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The current longitudinal study examined the influence of cognitive and lower extremity function on sedentary behavior continuously over 6 months in community-dwelling older adults with mild cognitive impairment (MCI). Multilevel models examined Montreal Cognitive Assessment (MoCA) change scores and the Short Physical Performance Battery (SPPB) on percent time in sedentary behavior among 17 older adults with MCI (50 to 74 observations for analysis). Sedentary behavior was measured daily and averaged monthly using wrist-worn actigraphy. Each 1-unit decrease in MoCA score was associated with an increase of 2 percentage points in sedentary behavior ( p ≤ 0.01). In addition, each 1-unit decrease in chair stand score (lower extremity strength) was associated with an increase of 5 percentage points in sedentary behavior ( p ≤ 0.01). Older adults experiencing cognitive decline and concurrent changes in lower extremity strength had the sharpest increase in sedentary behavior. Findings suggest lower body strengthening interventions may reduce sedentary behavior time and subsequently preserve physical functioning in this vulnerable population. [ Research in Gerontological Nursing, 14 (6), 285–291.]

Stroke is a leading cause of death and disability among adults age 65 and over in the United States. Modifiable risk factors for stroke include: obesity, poor nutrition, and lack of exercise. Sussex County, Delaware has the highest stroke rate among older adults in the state. Twenty-five percent of the population in Sussex County are 65 and over and about 70% of adults are overweight or obese. Consistent with the social ecological framework, the Stroke Population Risk Tool may be used at the individual level to identify those at an increased risk for stroke and to create individualized stroke specific education. At the community level, local nutrition, fitness, and senior services may be utilized - with older adults at the highest risk profile participating in a 12 week stroke education program focused on risk reduction behaviors, nutrition and exercise classes. At the policy level, the Walkability Assessment Tool may be utilized to encourage local municipalities to identify areas of the county which lack safe spaces to be physically active and to develop a plan to create a more exercise conducive environment. Taken together, the proposal discusses an implementable plan that may, in the long-term, effectively reduce the stroke rates of older adults in Sussex County and allow for the early identification of those at the greatest risk for stroke.

This study aimed to examine how changes in motor behavior are associated with falls, delirium, and urinary tract infections (UTIs). Twenty-three (128 observations) skilled nursing residents were examined for up to 18 months. In multilevel models, motor behaviors (e.g., time and distance traveled, gait speed), measured by a real-time locating system, were used to predict falls, UTIs, and delirium. Falls were associated with decreased gait speed ( OR = 0.01; p ≤ 0.001) and path distance ( OR = 0.99; p ≤ 0.05); delirium was associated with increased distance traveled ( OR = 1.01; p ≤ 0.001), path distance ( OR = 1.02; p ≤ 0.001), and decreased time traveled ( OR = 0.99; p ≤ 0.001) and path time ( OR = 0.99; p ≤ 0.001); UTIs were associated with increased distance traveled ( OR = 1.01; p ≤ 0.001), decreased time traveled ( OR = 0.99; p ≤ 0.001), and the number of paths ( OR = 0.91; p ≤ 0.01). Subtle changes in motor behavior may be an early warning sign of falls and acute events. Continuous monitoring may enable clinical staff to prevent, identify early, and/or delay these poor health outcomes.

Emergent work suggests that sleep is a robust biobehavioral predictor of pain; however, it remains unclear how sleep is prospectively linked to pain on a day-to-day basis among older adults. The current prospective study examined how sleep duration (total sleep time), quality (sleep efficiency, wake after sleep onset), and late and irregular sleep timing influenced next-day pain perception among community-dwelling older adults ( N = 10; 65 matched observations) with lower extremity chronic pain over 1 week. Multilevel modeling estimated the association between sleep (Actigraph GT9X Link) and pain perception (Brief Pain Inventory Short Form). Increased wake after sleep onset (B = 0.19, p = 0.04), sleep variability (B = 0.02, p = 0.01), and later midsleep time (B = 0.40, p < 0.05) were associated with increased pain interference the following day. Findings support the idea that timely sleep interventions may reduce the effect of poor sleep on next-day pain in older adults. [ Research in Gerontological Nursing, 14 (4), 173–179.]

