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Background Slow gait is predictive of functional impairments in older adults, while concomitant slow gait and cognitive complaints are associated with a greater risk for cognitive decline and dementia. However, functional neural correlates for gait speed maintenance are unclear. As the sensorimotor network (SMN) and frontoparietal network (FPN) are integral components of these functions, this study investigated differences in SMN and FPN in older adults with/without gait speed decline over 24 months; and whether these networks were associated with the maintenance of cognitive function. Methods We included 42 community-dwelling older adults aged >70 years from the MOBILIZE Boston Study. Resting-state fMRI was performed at the study baseline. Participant characteristics, gait speed, Mini-Mental State Examination, and Hopkins Verbal Learning Test (HVLT) were assessed at baseline and at 24-month follow-up. Decliners were identified as individuals with >0.05 meters/second decline in gait speed from baseline to 24 months. Of the 26 decliners and 16 maintainers, decliners exhibited a significant decline in delayed-recall performance on the HVLT over 24 months. Results Controlling for baseline age and multiple comparisons, contrary to initial hypothesis, maintainers exhibited lower baseline primary motor and premotor connectivity (p = .01) within the SMN, and greater baseline ventral visual–supramarginal gyrus connectivity within the FPN (p = .02) compared to decliners. Lower primary motor–premotor connectivity was correlated with maintenance of delayed-recall performance on the HVLT (p = .04). Conclusion These findings demonstrated a potential compensatory mechanism involved in the link between the decline in gait speed and episodic memory, whereby baseline connectivity of the SMN and FPN may underlie subsequent maintenance of gait speed and cognitive function in old age.

Age-associated changes in DNA methylation have been implicated as 1 mechanism to explain the development of frailty; however, previous cross-sectional studies of epigenetic age acceleration (eAA) and frailty have had inconsistent findings. Few longitudinal studies have considered the association of eAA with change in frailty. We sought to determine the association between eAA and change in frailty in the MOBILIZE Boston cohort. Participants were assessed at 2 visits 12–18 months apart. Intrinsic, extrinsic, GrimAge, and PhenoAge eAA were assessed from whole-blood DNA methylation at baseline using the Infinium 450k array. Frailty was assessed by a continuous frailty score based on the frailty phenotype and by frailty index (FI). Analysis was by correlation and linear regression with adjustment for age, sex, smoking status, and body mass index. Three hundred and ninety-five participants with a frailty score and 431 with an FI had epigenetic and follow-up frailty measures. Mean (standard deviation) ages were 77.8 (5.49) and 77.9 (5.47) for the frailty score and the FI cohorts respectively, and 232 (58.7%) and 257 (59.6%) were female. All participants with epigenetic data identified as White. Baseline frailty score was not correlated with intrinsic or extrinsic eAA, but was correlated with PhenoAge and, even after adjustment for covariates, GrimAge. Baseline FI was correlated with extrinsic, GrimAge, and PhenoAge eAA with and without adjustment. No eAA measure was associated with change in frailty, with or without adjustment. Our results suggest that no eAA measure was associated with change in frailty. Further studies should consider longer periods of follow-up and repeated eAA measurement.

Background In older adults, elevated gait variability when walking has been associated with both cognitive impairment and future falls. This study leveraged 3 existing data sets to determine relationships between gait variability and the strength of functional connectivity within and between large-scale brain networks in healthy older adults, those with mild-to-moderate functional impairment, and those with Parkinson’s disease (PD). Method Gait and resting-state functional magnetic resonance imaging data were extracted from existing data sets on: (i) 12 older adults without overt disease yet with slow gait and mild executive dysfunction; (ii) 12 older adults with intact cognitive-motor function and age- and sex-matched to the first cohort; and (iii) 15 individuals with PD. Gait variability (%, coefficient of variation of stride time) during preferred walking speed was measured and correlated with the degree of functional connectivity within and between 7 established large-scale functional brain networks. Results Regression models adjusted for age and sex revealed that in each cohort, those with less gait variability exhibited greater negative correlation between fluctuations in resting-state brain activity between the default network and the dorsal attention network (functionally limited older: β = 4.38, p = .027; healthy older: β = 1.66, p = .032; PD: β = 1.65, p = .005). No other within- or between-network connectivity outcomes were consistently related to gait variability across all 3 cohorts. Conclusion These results provide strong evidence that gait variability is uniquely related to functional connectivity between the default network and the dorsal attention network, and that this relationship may be independent of both functional status and underlying brain disease.

Balance impairment and falls are among the most prevalent and morbid conditions affecting older adults. A critical contributor to balance and gait function is the vestibular system; however, there remain substantial knowledge gaps regarding age-related vestibular loss and its contribution to balance impairment and falls in older adults. Given these knowledge gaps, the National Institute on Aging and the National Institute on Deafness and Other Communication Disorders convened a multidisciplinary workshop in April 2019 that brought together experts from a wide array of disciplines, such as vestibular physiology, neuroscience, movement science, rehabilitation, and geriatrics. The goal of the workshop was to identify key knowledge gaps on vestibular function and balance control in older adults and develop a research agenda to make substantial advancements in the field. This article provides a report of the proceedings of this workshop. Three key questions emerged from the workshop, specifically: (i) How does aging impact vestibular function?; (ii) How do we know what is the contribution of age-related vestibular impairment to an older adult’s balance problem?; and more broadly, (iii) Can we develop a nosology of balance impairments in older adults that can guide clinical practice? For each of these key questions, the current knowledge is reviewed, and the critical knowledge gaps and research strategies to address them are discussed. This document outlines an ambitious 5- to 10-year research agenda for increasing knowledge related to vestibular impairment and balance control in older adults, with the ultimate goal of linking this knowledge to more effective treatment.

Background Walking, especially while dual-tasking, requires functional activation of cognitive brain regions and their connected neural networks. This study examined the relationship between neurovascular coupling (NVC), as measured by the change in cerebral blood flow in response to performing a cognitive executive task, and dual-task walking performance. Methods Seventy community-dwelling older adults aged 84 ± 5 years within the Maintenance of Balance, Independent Living, Intellect and Zest in the Elderly (MOBILIZE) Boston Study were divided into LOW (n = 35) and HIGH (n = 35) NVC. NVC was quantified by transcranial Doppler ultrasound and stratified by the median change in cerebral blood flow velocity of the middle cerebral artery induced by the performance of the n-back task of executive function. Walking metrics included walking speed, step width, stride length, stride time, stride time variability, and double-support time from single- and dual-task walking conditions, as well as the “cost” of dual-tasking. Results During both single- and dual-task walking, older adults with LOW NVC displayed narrower step width (p = .02 and p = .02), shorter stride length (p = .01 and p = .02), and longer double-support time (p = .03 and p = .002) when compared with the HIGH group. During single-task walking only, LOW NVC was also linked to slower walking speed (p = .02). These associations were independent of age, height, hypertension, atrial fibrillation, and assistive device. The LOW and HIGH NVC groups did not differ in dual-task costs to walking performance. Conclusion In older adults, diminished capacity to regulate cerebral blood flow in response to an executive function task is linked to worse walking performance under both single- and dual-task conditions, but not necessarily dual-task costs.

