Search

Background: The purpose of this study was to develop a clinical support tool for osteoporosis clinic providers to support risk assessment and referrals for evidence‐based exercise therapy programs. Methods: A sequential Delphi method was used with a multidisciplinary group of national falls experts, to provide consensus on referral to exercise therapy for patients at risk for falls. The Delphi study included a primary research team, expert panel, and clinical partners to answer the questions: (1) "What patient characteristics are needed to develop a clinical support tool?"; (2) "What are the recommended exercise referrals for patients with osteoporosis at risk for falls?" The consensus process consisted of two rounds with 8 weeks between meetings. Two qualitative researchers analyzed the data using a modified version of a matrix analysis approach. Results: The following were the most important variables to include when determining exercise therapy referrals for patients with osteoporosis: Patient history and demographics, falls history over the last year, current physical function and balance, caregiver and transportation status, socioeconomic and insurance status, and patient preference. Potential exercise therapy referrals included one‐on‐one physical therapy, group physical therapy, home health, community‐based exercise programs, and not acceptable for exercise therapy. Conclusions: Patient characteristics including patient history, physical function and balance performance, socioeconomic and insurance status, and patient preference for exercise therapy are important to inform both the medical provider and patient with osteoporosis to choose the most appropriate exercise therapy referral. Adoption of the algorithmic suggestions may have a significant impact on uptake and adherence to exercise therapy, ultimately improving patient physical function and reducing falls risk. [ABSTRACT FROM AUTHOR]

Background: Published guidelines recommend high‐intensity statins following an ischemic stroke or transient ischemic attack (TIA). The authors examined the potential for disparate patterns of statin prescribing in a cluster randomized trial of transitional care following acute stroke or TIA. Methods: Medications taken before hospitalization and statins prescribed at discharge among stroke and TIA patients at 27 participating hospitals were examined. Any statin and intensive statin prescribed at discharge were compared by age (<65, 65–75, >75 years), racial category (White vs. Black), sex (male vs. female), and rurality (urban vs. non‐urban) using logistic mixed models. Results: Among 3211 patients (mean age 67 years; 47% female; 29% Black), 90% and 55%, respectively, were prescribed any statin or intensive statin therapy at discharge. White (vs. Black) patients (0.71, 0.51–0.98) less commonly received any statin prescription, while stroke (vs. TIA) patients (1.90, 1.38–2.62) and those residing in urban areas (1.66, 1.07–2.55) more commonly received any statin prescription. Among those prescribed a statin, only 42% of White and 51% of Black patients >75 years. were prescribed an intensive statin; the OR for intensive statin prescribing was 0.44 for patients >75 years and was similar in a subgroup not on a statin previously. Conclusion/Relevance: Following stroke or TIA, statin prescribing remains lower in White patients, in those with TIA, and in those in non‐urban areas. Intensive statin prescribing remains limited, particularly in patients >75 years. These data may inform efforts to improve guideline concordant prescribing for post‐stroke patients. [ABSTRACT FROM AUTHOR]

Background: Older patients hospitalized with acute decompensated heart failure (ADHF) have marked functional impairments, which may contribute to their delayed and incomplete recovery and persistently poor outcomes. However, whether impairment severity differs by race and sex is unknown. Methods: REHAB‐HF trial participants (≥60 years) were assessed just before discharge home from ADHF hospitalization. Physical function [Short Physical Performance Battery; 6‐min walk distance (6MWD)], frailty (Fried criteria), cognition [Montreal Cognitive Assessment (MoCA)], quality‐of‐life [Kansas City Cardiomyopathy Questionnaire, Short‐Form‐12, EuroQol‐5D‐5L], and depression [Geriatric Depression Scale (GDS)] were examined by race and sex. Results: This prespecified subgroup cross‐sectional analysis included 337 older adults (52% female, 50% Black). Black participants were on average younger than White participants (70.3 ± 7.2 vs. 74.7 ± 8.3 years). After age, body mass index, ejection fraction, comorbidity, and education adjustment, and impairments were similarly common and severe across groups except: Black male and Black and White female participants had more severely impaired walking function compared with White male participants [6MWD (m) 187 ± 12, 168 ± 9170 ± 11 vs. 239 ± 9, p < 0.001]; gait speed (m/s) (0.61 ± 0.03, 0.56 ± 0.02, 0.55 ± 0.02 vs. 0.69 ± 0.02, p < 0.001); White female participants had the highest frailty prevalence (72% vs. 47%–51%, p = 0.007); and Black participants had lower MoCA scores compared with White participants (20.9 ± 4.5 vs. 22.8 ± 3.9, p < 0.001). Depressive symptoms were common overall (43% GDS ≥5), yet underrecognized clinically (18%), especially in Black male participants compared with White male participants (7% vs. 20%). Conclusion: Among older patients hospitalized for ADHF, frailty and functional impairments with high potential to jeopardize patient HF self‐management, safety, and independence were common and severe across all race and sex groups. Impairment severity was often worse in Black participant and female participant groups. Formal screening across frailty and functional domains may identify those who may require greater support and more tailored care to reduce the risk of adverse events and excess hospitalizations and death. [ABSTRACT FROM AUTHOR]

