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Background Care partners are key members of patients’ health care teams, yet little is known about their experiences accessing patient information via electronic portals. Objective To better understand the characteristics and perceptions of care partners who read patients’ electronic visit notes. Patient involvement Focus groups with diverse patients from a community health center provided input into survey development. Methods We contacted patient portal users at 3 geographically distinct sites in the US via email in 2017 for an online survey including open ended questions which we qualitatively analyzed. Results Respondents chose whether to answer as care partners (N = 874) or patients (N = 28,782). Among care partner respondents, 44% were spouses, 43% children/other family members, and 14% friends/neighbors/other. Both care partners and patients reported that access to electronic notes was very important for promoting positive health behaviors, but care partners’ perceptions of importance were consistently more positive than patients’ perceptions of engagement behaviors. Open-ended comments included positive benefits such as: help with remembering the plan for care, coordinating care with other doctors, decreasing stress of care giving, improving efficiency of visits, and supporting patients from a geographical distance. They also offered suggestions for improving electronic portal and note experience for care partners such as having a separate log on for care partners; having doctors avoid judgmental language in their notes; and the ability to prompt needed medical care for patients. Discussion Care partners value electronic access to patients’ health information even more than patients. The majority of care partners were family members, whose feedback is important for improving portal design that effectively engages these care team members. Practical value Patient care in the time of COVID-19 increasingly requires social distancing which may place additional burden on care partners supporting vulnerable patients. Access to patient notes may promote quality of care by keeping care partners informed, and care partner’s input should be used to optimize portal design and electronic access to patient information.

Background Cardiovascular disease (CVD) risk factors are transmitted from parents to children. We prospectively examined the association between parental cardiovascular health (CVH) and time to onset of CVD in the offspring. Methods and results The study consisted of a total of 5967 offspring–mother–father trios derived from the Framingham Heart Study. Cardiovascular health score was defined using the seven American Heart Association’s CVH metrics attained at ideal levels: poor (0–2), intermediate (3–4), and ideal CVH (5–7). Multivariable-adjusted Cox proportional hazards regression models, Kaplan–Meier plots, and Irwin’s restricted mean were used to examine the association and sex-specific differences between parental CVH and offspring’s CVD-free survival. In a total of 71 974 person-years of follow-up among the offspring, 718 incident CVD events occurred. The overall CVD incidence rate was 10 per 1000 person-years [95% confidence interval (CI) 9.3–10.7]. Offspring of mothers with ideal CVH lived 9 more years free of CVD than offspring of mothers with poor CVH (P Conclusions We found that offspring of parents with ideal CVH had a greater CVD-free survival. Maternal CVH was a more robust predictor of offspring’s CVD-free survival than paternal CVH, underscoring the need for clinical and policy interventions that involve mothers to break the intergenerational cycle of CVD-related morbidity and mortality.

The study aim was to evaluate the associations among the presence of wisdom teeth (third molars, M3), periodontal disease, and serum C-reactive protein (CRP) in the US adult population, thus to generate population-based evidence to inform heart disease prevention and dental care.We performed secondary data analysis of the 2009-2010 National Health and Nutrition Examination Survey (NHANES), and included 3752 people aged 30 years and older who participated in the periodontal examination.Descriptive analyses were performed to determine the prevalence of M3 presence, periodontal disease, and elevated CRP. Multivariate logistic regression modeling was used to determine the association between M3 presence, periodontal disease, and elevated CRP.The prevalence of M3 presence, periodontal disease (probing periodontal pockets depth (PPD)≥ 4 mm), and elevated serum C-reactive protein level (≥5 mg/L) was 39%, 41%, and 19% respectively. M3 presence was highest among men, younger adults, Blacks and Hispanics compared to Non-Hispanic Whites, those who did not attend college, and people with low incomes (P 0.001). M3 presence, adjusted for sociodemographic and health characteristics, was independently associated with periodontal disease (adjusted [Adj.] odds ratio [OR] 1.61, 95% confidence interval [CI] 1.31, 1.97), and periodontal disease was independently associated with elevated serum CRP (Adj. OR 1.35, 95% CI 1.06, 1.73), but we did not find M3 presence associated with elevated serum CRP (Adj. OR 1.02, 95% CI 0.79, 1.31).We observed expected associations between M3 presence and periodontal disease, and periodontal disease and elevated CRP. However, M3 presence alone is not associated with elevated CRP. Further research into cardiovascular health hazards related to the retention of wisdom teeth is needed, including examining possible relationships with other inflammatory factors.

BACKGROUND: Patients actively involved in their care demonstrate better health outcomes. Using secure internet portals, clinicians are increasingly offering patients access to their narrative visit notes (open notes), but we know little about their understanding of notes written by clinicians. OBJECTIVE: We examined patients’ views on the clarity, accuracy, and thoroughness of notes, their suggestions for improvement, and associations between their perceptions and willingness to recommend clinicians to others. DESIGN: We conducted an online survey of patients in 3 large health systems, June–October 2017. We performed a mixed methods analysis of survey responses regarding a self-selected note. PARTICIPANTS: Respondents were 21,664 patients aged 18 years or older who had read at least 1 open note in the previous 12 months. MAIN MEASURES: We asked to what degree the patient recalled understanding the note, whether it described the visit accurately, whether anything important was missing, for suggestions to improve the note, and whether they would recommend the authoring clinician to others. KEY RESULTS: Nearly all patients (96%) reported they understood all or nearly all of the self-selected note, with few differences by clinician type or specialty. Overall, 93% agreed or somewhat agreed the note accurately described the visit, and 6% reported something important missing from the note. The most common suggestions for improvement related to structure and content, jargon, and accuracy. Patients who reported understanding only some or very little of the note, or found inaccuracies or omissions, were much less likely to recommend the clinician to family and friends. CONCLUSIONS: Patients overwhelmingly report understanding their visit notes and usually find them accurate, with few disparities according to sociodemographic or health characteristics. They have many suggestions for improving their quality, and if they understand a note poorly or find inaccuracies, they often have less confidence in their clinicians.

Objective The aim of this study was to assess the impact of the burden and patterns of multimorbidity on disability domains. Design In a cross-sectional study of 425 older adults from the Boston Rehabilitative Impairment Study of the Elderly, participants self-reported 13 chronic conditions and underwent assessment of body function (leg strength, velocity, and power, trunk extensor endurance, leg range of motion, foot sensation), activities (400-m walk test, Short Physical Performance Battery, Late Life Function and Disability Instrument function scores) and participation (Late Life Function and Disability Instrument participation scores). The association between multimorbidity patterns (identified by latent class analysis) and disablement measures, as well as multimorbidity burden (captured by a multimorbidity score) and disablement measures, was tested. Results Latent class analysis identified three classes-low multimorbidity, high multimorbidity, and predominantly musculoskeletal conditions. Class membership (multimorbidity pattern) was not associated with disablement measures, but multimorbidity score was associated with poor performance in all domains. A 1-point higher multimorbidity score was associated with lower scores in body functions (by 0.06 SD unit), activities (0.07-0.10 SD units), as well as participation (0.07-0.09 units). Conclusion Multimorbidity counts may be an excellent tool for risk stratification and identification of persons in need of rehabilitation. To claim cme credits Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to (1) describe and distinguish the effect of multimorbidity burden and multimorbidity patterns on three disability domains in older adults; (2) identify and discuss possible reasons why high multimorbidity burden may result in a restriction among social participation in older adults; and (3) detect disability risk among older patients during clinical assessment by using a simple count of common chronic conditions. Level Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

BACKGROUND: Clarifying the relationship between pain phenotypes and physical function in older adults may enhance screening and treatment for functional decline in primary care settings. OBJECTIVE: To investigate the association of more severe pain phenotypes with neuromuscular impairments or mobility limitations among older community-dwelling primary care patients. DESIGN: Cross-sectional analysis. SETTING: The Boston Rehabilitative Impairment Study of the Elderly. PARTICIPANTS: Adults aged 65 years or older. METHODS: We counted the number of musculoskeletal pain locations (none, single site, multisite, or widespread) using the McGill Pain Questionnaire and identified pain intensity tertiles using the Brief Pain Inventory. Neuromuscular attributes (trunk extensor muscle endurance, and leg speed, strength, strength asymmetry, and range of motion) and mobility (Short Physical Performance Battery [SPPB]) were assessed with performance-based measures. Additionally, self-reported mobility was measured on the Late Life Function and Disability Instrument (LLFDI). For neuromuscular attributes and LLFDI, scores in the lowest tertile indicated neuromuscular impairment or mobility limitations, respectively. For SPPB, a score