Background A claims-based frailty index (CFI) was developed based on a deficit-accumulation approach using self-reported health information. This study aimed to independently validate the CFI against physical performance and adverse health outcomes. Methods This retrospective cohort study included 3,642 community-dwelling older adults who had at least 1 health care encounter in the year prior to assessments of physical performance in the 2008 Health and Retirement Study wave. A CFI was estimated from Medicare claims data in the past year. Gait speed, grip strength, and the 2-year risk of death, institutionalization, disability, hospitalization, and prolonged (>30 days) skilled nursing facility (SNF) stay were evaluated for CFI categories (robust: Results The prevalence of robust, prefrail, mildly frail, and moderate-to-severely frail state was 52.7%, 38.0%, 7.1%, and 2.2%, respectively. Individuals with higher CFI had lower mean gait speed (moderate-to-severely frail vs robust: 0.39 vs 0.78 m/s) and weaker grip strength (19.8 vs 28.5 kg). Higher CFI was associated with death (moderate-to-severely frail vs robust: 46% vs 7%), institutionalization (21% vs 5%), activity of daily living disability (33% vs 9%), instrumental activity of daily living disability (100% vs 22%), hospitalization (79% vs 23%), and prolonged SNF stay (17% vs 2%). The odds ratios per 1-SD (=0.07) difference in CFI were 1.46–2.06 for these outcomes, which remained statistically significant after adjustment for age, sex, and a comorbidity index. Conclusion The CFI is useful to identify individuals with poor physical function and at greater risks of adverse health outcomes in Medicare data.

Background Frailty is a key determinant of health status and outcomes of health care interventions in older adults that is not readily measured in Medicare data. This study aimed to develop and validate a claims-based frailty index (CFI). Methods We used data from Medicare Current Beneficiary Survey 2006 (development sample: n = 5,593) and 2011 (validation sample: n = 4,424). A CFI was developed using the 2006 claims data to approximate a survey-based frailty index (SFI) calculated from the 2006 survey data as a reference standard. We compared CFI to combined comorbidity index (CCI) in the ability to predict death, disability, recurrent falls, and health care utilization in 2007. As validation, we calculated a CFI using the 2011 claims data to predict these outcomes in 2012. Results The CFI was correlated with SFI (correlation coefficient: 0.60). In the development sample, CFI was similar to CCI in predicting mortality (C statistic: 0.77 vs. 0.78), but better than CCI for disability, mobility impairment, and recurrent falls (C statistic: 0.62-0.66 vs. 0.56-0.60). Although both indices similarly explained the variation in hospital days, CFI outperformed CCI in explaining the variation in skilled nursing facility days. Adding CFI to age, sex, and CCI improved prediction. In the validation sample, CFI and CCI performed similarly for mortality (C statistic: 0.71 vs. 0.72). Other results were comparable to those from the development sample. Conclusion A novel frailty index can measure the risk for adverse health outcomes that is not otherwise quantified using demographic characteristics and traditional comorbidity measures in Medicare data.

Each year, 2.8 million older adults are treated for falls, with over 800,000 hospitalized. Evidence suggests vitamin D supplementation might reduce the risk of falls, potentially through improvements in skeletal muscle function; however, results are inconsistent. In 2013 the NIA issued a request for applications to assess the efficacy and dose-response of vitamin D supplementation for fall prevention across a range of doses and serum 25(OH)D concentrations, resulting in the funding of STURDY (Study To Understand Fall Reduction and Vitamin D in You). STURDY was a seamless dose-finding and confirmatory, double-masked, response adaptive Bayesian randomized trial designed to find the best dose of vitamin D supplementation for fall prevention. Participants (n=688, ≥70 years with serum 25(OH)D of 10-29 ng/mL) were randomized to 200 (control), 1000 , 2000, or 4000 IU/day of vitamin D3.The first participant was randomized on 10/30/2015 and data collection ended on 5/31/2019. The primary outcome was time to first fall or death, and the secondary outcome was gait speed. Dr. Appel will present the main findings of the effect of vitamin D supplementation on time to first fall. Dr. Wanigatunga will present a more detailed analysis of the effect of vitamin D supplementation on fall characteristics, including indoor vs. outdoor falls, consequential falls, and repeat fall risk. Dr. Guralnik will present the effect of vitamin D supplementation on physical functioning, including gait speed, SPPB, 6-minute walk, and TUG performance. Dr. Schrack will present the effect of vitamin D supplementation on objectively measured physical activity.

Background Changes in cerebral blood flow velocity (CBF) in response to a cognitive task (task-related ΔCBF) have been shown by Transcranial Doppler ultrasonography (TCD) to be reduced in slow walkers. However, it is unknown whether reduced task-related ΔCBF is associated with reduced neural activity in specific brain regions, as measured by blood-oxygen-level dependent (BOLD) functional magnetic resonance imaging (fMRI). Methods We assessed the regional changes in neural activity associated with reduced middle cerebral artery (MCA) task-related ΔCBF to an executive task and slow walking speed in 67 community-dwelling older adults from the MOBILIZE Boston Study. Participants underwent walking assessments and TCD ultrasonography measures of MCA ΔCBF during the n-back task of executive function. A subset of participants (n = 27) completed the same task during fMRI. Individual BOLD activation maps for the n-back task were correlated with TCD measures and network-level averages were associated with TCD and preferred walking speed. Results Participants with diminished task-related ΔCBF walked more slowly (β = .39, p = .001). fMRI revealed significant associations between task-related ΔCBF and regional BOLD activation in several brain regions/networks supplied by the MCA. Of these regions and networks, those within the executive network were most strongly associated with walking speed (β = .36, p = .01). Conclusions Task-related ΔCBF during an executive function task is related to activation in several neural networks and impairment in the ability to recruit the executive network in particular is associated with slow walking speed in older adults.

In older adults, assessment of standing postural control under various task and/or environmental conditions provides valuable insight into cognitive-motor function. To date, however, such assessments have been limited primarily to laboratory or clinical settings. We therefore created a smartphone App to enable remote assessments of postural control. This App provides users with standardized multi-media instructions and harnesses the phone’s internal motion sensors to capture postural sway, with the phone placed in the user’s pants pocket, during trials of standing with eyes open, eyes-closed, and while performing serial-subtractions (i.e., dual tasking). We then established the test-retest reliability of several metrics of postural sway derived from this assessment tool, as well as their sensitivity to the effect of age and standing condition. Fifteen healthy younger and 15 older adults completed multiple standing trials in two separate laboratory visits and on three separate days in their own homes. Postural sway metrics included the mean distance from the center of the trajectory and root mean square were derived from both transverse-plane acceleration and angular velocity time series. Each sway metric demonstrated excellent test-retest reliability, even when analyzed separately by group and standing condition (ICCs: 0.78-0.89). Moreover, each metric was sensitive to age group and standing condition, such that greater sway was observed in older adults as compared to younger adults (p

