTHOR]

Objectives: Patients with dementia are at high risk for hip fractures and often have poor outcomes when a fracture is sustained. Despite this poor prognosis, little data are available on what factors should be prioritized to guide surgical decision making in these cases. We aimed to understand the decision‐making process for older dementia patients hospitalized after hip fractures. Design: We performed a qualitative analysis of in‐depth elite interviews conducted with a clinical care team involved in management of patients with dementia after hospitalization for hip fractures. Setting: Interviews were conducted with an interprofessional team involved in the care of patients with dementia after being hospitalized for hip fractures. Participants: Interviewees included nine orthopaedic surgeons, three hospitalists, three geriatricians, five nurses, three occupational therapists, three physical therapists, and two clinical ethicists. Measurements: Verbatim transcripts of the interviews were analyzed and coded using QSR International's NVivo 10 qualitative database management software. Results: The three main themes that most interviewees discussed were pain control, functional status, and medical comorbidities. Interviewees brought up many factors related to restoring functional status including baseline functional status, rehabilitation potential, social support, and the importance of mobility. Dementia and its impact on rehabilitation potential were mentioned by all geriatricians. Conclusion: Although frailty, prognosis, and life expectancy were largely absent from the responses, the emphasis on dementia, advanced directives, and involving family or caregivers by the three geriatricians indicates the importance of including geriatricians in the decision‐making team for these patients. [ABSTRACT FROM AUTHOR]

PURPOSE The aim of this study was to evaluate the serum levels of retinoic acid (RA), an active form of vitamin A, in postmenopausal women with hip fractures from Zhengzhou, China. METHODS: This was a case‐control study from the Affiliated Hospital of Zhengzhou University. Serum samples were drawn from 375 postmenopausal women who were diagnosed as having hip fracture and 750 matched controls without fracture. Serum RA levels were evaluated as both a continuous variable and a categorical variable in quintiles. RESULTS: The results showed that the serum levels of RA were significantly (P =.039) higher in patients with hip fracture compared with controls. In univariate and multivariate logistic regression analysis, for each 1 ng/mL increase of serum level of RA, the unadjusted and adjusted risk of hip fracture would be increased by 5% (odds ratio [OR] = 1.05; 95% confidence interval [CI] = 1.00‐1.10; P =.035) and 2% (OR = 1.02; 95% CI = 0.95‐1.11; P =.096), respectively. In multivariate models comparing the fifth with the third quintiles of RA, the RA was associated with hip fracture, and adjusted risk of hip fracture would be increased by 52% (OR = 1.52; 95% CI = 1.13‐1.42; P =.011). CONCLUSIONS: The results of our study suggest that subclinical higher levels of RA may increase the risk of hip fracture in postmenopausal women, particularly among the top quintile of serum RA. J Am Geriatr Soc 67:336–341, 2019. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the association between cataract and cataract surgery and risks of osteoporosis and fracture. Design: Nationwide population‐based retrospective cohort study. Setting: Taiwan's National Health Insurance Research Database. Participants: Individuals with (n=57,972) and without (n=57,972) cataracts. Measurements Individuals with and without cataracts were matched 1:1 for age, sex, and index year. Those with cataracts were further divided into cataract surgery and nonsurgery groups. Incidences and hazard ratios (HR) for risks of developing osteoporosis and fracture were calculated using Cox proportional hazard regression models. Results: During mean follow‐up of 6.4 years, 17,450 participants with cataracts and 12,627 without developed osteoporosis or fractures. Having cataracts was significantly associated with risk of developing osteoporosis or fracture (adjusted HR (aHR) = 1.29, 95% confidence interval (CI) = 1.25–1.32, p <.001). In analyses for each event, cataract was significantly associated with greater likelihood of all outcomes (osteoporosis: aHR = 1.43, 95% CI = 1.37–1.50, p <.001; hip fracture: aHR = 1.16, 95% CI = 1.07–1.26, p <.001; vertebral fracture: (aHR = 1.25, 95% CI = 1.18–1.33, p <.001; other fractures: aHR = 1.24, 95% CI = 1.20–1.28, p <.001). Participants who underwent cataract surgery were at significantly lower risk of osteoporosis or fracture (aHR = 0.58, 95% CI = 0.56–0.59, p <.001), than those who did not. Undergoing cataract surgery was also associated with lower risks of all individual events (osteoporosis; hip, vertebral, other fracture). Conclusion: Cataract was independently associated with increased risks of osteoporosis and fracture. There might be an association between cataract surgery and lower risks of osteoporosis and fracture. J Am Geriatr Soc 67:254–260, 2019. [ABSTRACT FROM AUTHOR]