Introduction People with diabetes are more vulnerable to periodontal disease than those without; thus, practicing preventive oral health care is an important part of diabetes self-care. Our objective was to examine disparities in preventive oral health care among US adults with diabetes. Methods We performed a secondary analysis of data from the National Health and Nutrition Examination Survey (NHANES) 2011-2016. Periodontal examinations were conducted in adults aged 30 and older. We compared the weighted prevalence of periodontal disease and the practice of preventive oral health care, including practicing dental interproximal cleaning (flossing or using other interproximal cleaning devices) and use of preventive dental services, among people with and without diabetes. Multivariable logistic regressions were performed to examine the relationship between the presence of diabetes, periodontal disease, and preventive oral health care practices. Results Weighted prevalence of periodontal disease in the US population was higher among adults with diabetes than those without (58.0% vs 37.6%). This difference persisted after controlling for sociodemographic characteristics and smoking status. People with diabetes were more likely to have periodontal disease (adjusted odds ratio [aOR] 1.39; 95% CI, 1.17-1.65), less likely to practice daily interproximal cleaning (aOR 0.85; 95% CI, 0.75-0.95), and less likely to visit a dentist for preventive care in the past year (aOR 0.86; 95% CI, 0.76-0.96) than people without diabetes. Conclusion Adults with diabetes reported suboptimal preventive oral health care behaviors in use of preventive dental services and interproximal dental cleaning than people without diabetes, despite their health disparity related to periodontal disease. Educating people to improve their preventive oral health care is essential for good oral health and diabetes self-management.

This study was to investigate socio-demographic, chronic conditions and health factors associated with nutrition risk among Thai community-dwelling older adults. This was a cross-sectional study, involving 330 participants aged ≥ 60 years living in low-income suburban Chiang Mai, Northern Thailand. Of the 330 participants, 54.8% were at nutritional risk based on the Mini Nutritional Assessment. Multivariate analysis indicated factors significantly associated with nutritional risk were: aged ≥80 years (OR:8.59, 95% CI = 2.94–25.11), low income (OR: 2.35, 95% CI = 1.15–4.78), living alone (OR: 2.02, 95% CI = 0.20–0.78), moderate to severe pain (OR: 5.88, 95% CI = 2.30–15.02), dyslipidemia (OR: 5.12, 95% CI = 2.23–11.77), osteoarthritis (OR: 2.49, 95% CI = 1.14–5.48), poor physical performance (OR: 1.49, 95% CI = 1.70–3.15), and ≥1 fall in the previous year (OR: 2.22, 95% CI = 1.21–4.07). Results point to the need for multifactorial interventions to reduce risk for geriatric nutrition problems. Further studies are needed to determine effective solutions to the problem of malnutrition among older adults.

OBJECTIVES: To examine associations between mild cognitive impairment (MCI) and falls among primary care patients, and to investigate whether social engagement (SE) modifies these associations.DESIGN: Cross sectional analysis using baseline data from an observational cohort study.SETTING: Primary care.PARTICIPANTS: Community-dwelling older adults (N=430) at risk of mobility decline with a mean age of 76.6 years (range 65-96y).MAIN OUTCOME MEASURES: The number of falls in the past year was reported at the baseline interview. MCI was identified using a cutoff of 1.5 SD below the age-adjusted mean on at least 2 of the standardized cognitive performance tests. SE (eg, keeping in touch with friends and family, volunteering, participating social activities…) was assessed with the Late Life Function and Disability Instrument, and required a score above the median value 49.5 out of 100.RESULTS: MCI was present among 42% of participants and 42% reported at least 1 fall in the preceding year. Using generalized estimating equations, MCI was associated with a 77% greater rate of falls (PCONCLUSIONS: While MCI is associated with a greater risk for falls, higher levels of SE may play a protective role.

Purpose The aim of the study was to evaluate the effects of an intervention, based on a behavioral medicine approach in physical therapy (BMPI), on pain-related disability and physical performance as well as on pain severity, pain catastrophizing, physical activity levels, falls efficacy, and health-related quality of life (HRQL) by comparing the effects to standard care. Patients and methods The study was a pragmatic randomized controlled trial with a two-group design and included measurements preintervention and postintervention and a 12-week follow-up. In total, 105 older adults, aged >75 years with chronic musculoskeletal pain living alone at home and dependent on formal care to manage their everyday lives, were included in the study. All statistical analyses were performed using an intention to treat approach. Results The intervention, based on a behavioral medicine approach, compared to usual care, had a positive effect on pain-related disability, pain severity, level of physical activity, HRQL, management of everyday life, and self-efficacy. Conclusion BMPI can be a suitable evidence-based intervention for community-dwelling older adults, even for those who are very old and frail. BMPI can support and promote an active aging and "age in place" for the target population, which is currently the main goal of all interventions in this field.

Background Continuous electronic fetal monitoring (CEFM) is a standard of hospital care during the intrapartum period. We investigated its use on childbirth outcomes in low-risk pregnancies, and examined whether outcomes differed by gestational age within a term pregnancy. Methods A retrospective secondary data analysis using birth registry data from two diverse northeastern US states from 1992 to 2014. Chi-square test and the Fisher exact tests were used to examine associations between CEFM and childbirth outcomes. Multivariable Poisson regression models were used to estimate risk ratios of childbirth outcomes related to CEFM use, adjusting for potential confounders. Results Use of CEFM was independently associated with a 10% (State 1) and 40% (State 2) increased risk for primary cesarean delivery and an increased risk for assisted vaginal births (14% and 24%, respectively) after adjustment for confounders. CEFM use was not associated with reduced risk for infant mortality (neonatal mortality, 0-27 days, and post-neonatal mortality, 28-364 days) in term births (37-41 weeks' gestation). After stratifying term pregnancies into early term, full term, and late term, use of CEFM was associated with reduced risk for neonatal mortality in early-term births (37 0/7 weeks' to 38 6/7 weeks' gestation) in State 2 (RR 0.44 [95% CI 0.21-0.92]), but not in State 1. There was no association between CEFM use and infant mortality (neonatal and post-neonatal) in full-term or late-term births. Conclusions The study results do not support universal use of CEFM in pregnancies that are low-risk and at term.

Background Neuromuscular and clinical factors contribute to falls among older adults, yet the interrelated nature of these factors is not well understood. We investigated the relationships between these factors and how they contribute to falls, which may help optimize fall risk assessment and prevention. Methods A total of 365 primary care patients (age = 77 ± 7, 67% female) were included from the Boston Rehabilitative Impairment Study of the Elderly. Neuromuscular measures included leg strength and leg velocity, trunk extensor endurance, and knee range of motion. Clinical measures included memory, executive function, depressive symptoms, pain, sensory loss, vision, comorbidity, physical activity, mobility self-efficacy, and psychiatric medication. Factor analysis was used to evaluate clustering of factors. Negative binomial regression assessed the relationship of factors with three-year fall rate. Interactions were tested to examine whether clinical factors modified the relationship between neuromuscular factors and falls. Results Three factors emerged: (i) neuromuscular factors, pain, and self-efficacy; (ii) memory; and (iii) executive function. Having three neuromuscular impairments predicted higher fall rate (incidence rate ratio [95% confidence interval]: 3.39 [1.82–6.32]) but was attenuated by memory (1.69 [1.10–2.61]), mobility self-efficacy (0.99 [0.98–0.99]), psychiatric medication use (1.54 [1.10–2.14]), and pain (1.13 [1.04–1.23]). Pain modified the relationship between neuromuscular impairment burden (number of neuromuscular impairments) and falls. Having three neuromuscular impairments was associated with a higher fall rate in patients with high levels of pain (5.73 [2.46–13.34]) but not among those with low pain. Conclusions Neuromuscular impairment burden was strongly associated with fall rate in older adults with pain. These factors should be considered together during fall risk assessment, post fall assessment, and prevention.