BACKGROUND Older adults with mild cognitive impairment are at an increased risk for dementia of the Alzheimer's type. These older adults also report poorer sleep and more pain than their cognitively intact adult counterparts. Poor sleep and pain are both symptoms associated with an increased risk for dementia in later life. Symptom science research in the direction of how poor sleep affects pain among older adults, especially those with mild cognitive impairment, is needed for the development of targeted sleep interventions to reduce pain and potentially delay/reduce the risk for Alzheimer's disease in this population. OBJECTIVE The aim of the study was to examine a predictive model of the relationship between poor sleep and pain perception among community-dwelling older adults with mild cognitive impairment. METHODS A longitudinal prospective design with 58 continuous matched sleep-pain observations of 15 older adults with mild cognitive impairment for up to 6 months was used. Multilevel, mixed-modeling, statistical techniques were used to examine the effects of prior-week sleep on subsequent pain perception. Pain perception (pain intensity, pain interference, and pain behavior) is measured by the Patient-Reported Outcomes Measurement Information System during monthly in-person visits. The ActiGraph GT3X+ was used to measure sleep (total sleep time, sleep efficiency, awakenings after sleep onset) objectively and continuously for up to 6 months, along with other covariates (e.g., physical activity). RESULTS Increased awakenings after sleep onset in the prior week is associated with increased pain intensity, pain interference, and pain behavior. There was a trend toward sleep efficiency, and increased pain intensity and sleep efficiency predicted increased pain interference and pain behavior. There was no relationship between prior-week total sleep time and subsequent pain perception. DISCUSSION In this study, poor sleep in the prior week increased pain intensity, pain interference, and pain behavior. Interventions designed to decrease awakening after sleep onset and increase sleep efficiency specifically may effectively reduce pain in this population. Given that these symptoms are prevalent among older adults with mild cognitive impairment, sleep and pain interventions may also ameliorate some of the risk for Alzheimer's disease in this population.

Purpose of study The purpose of this study was to determine the influence of cognitive impairment (CI), 1 gait quality, and balance ability on walking distance and speed in an assisted living facility. Materials and methods This was a longitudinal cohort study of institutionalized older adults (N = 26; 555 observations) followed for up to 8 months. Hierarchical linear modeling statistical techniques were used to examine the effects of gait quality and balance ability (using the Tinetti Gait and Balance Test) and cognitive status (using the Montreal Cognitive Assessment) on walking activity (distance, sustained distance, sustained speed). The latter were measured objectively and continuously by a real-time locating system (RTLS). Results A one-point increase in balance ability was associated with an 8% increase in sustained walking distance (p = 0.03) and a 4% increase in sustained gait speed (p = 0.00). Gait quality was associated with decreased sustained gait speed (p = 0.03). Residents with moderate (ERR = 2.34;p = 0.01) or severe CI (trend with an ERR = 1.62; p = 0.06) had longer sustained walking distances at slower speeds when compared to residents with no CI. Conclusions After accounting for cognitive status, it was balance ability, not gait quality, that was a determinant of sustained walking distances and speeds. Therefore, balance interventions for older adults in assisted living may enable sustained walking activity. Given that CI was associated with more sustained walking, limiting sustained walking in the form of wandering behavior, especially for those with balance impairments, may prevent adverse events, including fall-related injury.

Purpose The aim of the study was to examine the characteristics of wandering associated with preserved versus worsened activities of daily living (ADL) function. Design Longitudinal prospective design. Twenty-two cognitively impaired residents of an assisted living facility with over 450 observations were followed up to 8 months. Methods Hierarchical linear modeling techniques examine how wandering activity (episodes, distance traveled, gait speed), measured by a real-time locating system, may affect ADL (the Barthel index, the Functional Independence Measure [FIM]). Findings Wandering episodes were associated with increased ADL (B = 0.11, p ≤ .05, FIM); wandering distance (B = -4.52, p ≤ .05, the Barthel index; B = -2.14, p ≤ .05, FIM) was associated with decreased ADL. Conclusion Walking an average of 0.81 miles per week with 18 or fewer wandering episodes is associated with decreased ability to perform ADL. Clinical relevance Tailored protocols that allow productive wandering with ongoing assessment for fatigue/other physiological needs to appropriately limit distance walked within wandering episodes are needed for this population.

Hemolytic uremic syndrome (HUS) is major global health care issue as it is the leading cause of acute kidney injury in children. It is a triad of acute kidney injury, microangiopathic hemolytic anemia, and thrombocytopenia. In recent years, major advances in our understanding of complement-driven inherited rare forms of HUS have been achieved. However, in children 90% of cases of HUS are associated with a Shiga toxin-producing enteric pathogen. The precise pathological mechanisms in this setting are yet to be elucidated. The purpose of this review is to discuss advances in our understanding of the pathophysiology underlying HUS and identify the key questions yet to be answered by the scientific community.

Objectives To develop and evaluate the psychometric properties of a new performance-based instrument (Physical and Cognitive Performance Test for Assisted Living Facilities (PCPT ALF)) designed to assess the physical and cognitive skills associated with performance of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Design There were three stages in this study: development of instrument items and validity testing, a feasibility pilot study, and a cross-sectional trial to establish construct and criterion validity and reliability. Setting One 116-bed assisted living facility (ALF). Participants After a pilot test with 10 residents, a cross-sectional trial was conducted with 55 additional residents. Measurements The Barthel Index and Functional Independence Measure were used to estimate criterion validity. Construct validity was examined using exploratory factor analyses (EFAs). Results Disattenuated correlations between the PCPT ALF and other tools were all greater than 0.72, supporting criterion validity. Internal consistency (physical ability, α = 0.95; cognitive support, α = 0.92) and 1-week test–retest reliability (PCPT ALF, P = .93) were high, as was interrater reliability (IRR) (physical ability, 0.99; cognitive support, 1.00). In two EFAs, a one-factor solution accounted for 64.1% of the variance for the physical ability subscale and 63.5% of the variance for the cognitive support subscale. Conclusion The findings provide early evidence of the PCPT ALF's validity and reliability. If confirmed, this study's findings may be used in future work to assess the success of interventions to prevent or slow decline in the skills associated with ADL and IADL performance in ALFs.

