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Background: The Centers for Medicare and Medicaid Services (CMS) introduced chronic care management (CCM) services in 2015 for patients with multiple chronic diseases. Few studies examine the utilization of CCM services by geographic region, sociodemographic, and clinical characteristics. Methods: We used 2014–2019 Medicare claims data from a 5% random sample of fee‐for‐service beneficiaries aged 65 years or over. We included beneficiaries potentially eligible for CCM services because they had multiple chronic conditions (1,073,729 in 2015 and 1,130,523 in 2019). We calculated the proportion of potentially eligible beneficiaries receiving CCM service each year for the total population and by geographic region, sociodemographic, and clinical characteristics. Results: The proportion of beneficiaries with two or more chronic conditions receiving CCM services increased from 1.1% in 2015 to 3.4% in 2019. The increase in CCM use was higher in the southern region, among dually eligible beneficiaries and beneficiaries with a greater burden of chronic conditions (2–5 conditions vs ≥10 conditions: 0.7% vs 2.0% in 2015; 2.1% vs 7.0% in 2019) and frailty (robust vs severely frail: 0.6% vs 3.3% in 2015; 1.9% vs 9.4% in 2019). Nearly one out of five recipients did not continue CCM service after the initial service. Conclusion: We found that CCM service is being used by a very small fraction of eligible patients. Barriers and facilitators to more effective CCM adoption should be identified and incorporated into strategies that encourage more widespread use of this Medicare benefit. [ABSTRACT FROM AUTHOR]

The article presents a study which explored the utilization rate of transitional care management (TCM) service by beneficiaries' characteristics associated with a higher risk of readmission. Topics discussed include patient characteristics and use of TCM service among random sample of medicare fee-for-service beneficiaries in 2015-2019, factors for readmission as well as barriers to TCM access, and limitations of the study.

• For the stroke subtypes, there were substantial interactions between the LDL-cholesterol groups and stroke subtype and all-cause mortality. • A higher risk of all-cause mortality was observed in patients with lower LDL-cholesterol levels for the large artery atherosclerosis subtype. • Patients with higher LDL-cholesterol levels had a higher risk of all-cause mortality for the cardioembolic stroke subtype. • There were U-shaped associations of LDL-cholesterol levels on early vascular outcomes in acute ischemic stroke patients. Because ischemic stroke is heterogeneous, the associations between low-density lipoprotein (LDL)-cholesterol levels and early vascular outcomes might be different according to the stroke subtype in acute ischemic stroke patients. This study was an analysis of a prospective, multicenter, stroke registry. Acute ischemic stroke patients previously not treated with statins were included. Admission LDL-cholesterol levels were divided into 7 groups at 20 mg/dl intervals for comparison. The primary early vascular outcome was a composite of stroke, myocardial infarction (MI) and all-cause mortality within 3 months. A total of 38,531 patients (age, 68.5 ± 12.8 yrs; male, 59.6%) were analyzed for this study. The 3-month cumulative incidences of the composite of stroke, MI, and all-cause mortality significantly differed among the LDL-cholesterol level groups, with the highest event rate (11.11%) in the lowest LDL-cholesterol group (<70 mg/dl). After adjustment, the U-shaped associations of LDL-cholesterol levels with primary outcome and all-cause mortality were observed. For the stroke subtypes, there were substantial interactions between the LDL-cholesterol groups and stroke subtype and all-cause mortality (P interaction =0.07). Different patterns, with higher risks of all-cause mortality in the lower LDL-cholesterol in the large artery atherosclerosis subtype (adjusted hazard ratio [aHR] 1.29, 95% confidence interval [CI] 0.98-1.69), but in the higher LDL-cholesterol in the cardioembolism subtype (aHR 1.71 95% CI [1.28-2.29]), were observed among stroke subtypes. We found that there were differential associations of admission LDL-cholesterol levels with all-cause mortality within 3 months among stroke subtypes. These results suggest that admission LDL-cholesterol and early vascular outcomes had complex relationships in patients with ischemic stroke according to the stroke subtypes. [ABSTRACT FROM AUTHOR]

Background: Professional society guidelines recommend limiting the use of antipsychotics in older patients with postoperative delirium. How these recommendations affected the use of antipsychotics and other psychoactive drugs in the postoperative period has not been studied. Methods: This retrospective cohort study included patients 65 years or older without psychiatric diagnoses who underwent major surgery in community hospitals (CHs) and academic medical centers (AMCs) in the United States. The outcome was the rate of hospital days exposed to antipsychotics, antidepressants, antiepileptics, benzodiazepines, hypnotics, and selective alpha‐2 receptor agonist dexmedetomidine in the postoperative period by hospital type. Results: The study included 4,098,431 surgical admissions from CHs (mean age 75.0 [standard deviation, 7.1] years; 50.8% female) during 2008–2018 and 2,310,529 surgical admissions from AMCs (75.0 [7.4] years; 49.4% female) during 2009–2018. In the intensive care unit (ICU) setting, the number of exposed days per 1000 hospital‐days declined for haloperidol (CHs: 33–21 days [p < 0.01]; AMCs: 24–15 days [p < 0.01]) and benzodiazepines (CHs: 261–136 days [p < 0.01]; AMCs: 150–77 days [p < 0.01]). The use of atypical antipsychotics, antidepressants, antiepileptics, and dexmedetomidine increased, while hypnotic use varied by the hospital type. In the non‐ICU setting, the rate declined for haloperidol in CHs but not in AMCs (CHs: 10–6 days [p < 0.01]; AMCs: 4–3 days [p = 0.52]) and for benzodiazepines in both settings (CHs: 126–56 days [p < 0.01]; AMCs: 30–27 days [p < 0.01]). The use of antiepileptics and antidepressants increased, while the use of atypical antipsychotics and hypnotics varied by the hospital type. Conclusions: The use of haloperidol and benzodiazepines in the postoperative period declined at both CHs and AMCs. These trends coincided with the increasing use of other psychoactive drugs. [ABSTRACT FROM AUTHOR]