While walking was once thought to be a highly automated process, it has been shown to be increasingly complex, requiring higher-level cognition, with older age. Like other cognitive tasks, walking becomes further complicated with increased cognitive load (e.g., the addition of an unrelated task) and often results in poorer performance (e.g., slower speed). It is not well known, however, how neural network communication relates to this “cost” in performance. The current study investigates the ability of resting-state functional MRI (fMRI) to explain task-related walking speed differences in 57 older adults (21 males; 84 ± 4.4 years) from the MOBILIZE Boston Study cohort. Participants underwent an MRI protocol and completed a gait assessment during two conditions: walking quietly at a preferred pace and while concurrently performing a serial subtraction task. Within and between neural network connectivity measures were calculated from pre-processed fMRI data and were correlated with age-adjusted dual-task cost, the percent change in speed between conditions. Though participants walked relatively fast during the single condition (1.2 ± 0.3 m/s), they were significantly slower during the serial subtraction task (0.95 ± 0.3 m/s; matched pairs t-test=14.4, p

Research in aging presents substantial challenges to the validity of experimental designs, including study attrition, concurrent illnesses and interventions, the influences of multimorbidity and polypharmacy, and structural barriers to participation. Maintenance of data completeness and quality is therefore of critical demand, yet difficult, especially given the typical distance between data collection and investigator attention. In this presentation we describe dynamic, interactive, customizable tools to facilitate exploratory analytics and quality control in aging research. These tools interface directly with common electronic data capture systems and standards. Importantly, they can be remotely deployed - securely accessed over the internet - and used by investigators and staff to interact with project data directly, without the need for an intermediary analyst. The use of these tools in clinical research will be demonstrated by describing their application to a cluster-randomized trial of an exercise intervention in supportive housing, and an epidemiologic study of bone microarchitecture.

BACKGROUND: Psychotropic drugs increase the risk of falls, but they are still frequently prescribed to treat behavioral symptoms associated with dementia in the nursing home. We examined whether there is an acute increased risk of falls in the days following a change to an antipsychotic or benzodiazepine drug prescription. METHODS: We collected information on 594 long-stay nursing home residents from two facilities who fell at least once between September 1, 2010 and May 31, 2013. Psychotropic drug changes were ascertained from the facilities' computerized medication administration log. We used the case-crossover design to compare the frequency of antipsychotic and benzodiazepine drug changes during the days before a fall with the frequency of drug changes at more remote times. RESULTS: Mean age was 87.5 years, and 75.1% were female. The risk of falls was higher in the 24 hours following benzodiazepine initiation compared with other times (odds ratio [OR] 3.79, 95% confidence interval [CI] 1.10, 13.00). There was no clear difference in risk following antipsychotic initiation (OR 2.42, CI 0.58, 10.06), but this could be due to the small sample size. Stopping a benzodiazepine was associated with a significantly reduced fall risk (OR 0.26, 95% CI 0.08-0.91). CONCLUSIONS: Benzodiazepines pose an immediate threat to fall risk, whereas it is less clear if antipsychotics also pose an immediate risk. Nursing home staff should be particularly vigilant in the days following the new prescription for a benzodiazepine in an effort to prevent injury. Language: en

Animal studies suggest that the renin–angiotensin–aldosterone system (RAAS) is involved in many central nervous system processes in hypertension, including cognitive function and cerebral hemodynamic control.1–3 Angiotensin II infusion into rats’ brains is associated with impaired memory,4 neurovascular uncoupling, and hypoperfusion.5 In transgenic mice, activation of brain RAAS impairs cognitive function by decreasing cerebral blood flow.6 In humans, the evidence supporting a role of RAAS in brain function is derived indirectly from the observation that drugs that inhibit RAAS may be associated with cognitive preservation.7 To our knowledge, studies showing a relationship between RAAS activity and neurocognitive function in hypertensive older adults are nonexistent. Aldosterone is the major contributor to the negative cardiovascular effects of RAAS. Higher circulating aldosterone predicts greater increase in blood pressure and incident hypertension with aging.8 In the Framingham cohort, higher aldosterone levels were associated with shorter leukocyte telomere length, suggesting a high inflammation and oxidative stress load.9 Aldosterone has multiple binding sites in the brain.10 However, its role in cognitive and cerebrovascular function has not been fully explored. On the vascular side, higher aldosterone levels are linked with endothelial dysfunction,11,12 which in turn may negatively affect cognitive function.13 While local brain endothelial function is difficult to assess, reactivity to changes in end-tidal CO2 may be an indirect marker of the central endothelium.14 Therefore, we hypothesized that in humans markers of elevated RAAS activity, higher aldosterone levels will be associated with lower scores on measures of cognition (memory and executive function) and impaired cerebral hemodynamics (autoregulation and vasoreactivity). Prior studies suggest that there is a genetic basis for the individual heterogeneity of vascular response to antihypertensive therapy.15 We previously reported that polymorphisms in the angiotensinogen gene that are associated with higher RAAS activity16 predicted a better cognitive outcome with antihypertensive therapy.17 It is not known if these observations are related to the class of antihypertensive used, such as those that modulate RAAS, or are related to lowering blood pressure control. We therefore wanted to investigate this difference (class effect vs. blood pressure–lowering effect) in a recently completed clinical trial. Our objective was to assess the association of circulating aldosterone and plasma renin activity (PRA) with cognitive function (memory and executive domains) and cerebral hemodynamics in hypertensive individuals off antihypertensive therapy. Our second objective was to investigate the impact of baseline RAAS markers on the cognitive/hemodynamic responses to antihypertensive therapy and/or controlling blood pressure to

Gait variability (i.e. stride time-to-stride time fluctuation) is a sensitive predictor of future falls, mental and functional declines in older adults. While gait variability reflects subtle changes due to aging or disease, its neural mechanism remains unclear. One hypothesized mechanism derives from an anti-correlated brain activity between the dorsal attention network (i.e. external-focus network) and default network (i.e. internal-focus network) with known involvement in sustained attention (i.e. moment-to-moment fluctuation). Here, we aimed to establish relationships between gait variability and functional connectivity of large-scale brain networks measured by resting-state functional MRI. We examined data from three separate cohorts: healthy older adults (H-O, N=13, 75.5+-8.0 y/o), functionally-limited older adults (FL-O, N=12, 76.2+-9.5 y/o), and individuals with Parkinson’s disease (PD, N=15, 63.2+-6.2 y/o). Gait variability (%, coefficient of variation of stride time) under preferred walking speed was measured and correlated with the degree of functional connectivity within and between seven well-known large-scale functional brain networks. Our results revealed that in all three cohorts, those with less gait variability exhibited greater anti-correlation in resting-state brain activity within the dorsal attention and default networks: H-O, b=1.64, p=.03; FL-O: b=4.38, p=.03; PD: b=1.65, p=.005, with age and sex controlled in the regression model. As this anti-correlation has been linked to performance within tasks of sustained attention, our results suggest that gait variability may depend upon the capacity to dissociate the neural activity of these two networks.

