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Background Although slow gait speed is an established risk factor for falls, few studies have evaluated change in gait speed as a predictor of falls or considered variability in effects by cognitive status. Change in gait speed may be a more useful metric because of its potential to identify decline in function. In addition, older adults with mild cognitive impairment are at an elevated risk of falls. The purpose of this research was to quantify the association between 12-month change in gait speed and falls in the subsequent 6 months among older adults with and without mild cognitive impairment. Methods Falls were self-reported every six months, and gait speed was ascertained annually among 2,776 participants in the Ginkgo Evaluation of Memory Study (2000–2008). Adjusted Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for fall risk relative to a 12-month change in gait speed. Results Slowing gait speed over 12 months was associated with increased risk of one or more falls (HR:1.13; 95% CI: 1.02 to 1.25) and multiple falls (HR:1.44; 95% CI: 1.18 to 1.75). Quickening gait speed was not associated with risk of one or more falls (HR 0.97; 95% CI: 0.87 to 1.08) or multiple falls (HR 1.04; 95% CI: 0.84 to 1.28), relative to those with a less than 0.10 m/s change in gait speed. Associations did not vary by cognitive status (pinteraction = 0.95 all falls, 0.25 multiple falls). Conclusions Decline in gait speed over 12 months is associated with an increased likelihood of falls among community-dwelling older adults, regardless of cognitive status. Routine checks of gait speed at outpatient visits may be warranted as a means to focus fall risk reduction efforts.

Background Although older adults living with dementia (OLWD) are at high risk for falls, few strategies that effectively reduce falls among OLWD have been identified. Dementia care partners (hereinafter referred to as “care partners”) may have a critical role in fall risk management (FRM). However, little is known about the ways care partners behave that may be relevant to FRM and how to effectively engage them in FRM. Methods Semi-structured, in-depth interviews were conducted with 14 primary care partners (age: 48–87; 79% women; 50% spouses/partners; 64% completed college; 21% people of colour) of community-dwelling OLWD to examine their FRM behaviours, and their observations of behaviours adopted by other care partners who were secondary in the caring role. Results The analysis of interview data suggested a novel behavioural framework that consisted of eight domains of FRM behaviours adopted across four stages. The domains of FRM behaviours were 1. functional mobility assistance, 2. assessing and addressing health conditions, 3. health promotion support, 4. safety supervision, 5. modification of the physical environment, 6. receiving, seeking, and coordinating care, 7. learning, and 8. self-adjustment. Four stages of FRM included 1. supporting before dementia onset, 2. preventing falls, 3. preparing to respond to falls, and 4. responding to falls. FRM behaviours varied by the care partners’ caring responsibilities. Primary care partners engaged in behaviours from all eight behavioural domains; they often provided functional mobility assistance, safety supervision, and modification of the physical environment for managing fall risk. They also adopted behaviours of assessing and addressing health conditions, health promotion support, and receiving, seeking and coordinating care without realizing their relevance to FRM. Secondary care partners were reported to assist in health promotion support, safety supervision, modification of the physical environment, and receiving, seeking, and coordinating care. Conclusions The multi-domain and multi-stage framework derived from this study can inform the development of tools and interventions to effectively engage care partners in managing fall risk for community-dwelling OLWD.

While many studies have assessed and measured patient attitudes toward deprescribing, less quantitative research has addressed the provider perspective. We thus sought to describe provider knowledge, beliefs, and self-efficacy to deprescribe, with a focus on opioids and sedative-hypnotics.An electronic anonymous survey was distributed to primary care providers at Kaiser Permanente Washington. Two reminder emails were sent. The survey included 10 questions on general deprescribing, and six questions each specific to opioid and sedative-hypnotic deprescribing. Knowledge questions used a multiple-choice response option format. Questions addressing beliefs and self-efficacy (i.e., confidence) used a 0-10 Likert scale. Scales were dichotomized at ≥7 to define agreement (belief questions) or confidence (self-efficacy questions). We calculated descriptive statistics to summarize the responses.Of 370 eligible primary care providers, 95 (26%) completed the survey. For general deprescribing questions, a majority believed that lack of patient willingness, withdrawal symptoms and fear of symptom return, and time constraints impeded deprescribing. Approximately half chose the correct answers about opioid deprescribing, 21% were confident that they could alleviate patient concerns about opioid tapering, and 32% were confident managing chronic non-cancer pain without opioids. For sedative-hypnotics, 64%-87% of respondents correctly answered questions about risks and the relative effectiveness of alternatives, but only one-third correctly answered a question about sedative-hypnotic tapering. Roughly half were confident in their ability to successfully engage patients in sedative deprescribing conversations and select alternatives. Only 54% and 34% were confident in writing a tapering protocol for opioids and sedative-hypnotics, respectively.Results suggest that raising provider awareness of patient willingness to deprescribe, addressing knowledge gaps, and increasing self-efficacy for deprescribing are important targets for improving deprescribing. Support for writing tapering protocols and prescribing evidence-based drug and non-drug alternatives may be important to improve care.

Background: Early mitigation orders for COVID-19 halted participation in community-based programs. We examined the early impact of “Stay Home, Stay Healthy” orders on functioning in older adults participating in a behavioral intervention study involving community-based exercise. Methods: A quasi-natural experiment, using mixed methods ( n = 39). Participants completed interviews and questionnaires after 3–4 weeks of the Stay Home, Stay Healthy directive. PROMIS-29 outcomes were compared to pre-COVID-19 responses. Results: Participants had a mean age of 74.1 (6.5) years, 79.5% were women, and 20.5% were racial/ethnic minorities. Compared to pre-COVID-19, there was a significant increase in anxiety and decrease in fatigue and social participation. Thematic analysis revealed five main themes related to disruption of daily life, the emotional and physical impact of stay-at-home orders, unexpected positive outcomes, and perspectives on messaging surrounding the pandemic. Conclusions: Efforts to curb the spread of COVID-19 have substantially impacted the lives of older adults participating in community-based exercise.