Background: Electronic frailty indices (eFIs) can expand measurement of frailty in research and practice and have demonstrated predictive validity in associations with clinical outcomes. However, their construct validity is less well studied. We aimed to assess the construct validity of the VA‐FI, an eFI developed for use in the U.S. Veterans Affairs Healthcare System. Methods: Veterans who underwent comprehensive geriatric assessments between January 31, 2019 and June 6, 2022 at VA Boston and had sufficient data documented for a comprehensive geriatric assessment‐frailty index (CGA‐FI) were included. The VA‐FI, based on diagnostic and procedural codes, and the CGA‐FI, based on geriatrician‐measured deficits, were calculated for each patient. Geriatricians also assessed the Clinical Frailty Scale (CFS), functional status (ADLs and IADLs), and 4‐meter gait speed (4MGS). Results: A total of 132 veterans were included, with median age 81.4 years (IQR 75.8–88.7). Across increasing levels of VA‐FI (<0.2; 0.2–0.4; >0.4), mean CGA‐FI increased (0.24; 0.30; 0.40). The VA‐FI was moderately correlated with the CGA‐FI (r 0.45, p < 0.001). Every 0.1‐unit increase in the VA‐FI was associated with an increase in the CGA‐FI (linear regression beta 0.05; 95% confidence interval [CI] 0.03–0.06), higher CFS category (ordinal regression OR 1.69; 95% CI 1.24–2.30), higher odds of ADL dependency (logistic regression OR 1.59; 95% CI 1.20–2.11), IADL dependency (logistic regression OR 1.68; 95% CI 1.23–2.30), and a decrease in 4MGS (linear regression beta −0.07, 95% CI −0.12 to −0.02). All models were adjusted for age and race, and associations held after further adjustment for the Charlson Comorbidity Index. Conclusion: Our results demonstrate the construct validity of the VA‐FI through its associations with clinical measures of frailty, including summary frailty measures, functional status, and objective physical performance. Our findings complement others' in showing that eFIs can capture functional and mobility domains of frailty beyond just comorbidity and may be useful to measure frailty among populations and individuals. [ABSTRACT FROM AUTHOR]

Background: Frail older adults may be less likely to receive guideline‐directed medical therapy (GDMT)—renin‐angiotensin blockers, beta‐blockers, and mineralocorticoid receptor antagonists—for heart failure with reduced ejection fraction (HFrEF). We aimed to examine the uptake of angiotensin receptor neprilysin inhibitor (ARNI) and GDMT in frail older adults with HFrEF. Methods: Using 2015–2019 Medicare data, we estimated the proportion of beneficiaries with HFrEF receiving ARNI and GDMT each year by frailty status, defined by a claims‐based frailty index. Logistic regression was used to identify clinical characteristics associated with ARNI initiation. Cox proportional hazards regression was used to examine the association of GDMT use in 2015 and death or heart failure hospitalization in 2016–2019. Results: Among 147,506–180,386 beneficiaries with HFrEF (mean age: 77 years; 27% women; 42.6–49.1% frail) in 2015–2019, the proportion of patients receiving ARNI increased in both non‐frail (0.4%–16.4%) and frail (0.3%–13.7%) patients (p for yearly‐trend‐by‐frailty = 0.970). Among those not receiving a renin‐angiotensin system blocker, patients with age ≥ 85 years (odds ratio [95% CI], 0.89 [0.80–0.99]), dementia (0.88 [0.81–0.96]), and frailty (0.87 [0.81–0.94]) were less likely to initiate ARNI. The proportion of patients receiving all 3 GDMT classes increased in non‐frail patients (22.0%–27.0%) but changed minimally in frail patients (19.6%–21.8%). Regardless of frailty status, treatment with at least 1 class of GDMT was associated with lower death or heart failure hospitalization than no GDMT medications (hazard ratio [95% CI], 0.94 [0.91–0.97], 0.92 [0.89–0.94], 0.94 [0.91–0.97] for 1, 2, and 3 classes, respectively). Conclusions: Our results suggest an evidence‐practice gap in the use of ARNI and GDMT in Medicare beneficiaries with HFrEF, particularly those with frailty. Efforts to narrow this gap are needed to reduce the burden of HFrEF in older adults. [ABSTRACT FROM AUTHOR]

In the article, the authors present their study on the trend of beta-blocker doses in various age groups among older people with heart failure with reduced ejection fraction (HFrEF). Also cited are the use of the Medicare Fee-for-Service (FFS0 claims data in the study, and the recommended target doses from the 2013 American College of Foundation/American Heart Association for HF management.

Background: Several validated scales have been developed to measure frailty, yet the direct relationship between these measures and their scores remains unknown. To bridge this gap, we created a crosswalk of the most commonly used frailty scales. Methods: We used data from 7070 community‐dwelling older adults who participated in National Health and Aging Trends Study (NHATS) Round 5 to construct a crosswalk among frailty scales. We operationalized the Study of Osteoporotic Fracture Index (SOF), FRAIL Scale, Frailty Phenotype, Clinical Frailty Scale (CFS), Vulnerable Elder Survey‐13 (VES‐13), Tilburg Frailty Indictor (TFI), Groningen Frailty Indicator (GFI), Edmonton Frailty Scale (EFS), and 40‐item Frailty Index (FI). A crosswalk between FI and the frailty scales was created using the equipercentile linking method, a statistical procedure that produces equivalent scoring between scales according to percentile distributions. To demonstrate its validity, we determined the 4‐year mortality risk across all scales for low‐risk (equivalent to FI <0.20), moderate‐risk (FI 0.20 to <0.40), and high‐risk (FI ≥0.40) categories. Results: Using NHATS, the feasibility of calculating frailty scores was at least 90% for all nine scales, with the FI having the highest number of calculable scores. Participants considered frail on FI (cutpoint of 0.25) corresponded to the following scores on each frailty measure: SOF 1.3, FRAIL 1.7, Phenotype 1.7, CFS 5.3, VES‐13 5.5, TFI 4.4, GFI 4.8, and EFS 5.8. Conversely, individuals considered frail according to the cutpoint of each frailty measure corresponded to the following FI scores: 0.37 for SOF, 0.40 for FRAIL, 0.42 for Phenotype, 0.21 for CFS, 0.16 for VES‐13, 0.28 for TFI, 0.21 for GFI, and 0.37 for EFS. Across frailty scales, the 4‐year mortality risks between the same categories were similar in magnitude. Conclusion: Our results provide clinicians and researchers with a useful tool to directly compare and interpret frailty scores across scales. [ABSTRACT FROM AUTHOR]