Successful completion of cognitive and motor tasks requires functional interactions between numerous brain networks over multiple temporal scales. Biological aging reduces the multi-scale “complexity” of the spontaneous fluctuations in network activity. Still, it is unknown if such “resting-state” complexity is sensitive to functional status, or modifiable via intervention. We hypothesized that resting-state complexity is lower in older adults with functional limitations, and, that it can be increased via repeated exposure to transcranial direct current stimulation (tDCS). Twelve older adults with mild-to-moderate executive dysfunction (i.e., Trail Making Test B time below the 25th percentile of age- and education-based norm) and slow gait (i.e., gait speed 4.7, p4.9, p

Chronic musculoskeletal pain (CMP) contributes to increased fall risk among older adults. Fall often occurs due to loss of standing balance. Standing postural control is “complex”, depending upon numerous inputs interacting across multiple temporal-spatial scales. The decreased complexity has been linked to increased fall risk. Pain may interfere with this metric of postural control, thus, lead to falls. The aim of this study is to determine whether CMP is associated with sway complexity in older adults. In the MOBILIZE Boston Study, 738 community-dwelling adults aged ≥70y completed a functional assessment, including eyes-open standing postural sway on a force plate. The degree of sway complexity was quantified using multiscale entropy. The Brief Pain Inventory and McGill Pain Map assessed global pain severity and pain locations, respectively. Relationships between pain and sway complexity were analyzed using multivariable Generalized Linear Models. More severe pain was significantly associated with peripheral neuropathy, impaired processing speed (Trail Making A (TMT-A)) and global cognitive function (Mini-Mental State Examination (MMSE). Those with moderate-to-severe pain had lower complexity compared to those with mild or no pain (p=0.01), adjusted for age, gender, education, neuropathy, and TMT-A or MMSE. Participants with lower leg pain had lower sway complexity than those without (p=0.01); no association between pain in other body sites and sway complexity were observed. CMP severity and lower leg pain are associated with decreased sway complexity in older adults. Future studies are needed to explore the underlying mechanisms through which the CMP affects sway complexity, thus, contributes to falls.

The ability to walk under normal and cognitive dual task conditions is essential for safe mobility in older adults. However, while assessments of gait provide important health information, they have been limited to laboratory settings. We aimed to create an easy-to-use smartphone App enabling remote dual task walking assessments, and to demonstrate its reliability and validity in relatively healthy younger and older adults. The iPhone-based App utilized multi-media instructions and the phone’s internal motion sensors to record movements during normal walking and walking with simultaneous serial-subtractions, with the phone placed in the user’s pants pocket. Fourteen younger and 12 older adults completed two lab visits, during which data were acquired by the App and GAITRite mat over multiple normal and dual task walking trials. Participants also used the App to complete assessments in their homes on three separate days. Outcomes included average stride time and the dual-task cost to stride time. Across all detected strides in laboratory trials, derived outcome measures from the App were highly correlated with those derived from the GAITRite mat (Stride Time: p

The control of walking depends upon the exchange of information across numerous brain networks. Within a given brain region, spontaneous (i.e., resting-state) fluctuations in neuronal activity are “complex,” containing meaningful information over multiple temporal scales. While this complexity appears to decline with advancing age, it is unknown if it associates with walking performance. The aim of this study was to determine the relationship between resting-state complexity and walking speed in older adults. Forty-three older adults from the MOBILIZE Boston Study completed a resting-state MRI and on a separate visit, assessment of walking under normal conditions (i.e., single-task) and while performing a cognitive serial-subtraction task (i.e., dual-task). Resting-state complexity within 50 pre-defined brain regions was calculated by computing the ‘multiscale entropy’ of the blood-oxygen-level-dependent time-series of each voxel, and then averaging across all voxels of each region. A machine learning technique termed ‘leave-one-subject-out support vector regression,’ adjusted for age, indicated that the estimation of both single- and dual-task walking speed based upon regional resting-state complexity was high (r>0.38, p0.31). Four additional regions associated with attentional control were correlated with dual-task walking speed only (mean p0.35). This study revealed that in older adults, walking speed correlates with region-specific multi-scale dynamics of resting-state brain activity, and dual task walking may be particularly dependent upon brain regions that give rise to the control of attention

Walking speed is one of the strongest predictors of health outcomes in older adults, and has been associated with falls, morbidity, and mortality. Slow walking has also been linked to reduced executive functioning and altered functional brain integrity. Specifically, our previous work has demonstrated that reduced activation of the executive network during a working memory (n-back) task is associated with slow walking speed in a cohort of older adults from the Maintenance of Balance, Independent Living, Intellect and Zest in the Elderly of Boston Study (MOBILIZE Boston Study). However, the simultaneous influence of underlying white matter integrity on executive functioning, executive network brain activation, and walking speed is unknown. Thus, we used diffusion weighted imaging and fMRI during the n-back task to assess associations between executive network structure, function, and walking speed. Whole-brain tract-based spatial statistics (TBSS) were used to identify regions of white matter microstructural integrity that were associated with slow walking speed. The integrity of these regions, quantified by fractional anisotropy (FA), was then correlated with n-back performance and executive network activation. Lower FA in the right superior longitudinal fasciculus, right anterior thalamic radiation, and the forceps minor of the corpus callosum was significantly associated with slow walking speed. Low FA in these frontal white matter regions was further associated with poor n-back performance (response speed) and reduced executive network activation. These findings suggest that microstructural damage to the right frontal white matter may partially account for altered executive network activation and slow walking speed in older adults.

Mobility limitations are common and hazardous in community-dwelling older adults but are largely understudied, particularly regarding the role of the central nervous system (CNS). This has limited development of clearly defined pathophysiology, clinical terminology, and effective treatments. Understanding how changes in the CNS contribute to mobility limitations has the potential to inform future intervention studies.A conference series was launched at the 2012 conference of the Gerontological Society of America in collaboration with the National Institute on Aging and the University of Pittsburgh. The overarching goal of the conference series is to facilitate the translation of research results into interventions that improve mobility for older adults.Evidence from basic, clinical, and epidemiological studies supports the CNS as an important contributor to mobility limitations in older adults without overt neurologic disease. Three main goals for future work that emerged were as follows: (a) develop models of mobility limitations in older adults that differentiate aging from disease-related processes and that fully integrate CNS with musculoskeletal contributors; (b) quantify the contribution of the CNS to mobility loss in older adults in the absence of overt neurologic diseases; (c) promote cross-disciplinary collaboration to generate new ideas and address current methodological issues and barriers, including real-world mobility measures and life-course approaches.In addition to greater cross-disciplinary research, there is a need for new approaches to training clinicians and investigators, which integrate concepts and methodologies from individual disciplines, focus on emerging methodologies, and prepare investigators to assess complex, multisystem associations.