Background Excessive and patterned ambulation is associated with falls, urinary tract infections, co-occurring delirium and other acute events among long-term care residents with cognitive impairment/dementia. This study will test a predictive longitudinal data model that may lead to the preservation of function of this vulnerable population. Methods/design This is a single group, longitudinal study with natural observations. Data from a real-time locating system (RTLS) will be used to objectively and continuously measure ambulation activity for up to 2 years. These data will be combined with longitudinal acute event and functional status data to capture patterns of change in health status over time. Theory-driven multilevel models will be used to test the trajectories of falls and other acute conditions as a function of the ambulation activity and demographic, functional status, gait quality and balance ability including potential mediation and/or moderation effects. Data-driven machine learning algorithms will be applied to run screening of the high dimensional RTLS data together with other variables to discover new and robust predictors of acute events. Discussion The findings from this study will lead to the early identification of older adults at risk for falls and the onset of acute medical conditions and interventions for individualized care.

The current retrospective, longitudinal study applied Andersen's Behavioral Model of Health Services Use to examine how demographic characteristics (age), available resources (e.g., a caregiver, the Mobile Veterans Program [MVP]) and health needs (e.g., cognitive and physical functioning, depressive symptoms) affect hospitalization and institutionalization outcomes among older adults using the MVP. Fifty-four Veterans (age 55 to 95) participating in the MVP for up to 2 years were examined using hierarchical linear modeling (HLM) and growth curve model. In the final HLM model, each 1-point increase in depressive symptoms was associated with 76% ( p ≤ 0.05) greater risk of institutionalization and 40% ( p ≤ 0.01) greater risk of hospitalization. Each 1-point increase in cognitive functioning was associated with 24% ( p ≤ 0.05) lower risk of institutionalization. The relationship between caregiver burden and hospitalization was attenuated by frequency of MVP visits. Services focused on reducing depressive symptoms may influence health service use and reduce caregiver burden in this population. [ Journal of Gerontological Nursing, 46 (5), 15–22.]

Background: Non-islet cell tumor-induced hypoglycemia is a rare paraneoplastic syndrome with approximately 300 reported cases in the literature. Classically these tumors secrete insulin-like growth factor-2 (IGF-2) to induce hypoglycemia, but the etiology and regulation of the hormone secretion remains poorly understood. We present a case of non-islet cell hypoglycemia from a spindle cell neoplasm of the lung, which appeared to show inconsistent secretion of IGF-2. Clinical case: A 72-year-old, non-diabetic male presented with episodes of altered mental status due to hypoglycemia with unintentional weight loss. Blood glucose was 35 mg/dL upon admission. CT chest showed an 18 cm tumor in the left hemithorax. The patient continued to have hypoglycemia throughout his hospital stay. At a time when the serum glucose was 48 mg/dL, a biochemical work up for hypoglycemia showed C-peptide 0.21 ng/mL (0.78-5.19 ng/mL), proinsulin 1.6 pmol/L (0-10 pmol/L), insulin 0.1 U/mL (1.9-23 U/mL), β-hydroxybutyrate 0.1 mmol/L (0-0.4 mmol/L), and a negative sulfonylurea screen. Given the large lung tumor, IGF hormones were measured: IGF-1 59 ng/mL (36-215 ng/mL), IGF-2 670 ng/mL (333-967 ng/mL). While both were within normal ranges, the IGF-2/IGF-1 ratio was 11.35. Biopsy of the lung mass showed benign spindle cell neoplasm, consistent with solitary fibrous tumor. The patient was diagnosed with paraneoplastic non-insulin mediated hypoglycemia and was transferred to our hospital for resection of the lung mass. During the first 96 hours after transfer, the patient had no hypoglycemic episodes and repeat laboratory values showed IGF-1 of 72 ng/mL, IGF-2 of 162 ng/mL, IGF-2/IGF-1 ratio of 2.25 with a glucose of 119 mg/dL, indicating the secretion of IGF-2 may have been intermittent. However, he later developed recurrent hypoglycemia and underwent resection of the tumor. Pathology showed a malignant solitary fibrous tumor. Blood sugars improved within 2 days after tumor resection and patient did not have further hypoglycemia. Discussion: Literature review shows that tumors causing non-islet cell hypoglycemia are large with one-third located in the chest and two-thirds in the retroperitoneum. They can secrete “big” IGF-2, which can activate insulin receptors to inhibit glucose output from the liver and increase uptake in muscle and adipose tissue leading to hypoglycemia. Interestingly, the IGF-2 level is not always outside the normal range, but a ratio of IGF-2/IGF-1 greater than 10 can be another marker of paraneoplastic hypoglycemia. We believe our case is unique in that during a 48-hour period of intense observation, the patient had no hypoglycemia and the IGF-2 levels and IGF-2/IGF-1 ratio decreased to the normal range. Thus, in patients with suspected tumor-mediated hypoglycemia, the IGF levels may need to be drawn during a hypoglycemic event, much like the workup for insulinoma.