BACKGROUND: Chronic musculoskeletal pain is highly prevalent in the older adults, and individuals with musculoskeletal pain frequently report pain in two or more sites. AIMS: To determine the prevalence and characteristics of multisite pain in relation to other geriatric syndromes and to evaluate whether multisite pain may represent a distinct geriatric syndrome. METHODS: The MOBILIZE Boston Study is a population-based cohort study of older adults that enrolled 749 participants aged 70 and older. Persistent pain in the back and major joint areas was assessed using a joint pain questionnaire. Assessment of other geriatric syndromes included urinary incontinence, fall history, ADL disability, and frailty. A number of risk factors for geriatric syndromes were assessed. RESULTS: The prevalence of multisite pain was 40% in this population of older adults. Many participants had more than one geriatric syndrome, indicating substantial overlap in the prevalence of these conditions. Nearly half (48%) of participants with urinary incontinence or falls, 61% with ADL disability, and 49% of those with frailty also had multisite pain. Shared risk factors for established geriatric conditions were similarly distributed among the elderly population who had multisite pain. Demographic and health characteristics associated with multisite pain and other geriatric syndromes, included gender (female), depression, number of comorbid conditions, and mobility limitations. CONCLUSION: Although prior studies have explored risk factors for chronic multisite pain, these findings reveal that multisite pain, often unexplained, bears many similarities to established geriatric syndromes. Multisite pain warrants further consideration as a unique geriatric syndrome.

Background Fall injuries are a leading cause of death in older adults. The potential impact of chronic pain characteristics on risk for injurious falls is not well understood. This prospective cohort study examined the relationship between chronic pain and risk for injurious falls in older adults. Method The MOBILIZE Boston Study enrolled 765 community-dwelling adults aged 70 years and older living in and around Boston, Massachusetts. Chronic pain characteristics, including pain severity, pain interference, and pain distribution, were measured at baseline using the Brief Pain Inventory subscales and a joint pain questionnaire. Occurrence of falls and fall-related injuries were recorded using monthly fall calendar postcards and fall follow-up interviews during the 4-year follow-up period. Results Negative binomial regression models showed that pain interference and pain distribution, but not pain severity, independently predicted injurious falls adjusting for potential confounders. Participants in the highest third of pain interference scores had a 61% greater risk of injurious falls compared to those reporting little or no pain interference. Compared to no pain, multisite pain was associated with a 57% greater risk of injurious falls. Stratified by gender, the association was only significant in women. In the short term, moderate-to-severe pain in a given month was associated with increased risk of injurious falls in the subsequent month. Conclusions Global pain measures are associated with increased risk of injurious falls in older adults. Pain assessment should be incorporated into fall risk assessments. Interventions are needed to prevent fall injuries among elders with chronic pain.

BACKGROUND: Pain catastrophizing has been associated with pain intensity and mobility limitations in adults, and may be associated with mobility problems among older adults with chronic pain. This study examined the associations between pain catastrophizing and pain characteristics, and physical performance in older people. METHODS: The MOBILIZE Boston Study II (MBS) included 354 adults aged ≥70 years, living in the Boston area, originally enrolled in the MBS I from 2005-2008. Pain catastrophizing was measured using the 13-item Pain Catastrophizing Scale (PCS), with scores ranging from 13-65. Pain severity and pain interference were assessed by subscales of the Brief Pain Inventory. Pain distribution was classified as none, single site, and multisite. Mobility performance was assessed using the Short Physical Performance Battery (SPPB). Falls were assessed prospectively using monthly fall calendar postcards. RESULTS: One-fourth of all participants (24%) had high scores on the PCS (score>30). PCS was inversely associated with age and was greater among those with osteoarthritis, depression, or anxiety (p-value

This cross-sectional study examines the association between chronic musculoskeletal pain and foot reaction time (RT) among older community-living adults. Participants were 307 adults aged 71 years and older in the MOBILIZE Boston Study II. Pain severity, interference, and location were measured by the Brief Pain Inventory and a joint pain questionnaire. With participants seated, simple foot reaction time was measured as self-selected foot response time to an intermittent light, and choice foot reaction time was measured as response time to the light on the corresponding side of the sensored gait mat. We performed multivariable linear regression to determine associations of pain and foot RT, adjusted for sociodemographic and health characteristics, and serially adjusted for cognitive function (MMSE or Trail Making A). Pain severity and interference were associated with slower simple foot reaction time (P < .05). Pain severity and knee pain were associated with slower choice foot reaction time (P < .05). Adjustment for cognitive measures had little impact on the pain-RT relationship. This significant relationship was only observed among participants with less education. These results support the idea that chronic pain may lead to slower foot RT, thus could represent a fall hazard in older adults. Neuromotor mechanisms underlying the pain-fall relationship warrant further investigation. PERSPECTIVE: This study provides insights on the mechanisms underlying the pain-fall relationship. Chronic pain may contribute to slower foot RT thus increase fall risk in older adults. This may help inform interventions such as stepping training to reduce fall risk in older adults living with chronic pain.

Background Evidence suggests familial aggregation and intergenerational associations for individual cardiovascular health ( CVH ) metrics. Over a 53‐year life course, we examined trends and association of CVH between parents and their offspring at similar mean ages. Methods and Results We conducted a series of cross‐sectional analyses of the FHS (Framingham Heart Study). Parent‐offspring pairs were assessed at exams where their mean age distributions were similar. Ideal CVH was defined using 5 CVH metrics: blood pressure (dL ), blood cholesterol (dL ), body mass index (2 ), and non‐smoking. Joinpoint regression and Chi‐squared test were used to assess linear trend; proportional‐odds regression was used to examine the association between parents and offspring CVH . A total of 2637 parents were paired with 3119 biological offspring throughout 6 exam cycles. Similar patterns of declining ideal CVH with advancing age were observed in parents and offspring. Small proportions of parents (4%) and offspring (17%) achieved 5 CVH metrics at ideal levels ( P ‐trend CVH had more than twice the odds of having poor CVH (pooled odds ratio, 2.59; 95% CI, 1.98–3.40). Over time, elevated glucose levels and obesity doubled among the offspring and were the main drivers for declining ideal CVH trends. Conclusions Parental CVH was positively associated with offspring CVH . However, intergenerational CVH gains from declining smoking rates, cholesterol, and blood pressure were offset by rising offspring obesity and elevated glucose levels. This suggests an intergenerational phenotypic shift of risk factors and the need for a family‐centered approach to cardiovascular care.

BACKGROUND: Given the evidence of the links between cognition and mobility, participation in cognitive activities may benefit neuromotor performance and mobility in older adults. AIMS: To examine the association between participation in cognitive activities and foot reaction time (RT) and gait speed in community-dwelling older adults. METHODS: The MOBILIZE Boston Study II (MBSII) re-enrolled 354 community-dwelling older adults aged ≥ 70 years from the original MBS cohort. Of these, 310 completed the performance testing and we excluded 3 participants who had Parkinson’s disease. Cognitive Activities Scale (CAS) assessed participation in 17 cognitive activities. Simple and Choice foot RT (SRT, CRT, msec) and gait speed (m/s) were measured using a sensored GAITRite® gait mat. RESULTS: The average age of the 307 participants was 84 years; 79% were white and 65% were women. The average CAS score was 25.5±11.7 indicating participation in approximately 26 activities per week on average. The average foot SRT was 245±57msec and average CRT was 323±85msec. Usual-paced gait speed was 0.9±0.3 m/s on average. More frequent participation in cognitive activities was associated with shorter SRT (β = −0.759, p=0.015) and CRT (β= −1.125, p=0.013), and faster gait speed (β=0.003, p=0.026), after adjusting for potential confounders. DISCUSSION: Participation in cognitively stimulating activities may be beneficial for neuromotor performance and mobility in older adults. CONCLUSIONS: Prospective and intervention studies are needed to determine whether participation in cognitive activities may prevent mobility decline over time, and thus reduce fall risk.