Background: Older patients with acute decompensated heart failure (ADHF) have severely impaired physical function (PF) and quality of life (QOL). However, relationships between impairments in PF and QOL are unknown but are relevant to clinical practice and trial design. Methods: We assessed 202 consecutive patients hospitalized with ADHF in the multicenter Rehabilitation Therapy in Older Acute HF Patients (REHAB‐HF) Trial. PF measures included Short Physical Performance Battery (SPPB) and 6‐min walk distance (6MWD). Disease‐specific QOL was assessed by the Kansas City Cardiomyopathy Questionnaire (KCCQ). General QOL was assessed by the Short Form‐12 (SF‐12) and EuroQol‐5D‐5L. PF was evaluated as a predictor of QOL using stepwise regression adjusted for age, sex, race, and New York Heart Association class. Results: Participants were 72 ± 8 years, 54% women, 55% minority race, 52% with reduced ejection fraction, and body mass index 33 ± 9 kg/m2. Participants had severe impairments in PF (6MWD 185 ± 99 m, SPPB 6.0 ± 2.5 units) and disease‐specific QOL (KCCQ Overall Score 41 ± 21 and Physical Score 47 ± 24) and general QOL (SF‐12 Physical Score 28 ± 9 and EuroQol Visual Analog Scale 57 ± 23). There were modest, statistically significant correlations between 6MWD and KCCQ Overall, KCCQ Physical Limitation, and SF‐12 Physical Scores (r = 0.23, p < 0.001; r = 0.30, p < 0.001; and r = 0.24, p = 0.001, respectively); and between SPPB and KCCQ Physical and SF‐12 Physical Scores (r = 0.20, p = 0.004, and r = 0.19, p = 0.007, respectively). Both 6MWD and SPPB were correlated with multiple components of the EuroQol‐5D‐5L. 6MWD was a significant, weak predictor of KCCQ Overall Score and SF‐12 Physical Score (estimate = 0.05 ± 0.01, p < 0.001 and estimate = 0.05 ± 0.02, p = 0.012, respectively). SPPB was a significant, weak predictor of KCCQ Physical Score and SF‐12 Physical Score (estimate = 1.37 ± 0.66, p = 0.040 and estimate = 0.54 ± 0.25, p = 0.030, respectively). CONCLUSION: In older, hospitalized ADHF patients, PF and QOL are both severely impaired but are only modestly related, suggesting that PF and QOL provide complementary information and assessment of both should be considered to fully assess clinically meaningful patient‐oriented outcomes. [ABSTRACT FROM AUTHOR]

The article presents COMprehensive Post-Acute Stroke Services (COMPASS) study on emergency department utilization after hospitalization discharge for acute stroke. Topics include Providing appropriate care during the recovery from this complex condition is a challenge for patients, caregivers, and health care providers; and COMPASS transitional care intervention was designed to integrate medical and community resources to meet the needs of stroke survivors and caregivers and optimize outcomes.

Many individuals who have had a stroke leave the hospital without postacute care services in place. Despite high risks of complications and readmission, there is no standard in the United States for postacute stroke care after discharge home. We describe the rationale and methods for the development of the COMprehensive Post‐Acute Stroke Services (COMPASS) care model and the structure and quality metrics used for implementation. COMPASS, an innovative, comprehensive extension of the TRAnsition Coaching for Stroke (TRACS) program, is a clinician‐led quality improvement model providing early supported discharge and transitional care for individuals who have had a stroke and have been discharged home. The effectiveness of the COMPASS model is being assessed in a cluster‐randomized pragmatic trial in 41 sites across North Carolina, with a recruitment goal of 6,000 participants. The COMPASS model is evidence based, person centered, and stakeholder driven. It involves identification and education of eligible individuals in the hospital; telephone follow‐up 2, 30, and 60 days after discharge; and a clinic visit within 14 days conducted by a nurse and advanced practice provider. Patient and caregiver self‐reported assessments of functional and social determinants of health are captured during the clinic visit using a web‐based application. Embedded algorithms immediately construct an individualized care plan. The COMPASS model's pragmatic design and quality metrics may support measurable best practices for postacute stroke care. [ABSTRACT FROM AUTHOR]