Sleep studies examine how pain is associated with poor sleep. However, emergent research suggests poor sleep increases pain and may interfere with activities of daily living (ADL) among older adults. This study will examine how poor sleep may affect next-day pain interference and how this relationship may vary by cognitive function. Ten community-dwelling older adults with lower extremity chronic pain wore an Actigraph GT9X Link for 7 days to measure poor sleep and next-day pain interference (Brief Pain Inventory; BPI). Multi-level mixed models accounted for intra-individual changes in sleep and pain interference and controlled for age, mild cognitive impairment (MCI) and depressive symptoms. Poor sleep among older adults with MCI (14 total observations) was also explored. Across 79 observations, increased number of awakenings (β=0.03; p≤ 0.05) and movement index scores (β=0.08; p≤ 0.05) were associated with increased next-day pain interference. In exploratory analyses, MCI intensified relationships between sleep efficiency (β=-0.10; p≤ 0.05), increased awakenings after sleep onset (β=0.01; p≤ 0.05) and increased length of sleep awakenings (β=0.39; p≤ 0.01) on next-day pain interference. This study’s findings suggest poor sleep is associated with next-day pain interference and the ability to perform ADL. Older adults with MCI may be at an increased risk for poor sleep and pain-related interference in ADL. Interventions designed to moderate the association between poor sleep and pain in general and for adults with MCI in particular may be warranted.

A real-time locating system (RTLS) can be used to track the walking activity of institutionalized older adults in long-term care who are at risk for wandering behaviors. The benefits of a RTLS are objective and continuous measurements of activity. Self-report methods of activity, especially wandering, by health care staff are vulnerable to floor effects and recall bias, and continuous clinical or research observation over the long-term can be time-consuming and expensive. Health care staff also fail to recognize the onset and/or duration of wandering behaviors, which are associated with a variety of adverse health outcomes in this population but amenable to intervention. RTLS technologies can measure the walking activity of institutionalized residents with cognitive impairment over time with a high degree of accuracy. This is particularly useful for the study of wandering, defined as walking for at least 60 seconds with few (if any) breaks in activity. Wandering is associated with disease progression, hospitalizations, falls and death. Previous work suggests older adults with poor balance ability and high sustained walking activity may be particularly susceptible to poor health outcomes. RTLS's are used to assess cognitive impairment and factors associated with gait and balance; however, supplemental paper and pencil gait/balance tools may be used to further refine risk profiles. This project discusses the use of a RTLS to measure walking activity and also gait quality and balance ability measures on this population.

Objective: To report the implementation/adoption of the Safe Home Program to support caregivers of persons with dementia in (1) ongoing surveillance, (2) provision of care, (3) prevention of injuries, and (4) improving home safety. Methods: For this demonstration project 4 assessment questionnaires (Safety Assessment Scale, Vigilance Scale, Peace of Mind Scale, and Sleep Disorders Inventory) were administered to each dyad to understand their technological needs. After identification and installation of appropriate technologies and education of the caregiver, a final visit (at 3 months) determined whether technologies were useful and being used. Results: The majority of caregivers utilized technologies for ongoing surveillance; other technologies included an identification program and medication organizer. Conclusion: Technologies focused on ongoing surveillance for persons with dementia at the home are needed. These technologies could be quickly adopted by caregivers to ameliorate some of the stress and burden associated with providing care for persons with dementia.