Background: Existing models to predict fall‐related injuries (FRI) in nursing homes (NH) focus on hip fractures, yet hip fractures comprise less than half of all FRIs. We developed and validated a series of models to predict the absolute risk of FRIs in NH residents. Methods: Retrospective cohort study of long‐stay US NH residents (≥100 days in the same facility) between January 1, 2016 and December 31, 2017 (n = 733,427) using Medicare claims and Minimum Data Set v3.0 clinical assessments. Predictors of FRIs were selected through LASSO logistic regression in a 2/3 random derivation sample and tested in a 1/3 validation sample. Sub‐distribution hazard ratios (HR) and 95% confidence intervals (95% CI) were estimated for 6‐month and 2‐year follow‐up. Discrimination was evaluated via C‐statistic, and calibration compared the predicted rate of FRI to the observed rate. To develop a parsimonious clinical tool, we calculated a score using the five strongest predictors in the Fine‐Gray model. Model performance was repeated in the validation sample. Results: Mean (Q1, Q3) age was 85.0 (77.5, 90.6) years and 69.6% were women. Within 2 years of follow‐up, 43,976 (6.0%) residents experienced ≥1 FRI. Seventy predictors were included in the model. The discrimination of the 2‐year prediction model was good (C‐index = 0.70), and the calibration was excellent. Calibration and discrimination of the 6‐month model were similar (C‐index = 0.71). In the clinical tool to predict 2‐year risk, the five characteristics included independence in activities of daily living (ADLs) (HR 2.27; 95% CI 2.14–2.41) and a history of non‐hip fracture (HR 2.02; 95% CI 1.94–2.12). Performance results were similar in the validation sample. Conclusions: We developed and validated a series of risk prediction models that can identify NH residents at greatest risk for FRI. In NH, these models should help target preventive strategies. [ABSTRACT FROM AUTHOR]

Background: Although the optimal use of prescribed medications for stroke survivors is critical for preventing secondary stroke, longitudinal observations of the natural course of medication persistence and adherence in Korean stroke survivors are rare. Furthermore, studies are needed to identify strong predictors influencing medication adherence and to determine whether these predictors change over time. Aims and objectives: To evaluate the longitudinal medication persistence and adherence at 3 months and 1 year after discharge in all stroke patients and to identify predictors of long‐term medication adherence in patients who can self‐medicate. Design: A multicentre, prospective, longitudinal descriptive study. Methods: A total of 600 consecutive ischaemic stroke patients were recruited from three stroke centres across Korea, from 1 September, 2017 to 28 February, 2019. Various factors related to medication adherence suggested by the World Health Organisation were investigated through face‐to‐face interviews at each centre during hospitalisation. Medication persistence and adherence were assessed at 3 months and 1 year after discharge using the eight‐item Morisky Medication Adherence Scale through telephone interviews. Results: Of 537 survivors at 3 months, 526 (98.0%) were persistent and 472 (89.7%) were adherent. Of 493 survivors at 1 year, 477 (96.8%) were persistent and 392 (82.2%) were adherent. Medication belief, income and health literacy were statistically significant predictors of three‐month medication adherence, which predicted one‐year medication adherence with older age and low income. Conclusions: Among Korean stroke survivors, three‐month and one‐year medication persistence and adherence were relatively good. Medication beliefs and three‐month medication adherence were important and modifiable factors predicting three‐month adherence and one‐year adherence, respectively. Relevance to clinical practice: To increase long‐term adherence to medication, various strategies are needed to improve beliefs about medication, taking into account the patient's age and level of knowledge. These interventions need to be initiated during hospitalisation to form early medication habits after discharge. [ABSTRACT FROM AUTHOR]

Background: Despite the growing literature on the importance of identifying and managing frailty, its assessment has been limited in clinical settings. With the goal of integrating frailty assessment into routine clinical practice, this quality improvement project aimed to determine the feasibility, acceptability, and utility of administering a telephone‐based frailty assessment. Methods: Between 9/2020 and 6/2021, we identified 169 established patients with serious illnesses in an academic primary care‐geriatric clinic. Patients were contacted via telephone, and their current medical, functional, nutritional, cognitive, and mood statuses were assessed using validated screening tools. A deficit‐accumulation frailty score was then calculated using an electronic medical record‐based frailty index calculator and standardized documentation with recommendations was generated for providers. The primary outcome was feasibility, measured as the proportion of patients successfully assessed. Secondary outcomes included completion rates of each domain, administration time, providers' perception, and clinical utility of the assessment. Results: A total of 139 (82.2%) patients, mean age of 82 years, 63.3% frail were successfully assessed. Of the 139 assessments, medical and functional domains were completed for all, while nutrition, mood, and cognition were completed by 88.5% (n = 123), 68.3% (n = 95), and 59.7% (n = 83) of the time, respectively. Conducting the full assessment took an average (standard deviation) time of 26.1 (7.3) minutes. Without the cognitive and mood domain, assessment took an average of 15.7 (7.5) minutes. Patients' providers found the information from the assessment helpful in evaluating and managing their patients. Care plans of 51.8% and 65.0% of patients who had mobility and mind issues, respectively, addressed these domains within 30 days after the assessment. Conclusion: Implementation of the telephone‐based frailty assessment is feasible, acceptable, and has the potential to influence the care plans of older adults. This work demonstrated how frailty assessment can be integrated with the outpatient setting. [ABSTRACT FROM AUTHOR]