In a prospective cohort of nondisabled adults aged 65 years or more in the Established Populations for Epidemiologic Studies of the Elderly (1981–1987 and 1985–1992), we used a competing risk approach to predict the 5-year risk of severe, persistent activities-of-daily-living (ADLs) disability, defined as dependence in ≥3 ADLs for 2 consecutive annual interviews or for 1 interview followed by death in the subsequent year. During 5 years, 6.8% developed severe, persistent ADL dependence, and 14.6% died without severe, persistent ADL dependence in the derivation cohort (n = 8,301); the corresponding percentages were 6.8% and 15.8% in the validation cohort (n = 4,177). A model based on age, current employment, visual impairment, self-rated health, diabetes mellitus, history of stroke or brain hemorrhage, cognitive function, and self-reported physical function showed good calibration. Discrimination, assessed by C statistics, for

Preoperative frailty assessment may be useful to predict functional status and mortality in older adults undergoing aortic valve replacement (AVR). We conducted a single-center prospective cohort study to compare frailty phenotype versus comprehensive geriatric assessment-based frailty index (CGA-FI) in predicting 6-month functional status and mortality after transcatheter and surgical AVR. Between February 2014 and December 2015, we assessed frailty phenotype and CGA-FI in patients 70 years or older who underwent transcatheter AVR (N=124) or surgical AVR (N=88). Telephone interviews were performed at 1, 3, and 6 months to assess the ability to perform 22 functional activities. The composite poor clinical outcome, defined as death or functional decline with the New York Heart Association class 3 or 4, occurred in 31 (26%) of 120 transcatheter AVR patients (drop-out: 4) and 8 (11%) of 76 surgical AVR patients (drop-out: 12). The risk of poor clinical outcome did not differ between patients with and without frailty phenotype undergoing transcatheter AVR (24 of 96 [25%] versus 7 of 24 [29%]; p=0.68) and surgical AVR (5 of 27 [19%] versus 3 of 49 [6%]; p=0.11). However, the risk increased with CGA-FI (≤0.20, 0.21–0.40, >0.40) in transcatheter AVR (1 of 12 [8%], 12 of 64 [19%], 18 of 44 [41%]; p=0.01) and surgical AVR (1 of 29 [3%], 5 of 42 [12%], 2 of 5 [40%]; p=0.04). In conclusion, CGA-FI predicts 6-month functional status and mortality after transcatheter and surgical AVR, but frailty phenotype has a limited role in this population with high prevalence of frailty.

Tracking falls among elders is challenging. In this reliability study, which took place between October 2007 and February 2008, the authors compared participants’ daily recordings of falls on calendars with a telephone survey of recall of falls over the previous 3 months within the population-based MOBILIZE Boston Study cohort, a cohort of 765 elders. From the cohort, 218 participants were randomly selected. Falls were tracked prospectively on daily calendars (mailed back monthly). Telephone recalls of falls over the previous 3 months were conducted in January and February 2008. Agreement, sensitivity, and specificity were calculated to compare the occurrence of falls as determined by 3-month recall with falls recorded by daily calendar (gold standard) during the same 3-month period. Results showed good agreement between recall and calendars: 27 persons reported a fall by both methods. However, while the 3-month recall correctly classified persons who did not fall (164 persons by both methods), it missed 25% of participants who fell (of 36 participants with a calendar-reported fall, 9 did not report a fall by telephone recall). Kappa was 0.74 (95% confidence interval: 0.68, 0.80), sensitivity was 75%, and specificity was 96%. Retrospective 3-month recall of falls resulted in underreporting of falls by as much as 25% compared with daily calendars. Calendars should be considered the preferred method of ascertaining falls in longitudinal studies.

Balance during quiet stance involves the complex interactions of multiple postural control systems, which may degrade with frailty. The complexity of center of pressure (COP) dynamics, as quantified using multiscale entropy (MSE), during quiet standing is lower in older adults, especially those with falls. We hypothesized that COP dynamics from frail elderly individuals demonstrate less complexity than those from nonfrail elderly controls; complexity decreases when performing a dual task; and postural complexity during quiet standing is independent of other conventional correlates of balance control, such as age and vision.We analyzed data from a population-based study of community-dwelling older adults. Frailty phenotype (nonfrail, prefrail, or frail) was determined for 550 participants (age 77.9 +/- 5.5 years). COP excursions were quantified for 10 trials of 30 seconds each. Participants concurrently performed a serial subtraction task in half of the trials. Complexity of balance dynamics was quantified using MSE. Root-mean-square sway amplitude was also computed.Of the 550, 38% were prefrail and 9% were frail. Complexity of the COP dynamics in the anteroposterior direction was lower in prefrail (8.78 +/- 1.91 [mean +/- SD]) and frail (8.38 +/- 2.13) versus nonfrail (9.20 +/- 1.74) groups (p.001). Complexity reduced by a comparable amount in all three groups while performing the subtraction task (p.001). Quiet standing complexity was independently associated with frailty after adjusting for covariates related to balance while sway amplitude was not.Cognitive distractions during standing may further compromise balance control in frail individuals, leading to an increased risk of falls.

Background. Our objectives were to investigate the existence of a group of nondemented elderly individuals who simultaneously have impairments in cognition, mobility, and mood, and to examine the association between being a member of this group and elevated blood pressure and other cardiovascular conditions. Methods. The Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston study is an ongoing prospective observational study of community-dwelling individuals. We analyzed the cross-sectional data collected at baseline ( N = 580, mean age = 77.8 years, 64% women, 14% African American, mean Mini-Mental State Examination = 27.2). Using latent profi le analysis, we investigated the existence of a group of elderly participants with impairments in executive function (Trail Making Test Part B [TMT-B]), gait speed (two 4-m walk tests), and depressive symptoms (Center for Epidemiological Studies-Depression scale [CES-D]). Results. We identifi ed a group ( n = 99 [17%]) with prolonged TMT-B, slow gait speed, and high CES-D scores. This group did not exist when we used a memory measure. Hypertension ( p = .001), diabetes ( p = .0002), congestive heart failure ( p = .006), stroke ( p = .005), and higher Framingham cardiovascular risk score ( p = .0001) were associated with an increased likelihood of being a member in this group. This association with elevated systolic and pulse pressure, and stroke remained signifi cant after multiple covariate adjustments. Conclusions. There exists a group of elderly individuals in whom poor executive function, slow gait speed, and depressive symptoms occur simultaneously. Memory measures did not identify such a grouping. Elevated blood pressure and other cardiovascular diseases are independently associated with being a member of this group. Assessing these domains is an important part of the evaluation of the elderly patients with high vascular risk.

Biological cycles can be entrained by internal rhythmic phenomena, as well as by external periodic inputs. Coupling between locomotor, respiratory, and cardiac rhythms has been reported in humans during walking and running (1–3) and has been modeled in animals (4,5). Complex physiological mechanisms coordinate interactions among the locomotor and cardiovascular systems during walking. Locomotor circuits generating patterns and timing of the gait cycle interact with brainstem cardiorespiratory networks (6). These networks synchronize vagally mediated fluctuations in cardiac cycle with respiration (7) and regulate interactions with sympathetically mediated fluctuations in blood pressure (BP) through the baroreflexes (8). Changes in muscle force and blood flow during the gait cycle provide periodic inputs to the cardiovascular system (1). The peripheral concept of cardiac–locomotor coupling was based on the phase dependency between active muscle contraction and cardiac cycle (3,9). Central entrainment from locomotor to respiratory to cardiac cycles was demonstrated during stimulation of the locomotor mesencephalic area in decerebrated vagotomized cats (4). The dynamics of cardiac and locomotor rhythms are altered by aging and are sensitive predictors of age-related disorders (10). Synchronization of cardiac and locomotor rhythms may have physiological significance by optimizing cardiovascular performance and perfusion of exercising muscle during rhythmic exercise (1). Walking speed is an indicator of functional status (11,12) in elderly people, and slow walking has been prospectively associated with poor outcome, altered cerebral blood flow regulation, and cognitive decline (13,14). We hypothesized that aging affects the dynamic interactions between locomotor and cardiovascular systems and cerebral blood flow. Therefore, we studied cardiac–locomotor coupling during walking at incremental treadmill speeds up to normal walking speed (NWS) in healthy young and elderly people.