INTRODUCTION In this editorial, we report on the development of a smartwatch designed to enhance the Smart Home at the Department of Veterans Affairs (VA) hospital in Tampa, a project that uses advanced tracking technology to help Veteran patients with traumatic brain injury (TBI) independently plan, organize, and complete everyday activities [1]. The literature is replete with examples of proposed technologies designed to influence or control behavior, the most recent incarnation being "persuasive technologies" [2-3]. While handheld smartphones have been the pervasive device that readers are most likely to have experience with, new devices targeted at the consumer market now include Google Glass and Samsung's Galaxy Gear smartwatch. Both devices attempt to make the interaction with wireless computing infrastructures a ubiquitous experience. Similarly, many new persuasive applications have been developed to run on common devices such as smartphones, PDAs, and standard computer systems. These applications are often designed to prompt for desired behaviors contingent on time of day to provide basic reminder functions. Very few of these applications use global positioning system (GPS) to derive location and far fewer still are based on precise indoor location [4]. A handful of technologies combine time of day with coarse indoor location to provide targeted prompts to individuals, as for example Takeuchi and Sugimoto, who developed a smartphone application that guides and makes purchasing suggestions to shoppers in Japan [5]. The application of precise location-aware technologies to indoor navigation has been difficult to implement because of poor in-building GPS performance and the high cost of constructing indoor reference grids to duplicate the ranging functions performed outdoors by GPS satellites [6]. For certain applications, ultrawideband (UWB) technologies have shown considerable promise, although the implementation costs can be significant [7]. In a prior Journal of Rehabilitation Research and Development editorial, we reported on the James A. Haley Veterans' Hospital Polytrauma Transitional Rehabilitation Program (PTRP) Smart Home [1] that employs a UWB tracking system from Ubisense that is capable of resolving locations to around 20 cm (vs GPS's 3-5 m accuracy) anywhere in the facility. The system's Smart Home technologies permit selective medication prompting, automated check-in and check-out from the facility, and guidance to therapeutic sessions by presenting prompts on wall-mounted, touch-sensitive screens. To date, 30 PTRP patients have firsthand experience with the Smart Home tracking technology. While the Smart Home results have been generally positive, we encountered a human-factors issue while deploying this technology in that Veterans would sometimes miss or ignore a prompting message even though the screen delivering the message was very close to the Veteran. In an effort to address this issue, a metric was added to track the changes in Veterans' location. Confirmation that a Veteran saw and responded to the prompt was presumed when the change in the Veteran's location was to that of the prompted destination. Preliminary examination of the data indicated a nominal prompt compliance rate of 75 percent. While seemingly quite high, this can and should be increased. Providing auditory cues when a message appears on the screen may improve the response rate, but providing multiple auditory cues throughout the facility would be an annoying distraction to others. A more personalized approach might be for the Veteran to wear a wireless prompting device with the capability of providing vibrotactile, auditory, and/or visual alerts based on location context. It is axiomatic that poor compliance with a prompt will occur if the item to be acted on is a large distance away. For example, if a Veteran is prompted to take medication when the pill bottle is not in the immediate vicinity, the Veteran may say, "I must remember to take my medication when I get home. …

Purpose. To examine the relationship between vigorous physical activity and dementia risk. Design. Prospective study design utilizing physical activity data from the Health and Retirement Study and cognitive outcome data from the Aging, Demographics, and Memory Study. Setting. Community-based. Subjects. Adults age 71 and over (N = 808) with 3 to 7 years of physical activity information prior to dementia/no dementia diagnosis. Measures. Physical activity was measured by participation in vigorous activities such as aerobics, sports, running, bicycling, and heavy housework three or more times per week (yes/no). Dementia diagnosis was based on an expert panel (e.g., neuropsychologists, neurologists, geropsychiatrists) who performed and reviewed a battery of neuropsychological tests. Analysis. Binary logistic regression models were used to account for demographic characteristics, genetic risk factors (one or two apolipoprotein E ε4 alleles), health behaviors (e.g., smoking, drinking alcohol), health indicators (body mass index), and health conditions (e.g., diabetes, heart disease) in a sequential model-building process. Results. The relationship between vigorous physical activity and dementia risk remained robust across models. In the final model, older adults who were physically active were 21% (p ≤ .05) less likely than their counterparts to be diagnosed with dementia. Conclusion. Vigorous physical activity may reduce the risk for dementia independently of the factors examined here. This study's findings are important given that few preventative strategies for dementia have been explored beyond hormonal therapy and anti-inflammatory drugs.

Objectives. T o prospectively examine the relationship between body weight, frailty, and the disablement process. Method. Longitudinal data from the Health and Retirement Study (1998–2006) were used to examine the relationship between being underweight, overweight, or obese (compared with normal weight) and the onset and progression of functional limitations and disabilities in instrumental activities of daily living (IADL) and activities of daily living (ADL) among a nationally representative sample of community-dwelling older adults (aged 50 and older) with characteristics of frailty (n = 11,491). Nonlinear multilevel models additionally adjusted for demographic characteristics and intra-individual changes in body weight, socioeconomic status, health behaviors, and health conditions over the course of 8 years. Results. Compared with their nonfrail normal weight counterparts, prefrail obese respondents ha ve a 16% (p ≤ 0.001) reduction in the expected functional limitations rate and frail overweight and obese respondents have a 10% (p ≤ 0.01) and 36% (p ≤ 0.001) reduction in the expected functional limitations rate, respectively. In addition, frail obese respondents have a 27% (p ≤ 0.05) reduction in the expected ADL disability rate. Discussion. This study’ s findings suggest that underweight, overweight, and obese status differentially affect the risk for functional limitations and disabilities in IADL and ADL. Among prefrail and frail adults, some excess body weight in later life may be beneficial, reducing the rate of functional limitations and disability.

Objective: The primary aim of this study is to examine the prevalence of and antecedents to missing incidents among community-dwelling persons with dementia. Methods: This prospective study used mailed surveys and telephone interviews. Results: The prevalence of having any incident was 0.46/year; the overall prevalence for missing incidents in this study was 0.65/year. Missing incidents had few antecedents and occurred largely when persons with dementia were performing everyday activities that they normally completed without incident. Conclusion: Given that a missing incident is relatively common among persons with dementia, health care professionals should assist caregivers with a missing incident plan early in the disease process. Also, as missing persons are found by persons other than the caregiver and caregivers underutilize identification devices, health care professionals may recommend the use of identification devices to facilitate a safe return.