Objective: To understand the association of frailty with females' and males' self-reported sexual functioning. Methods: Logistic regression on 5 domains of sexual function by frailty status (robust, pre-frail, frail) were analyzed from 2058 respondents to National Social Life, Health, and Aging Project (2010–2011). Results: Females had similar frailty profiles to males, but more often reported low overall sexual functioning (12.9% v. 4.0%). Compared to robust, pre-frail and frail males had higher odds of sexual function-related: anxiety (pre-frail OR 1.91 95% CI [1.33, 2.74]; frail OR 2.13 95% CI [1.03, 4.41]), negative changes (pre-frail: OR 1.40, 95% CI [1.00, 1.96]; frail: OR 2.42, 95% CI [1.51, 3.89]), and erectile dysfunction (pre-frail: OR 1.81, 95% CI [1.23,2.68]; frail: 2.00, 95% CI [1.00,4.02]); frail females had 1.69 times higher odds (95% CI [1.16,2.48]) of negative changes. Discussion: Frailty may be a clinical indicator of sexual functioning decline for males more than females. [ABSTRACT FROM AUTHOR]

Poor compliance with medications is a growing concern in geriatric care and is increasingly more relevant among people living with HIV (PLWH) as they age. Our goal was to understand geriatric conditions associated with antiretroviral therapy (ART) nonadherence in a Medicare population of older PLWH. We analyzed Medicare data from PLWH aged 50 years or older who were continuously enrolled in fee-for-service Medicare from January 1, 2014 to June 30, 2015. Prevalent geriatric conditions (dementia, depression, falls, hip fracture, sensory deficits, osteoporosis, orthostatic hypotension, urinary incontinence, frailty) were identified in January 1, 2014–December 31, 2014. ART nonadherence was defined as <80% proportion of days covered (PDC) by at least two ART medications in January 1, 2015–June 30, 2015. We examined geriatric condition association with nonadherence using lowest Akaike Information Criterion multi-variate logistic models, controlling for age, sex, race, census region, substance use, Medicaid eligibility, and polypharmacy. Of 8778 PLWH, 23% (n = 2042) had <80% PDC. The average age was 60 years (standard deviation ±8), and >70% were males. In adjusted models, age was not associated with nonadherence, frailty status was the only geriatric condition associated with nonadherence [robust: reference, prefrail odds ratio (OR): 0.97, confidence interval (95% CI) 0.86–1.10, frail OR: 1.34 95% CI 1.11–1.61], and odds of nonadherence were lower for polypharmacy [OR: 0.48 (0.43–0.54)]. Our findings suggest that patient-centered care plans aimed at improving ART adherence among older PLWH would benefit from long-term surveillance; a deeper understanding of the role of frailty and polypharmacy, even at chronologically younger ages in PLWH. [ABSTRACT FROM AUTHOR]

Both the healthcare and religious landscapes in the United States are rapidly changing. Despite the dynamic environment that spiritual care managers face, many do not receive management training prior to assuming their roles and many receive little or no training once they are in their roles. This study used mixed methods to examine the applicability of the National Center for Healthcare Leadership (NCHL) competency model to spiritual care manager roles. Interviews were conducted with 10 spiritual care managers across the country, using a Behavioral Event Interviewing (BEI) methodology. Interviews were quantitatively analyzed by using Natural Language Processing and qualitatively analyzed by thematic approach using NVIVO. The results found the EXECUTION domain to be the most discussed theme, followed by RELATIONS, TRANSFORMATION, and BOUNDARY SPANNING. Collectively these analyses suggest the NCHL Leadership Competency Model can provide a useful framework for understanding the roles and development needs of spiritual care managers. [ABSTRACT FROM AUTHOR]

Background: Given limited life expectancy of nursing home (NH) residents, harms of continuing beta‐blockers (BBs) may outweigh clinical benefits. Our objective was to describe beta‐blocker discontinuation for NH residents during the last year of life, and identify characteristics associated with earlier discontinuation. Methods: This was a retrospective cohort study that included all long‐stay residents in fee‐for‐service Medicare who died in 2016 and were prescribed oral BBs 1 year before death. Beta‐blocker discontinuation was defined as a gap in medication on hand for ≥45 days per Medicare Part D claims, measured from the last date drug was on hand. Comorbidities were obtained from Chronic Condition Warehouse, and other characteristics from the Minimum Data Set. Kaplan–Meier curves were used to describe time to first discontinuation. Findings were stratified by cardiac diagnoses, perceived life expectancy of <6 months, or elevated mortality index. Results: Eighty‐eight thousand two hundred and eighty‐four residents were prescribed ≥1 daily BB 12 months before death. Mean age was 84.1 years and 69.2% were female. Of these, 60,573 residents (68.6%) remained on a BB in the last 45 days of life, and 57,880 residents (65.6%) had ≥1 cardiac diagnosis. Only 5239 residents (5.9%) had elevated mortality index, whereas 16,798 residents (19.0%) had perceived poor prognosis. In the last year of life, there was no difference in beta‐blocker discontinuation pattern between residents with and without cardiac diagnoses. Residents with perceived poor prognosis and elevated mortality index discontinued BBs earlier. For example, mean time until discontinuation among residents with poor perceived prognosis was 245 versus 279 days in residents without such prognosis (p < 0.0001). Conclusions: BBs are commonly prescribed to NH residents in the final year of life. Overall, discontinuation occurs earlier in residents for whom clinicians perceive limited life expectancy, suggesting that improved prognostication may offer an important opportunity to reduce polypharmacy toward end of life. [ABSTRACT FROM AUTHOR]

Introduction Multicomponent interventions improve physical function and frailty in older adults, but their long-term benefit remains uncertain. Methods This prospective non-randomised study was conducted in 383 older Koreans (mean age, 76.8 years; female 72.3%) who were living alone or receiving medical aid. Of these, 187 individuals chose to receive a 24-week intervention that consisted of group exercise, nutritional supplements, depression management, deprescribing and home hazard reduction. The remaining 196 individuals received usual care. We compared the short physical performance battery (SPPB) score (0–12 points), frailty phenotype scale (0–5 points) and deficit-accumulation frailty index (0–1) at baseline, 6, 18 and 30 months. Results After 1:1 propensity score matching (n  = 117 per group), the mean SPPB scores for the intervention and comparison groups were 7.6 versus 7.6 at baseline, 10.7 versus 7.1 at 6 months (mean difference, 3.5; 95% confidence interval [CI], 2.8–4.2), 9.1 versus 7.8 at 18 months (1.3; 95% CI, 0.6–2.0) and 8.6 versus 7.5 at 30 months (1.1; 95% CI, 0.4–1.8). The intervention group had lower frailty phenotype scale (1.1 versus 1.8; difference, −0.7; 95% CI −1.0 to −0.3) and frailty index (0.22 versus 0.27; difference, −0.04; −0.06 to −0.02) at 6 months, but similar scores at 18 and 30 months. The 30-month mean institutionalisation-free survival time was 28.5 months in the intervention group versus 23.3 months in the comparison group (difference, 5.2 months; 95% CI, 3.1–7.4). Conclusions The 24-week multicomponent intervention showed sustained improvement in physical function, temporary reduction in frailty and longer institutionalisation-free survival over 30 months. [ABSTRACT FROM AUTHOR]