Objectives Evaluate fall risk with the Short Physical Performance Battery (SPPB) and examine its application within the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) tool advocated by the Centers for Disease Control and Prevention. Design Prospective longitudinal cohort study. Setting and Participants 417 community-dwelling adults aged ≥65 years at risk for mobility decline, recruited from 9 primary care practices. Methods The SPPB, a 3-part performance-based test (gait time, chair stand, and balance), was assessed at baseline. Previously established cutpoints were used to categorize participant scores into 3 groups: low, middle, and best performers. Self-reported falls were assessed in-person at baseline and via phone interviews quarterly for 4 years. Multivariable negative binomial regression models were used to evaluate the relationship of the SPPB and each of its 3 components with fall rates over 1 and 4 years of follow-up. Additional analysis were stratified by fall risk screen status (+/−) based on self-reported fall history and balance self-efficacy using an adapted STEADI model. Results Participants had median age 76 years (interquartile range 70-82) and were 67.2% female with mean baseline SPPB 8.7 ± 2.3. Poor performance on the SPPB and on each of its 3 components independently predicted higher fall risk in the first year. After 4 years, the low total baseline SPPB [rate ratio (RR) 1.53, confidence interval (CI) 1.09-2.17] and gait time performances (RR 1.61, CI 1.07-2.41) predicted higher fall risk. After stratifying the sample according to the STEADI model, we observed the highest 1-year fall risk among those with a (+) fall risk screen who also scored lowest on the SPPB. Conclusions and Implications The SPPB is a performance measure with clinical utility for fall risk stratification over 1 and 4 years of follow-up among older adults. It shows promise as a complement to the STEADI guidelines, but its full benefits should be confirmed within a larger study.

Background and PurposeDiagnostic algorithms are invaluable tools for screening diabetes. This review aimed to evaluate and identify the most robust methodological approaches for developing diagnostic algorithms for screening diabetes.MethodsFollowing a literature search, methodological quality of algorithm development studies was evaluated using the TRIPOD guidelines (Collins, Reitsma, Altman, & Moons, 2015).ResultsMethods used for developing the algorithms included logistic regression models, classification and regression trees, Random Forest and TreeNet, Artificial Neural Networks, and Naïve Bayes. Methodological issues for algorithm development studies were related to handling of missing values, reporting recruitment methods, categorization of continuous variables, and statistical controls.ConclusionsMost studies exhibited critical methodological flaws and poor adherence to reporting standards. Diabetes screening algorithms can easily be availed electronically and utilized by nurses at minimal cost even in underserved areas.

PURPOSE To test whether an 8-wk exergaming (EG) program would improve cognition and gait characteristics compared with a traditional physical exercise (TPE) program in older adults at risk for falling. METHODS A pilot quasi-experimental study was conducted in adults age ≥65 yr at risk for falls, living in senior communities. Participants enrolled (n = 35) in either exercise program offered twice weekly for 8 wk. Cognition and single-task and dual-task gait characteristics were measured before and after the 8-wk exercise intervention. For each outcome, a repeated-measures ANCOVA adjusted for age, gender, and exercise intensity (ratings of perceived exertion, RPE) was used to examine the group-time interaction. RESULTS Twenty-nine participants (age, 77 ± 7 yr) completed either the EG program (n = 15) or the TPE program (n = 14). Statistically significant group-time interactions were observed in Trail Making Test Part A (P < 0.05) and single-task gait speed, stride length, swing time percentage, and double support percentage (all P < 0.05), and marginal group differences were observed in Mini-Mental State Examination (P = 0.07), all favoring the EG program. There were no statistically significant group differences in dual-task gait measurements except for swing time percentage and double support percentage, favoring the EG program. CONCLUSIONS An 8-wk EG program for older adults at risk for falls contributed to modest improvements in a number of cognitive measures and single-task but limited improvements in dual-task gait measures, compared with TPE. These findings support the need for larger trials to determine cognitive and mobility benefits related to EG.

Background This study aims to test whether persistent pain quality is associated with incident or worsening disability in four domains: mobility, activity of daily living (ADL) and instrumental activity of daily living (IADL) difficulty, and physical performance. Methods From the MOBILIZE Boston Study, a population-based cohort of adults aged ≥70 years, we studied participants with chronic pain who endorsed at least one pain quality descriptor (N = 398) and completed baseline and 18-month assessments. Pain quality was assessed using an adapted short-form McGill Pain Questionnaire with 20 pain quality descriptors in three categories: sensory, cognitive/affective, neuropathic. Persistence was defined as endorsing the same category at baseline and 18 months. Self-reported outcomes included mobility, ADL, and IADL difficulty. Physical performance was assessed using the short physical performance battery. Results After adjusting for baseline pain severity and other covariates, individuals with three persistent categories had a greater risk of developing new or worsening IADL difficulty relative to those with one persistent category (relative risk [RR] 2.69, 95% confidence interval [CI] 1.34, 7.79). Similar results were observed for ADL difficulty (RR 5.83, 95% CI 1.32, 25.85), but no differences were noted in risk for mobility difficulty. There was no significant linear trend in physical performance over 18 months according to number of persistent categories (p =.68). Conclusion Elders with persistent pain quality experienced a higher risk of developing new or worsening IADL and ADL disability with each additional category but not mobility difficulty or poorer physical performance. Longitudinal assessment of pain quality could be useful in determining risk for global disability among elders with chronic pain.

OBJECTIVES To examine the cross‐sectional relationship between chronic pain and complex attention in a population of community‐living older adults. DESIGN Prospective cross‐sectional cohort study. SETTING Population‐based Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston Study II. PARTICIPANTS Individuals aged 71 to 101 (N=354). MEASUREMENTS Chronic pain was measured using the pain severity and interference subscales of the Brief Pain Inventory. Four subscales of the Test of Everyday Attention were used to measure domains of attention switching and selective, sustained, and divided attention. RESULTS Before and after multivariable adjustment, pain severity was associated with poorer scores on measures of selective and sustained attention. Pain interference scores also were significantly inversely associated with selective attention. CONCLUSION Chronic pain is associated with poorer performance in selective and sustained attention in community‐dwelling older adults. Further research is needed to determine whether effective pain management could lead to better attentional performance in older adults. Older adults who live with chronic pain, often undertreated, are potentially at risk of cognitive difficulties and related functional consequences.

BACKGROUND: Chronic pain is associated with poorer cognition and mobility, and fall risk in older adults. AIMS: To investigate the feasibility of a randomized trial of mind-body exercise (Tai Chi) versus light physical exercise in older adults with multisite pain. METHODS: Adults aged ≥ 65y with multisite pain who reported falling in the past year or current use of an assistive device were recruited from Boston area communities. Participants were randomized to either a Tai Chi or a light physical exercise program, offered twice weekly for 12 weeks. The primary outcomes were feasibility and acceptability. Secondary outcomes included pain characteristics, cognition, physical function, gait mobility, fear of falling, and fall frequency. RESULTS: Of 176 adults screened, 85 were eligible, and 54 consented and enrolled (average age 75±8y; 96.30% white; 75.93% female). The dropout rate was 18% for Tai Chi and 12% for light physical exercise. For those completing the study, exercise class attendance was 76% for Tai Chi and 82% for light physical exercise. There were no significant group differences in most secondary outcomes. Tai Chi significantly lowered pain severity (4.58±1.73 to 3.73±1.79, p

Background/Study Context: Approximately one third of older adults over the age of 65, and over 40% of those over 80 years, fall each year, leading to fractures, morbidity, and mortality. Annual direct medical costs due to falls in the United States are approximately $19.2 billion. The identification of new treatable risk factors for falls has the potential to advance their prevention and rehabilitation. Methods A cross-sectional study of 127 community-dwelling adults aged 67-99 years was conducted. An electronic gait walkway was used to assess gait coordination, measured as the Phase Coordination Index during normal speed walking. A motion capture system was used to assess rhythmic interlimb antiphase ankle coordination, measured as the standard deviation of ankle relative phase. Having fallen in the previous year was self-reported retrospectively. Odds ratios for falling as a function of coordination quartiles were determined using multivariable logistic regression. Results Adjusting for age, sex, body mass index, number of chronic conditions, Mini-Mental State Examination score, gait speed, and the variability of step length, time, and width, the odds ratios for falling based upon being in the 4th (the poorest) quartiles of gait or ankle coordination were 5.5 (95% confidence interval [CI]: 1.2-24.7) and 8.2 (95% CI: 2.2-31.3), respectively, and 3.7 (95% CI: 1.0-13.8) for the 3rd quartile of gait coordination, compared with the best (the 1st) coordination quartiles. Similar results were found in regression without adjustment for gait characteristics. Conclusion The results support the hypothesis that impaired gait and rhythmic interlimb ankle coordination are associated with a history of falls in the past year. Prospective longitudinal research is needed to determine the possible direction of causality between falls and impaired coordination.