Objective To examine how intraindividual changes in ambulation characteristics may be used to predict falls. Design Longitudinal study design. Setting Assisted living facility. Participants Ambulatory older adults (N=26; mean age, 79y). Interventions Not applicable. Main Outcome Measures Continuous measure of average weekly ambulation characteristics (time and distance walked, speed, path measures [eg, path time and distance, number of paths (where a path is at least 60s of uninterrupted walking separated by at least a 30-s stop)]), accounting for weekly changes in these ambulation characteristics on an individual level over time along with falls (yes/no) and cognitive impairment (CI) (measured by the Montreal Cognitive Assessment). Results In hierarchical linear models accounting for intraindividual changes in ambulation characteristics over the 8-month course of the study and level of CI, path distance (odds ratio, 1.02; P ≤.001) was associated with an increased risk of a fall. In the short-term, intraindividual changes in path distance were associated with a fall within the 4-week interval the change was noted. Path distance had fair sensitivity (.74) and specificity (.66) to a fall (area under the curve, .70). Conclusions Study findings suggest that falls may have specific predictors, specifically that older adults with CI are more likely to fall when walking continuously with little/no breaks. Interventions focused on reducing path-associated fatigue may effectively reduce fall incidence in this population.

Common causes of pulmonary-renal syndrome include anti-glomerular basement membrane (anti-GBM) disease anti-neutrophil cytoplasmic antibody (ANCA) positive vasculitis, and systemic lupus erythematosus. We describe a case of life-threatening pulmonary hemorrhage associated with Campylobacter hemolytic uremic syndrome (HUS), which we believe is a new disease entity. We hypothesize that the cause of this pulmonary-renal syndrome was an immunological reaction to Campylobacter; and that the initiation of high-dose steroids was responsible for the rapid reversal of the patient's pulmonary and renal impairment. The aim of this article is to raise awareness of this unusual cause of a pulmonary-renal syndrome, guiding physicians to recognize it as a potential complication, and to consider high-dose steroids in managing the condition.

Literature shows that some health outcomes (e.g., eating, breathing, and speaking) are directly related to posture. Evidence of outcomes mediated by wheelchair seated posture is limited to interface pressure, physical function, and wheelchair skills and safety. This study's purpose was to develop and validate a rapid, low-burden, paper-pencil assessment of wheelchair seated posture for research use and to test feasibility of its use with a sample of older adults. We used a prospective design and a convenience sample of older adults who were receiving rehabilitation services in a community living center. Forty-nine older wheelchair users participated. Main measures were the Seated Posture Scale (SPS), Modified Ashworth Scale, Barthel Index, Visual Descriptor Scale, scale-content validity index (S-CVI), Cronbach alpha, and test-retest reliability. Rating by six experts yielded the overall content validity score (S-CVI) of 0.744. Total SPS score correlated positively with physical function (Barthel Index, r = 0.46, p < 0.001) and negatively with muscle tone (Modified Ashworth Scale, r = -0.44, p = 0.001), supporting SPS construct validity. Internal consistency was 0.66 (Cronbach alpha). Test-retest reliability yielded Pearson product-moment correlations of 0.89 to 0.99. We conclude that the SPS has sufficient preliminary validity and reliability to support its use as an evaluation of wheelchair seated posture in outcomes research.

The aim of this study is to describe the process of staff and patient adoption and compliance of a real-time locating system (RTLS) across two health care settings and present lessons learned. While previous work has examined the technological feasibility of tracking staff and patients in a health care setting in real-time, these studies have not described the critical adoption issues that must be overcome for deployment. The ability to track and monitor individual staff and patients presents new opportunities for improving workflow, patient health and reducing health care costs. A RTLS is introduced in both a long-term care and a polytrauma transitional rehabilitation program (PTRP) in a Veterans Hospital to track staff and patient locations and five lessons learned are presented from our experiences and responses to emergent technological, work-related and social barriers to adoption. We conclude that successful tracking in a health care environment requires time and careful consideration of existing work, policies and stakeholder needs which directly impact the efficacy of the technology.

Objective A laboratory evaluation was conducted on selected commercial technologies designed to prevent or manage dementia-related missing incidents from the home. Methods Fourteen products representing four unique categories (Pressure Activated Systems, Pull Tab Alarms, Audible Alarms, and Optically Activated Alarms) of behavioral management were evaluated under controlled laboratory conditions for: sound pressure levels (dB), power consumption (watts), battery life, and alarm frequency (pitch). Other variables such as activation force and monitoring/tracking capabilities were tested where applicable to the device category. Results There was wide performance variability regardless of device category, indicating that the devices may fail to successfully capture a missing incident. Implications The development of standardized protocols for testing devices intended for use in the home setting coupled with a broader evaluation of existing technologies would provide a more complete understanding of which products may manage or inhibit missing incidents in persons with dementia.