Background/objectives: Restricted mean survival time (RMST) summarizes treatment effect in terms of a gain or loss in the event‐free days. It remains uncertain whether communicating treatment benefit and harm using RMST‐based summary is more effective than conventional summary based on absolute and relative risk reduction. We compared the effect of RMST‐based approach and conventional approach on decisional conflict using an example of intensive versus standard blood pressure‐lowering strategies. Design: On‐line survey. Setting: A convenience sample of patients in the United States. Participants: Two hundred adults aged 65 and older with hypertension requiring anti‐hypertensive treatment (response rate 85.5%). Interventions: Participants were randomly assigned to either RMST‐based summary or conventional summary about the benefit and harm of blood pressure‐lowering strategies. Measurements: Decisional Conflict Scale (DCS), ranging from 0 (no conflict) to 100 (high conflict), and preference for intensive blood pressure‐lowering strategy. Results: Participants assigned to RMST‐based approach (n = 100) and conventional approach (n = 100) had similar age (mean [standard deviation, SD]: 72.3 [5.6] vs 72.8 [5.5] years) and proportions of female (50 [50.0%] vs 61 [61.0%]) and white race (92 [92.0%] vs 92 [92.0%]). The mean (SD) DCS score was 25.2 (15.0) for RMST‐based approach and 25.6 (14.1) for conventional approach (p = 0.84). The number (%) of participants who preferred intensive strategy was 10 (10.0%) for RMST‐based approach and 14 (14.0%) for conventional approach (p = 0.52). The results were consistent in subgroups defined by age, sex, education level, cardiovascular disease status, and predicted mortality risk categories. Conclusion: In a sample of relatively healthy older adults with hypertension, RMST‐based approach was as effective as conventional approach on decisional conflict about choosing a blood pressure‐lowering strategy. This study provides proof‐of‐concept evidence that RMST‐based approach can be used in conjunction with absolute and relative risk reduction for communicating treatment benefit and harm in a decision aid. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The aim of this study was to determine common structural and functional networks associated with asymmetric step length after unilateral ischemic stroke. METHODS: Thirty-nine chronic stroke patients were divided into two groups, based on the presence or absence of asymmetric step length. In each group, each lesion was mapped onto a brain magnetic resonance image. The structural and functional networks of brain regions connected to each lesion were identified using a public diffusion tensor and resting state function magnetic resonance image dataset. To identify brain regions associated with asymmetric step length, we conducted voxel-wise independent sample t-tests for structural and function lesion network maps. RESULTS: At least 85% of lesions showed functional network overlap in the bilateral frontal lobe. Functional connectivity of the dorsolateral prefrontal cortex in the contralesional hemisphere was significantly decreased in group 1 compared to that in group 2. CONCLUSIONS: The dorsolateral prefrontal cortex may have an important role in compensating for an asymmetric step length after a unilateral stroke. [ABSTRACT FROM AUTHOR]

Purpose: Forward head posture is identified as the flexion of the lower cervical spine along with the extension of the upper cervical spine, with an overall increase in the cervical curve. This study aimed to compare the immediate effect of upper-cervical level and cervicothoracic junction level manual therapy on head posture, cervical range of motion and muscle activity of the subjects with forward head posture. Methods: A total 22 subjects with chronic neck pain (numeric pain rating scale >3, forward head posture: cranio-vertebral angle <51°) participated in the study and were randomly allocated into the upper-cervical (n = 11) and cervicothoracic junction (n = 11) groups. Cranio-vertebral angle, cervical range of motion, and electromyography amplitude during performance of the craniocervical flexion test were measured before and immediately after the intervention. Results/findings: There were no significant main effects for the group by time outcome score of craniovertebral angle and electromyography amplitude. However, in the range of motion of the cervical area, the cervicothoracic junction group showed a significant increase in extension and right rotation than the upper-cervical group (p < 0.05). Moreover, in both groups, the electromyography amplitude of the sternocleidomastoid muscle was significantly reduced after intervention. The electromyography amplitude of the anterior scalene muscle in only the cervicothoracic junction group was significantly reduced after intervention (p < 0.05). Conclusion: Cervicothoracic junction manual therapy improved cervical alignment, cervical mobility (extension, rotation), and muscle recruitment ability in subjects with forward head posture. These observations may partially explain the efficacy of this manual therapy in rehabilitation of individuals with mechanical neck disorder (with forward head posture). Forward head posture is identified as the flexion of the lower cervical spine along with the extension of the upper cervical spine, with an overall increase in the cervical curve. Cervicothoracic area manual therapy in subjects with neck pain and forward head posture better improved the muscle recruitment ability than upper cervical area manual therapy during motor tasks. [ABSTRACT FROM AUTHOR]