Almost half of older adults experience multisite musculoskeletal pain (MMP) contributing to difficulty in daily activities but little is known about specific domains by which pain interferes in daily living. This study aims to determine domains of pain interference (PI) related to MMP in a cohort of older adults living in the community. The MOBILIZE Boston Study (MBS) is a cohort study of 749 adults aged ≥70y. Musculoskeletal (MSK) pain was assessed using the joint pain questionnaire and grouped as: no pain, single site, and multisite pain. The Brief Pain Inventory PI sub-scale assessed level of interference (0-10 rating) in 7 categories in the previous week including general activity, mood, walking, work, relationships with people, sleep, and enjoyment of life. Interference items were grouped as: none (0 rating), mild (>0, ≤2), moderate ( ≥2, ≤5), and severe (≥5) PI. There was a strong gradient of PI according to pain groups with severe walking interference in 36.5% of those with MMP compared to 3.8% of those with no MSK pain. The least PI was in relationships with others (9.1% of MMP vs 1.1% of no MSK pain). Reports of interference in other domains were intermediate (20-26% of MMP vs 3-4% of no MSK pain). Women and those with Less education reported the most PI in every domain but no differences were observed by age. Greater attention to specific domains of pain interference such as walking could have substantial benefits for reducing the overall impact of MMP among older adults.

This mixed methods study evaluated student and provider attitudes and expectations about offering students online access to their student health services visit notes (open notes). Six (N=6) health care providers from four public universities in northeastern Massachusetts participated. Qualitative interviews were completed by students (N=14) from one University in fall of 2013 and an online survey was completed at two universities in Spring of 2014. Attitudes and expectations were explored using qualitative data and descriptive statistics were used to analyze survey questions. Students’ interviews revealed that they desire control over their health and open notes would give them insight and involvement in their health care. Survey data supported these themes. In contrast, providers worried about how it could impact provider-patient relationships. Open notes has the potential to promote students’ understanding and responsibility for their healthcare, which could assist students in their transition from pediatric to adult health care.

The purpose of this exploratory study was to examine the effects of Tai Chi on blood levels of beta endorphin (β-endorphin) and inflammatory markers in older adults with chronic pain. Forty community-dwelling older adults with chronic pain were randomized to Tai Chi or light physical exercise, and each offered twice weekly for 12 weeks. Following the 12-week intervention, neither Tai Chi nor light physical exercise changed levels of β-endorphin and inflammatory markers. However, in older adults who completed 70% or more classes, Tai Chi significantly lowered levels of β-endorphin (p

Background Following a 2010-2011 pilot intervention in which a limited sample of primary care doctors offered their patients secure Web-based portal access to their office visit notes, the participating sites expanded OpenNotes to nearly all clinicians in primary care, medical, and surgical specialty practices. Objective The aim of this study was to examine the ongoing experiences and perceptions of patients who read ambulatory visit notes written by a broad range of doctors, nurses, and other clinicians. Methods A total of 3 large US health systems in Boston, Seattle, and rural Pennsylvania conducted a Web-based survey of adult patients who used portal accounts and had at least 1 visit note available in a recent 12-month period. The main outcome measures included patient-reported behaviors and their perceptions concerning benefits versus risks. Results Among 136,815 patients who received invitations, 21.68% (29,656/136,815) responded. Of the 28,782 patient respondents, 62.82% (18,081/28,782) were female, 72.90% (20,982/28,782) were aged 45 years or older, 76.94% (22,146/28,782) were white, and 14.30% (4115/28,782) reported fair or poor health. Among the 22,947 who reported reading 1 or more notes, 3 out of 4 reported reading them for 1 year or longer, half reported reading at least 4 notes, and 37.74% (8588/22,753) shared a note with someone else. Patients rated note reading as very important for helping take care of their health (16,354/22,520, 72.62%), feeling in control of their care (15,726/22,515, 69.85%), and remembering the plan of care (14,821/22,516, 65.82%). Few were very confused (737/22,304, 3.3%) or more worried (1078/22,303, 4.83%) after reading notes. About a third reported being encouraged by their clinicians to read notes and a third told their clinicians they had read them. Less educated, nonwhite, older, and Hispanic patients, and individuals who usually did not speak English at home, were those most likely to report major benefits from note reading. Nearly all respondents (22,593/22,947, 98.46%) thought Web-based access to visit notes a good idea, and 62.38% (13,427/21,525) rated this practice as very important for choosing a future provider. Conclusions In this first large-scale survey of patient experiences with a broad range of clinicians working in practices in which shared notes are well established, patients find note reading very important for their health management and share their notes frequently with others. Patients are rarely troubled by what they read, and those traditionally underserved in the United States report particular benefit. However, fewer than half of clinicians and patients actively address their shared notes during visits. As the practice continues to spread rapidly in the United States and internationally, our findings indicate that OpenNotes brings benefits to patients that largely outweigh the risks.

Objective To investigate a proposed cognitively-mediated pathway whereby pain contributes to gait impairments by acting as a distractor in community-living older adults. Design A cross-sectional study of a population-based cohort of older adults. Setting Urban and suburban communities in a large metropolitan area. Participants Community-living participants (N=302) 70 years and older recruited from a previous population-based cohort. Interventions Not applicable. Main Outcome Measures Gait parameters including gait speed, stride length, double support and swing characteristics, and variability were assessed under single- and dual-task conditions involving cognitive challenges (eg, counting backward). A joint pain questionnaire assessed pain distribution in the back and major joints. We examined pain-gait relationships using multivariable linear regression and bootstrapping mediation procedures. Results Forty-three percent of participants had pain in 2 or more musculoskeletal sites. Pain distribution was related to slower gait speed and other gait characteristics for all gait conditions. Associations persisted after adjustment for age, sex, education, body mass index, medication, and vision. Decrements in gait measures related to pain were comparable with decrements in gait related to dual-task conditions. There were no differences in dual-task cost among the pain distribution groups. Adjusted for confounders, pain-gait relationships appear mediated by selective attention. Conclusions These findings suggest that chronic pain contributes to decrements in gait, including slower gait speed, and that it operates through a cognitively-mediated pathway. Further research is needed to understand the mechanisms via pain alters mobility and to develop interventions to improve mobility among older adults with chronic pain.

Older adults frequently report pain; cross-sectional studies have shown that pain is associated with worse cognitive function. However, longitudinal studies are lacking. We prospectively studied 441 participants without dementia, including 285 with pain, aged 65 years and older, enrolled in the Central Control of Mobility in Aging study, a prospective cohort study. We analyzed the longitudinal association between pain (measured with the Medical Outcomes Study pain severity scale) and major cognitive impairment (measured with the Repeatable Battery for the Assessment of Neuropsychological Status and the Trail Making Test Delta) using Cox regression analysis adjusted for age, gender, ethnicity, and education. Over a mean follow-up of 2.75 years (standard deviation = 1.94), there was no difference in the risk of developing cognitive impairment between participants with pain and participants without pain. However, among those with pain, risk for developing major memory impairment was higher among those with high levels of pain than those with low levels of pain (adjusted hazard ratio = 3.47, 95% confidence interval = 1.42–8.46). The association with pain and incident impairments in attention or executive function was not significant. We did not find that pain is associated with incident cognitive impairment in general, but among older adults with pain, a high level of pain is associated with increased risk of developing incident memory impairment. Perspective Our study results suggest that high levels of pain may contribute to incident memory impairment. Further research is needed to determine whether a high level of chronic pain is a modifiable risk factor for cognitive impairment in older adults.