This study tested whether implanted embryonic stem cell-derived early-differentiated cells (EDCs) lead to improvement in cardiac function by preventing cardiac apoptosis in aging rats after myocardial infarction. Cardiac apoptosis after transplantation of EDCs was assessed in situ by terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling reaction (TUNEL) staining as well as by measurements of protein levels of cleaved caspases 3, Bax, and Bcl-2. Our results indicate that cell transplantation improved cardiac function at 6-months observation. The frequency of apoptotic cells in the peri-infarcted myocardium 3 days after cell transplantation was significantly decreased in the cell transplantation group. EDC therapy decreased the protein levels of cleaved caspase 3 and Bax, and increased the level of Bcl-2 in comparison to myocardial infarction control. Additionally, the number of apoptotic cells decreased significantly in cardiomyocytes precocultured with EDCs. This study demonstrates that functional improvement of EDC transplantation may at least in part be related to a reduction in cardiomyocyte apoptosis.

Little is known about the long-term effects of analgesics on functional status and well-being of nursing home residents with chronic pain.Using the Minimum Data Set, we performed a longitudinal study of nursing home residents (n = 10,372) with persistent pain. Using propensity score adjustment techniques, we compared the effect of different analgesics on changes in physical, cognitive, emotional, and social functioning, and examined rates of adverse events over a 6-month period.There was no change in the analgesic class for at least 6 months for 35.4% of residents, including 40% who received no analgesics during this time. Use of nonopioids was 37.9%, short-acting opioids was 18.9%, and long-acting opioids was 3.3%. We found improvement in functional status (adjusted hazard ratio = 1.85; 95% confidence interval [CI], 1.05-3.23) and social engagement (adjusted hazard ratio = 1.58; 95%, CI, 0.99-2.50) with long-acting opioids compared with short-acting opioids. There were no changes in cognitive status or mood status, or increased risk of depression with use of any analgesics, including opioids. There was a trend toward a lower risk of falls with use of any analgesics (adjusted odds ratio = 0.87; 95% CI, 0.70-1.06). Rates of other adverse events (i.e., constipation, delirium, dehydration, pneumonia) were not found to be higher among chronic opioid users compared to those taking no analgesics or nonopioids.The use of long-acting opioids may be a relatively safe option in the management of persistent nonmalignant pain in the nursing home population, yielding benefits in functional status and social engagement.

BACKGROUND: Current data suggest that 30%-50% of patients with syncope leave the hospital without a defined etiology of their syncopal event. Recent studies have shown significant differences in both presentation and therapy in women with coronary disease and congestive heart failure. METHODS: To assess the impact of sex on the frequency of syncope and the rate of identifying a specific etiology among elderly patients who present to the emergency department (ED), a retrospective chart review was performed during a 1-year period. Consecutive patients older than 65 years presenting with syncope to a large urban teaching hospital were enrolled. Inclusion criterion was documented loss of consciousness with no other obvious etiology of loss of consciousness such as stroke or seizure. Charts were screened for presenting history, ethnicity, sex, comorbid conditions, living circumstances, outpatient medication, and cardiac risk factors and outcomes including acute coronary syndromes, myocardial infarction, and death. RESULTS: During 1 year of observation, 7496 women (60%) of 12,401 patients over the age of 65 presented to our ED, and 219 (2.9%) of these met inclusion criteria for syncope. In comparison, 4905 (40%) men presented to the ED, 104 (2.1%) of whom had syncope (relative risk of syncope for women vs men, 1.38; 95% confidence interval, 1.09-1.74). Men were more likely to have comorbid conditions including coronary artery disease (p < or =.01), prior myocardial infarction (p < or =.03), and diabetes mellitus (p < or =.03) than were women. No sex differences were noted in living circumstances, such as living alone, with assistance, or in an institution. Forty-two percent of patients received no diagnosis on discharge from the hospital. Sixty-nine of 147 women admitted (47%) had no etiology of their syncope as compared to 27 (32%) of men. The relative risk for no diagnosis in women versus men was 1.67 (95% confidence interval, 1.07-2.61). CONCLUSIONS: Considerable numbers of patients presenting to EDs with syncope remain without a diagnosis. Women, despite being less likely to have concomitant coronary artery disease or diabetes, are significantly more likely to present to an ED with syncope, yet less likely to be discharged with a defined etiology.

Cerebral white matter lesions (WMLs), also called "leukoaraiosis," are common neuroradiological findings in elderly people. WMLs are often located at periventricular and subcortical areas and manifest as hyperintensities in magnetic resonance imaging. Recent studies suggest that cardiovascular risk factors are associated with the development of WMLs. These lesions are associated with different geriatric syndromes such as falls, executive cognitive impairment, depressive symptoms, and urinary incontinence. Damage to associative pathways in frontal and subcortical regions due to hypoperfusion may disrupt frontal executive, motor control, and other systems, resulting in these manifestations. WMLs are associated with substantial disability and should not be considered a benign and silent condition as once believed. Interventions addressing cardiovascular risk factors should be undertaken in early or mid-life in order to prevent late-life functional impairment associated with WMLs. After these lesions develop and impair executive cognitive functions, the patient's ability to comply with a complex risk reduction program may be significantly compromised.

BACKGROUND Aging is associated with diminished baroreflex sensitivity (gain), which predisposes elderly people to orthostatic hypotension, syncope, and cardiovascular morbidity. Aging is also associated with systolic blood pressure (SBP) elevation and carotid artery stiffness, which may both affect baroreflex gain. METHODS We examined the relation between SBP, carotid artery stiffness, and baroreflex gain in 34 healthy elderly (71 +/- 4 years) and 10 healthy young (31 +/- 3 years) subjects. SBP (Finapres) and carotid artery stiffness (ultrasound measures of relative carotid artery diameter changes during each blood pressure pulse) were measured. The gain of the transfer function relating the R-R interval to SBP fluctuations at a frequency of 0.05-0.15 Hz was used to assess cardiovagal baroreflex gain. RESULTS Elderly subjects had higher carotid artery stiffness (14.2 +/- 5.1 vs 6.6 +/- 1.8, p