In response to the epidemic of falls and serious falls-related injuries in older persons, in 2014, the Patient Centered Outcomes Research Institute ( PCORI) and the National Institute on Aging funded a pragmatic trial, Strategies to Reduce Injuries and Develop confidence in Elders ( STRIDE) to compare the effects of a multifactorial intervention with those of an enhanced usual care intervention. The STRIDE multifactorial intervention consists of five major components that registered nurses deliver in the role of falls care managers, co-managing fall risk in partnership with patients and their primary care providers ( PCPs). The components include a standardized assessment of eight modifiable risk factors (medications; postural hypotension; feet and footwear; vision; vitamin D; osteoporosis; home safety; strength, gait, and balance impairment) and the use of protocols and algorithms to generate recommended management of risk factors; explanation of assessment results to the patient (and caregiver when appropriate) using basic motivational interviewing techniques to elicit patient priorities, preferences, and readiness to participate in treatments; co-creation of individualized falls care plans that patients' PCPs review, modify, and approve; implementation of the falls care plan; and ongoing monitoring of response, regularly scheduled re-assessments of fall risk, and revisions of the falls care plan. Custom-designed falls care management software facilitates risk factor assessment, the identification of recommended interventions, clinic note generation, and longitudinal care management. The trial testing the effectiveness of the STRIDE intervention is in progress, with results expected in late 2019. [ABSTRACT FROM AUTHOR]

This editorial comments on the article by Juraschek et al. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine fracture risk in U.S. stroke patients and identify patient characteristics that predict highest fracture risk in two complementary cohorts. DESIGN: Secondary analyses of two prospective cohorts. SETTING: Veterans Affairs (VA) Medical Centers. PARTICIPANTS: The VA Acute Stroke (VASt) cohort includes 1,073 veterans admitted to nine VA hospitals for stroke between April 1995 and March 1997. The Integrated Stroke Outcomes Database (ISOD) includes 6,578 veterans who received inpatient rehabilitation for stroke at 121 VA facilities during fiscal years 2001 and 2002. MEASUREMENTS: Fractures detected using International Classification of Diseases, 9th Revision, codes in the VA computerized patient record system; baseline patient characteristics and stroke features; Functional Independence Measures scores in ISOD. RESULTS: Estimated 2-year fracture rates after stroke in the VASt and ISOD cohorts were 6.1% and 4.7%, respectively. Longer hospitalizations for stroke ( P=.06) and new motor or sensory impairment ( P=.09) showed trends toward greater risk in the VASt cohort. Female sex ( P <.001), cognitive impairment ( P=.01), and nonblack race ( P=.04) were associated with higher fracture risk in the ISOD. Intermediate functional impairment conferred higher fracture risk than mild or severe functional impairment. CONCLUSION: Veterans who suffer a stroke are at high risk of subsequent fracture, which can lead to further disability. Women, nonblacks, and those with intermediate functional impairment were at particularly high risk of fracture. Future study should investigate therapies to decrease fracture risk in stroke patients. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine the effect of exercise on depressive symptoms and the effect of baseline depressive symptoms on the benefits from exercise in stroke survivors who have completed acute rehabilitation. DESIGN: Planned secondary analysis of the data from a 9-month randomized, controlled trial. SETTING: Participant homes. PARTICIPANTS: One hundred stroke survivors who had completed acute rehabilitation. INTERVENTION: A progressive, structured, 3-month physical exercise program. MEASUREMENTS: Demographics, stroke characteristics, impairments, functional limitations, the Geriatric Depression Scale, the Stroke Impact Scale, and the Medical Outcomes Study 36-Item Short Form. RESULTS: Baseline rates of depressive symptoms and other stroke sequelae were similar between the two arms. Ninety-three participants were assessed immediately after the intervention (3 months after enrollment), and 80 were assessed 9 months after enrollment. Six (14%) of the exercise group and 16 (35.6%) of the usual-care group had depressive symptoms at 3 months ( P=.03). At 9 months, three (7.5%) of the exercisers had significant depressive symptoms compared with 10 (25%) who received usual care ( P=.07). Participants with and without baseline depressive symptoms had equivalent treatment-related gains in impairments and functional limitations, but only participants with depressive symptoms had improved quality of life. CONCLUSION: Exercise may help reduce poststroke depressive symptoms. Depressive symptoms do not limit gains in physical function due to exercise. Exercise may contribute to improved quality of life in those with poststroke depressive symptoms. [ABSTRACT FROM AUTHOR]