OBJECTIVES Determine the effects of missing data in frailty identification and risk prediction. DESIGN: Analysis of the National Health in Aging Trends Study. SETTING: Community. PARTICIPANTS: About 6206 older adults. MEASUREMENTS: A 41‐variable frailty index (FI) was constructed with the following domains: comorbidities, activities of daily living (ADLs), instrumental activities of daily living, self‐reported physical limitations, physical performance, and neuropsychiatric tests. We evaluated discrimination after removing single and multiple domains, comparing C‐statistics for predicting 5‐year risk of mortality and 1‐year risks of disability and falls. RESULTS: The full FI yielded a mean of.18 and C‐statistics of.72 (95% confidence interval,.70‐.74) for mortality,.80 (.77‐.82) for disability, and.66 (.64‐.68) for falls. Removal of any single domain shifted the FI distribution, resulting in a mean FI ranging from.13 (removing comorbidities) to.20 (removing ADLs) and frailty prevalence (FI ≥.25) from 16.0% to 28.7%. Among robust participants models missing ADLs misclassified most often, (19% as pre‐frail). Among pre‐frail and frail participants missing comorbidities misclassified most often(69.2% from pre‐frail to robust, 24% from frail to pre‐frail, and 4.9% from frail to robust). Removal of any single domain minimally changed C‐statistics: mortality,.71‐.73; disability,.79‐.80; and falls,.64‐.66. Removing neuropsychiatric testing and physical performance yielded comparable C‐statistics of.70,.78, and.66 for mortality, ADLs, and falls, respectively. However, removal of three or four domains based on likely availability decreased C‐statistics for mortality (.69,.66),disability (.75,.70), and falls (.64,.63), respectively. CONCLUSION: While FI discrimination is robust to missing information in any single domain, risk prediction is affected by absence of multiple domains. This work informs the application of FI as a clinical and research tool. J Am Geriatr Soc 68:1771‐1777, 2020. [ABSTRACT FROM AUTHOR]

Objective: Studies have shown that ozone in an aqueous state on a scar, because of its antibacterial effect, aids wound-healing. This study aimed to compare the pain control effect, based on the time to wound healing, of using a sitz bath with ozonised water with that of using a sitz bath with ordinary tap water in patients who have had a haemorrhoidectomy. Method: Patients were divided into two equal-sized groups: Group O used a sitz bath with ozonised water after haemorrhoidectomy and patients in Group T used a sitz bath with ordinary tap water. Different concentrations (1ppm, 2ppm and 4ppm) of ozonized water were tested to determine their bactericidal activities. Pain levels were measured using the Visual Analogue Scale (ranging from 0–10 where 0 is 'no pain' and 10 is 'unbearable pain'), on days two, three and seven. Cohort analysis was retrospectively performed on the prospectively randomised collected data for this study. Results: A total of 80 patients participated in the study. No case showed any signs of bacterial growth. On postoperative day seven, patients in Group O showed a significantly lower pain level than those in Group T (1.35±0.48 versus 2.40±0.9; p<0.001). The time needed for anus scars to be completely healed was significantly shorter for Group O than that for Group T (2.75±0.63 weeks versus 3.85±0.80 weeks; p<0.001). Conclusion: The results of this study showed that using a sitz bath with ozonised water reduced pain and accelerated healing in patients who have had a haemorrhoidectomy. [ABSTRACT FROM AUTHOR]

Aim We investigated the differences in determinant factors for functional outcomes between patients aged >80 years and those aged <80 years after acute ischemic stroke ( AIS). In particular, we would like to know the differential impacts of initial total cholesterol ( TC) levels between the two groups. Methods We defined a poor outcome as 3-6 modified Rankin Scale 90 days after AIS. Results In the present study, 2772 participants were enrolled. Among them, 374 patients (13.5%) were aged >80 years, and 1061 patients had a poor outcome 90 days after AIS. The proportion was significantly higher in patients aged >80 years than in those aged <80 years after AIS. Regarding factors relating to poor outcomes, previous history of stroke, stroke severity and stroke subtypes of ischemic stroke were independent factors in patients aged <80 years, and the stroke severity and initial TC level independently influenced the outcome for patients aged >80 years. In particular, risk of poor outcome adjusted for age, stroke severity and subtypes of ischemic stroke for patients ( OR [95% CI]) in the first quartile range (≤157 mg%) were 2.21 (1.06-4.62), in the third quartile range (184-210 mg%) 2.76 (1.27-6.01) and in the fourth quartile range (≥211 mg%) 2.75 (1.21-6.24) compared with those in the second quartile range (158-183 mg%) in patients aged >80 years. Conclusions There were also some differences in related factors regarding occurrences of poor outcome between the two groups. In particular, the initial TC level might play a crucial role for the outcome after AIS in the very old population. Geriatr Gerontol Int 2015; 15: 1227-1233. [ABSTRACT FROM AUTHOR]

Objectives To examine whether the benefit of statins varied according to cardiovascular ( CV) and non- CV mortality of the treated population. Design Meta-analysis and meta-regression of 16 randomized placebo-controlled trials. Setting Community and hospital. Participants Statin- (n = 59,671) and placebo-treated (n = 59,707) individuals with and without CV disease (mean age 55 to 75). Measurements Meta-regression was used to model relative risks ( RRs) of major CV events (myocardial infarction and stroke) and total mortality for statins versus placebo as a function of CV and non- CV mortality risks of the study population. Results Every 1% increase in 5-year non- CV mortality risk of the study population was associated with a 3.7% (95% confidence interval ( CI) = 1.2 to 6.3%) greater RR of major CV events and a 4.4% (95% CI = 2.1 to 6.9%) greater RR of total mortality. (Higher RRs indicate smaller benefits.) CV mortality was not associated with statin effects ( P > .05). In stratified analysis according to CV (≥5.3% vs <5.3%) and non- CV mortality (≥3.8% vs <3.8%) of the study population, statins had little mortality benefit in populations with high non- CV mortality, regardless of CV mortality (random-effects pooled RR = 0.81, 95% CI = 0.72 to 0.91, for low CV and low non- CV mortality; random-effects pooled RR = 0.90, 95% CI = 0.76 to 1.06 for low CV and high non- CV mortality; random-effects pooled RR = 0.79, 95% CI = 0.72 to 0.87 for high CV and low non- CV mortality; random-effects pooled RR = 0.94, 95% CI = 0.87 to 1.02 for high CV and high non- CV mortality). The CV event reduction was also attenuated in populations with high non- CV mortality (random-effects pooled RR = 0.67, 95% CI = 0.60 to 0.75, for low CV and low non- CV mortality; random-effects pooled RR = 0.73, 95% CI = 0.66 to 0.81 for low CV and high non- CV mortality; random-effects pooled RR = 0.77, 95% CI = 0.69 to 0.87 for high CV and low non- CV mortality; random-effects pooled RR = 0.83, 95% CI = 0.74 to 0.92 for high CV and high non- CV mortality). Conclusion Benefits of statins may depend on the non- CV mortality risk of the treated population. This should be confirmed using individual-level data. [ABSTRACT FROM AUTHOR]