Transcatheter aortic valve replacement (TAVR) has emerged as a minimally invasive alternative treatment to surgical aortic valve replacement (SAVR) in high-risk patients. Postoperative delirium after SAVR is common; delirium rates after TAVR have not been established. We conducted a single-center prospective cohort study to determine the incidence and predictors of delirium in older patients undergoing TAVR (106) and SAVR (73). The Confusion Assessment Method was used daily to assess delirium. Relative to SAVR, TAVR patients were older (84 vs. 78 years), more likely to be frail (Fried phenotype) (82% vs. 36%), but had lower delirium incidence (26% vs. 51%). We identified the following preoperative delirium risk factors after TAVR: Mini-Mental State Examination score

A hypothesized but unexplored mechanism for delirium in older persons is that changes in plasma large neutral amino acid (LNAA) concentrations alter brain serotonin levels, result in neurotoxicity, or both. Therefore we performed a prospective study of 21 acutely febrile long-term-care residents to study the relationship between LNAA changes and delirium. Plasma LNAA concentrations were evaluated during illness and 1 month later. Delirium was diagnosed by using the Confusion Assessment Method. Other data included age, body mass index, cognitive impairment, comorbidity, gender, maximum temperature, and medication use. Seven subjects (33%) were delirious during febrile illness. Although the phenylalanine (PHE)/LNAA ratio was higher during illness in both delirious and nondelirious groups, a two-sample t test demonstrated that delirium was associated with a higher illness PHE/LNAA ratio ( p 5 .03). The amount of change in PHE/LNAA from illness to recovery was not different between the delirious and nondelirious groups. Tryptophan/LNAA was not associated with delirium during illness or at recovery. These findings identify another potentially fruitful area of investigation for the prevention and treatment of delirium in older persons. ELIRIUM may be the most common, and perhaps the most important, complication of illness in older persons. Although epidemiologic studies have identified important risk factors associated with the occurrence of delirium, such as advanced age, cognitive impairment, and illness severity, knowledge regarding the pathophysiology of this difficult problem is lacking (1). One hypothesis is that changes in large neutral amino acids (LNAAs), which are precursors of several neurotransmitters that are involved in arousal, attention, and cognition, may play a role in delirium (2). All LNAAs (isoleucine, leucine, methionine, phenylalanine, tryptophan, tyrosine, and valine) enter the brain by using the same saturable carrier, in competition with each other. As the concentration of one LNAA increases, central nervous system entry of other LNAAs decline (3). For example, brain concentrations of serotonin may increase if the relative blood concentration of tryptophan (TRP) increases. Alternatively, serotonin concentrations may decrease if other LNAA concentrations are increased relative to TRP. Phenylalanine (PHE) has the additional interesting property of possible conversion to neurotoxic metabolites (4) and competes with TRP for entry into the brain and subsequent metabolism. This study tests the hypothesis that alterations in plasma LNAA concentrations, particularly the PHE/LNAA and TRP/LNAA ratios, are associated with delirium in febrile elderly patients.

The purpose of this article is to review current knowledge regarding potential neural mechanisms of delirium. A MEDLINE search for relevant English language articles was undertaken using various combinations of delirium (including cognitive disorders, encephalopathy, and confusion) with pathogenesis and pathophysiology. These articles were scanned for content related to hypotheses concerning the neurobiology of delirium. Additional references were obtained from a manual search of the bibliography of these articles. A secondary MEDLINE search of delirium with the mechanism in question (i.e., serotonin, acetylcholine, etc.) was then undertaken. Literature review was last updated as of April 1998. Despite being a common problem among elderly patients, the mechanisms of delirium are poorly understood. Delirium is a syndrome that may occur as the result of multiple complex interacting neurotransmitter systems and pathologic processes. The neurotransmitters acetylcholine and serotonin may play particularly important roles in common medical and surgical delirium. Other neurotransmitters such as dopamine and gamma-aminobutyric acid each may be involved in the development of delirium under special conditions. Other neurobiologic factors such as cytokines, cortisol abnormalities, and oxygen free radicals will require further study to define their role in delirium. Distinct neuropathologic processes leading to delirium are beginning to be defined. Such mechanisms may differ in various clinical settings. There is probably no final common pathway to delirium, but rather, delirium is the final common symptom of multiple neurotransmitter abnormalities. Further situation-specific studies of delirium pathophysiology should lead to more effective prevention and treatment strategies.

Objective: to determine how nursing home characteristics affect pressure sores and disruptive behaviour. Method: residents (n = 5518, aged $ 60 years) were selected from 70 nursing homes in the National Health Care chain. Homes were classified as high- or low-risk based on incidence tertiles of pressure sores or disruptive behaviour (1989‐90). Point-prevalence and cumulative incidence of pressure sores and disruptive behaviour were examined along with other functional and service variables. Results: the overall incidence of pressure sores was 11.4% and the relative risk was 4.3 times greater in high- than low-risk homes; for disruptive behaviour, the incidence was 27% and the relative risk was 7.1 times greater in the high-risk group. At baseline, fewer subjects in homes with a high risk of pressure sores were white or in restraints, but more had received physician visits monthly and had had problems with transfers and eating. High-risk homes also had fewer beds and used less non-licensed nursing staff time. At follow-up (1987‐90), 52% of homes in the lowrisk group and 35% of those in the high-risk group had maintained their risk status; low-risk homes were more likely to have rehabilitation and maintenance activities. Having multiple clinical risk factors was associated with more pressure sores in high- (but not low-) risk homes, suggesting a care-burden threshold. By logistic regression, the best predictor of pressure sores was a home’s prior (1987‐88) incidence status. Interestingly, 67% of homes with a high risk of pressure sores were also high-risk for disruptive behaviour, while only 27% of homes with a low risk of pressure sores were high-risk for disruptive behaviour. A threshold effect was also observed between multiple risk factors and behaviour. More homes with a high risk of disruptive behaviour (68%) remained at risk over 4 years, and the best predictor of outcome was a home’s previous morbidity level. Conclusion: nursing-home characteristics may have a greater impact than clinical factors on pressure sores and disruptive behaviour in long-stay, institutionalized elders.

Background Because there is a lack of databases specific to long-term care, standardized assessments of nursing home residents are seen as a potential new resource for studying an important but neglected population. We describe the design and principal population characteristics of the first integrated database combining detailed clinical information and administrative claims data. Methods We studied nearly 300,000 residents admitted between 1992 and 1994 to all Medicare/Medicaid certified nursing homes of five U.S. states (Kansas, Maine, Mississippi, New York, and South Dakota). The database crosslinks: (a) Resident Data: over 350 items (demographic, diagnostic, clinical, and treatments) collected with the Minimum Data Set; (b) Drug Data: brand name, dosage route, and frequency of administration for all drugs consumed by each resident; (c) Medicare Data: eligibility and inpatient hospital claims; (d) Facilities Data: structural and staffing information on nursing homes; and (e) Country Data: information on population, health professions and facility data, and economic parameters. Results Ninety-two percent of the residents were aged 65 years and older. Residents were predominantly white (85%) and female (72%). The average number of medical diagnoses was above three, and residents were receiving an average of six medications. Sixty-five percent of residents had at least one hospital claim following the initial assessment, most commonly related to cardiovascular diseases and metabolic disorders. Fifty-five percent of the facilities were for-profit and 33% were of small size. Quality indicators and staffing level varied significantly by state. Conclusions The SAGE (Systematic Assessment of Geriatric drug use via Epidemiology) database provides a unique resource to study the relation between treatments received and outcomes experienced, particularly functional and health services outcomes, that have not been possible before in very old, frail people.