To assess whether group exercise and coping classes reduce physical and psychological impairments and functional disability in older women with prevalent vertebral fractures (VFs). Randomized, controlled trial (modified cross-over) with site as unit of assignment; testing at baseline and 3, 6, 9, and 12 months. Nine North Carolina retirement communities. One hundred eighty-five postmenopausal Caucasian women (mean age 81), each with at least one VFs. The intervention group had 6 months of exercise (3 meetings weekly, 45 minutes each) and coping classes (2 meetings weekly, 45 minutes each) in Phase 1, followed by 6 months of self-maintenance. The control group had 6 months of health education control intervention (1 meeting weekly, 45 minutes) in Phase 1, followed by the intervention described above. Change in trunk extension strength, change in pain with activities, and change in psychological symptoms. Between-group differences in the change in trunk extension strength (10.68 foot pounds, P<.001) and psychological symptoms (−0.08, P=.011) were significant for Phase 1. Changes in pain with activities did not differ between groups (−0.03, P=.64); there was no change in the pain endpoint. In Phase 2, controls showed significant changes in trunk strength (15.02 foot pounds, P<.001) and psychological symptoms (−0.11, P=.006) from baseline. Change in pain with activities was not significant (−0.03, P=.70). During self-maintenance, the intervention group did not worsen in psychological symptoms, but improved trunk extension strength was not maintained. Weak trunk extension strength and psychological symptoms associated with VFs can be improved in older women using group treatment, and psychological improvements are retained for at least 6 months. [ABSTRACT FROM AUTHOR]

To expand the ability to assess physical frailty by developing a Clinical Global Impression of Change in Physical Frailty (CGIC-PF) instrument. Qualitative and quantitative instrument development. Academic centers. Six expert panel members, 46 clinicians, 24 patients, and 12 caregivers. Literature review and structured group processes with experts, clinicians, and consumers were used to generate an initial list of domains and indicators. Structured interviews with clinical experts in the area of frailty were used to establish relevance and feasibility of measurement of domains. Interrater reliability was assessed through a Web-based study. Geriatricians pilot tested the feasibility of the baseline CGIC-PF with 10 patients. The CGIC-PF includes six intrinsic domains (mobility, balance, strength, endurance, nutrition, and neuromotor performance) and seven consequences domains (medical complexity, healthcare utilization, appearance, self-perceived health, activities of daily living, emotional status, and social status). Each domain has two to four clinical indicators. Change is scored on a 7-point scale from markedly worse to markedly improved. Average interrater reliability of the CGIC-PF for the Web-based cases was 0.97. Geriatricians completed a baseline CGIC-PF on their own patients in 10 minutes or less. The CGIC-PF is a structured assessment of change in physical frailty with defined content and process. It has strong face validity, reliability, and feasibility for use in clinical research. It may be useful as one criterion of change and as an anchor for change in other measures. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To assess the ability of gait speed alone and a three-item lower extremity performance battery to predict 12-month rates of hospitalization, decline in health, and decline in function in primary care settings serving older adults. DESIGN: Prospective cohort study. SETTING: Primary care programs of a Medicare health maintenance organization (HMO) and Veterans Affairs (VA) system. PARTICIPANTS: Four hundred eighty-seven persons aged 65 and older. MEASUREMENTS: Lower extremity performance Established Population for Epidemiologic Studies of the Elderly (EPESE) battery including gait speed, chair stands, and tandem balance tests; demographics; health care use; health status; functional status; probability of repeated admission scale (Pra); and primary physician's hospitalization risk estimate. RESULTS: Veterans had poorer health and higher use than HMO members. Gait speed alone and the EPESE battery predicted hospitalization; 41% (21/51) of slow walkers (gait speed <0.6 m/s) were hospitalized at least once, compared with 26% (70/266) of intermediate walkers (0.6–1.0 m/s) and 11% (15/136) of fast walkers (>1.0 m/s) (P < .0001). The relationship was stronger in the HMO than in the VA. Both performance measures remained independent predictors after accounting for Pra. The EPESE battery was superior to gait speed when both Pra and primary physician's risk estimate were included. Both performance measures predicted decline in function and health status in both health systems. Performance measures, alone or in combination with self-report measures, were more able to predict outcomes than self-report alone. CONCLUSION: Gait speed and a physical performance battery are brief, quantitative estimates of future risk for hospitalization and decline in health and function in clinical populations of older adults. Physical performance measures might serve as easily accessible “vital signs” to screen older adults in clinical settings. [ABSTRACT FROM AUTHOR]

Presents a prospective cohort study to provide recovery rates after stroke for specific functions using the Orpington Prognostic Scale (OPS). Identification of cut-points on the OPS that can predict clinically meaningful differences in outcome rates; Assessment of the overall discrimination ability of the OPS.

Examines the Commission for Environmental Cooperation's (CEC) contribution to the North American environmental management system and explores the implications of its expansion across the hemisphere. Structure of the pre-1994 system for international environmental cooperation in North America; CEC's institutional and political constraints.