We aimed to examine the risk for disability as per Late Life Function and Disability Instrument (LLFDI) scores over 2 years among older adults based on mobility limitation and cognitive impairment status at baseline. Participants were classified according to gait speed (SLOW, if less than 0.8 m/s) and Mild Cognitive Impairment (MCI, based on neurocognitive test scores) into MCI-SLOW-, MCI-SLOW+, MCI+SLOW-, MCI+SLOW+ categories. Risk estimates were derived from generalized linear mixed models adjusting for socio-demographics, BMI, pain, physical activity, depression, and multimorbidity. MCISLOW profiles were differentially associated with lower limb function and participation in life roles over 2 years of follow up. When compared to MCI-SLOW-, MCI+SLOW+ participants (6.54 lower basic function and 9.79 lower advanced function) and MCI-SLOW+ (4.16, 8.65 lower) had significantly greater decline; MCI+SLOW- participants were not significantly different. However, MCI+ participants shows significant worsening of frequency of participation compared to MCI- participants irrespective of gait speed. Combined screening of mobility and cognition may provide a better assessment of disability risk and thereby better informing a plan for preventative rehabilitative care.

Malnourishment among older people is growing rapidly in Thailand. It is caused by aging process, inadequate access to food, and financial support. This study was to identify sociodemographic factors, chronic conditions, and health factors associated with the nutrition status among Thai community-dwelling older adults. This was a cross-sectional study, involving 147 older adults aged ≥ 60 years living in low income suburban Chiang Mai, Thailand. A structured questionnaire was used to obtain information on sociodemographic factors, health characteristics, and functional status. Nutritional status was assessed by using the Mini Nutritional Assessment (MNA). MNA has two categories as “nutritional risk” (scored

Although total knee replacement (TKR) surgery has become a common treatment for knee osteoarthritis, little is known about the overall impact of TKR on pain and mobility in the older population. This cross-sectional study examined chronic pain and mobility among community living adults aged ≥70y with and without TKR. The MOBILIZE Boston Study enrolled 765 older adults living in the Boston area. Pain characteristics including pain severity and interference were measured using the Brief Pain Inventory (BPI), and mobility was assessed by the Short Physical Performance Battery (SPPB), gait speed, and self-reported mobility difficulty. History of TKR was confirmed during the clinic visit. We used independent t-test, multivariable linear and logistic regressions adjusting for sociodemographic and health characteristics. History of TKR, found in 10% of the study population, was significantly associated with body mass index (BMI), osteoarthritis, and walking shorter distances compared to no TKR. Adjusted for sociodemographic and health factors, TKR was associated with more pain, more mobility difficulty, lower SPPB scores, and slower gait speed compared to no TKR (p-value

Accumulating evidence points to an increased fall risk among older adults who have persistent multisite pain. A better understanding of this pain hazard could lead to new interventions to reduce fall risk in older adults. The MOBILIZE Boston Study II included a battery of tests to assess the attentional domain, as well as the problem of persistent multisite pain. The 354 participants completed monthly fall calendars during the subsequent 2 years. Incidence rate ratios for falls were derived from multivariable negative binomial models, adjusted for fall risk factors. We found that elders who had multisite pain had a 51% increase in fall risk (adj. IRR=1.51, 95% CI: 1.51–2.10). Several measures of attention mediated the pain-falls relationship including measures of selective attention, visual attention and attentional switching. Studies are needed to determine whether interventions that incorporate attentional challenges could reduce fall risk in older adults who have multisite pain.

Identifying the internal relationships in the data is the basis of data analysis and prediction. Traditional statistics methods focus on testing the correlation of variables pairwise. However, the correlation has rather limited performance on real causal influence. In this paper, we focus on an interpretable and visible approach to detect causal relationship networks in order to study risk factors of older adult falls. Learning the skeleton of the network is challenging since it is hard to mine indirect relationships. Variables could have dependence given other variables. Furthermore, orienting appropriate direction is tough because real-world data may include hidden information. Researchers cannot control it like a simulated data set. Here we propose a method based on the Bayesian causal relationship, which we call the Time Logic PC algorithm (TL-PC). We use the TL-PC on the older adults fall application and show the explainable and reliable time logical causal relationships.

ObjectivesTo develop and evaluate the validity of a scale to assess patients’ perceived benefits and risks of reading ambulatory visit notes online (open notes).DesignFour studies were used to evaluate the construct validity of a benefits and risks scale. Study 1 refined the items; study 2 evaluated underlying factor structure and identified the items; study 3 evaluated study 2 results in a separate sample; and study 4 examined factorial invariance of the developed scale across educational subsamples.SettingAmbulatory care in three large health systems in the USA.ParticipantsParticipants in three US health systems who responded to one of two online surveys asking about benefits and risks of reading visit notes: a psychometrics survey of primary care patients, and a large general survey of patients across all ambulatory specialties. Sample sizes: n=439 (study 1); n=439 (study 2); n=500 (study 3); and n=250 (study 4).Primary and secondary outcome measuresQuestionnaire items about patients’ perceived benefits and risks of reading online visit notes.ResultsStudy 1 resulted in the selection of a 10-point importance response option format over a 4-point agreement scale. Exploratory factor analysis (EFA) in study 2 resulted in two-factor solution: a four-item benefits factor with good reliability (alpha=0.83) and a three-item risks factor with poor reliability (alpha=0.52). The factor structure was confirmed in study 3, and confirmatory factor analysis of benefit items resulted in an excellent fitting model, X2(2)=2.949; confirmatory factor index=0.998; root mean square error of approximation=0.04 (0.00, 0.142); loadings 0.68−0.86; alpha=0.88. Study 4 supported configural, measurement and structural invariance for the benefits scale across high and low-education patient groups.ConclusionsThe findings suggest that the four-item benefits scale has excellent construct validity and preliminary evidence of generalising across different patient populations. Further scale development is needed to understand perceived risks of reading open notes.

This study aimed to characterize the prevalence of various pain qualities in older adults with chronic nonmalignant pain and determine the association of pain quality to other pain characteristics namely: severity, interference, distribution, and pain-associated conditions. In the population-based MOBILIZE Boston Study, 560 participants aged ≥70 years reported chronic pain in the baseline assessment, which included a home interview and clinic exam. Pain quality was assessed using a modified version of the McGill Pain Questionnaire (MPQ) consisting of 20 descriptors from which 3 categories were derived: cognitive/affective, sensory, and neuropathic. Presence of ≥2 pain-associated conditions was significantly associated with 18 of the 20 pain quality descriptors. Sensory descriptors were endorsed by nearly all older adults with chronic pain (93%), followed by cognitive/affective (83.4%) and neuropathic descriptors (68.6%). Neuropathic descriptors were associated with the greatest number of pain-associated conditions including osteoarthritis of the hand and knee. More than half of participants (59%) endorsed descriptors in all 3 categories and had more severe pain and interference, and multisite or widespread pain than those endorsing 1 or 2 categories. Strong associations were observed between pain quality and measures of pain severity, interference, and distribution (P < 0.0001). Findings from this study indicate that older adults have multiple pain-associated conditions that likely reflect multiple physiological mechanisms for pain. Linking pain qualities with other associated pain characteristics serve to develop a multidimensional approach to geriatric pain assessment. Future research is needed to investigate the physiological mechanisms responsible for the variability in pain qualities endorsed by older adults.

Objective To identify neuromuscular impairments most predictive of unfavorable mobility outcomes in late life. Design Longitudinal cohort study. Setting Research clinic. Participants Community-dwelling primary care patients aged ≥65 years (N=391) with self-reported mobility modifications, randomly selected from a research registry. Interventions Not applicable. Main Outcome Measures Categories of decline in and persistently poor mobility across baseline, 1 and 2 years of follow-up in the Lower-Extremity Function scales of the Late-Life Function and Disability Instrument. The following categories of impairment were assessed as potential predictors of mobility change: strength (leg strength), speed of movement (leg velocity, reaction time, rapid leg coordination), range of motion (ROM) (knee flexion/knee extension/ankle ROM), asymmetry (asymmetry of leg strength and knee flexion/extension ROM measures), and trunk stability (trunk extensor endurance, kyphosis). Results The largest effect sizes were found for baseline weaker leg strength (odds ratio [95% confidence interval]: 3.45 [1.72–6.95]), trunk extensor endurance (2.98 [1.56–5.70]), and slower leg velocity (2.35 [1.21–4.58]) predicting a greater likelihood of persistently poor function over 2 years. Baseline weaker leg strength, trunk extensor endurance, and restricted knee flexion motion also predicted a greater likelihood of decline in function (1.72 [1.10–2.70], 1.83 [1.13–2.95], and 2.03 [1.24–3.35], respectively). Conclusions Older adults exhibiting poor mobility may be prime candidates for rehabilitation focused on improving these impairments. These findings lay the groundwork for developing interventions aimed at optimizing rehabilitative care and disability prevention, and highlight the importance of both well-recognized (leg strength) and novel impairments (leg velocity, trunk extensor muscle endurance).