Purpose Elders in retirement communities face many challenges concerning information and communication. We know little about whether or how online technologies help meet their medical and social needs. The objective of this study was to gain insights into how these elders and their families manage health information and communication. Design and methods Qualitative analysis of 10 focus groups with elders and family members. Participants were 30 elders at least 75 years of age residing in 5 senior living communities in and near Boston, MA, and 23 family members. Results Elders and families turned first to their personal networks when they needed information or help. They stayed informed about elders' health primarily by talking directly with providers. They used online resources infrequently, including portal access to medical records. They wanted online access to medication lists and visit notes, up-to-date information about local services and social activities, and a way to avoid the overwhelming nature of Internet searches. Implications Elders in senior living communities and their families piece together information primarily from word of mouth communication. In the future, electronic social and collaborative technologies may make information gathering easier.

Background Chronic cognitive impairment is a major problem in U.S. nursing homes, yet traditional assessment systems in most facilities included only limited information on cognitive status. Following the Congressional mandate in the Omnibus Reconciliation Act of 1987 (OBRA '87), U.S. nursing homes now complete the Minimum Data Set (MDS), a standardized, comprehensive assessment of each resident's functional, medical, psychosocial, and cognitive status. We designed a Cognitive Performance Scale (CPS) that uses MDS data to assign residents into easily understood cognitive performance categories. Methods Information was drawn from three data sets, including two multistate data sets constructed for the Health Care Financing Administration. The prevalence and reliability of the MDS cognitive performance variables were established when assessed by trained nursing personnel. Five selected MDS items were combined to create the single, functionally meaningful seven-category hierarchical Cognitive Performance Scale. Results The CPS scale corresponded closely with scores generated by the Mini-Mental State Examination and the Test for Severe Impairment, nursing judgments of disorientation, and neurological diagnoses of Alzheimer's disease and other dementias. Conclusions The new CPS provides a functional view of cognitive performance, using readily available MDS data. It should prove useful to clinicians and investigators using the MDS to determine a resident's cognitive assets.

BACKGROUND Delirium is often considered a transient cognitive syndrome. Its effect on long-term physical function, however, has not been well defined. METHODS In a prospective study of 325 hospitalized community and nursing home elderly, we analyzed the effect of in-hospital delirium on subsequent physical function. ADL performance was assessed prior to admission, and at 3 and 6 months after hospital discharge. RESULTS There was a strong univariate (unadjusted) association between incident delirium and functional decline (p < .02). Delirious subjects lost a mean of almost one ADL, as measured 3 months after hospital discharge. Using multivariate linear regression analysis, with adjusted change in function as the dependent variable, delirium persisted as the sole predictor of loss of function (p = .009) at 3 months after discharge. The functional decline persisted at 6 months after hospital discharge. CONCLUSION This finding of a nontransient, perhaps permanent consequence of delirium invites reexamination of the definition of delirium from that of an acute, reversible syndrome to one of acute onset with long-term sequelae.

The prevalence of postural change in blood pressure and its association with age and systolic blood pressure were examined in data from 8,574 White nondiabetic persons aged 25-74 who participated in the second National Health and Nutrition Examination Survey (1976-1980). Postural change in blood pressure was defined as a drop of 20 mm Hg or more on change from supine to seated position. In subjects on no antihypertensive medications (n = 7,316), the prevalence of postural change in blood pressure increased with older age and with higher blood pressure levels, regardless of age. However, systolic blood pressure levels also increased with age. In logistic regression models, level of supine systolic blood pressure was strongly related to postural change in blood pressure (Relative odds (RO) = 1.59, 95% confidence interval (CI) = 1.49, 1.70 for a 10 mm Hg increase in systolic blood pressure) whereas age was not related to postural change in blood pressure (RO for age = 1.07, Cl = .89, 1.19 for a 10-year increase in age). Results were similar for those medicated for hypertension. All results were unchanged by addition of health status indicators, including reports of hospitalization and number of medical conditions, to the model. These data suggest that the age-related increase in the prevalence of postural hypotension previously reported may be partially explained by age-associated increases in systolic blood pressure.

To determine causes and clinical correlates of recurrent falls in ambulatory frail elderly people, we evaluated 70 recurrent fallers and 56 nonfallers (mean age = 87 years) from two long-term care facilities. Evaluations included a detailed history, physical examination, performance-oriented mobility assessment, and laboratory studies. Primary causes including stroke, parkinsonism, blindness, drug-related hypotension, and arthritis were established for the most recent fall in 51 (73%) fallers. Eighteen fallers (26%) had multiple conditions that could not be prioritized for their contribution to the fall. Fallers were more often women, were functionally more impaired, and were taking more medications than nonfallers. Specific diseases did not distinguish fallers from nonfallers. Fallers of both sexes took more steps to turn 360 degrees, could not stand up from a chair without pushing off, had a higher prevalence of antidepressant use, and had impaired position sensation. These easily obtained clinical variables characterized nearly three-quarters of ambulatory elderly nursing home residents with a history of recurrent falls.

Aging and associated increases in systolic blood pressure may cumulatively produce alterations in many blood pressure regulatory mechanisms that impair an older person's ability to adapt to hypotensive stress. Both age and hypertension impair baroreflex sensitivity and decrease compliance of the heart and vasculature. These changes increase the risk of hypotensive responses to activities that reduce cardiac preload and to conditions that produce tachycardia or eliminate atrial contraction. Common clinical examples include orthostatic and postprandial hypotension, nitrate intolerance, and atrial fibrillation. The increased intra- and interindividual variability in blood pressure, resulting from impaired homeostatic capacity, challenges established diagnostic criteria for hyper- and hypotensive syndromes and necessitates new multivariate approaches to research data analysis. Gerontologic investigations utilizing blood pressure measurements should examine individual as well as group responses, and stratify subjects by level of basal blood pressure to isolate the effect of aging from the effects of blood pressure elevation.

SUMMARY Although syncope is common in the elderly, little is known of its epidemiology and prognosis. A retrospective analysis of syncope in 711 very old (mean age 87 years) institutionalised patients revealed a 10 year prevalence of 23 per cent and one year incidence of 7 per cent. A two-year prospective follow-up of this population revea1cd a yearly incidence of 6 per cent and recurrence rate of 30 per cent. Of 67 patients who developed syncope during follow-up, a cause was established in 46; 14 (21 per cent) had cardiac and 32 (48 per cent) had non-cardiac aetiologies. Twenty-one cases (31 per cent) remained unexplained. Patients who developed syncope were initially more functionally disabled ( p = 0.003) and subsequently changed function more frequently ( p = 0.03) than those with out the development of syncope, but two year rates of hospitalisation and death were not different between the two groups. Life-table survival analysis showed no difference in the mortality of subgroups with cardiac, non-cardiac, and unknown aetiologies of syncope. Syncope is common in multiply impaired elders and is likely a manifestation of co-morbid disease rather than an independent contributor to mortality.