Objective Obesity is associated with an increased risk of osteoarthritis (OA) of the knee. Emerging evidence suggests that adipokines, substances produced by adipose tissue, may play a role in the development of knee OA. The aim of this study was to determine whether the inflammatory adipokine leptin partially mediates the relationship between body mass index (BMI) and knee OA. Methods We used baseline data from 653 participants who were 70 years of age or older in the population-based Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly Boston Study. Height and weight were measured, and participants were assessed for knee OA using clinical criteria. Serum leptin was measured using a microsphere-based assay. Results The average BMI and the average serum leptin level were 27.5 kg/m2 and 589 p M, respectively; the prevalence of knee OA was 24.7%. In regression models adjusted for covariates, we found that a 5-kg/m2 increase in BMI was associated with 32% increased odds of knee OA (odds ratio [OR] 1.32, 95% confidence interval [95% CI] 1.10, 1.58); a 200-p M increase in serum leptin levels was associated with 11% increased odds of knee OA (OR 1.11, 95% CI 1.05, 1.17). The ratio of the standardized coefficients for the indirect:total effect calculated using the product-of-coefficients method was 0.49, suggesting that approximately half of the total effect of BMI on knee OA may be mediated by serum leptin. The estimated 95% CIs for the mediated effect suggest that this effect is statistically significant. Similarly, mediation analysis using a counterfactual approach suggested that the effect of leptin mediation was statistically significant. Conclusion We found that almost half of the association between elevated BMI and knee OA could be explained by the inflammatory adipokine leptin. [ABSTRACT FROM AUTHOR]

In a prospective cohort of nondisabled adults aged 65 years or more in the Established Populations for Epidemiologic Studies of the Elderly (1981–1987 and 1985–1992), we used a competing risk approach to predict the 5-year risk of severe, persistent activities-of-daily-living (ADLs) disability, defined as dependence in ≥3 ADLs for 2 consecutive annual interviews or for 1 interview followed by death in the subsequent year. During 5 years, 6.8% developed severe, persistent ADL dependence, and 14.6% died without severe, persistent ADL dependence in the derivation cohort (n = 8,301); the corresponding percentages were 6.8% and 15.8% in the validation cohort (n = 4,177). A model based on age, current employment, visual impairment, self-rated health, diabetes mellitus, history of stroke or brain hemorrhage, cognitive function, and self-reported physical function showed good calibration. Discrimination, assessed by C statistics, for <70, 70–74, 75–79, and ≥80 years, was 0.75, 0.74, 0.65, and 0.66 in the derivation cohort and 0.70, 0.72, 0.70, and 0.65 in the validation cohort, respectively. In conclusion, a simple risk score based on routinely available clinical information can predict severe, persistent disability in 5 years. Future studies should examine whether physical performance measures can further improve prediction in the oldest old. [ABSTRACT FROM PUBLISHER]

A letter to the editor is presented in response to an article on rural and urban disparities in frailty and aging-related health conditions in Korea.

Residency specialty choice, a complex decision-making process, is often influenced by confidence level built upon knowledge, experience, and fit with the specialty. Despite the need for physiatrists with population growth, especially people with disability and older patients, limited growth in the number of residency positions and delayed exposure to the field of physical medicine and rehabilitation potentially contribute to a lack of confidence in pursuing physical medicine and rehabilitation. Early introduction to a specialty has been shown to impact specialty selection. Thus, this study aims to explore the impact of timing of exposure to physiatry on the confidence level of physical medicine and rehabilitation residents in their specialty choice. A survey for current physical medicine and rehabilitation residents was developed and distributed to residency program directors with a request to forward it to all residents. The response rate was low at 13%; however, the results provide a window into the experience of today's medical and premedical students. Interestingly, of the 175 respondents, a similar number reported first exposure to physiatry during third year and before medical school. In addition, earlier exposure was associated with higher confidence levels in specialty choice, the most powerful factor being the exposure to the specialty before starting medical school or during the preclinical years in medical school. These findings highlight opportunities to improve the physiatry workforce by providing earlier exposure to the specialty, even before medical school. Based on the results of the survey and ongoing discussions among medical students, residents, and faculty leaders, the authors review current recruitment efforts and new ideas. [ABSTRACT FROM AUTHOR]

Sodium-glucose cotransporter-2 inhibitors (SGLT-2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) offer cardiovascular benefits, whereas thiazolidinediones (TZDs) and sulfonylureas (SUs) increase cardiovascular risk. The objective of this study was to describe the use of SGLT-2is, GLP-1RAs, TZDs, and SUs before and after a heart failure (HF)-related hospitalization in nursing home (NH) residents with type 2 diabetes (T2D). This was a cohort study using a 20% sample of Medicare claims linked with Minimum Data Set resident assessments. The study population was long-stay NH residents with T2D and an HF-related hospitalization between January 1, 2013, and August 31, 2018. For individuals with multiple HF hospitalizations, 1 hospitalization was randomly selected. We ascertained diabetes medications using Medicare Part D claims during the 120 days before and after hospital discharge (or skilled nursing facility discharge, where applicable). We calculated (1) the proportion of study participants who received a medication class of interest during pre- and posthospitalization periods; (2) the proportion of continuous users; and (3) the proportion of posthospitalization users who were new users. A total of 12,990 NH residents with T2D and an HF-related hospitalization were included (mean age 78 years, 66% female, 19% Black). Before hospitalization, 1.5% received TZDs, 14.1% received SUs, 1.2% received GLP-1RAs, and 0.3% received SGLT-2is. Among prehospitalization users of TZDs, SUs, GLP-1RAs, and SGLT-2is, 49%, 62%, 60%, and 40% continued the medications, respectively. Among posthospitalization users of TZDs, SUs, GLP-1RAs, and SGLT-2is, 37%, 10%, 28%, and 11%, respectively, were new users. Among NH residents with hospitalized HF, GLP-1RAs and SGLT-2is were seldom used. TZDs and SUs were still used by many residents with T2D after HF hospitalizations. Barriers may exist in the use of newer diabetes medications to prevent heart failure in NH residents with T2D, which warrants further studies in older adults with multimorbidity. [ABSTRACT FROM AUTHOR]