Background/Aims: To examine the cognitive reserve hypothesis by comparing the contribution of early childhood and life course factors related to cognitive functioning in a nationally representative sample of older Americans. Methods: We examined a prospective, national probability cohort study (Health and Retirement Study; 1998-2010) of older adults (n = 8,833) in the contiguous 48 United States. The main cognitive functioning outcome was a 35-point composite of memory (recall), mental status, and working memory tests. The main predictors were childhood socioeconomic position (SEP) and health, and individual-level adult achievement and health. Results: Individual-level achievement indicators (i.e., education, income, and wealth) were positively and significantly associated with baseline cognitive function, while adult health was negatively associated with cognitive function. Controlling for individual-level adult achievement and other model covariates, childhood health presented a relatively small negative, but statistically significant association with initial cognitive function. Neither individual achievement nor childhood SEP was statistically linked to decline over time. Conclusions: Cognitive reserve purportedly acquired through learning and mental stimulation across the life course was associated with higher initial global cognitive functioning over the 12-year period in this nationally representative study of older Americans. We found little supporting evidence that childhood economic conditions were negatively associated with cognitive function and change, particularly when individual-level achievement is considered.

Based in successful aging theory and terminal cognitive drop research, this paper investigates cerebrovascular burden (CVB), depressive symptoms, and cognitive decline as threats to longevity. A subsample of stroke-free women over the age of 80 was identified in the Health and Retirement Survey (years 2000–2008). Mortality at 2, 6, and 8 year intervals was predicted using CVB (diabetes, heart disease, hypertension), depressive symptoms (Center for Epidemiological Studies Depression Scale), and cognitive decline (decline of 1 standard deviation or more on the 35-point Telephone Interview for Cognitive Status over 2 years). At most waves (2002, 2004, and 2006) mortality was predicted by CVB, depressive symptoms, and cognitive drop measured 2 years prior. CVB and depressive symptoms at the 2000 wave predicted mortality at 6 and 8 years. Older women with the greatest longevity had low CVB, robust cognitive functioning, and few depression symptoms, supporting successful aging theory and terminal cognitive drop.

Objective To determine whether a Real Time Locating System (RTLS) can be used to accurately detect a fall and discuss the application of RTLS as a fall detection system in the home and health care environments. Methods Phase I used a mannequin to determine the feasibility of RTLS to detect a fall from three positional conditions of: standing, seated in a wheelchair, and laying on a bed. Phase II used a human subject to be an ecologically valid simulation of a fall from these conditions. Ten trials of each of these three conditions were conducted across subjects. The observed time of the fall (the ‘gold standard’) was compared with the RTLS tag position. A Receiver Operating Characteristic (ROC) curve was used to report the Area Under the Curve (AUC) with 95% confidence intervals (CI) and Cohen’s kappa (ϰ) was used to examine inter-rater reliability between the observed fall and the fall detected by the RTLS. Results RTLS accurately identified 89% (p≤0.001) of the mannequin falls and 80% (p≤0.001) of the human falls. Across subjects there were low false positive rates (specificity); 17% for the mannequin and 16% for the human. Interrater reliability was very good (ϰ=0.82; CI: 0.80-0.84) for mannequin falls and good (ϰ =0.72; CI: 0.69-0.74) for human falls. Implications RTLS technology may be used to improve caregiver and staff response times, patient-care, and reduce health care costs associated with falls in later life.

Objective: Guided by a life-course approach to chronic disease, this study examined the ways in which childhood deprivation (low parental education and father’s manual occupation) may be associated with coronary heart disease (CHD). Method: Multilevel modeling techniques and a nationally representative sample of Americans above age 50 from the Health and Retirement Study (HRS; N = 18,465) were used to examine childhood and CHD relationships over the course of 6 years (1998-2004). Results: Having a father with ≤8 years of education was associated with 11% higher odds of CHD, accounting for demographic characteristics, adult socioeconomic status (SES; education, income, and wealth), CHD risks (diabetes, hypertension, cigarette smoking, and obesity), and other factors (childhood health, exercise, stroke, and marital status). Discussion: Policies and programs aimed at improving the conditions of poor children and their families may effectively reduce the prevalence of CHD in later life.

Objectives. We compared risk for several medical illnesses between immigrant and US-born older Mexican Americans to determine the relationship between functional health and years of US residency among immigrants. Methods. Cross-sectional, multistage probability sample data for 3050 Mexican Americans aged 65 years or older from 5 US southwestern states were analyzed. Self-rated health, medical illnesses, and functional measures were examined in multivariate regression models that included nativity and years of US residency as key predictors. Results. Self-rated health and medical illnesses of immigrant and US-born groups did not differ significantly. Immigrants with longer US residency had significantly higher cognitive functioning scores and fewer problems with functional activities after adjustment for predisposing and medical need factors. Conclusions. Among older Mexican Americans, immigrant health advantages over their US-born counterparts were not apparent. Immigrants had better health functioning with longer US residency that may derive from greater socioeconomic resources. Our findings suggest that the negative acculturation–health relationship found among younger immigrant adults may become a positive relationship in later life.