Background: Access to online patient portals is key to improving care, but we have limited understanding of patient perceptions of online portals and the characteristics of people who use them. Methods: Using a national survey of 3677 respondents, we describe perceptions and utilization of online personal health information (PHI) portals. Results: Most respondents (92%) considered online PHI access important, yet only 34% were offered access to online PHI by a health care provider, and just 28% accessed online PHI in the past year. While there were no differences across race or ethnicity in importance of access, black and Hispanic respondents were significantly less likely to be offered access (P = .006 and Conclusion: Health care providers are crucial to the adoption and use of online patient portals and should be encouraged to offer consistent access regardless of patient race and ethnicity.

Background Patient advocates and safety experts encourage adoption of transparent health records, but sceptics worry that shared notes may offend patients, erode trust or promote defensive medicine. As electronic health records disseminate, such disparate views fuel policy debates about risks and benefits of sharing visit notes with patients through portals. Methods Presurveys and postsurveys from 99 volunteer doctors at three US sites who participated in OpenNotes and postsurveys from 4592 patients who read at least one note and submitted a survey. Results Patients read notes to be better informed and because they were curious; about a third read them to check accuracy. In total, 7% (331) of patients reported contacting their doctor9s office about their note. Of these, 29% perceived an error, and 85% were satisfied with its resolution. Nearly all patients reported feeling better (37%) or the same (62%) about their doctor. Patients who were older (>63), male, non-white, had fair/poor self-reported health or had less formal education were more likely to report feeling better about their doctor. Among doctors, 26% anticipated documentation errors, and 44% thought patients would disagree with notes. After a year, 53% believed patient satisfaction increased, and 51% thought patients trusted them more. None reported ordering more tests or referrals. Conclusions Despite concerns about errors, offending language or defensive practice, transparent notes overall did not harm the patient–doctor relationship. Rather, doctors and patients perceived relational benefits. Traditionally more vulnerable populations—non-white, those with poorer self-reported health and those with fewer years of formal education—may be particularly likely to feel better about their doctor after reading their notes. Further informing debate about OpenNotes, the findings suggest transparent records may improve patient satisfaction, trust and safety.

Purpose OpenNotes is a growing national initiative inviting patients to read clinician progress notes (open notes) through a secure electronic portal. The goals of this study were to (1) identify resident and faculty preceptor attitudes about sharing notes with patients, and (2) assess specific educational needs, policy recommendations, and approaches to facilitate open notes implementation. Method This was a qualitative study using focus groups with residents and faculty physicians who supervise residents, representing primary care, general surgery, surgical and procedural specialties, and nonprocedural specialties, from Beth Israel Deaconess Medical Center and Geisinger Health System in spring 2013. Data were audio recorded and transcribed verbatim, then coded and organized into themes. Results Thirty-six clinicians (24 [66.7%] residents and 12 [33.3%] faculty physicians) participated. Four main themes emerged: (1) implications of full transparency, (2) note audiences and ideology, (3) trust between patients and doctors, and (4) time pressures. Residents and faculty discussed how open notes might yield more engaged patients and better notes but were concerned about the time needed to edit notes and respond to patient inquiries. Residents were uncertain how much detail they should share with patients and were concerned about the potential to harm the patient-doctor relationship. Residents and faculty offered several recommendations for open notes implementation. Conclusions Overall, participants were ambivalent about resident participation in open notes. Residents and faculty identified clinical and educational benefits to open notes but were concerned about potential effects on the patient-doctor relationship, requirements for oversight, and increased workload and burnout.

Background For older adults with mobility problems, one focus of rehabilitation is treating the underlying neuromuscular impairment(s) that lead to functional decline and disability. Knowing which neuromuscular impairments contribute to basic mobility tasks among older adults with back pain will fill an important knowledge gap and is a critical step towards developing mechanistically based rehabilitative interventions. Objective To evaluate the relationship of neuromuscular impairments with performance of mobility tasks among older adults with and without back pain. Design Cross-sectional analysis of baseline data from the Boston Rehabilitative Impairment Study of the Elderly. Setting Primary care−based population. Patients Participants (N = 430) were older primary care patients who completed assessments of neuromuscular impairments and mobility tasks. Methods Back pain was assessed by the use of an established comorbidity questionnaire. Neuromuscular impairments included trunk extensor muscle endurance, kyphosis, leg strength, leg strength asymmetry, leg speed, mean reaction time, leg coordination, and knee and ankle range of motion. Main Outcome Measurements Mobility tasks included gait speed, standing balance, chair stand, and patient-reported functional status. Analysis of covariance was used to generate adjusted means for neuromuscular impairments that differed significantly by back pain status. Separate multivariable regression models evaluated the association between neuromuscular impairments and mobility based on back pain status after we adjusted for sociodemographic factors and physiologic impairments. Results Participants had an average age of 77 years, 68% were female, and 31% reported back pain. Trunk extensor muscle endurance, leg strength, and rapid leg coordination were significantly lower among those with back pain compared to those without ( P P = .01, P = .04, respectively). Patterns of neuromuscular impairments that were associated with mobility tasks differed according to back pain status. Conclusions The neuromuscular impairment profiles associated with mobility function among older adults with back pain vary compared with older adults without back pain.

Background Pain related to many age-related chronic conditions is a burdensome problem in elderly adults and may also interfere with cognitive functioning. The purpose of this study was to examine the cross-sectional relationship between measures of pain severity and pain interference and cognitive performance in community-living older adults. Methods We studied 765 participants in the Maintenance of Balance Independent Living Intellect and Zest (MOBILIZE) Boston Study, a population-based study of persons aged 70 and older. Global pain severity and interference were measured using the Brief Pain Inventory subscales. The neuropsychological battery included measures of attentional capacity (Trail Making Test A, WORLD Test), executive function (Trail Making Test B and Delta, Clock-in-a-Box, Letter Fluency), memory (Hopkins Verbal Learning Test), and a global composite measure of cognitive function. Multivariable linear regression models were used to analyze the relationship between pain and cognitive functioning. Results Elderly adults with more severe pain or more pain interference had poorer performance on memory tests and executive functioning compared to elders with none or less pain. Pain interference was also associated with impaired attentional capacity. Additional adjustment for chronic conditions, behaviors, and psychiatric medication resulted in attenuation of many of the observed associations. However, the association between pain interference and general cognitive function persisted. Conclusions Our findings point to the need for further research to understand how chronic pain may contribute to decline in cognitive function and to determine strategies that may help in preventing or managing these potential consequences of pain on cognitive function in older adults.

Independent control of the right and left ankles (differentiation) may be a motor control mechanism linking impaired coordination and mobility limitations. We tested the hypotheses that motor control differentiation of the ankles, as measured using Cross-Sample Entropy, during antiphase coordination at two movement frequencies, is associated with impaired coordination (high ankle coordination variability) and mobility limitations (Short Physical Performance Battery score ≤9). We conducted a cross-sectional study of community-dwelling older adults (N = 133) aged 80.04 (±4.67) years. In linear regression modeling, low ankle Cross-Sample Entropy (low motor control differentiation) was associated with poor (i.e., high) coordination variability at the slower (P = 0.026), but not the faster (P = 0.447), ankle movement frequency. In logistic regression modeling, low Cross-Sample Entropy at the slower (OR = 1.67; 95 % CI: 1.07–2.59) and faster (OR = 2.38; 95 % CI: 1.43–3.94) ankle movement frequencies were associated with increased odds for mobility limitations. Our findings support the hypothesis that ankle differentiation may be a motor control mechanism that links impaired coordination with mobility limitations.