Risk stratification tools are useful to provide appropriate clinical care for older patients with pneumonia. This study aimed to compare a Frailty Index (FI) with pneumonia severity measures, CURB-65, and the Pneumonia Severity Index (PSI), for predicting mortality and persistent disability after pneumonia. Single-center prospective cohort study. The study included 190 patients aged ≥65 years who were hospitalized with pneumonia at a university hospital in Korea between October 2019 and September 2020. At admission, a 50-item deficit-accumulation FI (range: 0-1), CURB-65 (range: 0-5), and PSI (range: 0-395) scores were calculated. The outcomes were death and a composite outcome of death or decline in ability to perform daily activities and physical task 6 months later. The median age was 79 years (interquartile range: 74-85), and 70 (36.8%) patients were women. The patients who died (n = 53) had higher FI (median, 0.46 vs 0.20; P <.011), CURB-65 score (median, 3 vs 2; P =.001), and PSI score (median, 149 vs 116; P <.001) than those who did not. The C -statistics (95% confidence intervals) for 6-month mortality were 0.69 (0.61-0.77) for the FI, 0.62 (0.53-0.71) for CURB-65, and 0.71 (0.62-0.79) for the PSI (P =.019). The C -statistics for the 6-month composite outcome were 0.73 (0.65-0.81) for the FI, 0.64 (0.55-0.73) for CURB-65, and 0.69 (0.60-0.77) for the PSI (P =.096). The C -statistics improved when the FI was added to CURB-65 (from 0.64 to 0.74; P =.003) and to the PSI (from 0.69 to 0.75; P =.044) for the composite outcome. Measuring frailty provides additive value to widely used pneumonia severity measures in predicting death or persistent hospitalization-associated disability in older adults after pneumonia hospitalization. Early recognition of frailty may be useful to identify those who require in-hospital and post-acute care interventions for functional recovery. [ABSTRACT FROM AUTHOR]

Abstract: Ethnopharmacological relevance: The fruits of Schisandra chinensis (Trucz.) Baill. (Schisandraceae) which have been used as a tonic especially for kidney yin deficiency in Chinese traditional medicine are recently receiving attention for its preventive activity on age-related neurodegenerative diseases. A variety of studies demonstrated the cognitive-enhancing effects of Schisandra chinensis through animal tests and also in clinical trials. Aim of study: In this study, we attempted to investigate the effects of the lignan-riched extract of Schisandra chinensis fruits (ESP-806) on neurotoxicity and memory impairment induced by Aβ1–42 injection in mice. Materials and methods: The fruits of Schisandra chinensis were extracted with the mixture of n-hexane:ethanol (9:1), which is riched with bioactive dibenzocyclooctadiene lignans, schizandrin, gomisin N, wuweigisu C. After oral treatment of ESP-806 (100mg/kg body weight) followed by injection of Aβ1–42 (2μg/mouse, i.c.v.), novel object recognition and passive avoidance tests were evaluated. To verify the cognition enhancing effects of ESP-806, we examined the effects of ESP-806 on the activities of β-secretase and acetylcholinesterase, and the contents of Aβ and the reduced glutathione within the cortex and hippocampus of Aβ-injected mice. Results: Oral treatment of ESP-806 (100mg/kg body weight) significantly attenuated Aβ1–42-induced memory impairment evaluated by behavioral tests. Furthermore, the treatment of ESP-806 attenuated the elevation of β-secretase activity accompanying the reduced level of Aβ1–42 in the cortex and hippocampus of the brain. ESP-806 also significantly inhibited the acetylcholinesterase activity in the hippocampus and increased the content of the reduced glutathione in the cortex and hippocampus of mouse brain. Conclusions: These data suggested that the extract of Schisandra chinensis fruits riched with dibenzocyclooctadiene lignans may be useful in the prevention and treatment of Alzheimer''s disease. [Copyright &y& Elsevier]

To examine functional outcomes of post-acute care for coronavirus disease 2019 (COVID-19) in skilled nursing facilities (SNFs). Retrospective cohort. Seventy-three community-dwelling adults ≥65 years of age admitted for post-acute care from 2 SNFs from March 15, 2020, to May 30, 2020. COVID-19 status was determined from chart review. Frailty was measured with a deficit accumulation frailty index (FI), categorized into nonfrail, mild frailty, and moderate-to-severe frailty. The primary outcome was community discharge. Secondary outcomes included change in functional status from SNF admission to discharge, based on modified Barthel index (mBI) and continuous functional scale scored by physical (PT) and occupational therapists (OT). Among 73 admissions (31 COVID-19 negative, 42 COVID-19 positive), mean [standard deviation (SD)] age was 83.5 (8.8) and 42 (57.5%) were female, with mean FI of 0.31 (0.01) with no differences by COVID-19 status. The mean length of SNF stay for rehabilitation was 21.2 days (SD 11.1) for COVID-19 negative with 20 (64.5%) patients discharged to community, compared to 23.0 (SD 12.2) and 31 (73.8%) among patients who tested positive for COVID-19. Among those discharged to the community, all groups improved in mBI, PT, and OT score. Those with moderate-to-severe frailty (FI >0.35) had lower mBI scores on discharge [92.0 (6.7) not frail, 81.0 (15.4) mild frailty, 48.6 (20.4) moderate-to-severe frailty; P =.002], lower PT scores on discharge [54.2 (3.9) nonfrail, 51.5 (8.0) mild frailty, 37.1 (9.7) moderate-to-severe frailty; P =.002], and lower OT score on discharge [52.9 (3.2) nonfrail, 45.8 (9.4) mild frailty, 32.4 (7.4) moderate or worse frailty; P =.001]. Older adults admitted to a SNF for post-acute care with COVID-19 had community discharge rates and functional improvement comparable to a COVID-19 negative group. However, those who are frailer at admission tended to have lower function at discharge. [ABSTRACT FROM AUTHOR]