Purpose: The purpose of this study was to examine racial/ethnic differences in the relationship between functional disability and the use of health care services in a nationally representative sample of older adults by using the Andersen behavioral model of health services utilization. Design and Methods: The study used 12 years of longitudinal data from the Health and Retirement Study (1992–2004), a nationally representative sample of communitydwelling adults older than 50 in 1992 (N = 8,947). Nonlinear multilevel models used self-reported health care service utilization (physician visits and hospital admissions) to predict racial/ethnic differences in disability (activities of daily living and mobility limitations). The models also evaluated the roles of other predisposing (age and gender), health need (medical conditions and self-rated health), and enabling factors (health insurance, education, income, and wealth). Results: Blacks and Latinos utilizing physician visits and hospital admissions were associated with significantly more activity of daily living disability than Whites (p , .001). Blacks utilizing physician visits (p , .001) and hospital admissions (p , .05) and Latinos utilizing hospital admissions (p , .05) were associated with more mobility disability than Whites. Other predisposing, health need, and enabling factors did not account for these racial/ethnic differences. Implications: Nationally, health care use for Blacks and Latinos was associated with more disabilities than for Whites after we accounted for predisposing, health need, and enabling factors. The findings suggest that improving health care quality for all Americans may supersede equal access to health care for reducing ethnic and racial disparities in functional health.

This study used a life course approach to examine the ways in which childhood socioeconomic status (SES) may account for some of the racial differences in disability in later life. Eight years (5 waves) of longitudinal data from the US Health and Retirement Study (HRS; 1998-2006), a nationally representative sample of community-dwelling Black and White Americans over age 50 (N=14,588), were used in nonlinear multilevel models. Parental education and father's occupation were used to predict racial differences in activities of daily living (ADL) and instrumental activities of daily living (IADL). The role of adult SES (education, income, and wealth) and health behaviors (smoking, drinking alcohol, exercising, and being obese) were also examined and models were adjusted for health conditions (heart problems, diabetes, stroke, hypertension, cancer, lung disease, and arthritis). With the inclusion of childhood SES indicators, racial differences in ADL and IADL disability were reduced. Adult SES and health behaviors mediated some of the relationship between low childhood SES and disability, though low childhood SES continued to be associated with disability net of these. In support of a life course approach, these findings suggest that socioeconomic conditions in early life may have implications for racial differences in disability between older Black and older White adults.

Objectives. This study described activities that older people undertake to reduce the volume of their possessions in the course of a residential move to smaller quarters, a process with practical, cognitive, emotional, and social dimensions. Methods. Qualitative interviews were conducted with members of 30 households who had moved in the prior year. The disbandment period, typically lasting about 2 months, was a particular focus of the interview. Results. The interviews suggested nine reasons why people had accumulated and kept things, which now became problematic for the impending move. The initial steps of disbandment entailed decisions about major furniture and meaningful gifts to family and friends, followed by evaluation of the remaining belongings for retention, sale, further gifts, donation, or discard. Things not divested by one means were reassigned to another strategy. People took pleasure in dispositions that saw their things used, cared for, and valued as they had done, thus fulfilling a responsibility to their belongings. Discussion. Disbandment is an acute episode of a more general, lifelong process of possession management. It is an encounter with things that are meaningful to the self, but as it unfolds, it also makes new meaning for things. ‘‘It’s not a matter of what you can take, but what you can’t take.’’ —Man, age 83, who moved from a house to a two-bedroom duplex

In this study inflammatory responses were determined in rat lungs 0, 1, 3, and 8 days following single 2- and 4-hr exposures to 1.8 ppm ozone. Analysis of lavage fluid immediately following exposure demonstrated enhanced lactate dehydrogenase activity and decreased numbers of lavageable macrophages but no alterations in albumin content. Similar analyses at one day postexposure demonstrated 282% and 456% increases in albumin content and enhanced numbers of lavageable neutrophils from a control value of 0.01 +/- 0.01 to 0.27 +/- 0.10 and 0.78 +/- 0.11 million cells per lung for 2-hr and 4-hr exposures, respectively. The observed increased levels of albumin were also present at 3 days, at which time the number of lavageable neutrophils was not significantly different than control. At both one and 3 days postexposure, lavageable lymphocytes were significantly increased 10-fold from a control value of 0.03 +/- 0.01 million cells per lung. However, the number of lavageable macrophages was unaltered on day 1, but enhanced on day 3, giving values of 0.67 +/- 0.05 (control), 2.25 +/- 0.46 (2 hr), and 2.70 +/- 1.05 (4 hr) million cells per lung. By 8 days both inflammatory cell numbers and albumin levels had returned to control values. Since these data demonstrated different time courses for each inflammatory cell type, this reversible model of acute lung injury should be useful for establishing possible involvement of these cells in processes of lung injury.