This survey study assesses the frequency and types of errors identified by patients who read open ambulatory visit notes., Key Points Question How often do patients who read open ambulatory visit notes perceive mistakes, and what types of mistakes do they report? Findings In this survey study of 136 815 patients, 29 656 provided a response, and 1 in 5 patients who read a note reported finding a mistake and 40% perceived the mistake as serious. Among patient-reported very serious errors, the most common characterizations were mistakes in diagnoses, medical history, medications, physical examination, test results, notes on the wrong patient, and sidedness. Meaning As health information transparency increases, patients may perceive important errors in their visit notes, and inviting them to report mistakes that they believe are very serious may be associated with improved record accuracy and patient engagement in safety., Importance As health information transparency increases, patients more often seek their health data. More than 44 million patients in the US can now readily access their ambulatory visit notes online, and the practice is increasing abroad. Few studies have assessed documentation errors that patients identify in their notes and how these may inform patient engagement and safety strategies. Objective To assess the frequency and types of errors identified by patients who read open ambulatory visit notes. Design, Setting, and Participants In this survey study, a total of 136 815 patients at 3 US health care organizations with open notes, including 79 academic and community ambulatory care practices, received invitations to an online survey from June 5 to October 20, 2017. Patients who had at least 1 ambulatory note and had logged onto the portal at least once in the past 12 months were included. Data analysis was performed from July 3, 2018, to April 27, 2020. Exposures Access to ambulatory care open notes through patient portals for up to 7 years (2010-2017). Main Outcomes and Measures Proportion of patients reporting a mistake and how serious they perceived the mistake to be, factors associated with finding errors characterized by patients as serious, and categories of patient-reported errors. Results Of 136 815 patients who received survey invitations, 29 656 (21.7%) responded and 22 889 patients (mean [SD] age, 55.16 [15.96] years; 14 447 [63.1%] female; 18 301 [80.0%] white) read 1 or more notes in the past 12 months and completed error questions. Of these patients, 4830 (21.1%) reported a perceived mistake and 2043 (42.3%) reported that the mistake was serious (somewhat serious: 1563 [32.4%]; very serious: 480 [9.9%]). In multivariable analysis, female patients (relative risk [RR], 1.79; 95% CI, 1.72-1.85), more educated patients (RR, 1.38; 95% CI, 1.29-1.48), sicker patients (RR, 1.89; 95% CI, 1.84-1.94), those aged 45 to 64 years (RR, 2.23; 95% CI, 2.06-2.42), those 65 years or older (RR, 2.00; 95% CI, 1.73-2.32), and those who read more than 1 note (2-3 notes: RR, 1.82; 95% CI, 1.34-2.47; ≥4 notes: RR, 3.09; 95% CI, 2.02-4.73) were more likely to report a mistake that they found to be serious compared with their reference groups. After categorization of patient-reported very serious mistakes, those specifically mentioning the word diagnosis or describing a specific error in current or past diagnoses were most common (98 of 356 [27.5%]), followed by inaccurate medical history (85 of 356 [23.9%]), medications or allergies (50 of 356 [14.0%]), and tests, procedures, or results (30 of 356 [8.4%]). A total of 23 (6.5%) reflected notes reportedly written on the wrong patient. Of 433 very serious errors, 255 (58.9%) included at least 1 perceived error potentially associated with the diagnostic process (eg, history, physical examination, tests, referrals, and communication). Conclusions and Relevance In this study, patients who read ambulatory notes online perceived mistakes, a substantial proportion of which they found to be serious. Older and sicker patients were twice as likely to report a serious error compared with younger and healthier patients, indicating important safety and quality implications. Sharing notes with patients may help engage them to improve record accuracy and health care safety together with practitioners.

Importance The 21st Century Cures Act of 2016 requires that patients be given electronic access to all the information in their electronic medical records. The regulations for implementation of this law give patients far easier access to information about their care, including the notes their clinicians write. Objective To assess clinicians’ views and experiences with sharing clinical notes (open notes) with patients. Design, Setting, and Participants Web-based survey study of physicians, advanced practice nurses, registered nurses, physician assistants, and therapists at 3 health systems in Boston, Massachusetts; Seattle, Washington; and rural Pennsylvania where notes have been shared across all outpatient specialties for at least 4 years. Participants were clinicians in hospital-based offices and community practices who had written at least 1 note opened by a patient in the year prior to the survey, which was administered from May 21, 2018, to August 31, 2018. Main Outcomes and Measures Clinicians’ experiences with and perceptions of sharing clinical notes with patients. Results Invitations were sent to 6064 clinicians; 1628 (27%) responded. Respondents were more likely than nonrespondents to be female (65% vs 55%) and to be younger (mean [SD] age, 42.1 [12.6] vs 44.9 [12.7] years). The majority of respondents were physicians (951 [58%]), female (1023 [65%]), licensed to practice in 2000 or later (940 [61%]), and spent fewer than 40 hours per week in direct patient care (1083 [71%]). Most viewed open notes positively, agreeing they are a good idea (1182 participants [74%]); of 1314 clinicians who were aware that patients were reading their notes, 965 (74%) agreed that open notes were useful for engaging patients. In all, 798 clinicians (61%) would recommend the practice to colleagues. A total of 292 physicians (37%) reported spending more time on documentation, and many reported specific changes in the way they write their notes, the most frequent of which related to use of language that could be perceived as critical of the patient (422 respondents [58%]). Most physicians (1234 [78%]) favored being able to determine readily that their notes had been read by their patients. Conclusions and Relevance In this survey of clinicians in a wide range of specialties who had several years of experience offering their patients ready access to their notes, more than two-thirds supported this new practice. Even among subgroups of clinicians who were less enthusiastic, most endorsed the idea of sharing notes and believed the practice could be helpful for engaging patients more actively in their care.

This study examined the feasibility and acceptability of an exergaming program that utilized custom exergames, and compared it to a traditional physical exercise (control) program in older adults at risk for falls. A quasi-experimental study was conducted in older adults who lived in senior living communities. Participants enrolled in either program offered twice weekly for 8 weeks based on their residential site. Thirty-five participants enrolled in the study (mean age 77±7y) and 29 (82%) completed the follow-up assessment (exergaming: 93%; control: 73%). Overall attendance was 73% (exergaming: 79%; control: 68%), and 22 participants returned their program satisfaction form. There were no significant between-group differences in ratings of overall quality, enjoyment, instructors, peers, and facility of their assigned exercise programs. The exergaming intervention was well received and perceived as enjoyable. This study demonstrates that an 8-week exergaming intervention is feasible and acceptable for older adults at risk for falls.

Fall injuries are a leading cause of death among older adults, and chronic pain has been identified as a fall risk factor. However, the potential impact of chronic pain on injurious falls is unknown. This prospective study examined the relation between chronic pain and injurious falls in a 4-year follow-up of community-dwelling older adults. The MOBILIZE Boston study recruited 765 older adults aged ≥70y living in the Boston area. Pain characteristics, including pain severity, pain interference, and pain location, were measured at baseline using the Brief Pain Inventory subscales and a joint pain questionnaire. Musculoskeletal pain distribution was categorized as “no pain”, “single site pain”, or “multisite pain”. Injurious falls were ascertained in telephone interviews following reports of falls on the monthly fall calendar postcards. The overall rate of injurious falls was 35/100 person-years. Negative binomial models, adjusting for sociodemographics, BMI, chronic conditions, mobility difficulty, analgesic and psychiatric medications, and depression, showed that pain interference and pain distribution, but not pain severity, independently predicted injurious falls. Participants in the highest third of pain interference scores had a 53% greater risk of injurious falls compared to those in the lowest pain interference group (adj.IRR=1.53, 95% CI: 1.15, 2.05). Older adults with multisite pain had a 50% higher risk of injurious falls than those without pain (adj.IRR=1.50, 95% CI: 1.16, 1.93). Risk of injurious falls related to pain was stronger among women than men. Research is needed to determine effective strategies to prevent fall injuries among older adults with chronic pain.

Both chronic pain and fear of falling can lead to activity restriction and increased fall risk among vulnerable elders. Little is known about pain characteristics that may be associated with fear of falling, contributing to restricted activity. We studied 765 adults aged ≥65y (mean=78.9y) in the MOBILIZE Boston Study, to evaluate the cross-sectional relationship between pain characteristics and fear of falling measured using the Falls Efficacy Scale (FES). In addition, we examined the impact of pain and fear of falling on restricted activity. We measured 3 domains of global pain: pain distribution (none, single site or multisite pain), and Brief Pain Inventory subscales of pain severity and pain interference. Restricted activity days (RADs) refer to the count of self-reported days of reduced activity due to illness or injury in the previous 12 months. We performed multivariable logistic regressions predicting fear of falling (FES