Falls and fall-related injuries are of growing concern among older adults. Use of fall-risk-increasing drugs (FRIDs) is a potentially modifiable risk factor. This narrative review describes randomized controlled trials that focused on interventions to reduce FRID use and examined fall-related outcomes (e.g., falls, fractures, risk of injury) as the primary outcome. A comprehensive literature search was conducted to identify eligible studies. Two reviewers screened titles and abstracts and then performed a full-text review of relevant articles. Each study is summarized, and a discussion of strengths and limitations is provided. 7 of 22 trials were included in this narrative review. Two studies used a computerized decision support intervention, three used a health professional-led (pharmacist or geriatrician) intervention, and two were direct medication withdrawal interventions. Three studies showed a reduction in fall-related outcomes (two identified fall injuries using claims data; one used an injury risk prediction score). Of these, only one reported FRID reduction. Of four studies that did not find a reduction in falls, one study reported a significant reduction in FRIDs, two found no reduction, and one did not report on this outcome. Most interventions consisted of a one-time FRID assessment, and most targeted either providers or patients (not both). Most interventions did not reduce FRID use or change fall-related outcomes. Future studies should test “multi-pronged” intervention strategies that simultaneously target both patients and their providers and include more than a single intervention interaction to reduce this modifiable fall risk factor.

OBJECTIVES To examine: (1) prevalence of fall risk-increasing drug (FRID) use among older adults with a fall-related injury, (2) which FRIDs were most frequently prescribed, (3) whether FRID use was reduced following the fall-related healthcare episode, and (4) which interventions have reduced falls or FRID use in older adults with a history of falls. DESIGN Systematic review. PARTICIPANTS Observational and intervention studies that assessed (or intervened on) FRID use in participants aged 60 years or older who had experienced a fall. MEASUREMENTS PubMed and EMBASE were searched through June 30, 2019. Two reviewers independently extracted data and evaluated studies for bias. Discrepancies were resolved by consensus. RESULTS Fourteen of 638 articles met selection criteria: 10 observational studies and 4 intervention studies. FRID use prevalence at time of fall-related injury ranged from 65% to 93%. Antidepressants and sedatives-hypnotics were the most commonly prescribed FRIDs. Of the 10 observational studies, only 2 used a design adequate to capture changes in FRID use after a fall-related injury, neither finding a reduction in FRID use. Three randomized controlled studies conducted in various settings (hospital, emergency department, and community pharmacy) with 12-month follow-up did not find a reduction in falls with interventions to reduce FRID use, although the study conducted in the community pharmacy setting was effective in reducing FRID use. In a nonrandomized (pre-post) intervention study conducted in an outpatient geriatrics clinic, falls were reduced in the intervention group. CONCLUSIONS Limited evidence indicates high prevalence of FRID use among older adults who have experienced a fall-related injury and no reduction in overall FRID use following the fall-related healthcare encounter. There is a need for well-designed interventions to reduce FRID use and falls in older adults with a history of falls. Reducing FRID use as a stand-alone intervention may not be effective in reducing recurrent falls. J Am Geriatr Soc 68:1334-1343, 2020.

Background Central nervous system (CNS)-active medication use is an important modifiable risk factor for falls in older adults. A fall-related injury should prompt providers to evaluate and reduce CNS-active medications to prevent recurrent falls. We evaluated change in CNS-active medications up to 12 months following a fall-related injury in community-dwelling older adults compared with a matched cohort without fall-related injury. Methods Participants were from the Adult Changes in Thought study conducted at Kaiser Permanente Washington. Fall-related injury codes between 1994 and 2014 defined index encounters in participants with no evidence of such injuries in the preceding year. We matched each fall-related injury index encounter with up to five randomly selected clinical encounters from participants without injury. Using automated pharmacy data, we estimated the average change in CNS-active medication use at 3, 6, and 12 months post-index according to the presence or absence of CNS-active medication use before index. Results One thousand five hundred sixteen participants with fall-related injury index encounters (449 CNS-active users, 1067 nonusers) were matched to 7014 index encounters from people without fall-related injuries (1751 users, 5236 nonusers). Among CNS-active users at the index encounter, those with fall-related injury had an average decrease in standard daily doses (SDDs) at 12 months (-0.43; 95% CI: -0.63 to -0.23), and those without injury had a greater (p = 0.047) average decrease (-0.66; 95% CI: -0.78 to -0.55). Among nonusers at index, those with fall-related injury had a smaller increase than those without injury (+0.17, 95% CI: +0.13 to +0.21, vs. +0.24, 95% CI: +0.20 to +0.28, p = 0.005). Conclusions The differences in CNS-active medication use change over 12 months between those with and without fall-related injury were small and unlikely to be clinically significant. These results suggest that fall risk-increasing drug use is not reduced following a fall-related injury, thus opportunities exist to reduce CNS-active medications, a potentially modifiable risk factor for falls.

Although the prognostic value of physical capacity is well-established, less is known about longitudinal patterns of physical capacity among community-dwelling older adults. We sought to describe long-term trajectories of physical capacity in a nationally representative sample of Medicare beneficiaries.Cohort study SETTING AND PARTICIPANTS: Annually collected data on 6,783 community-dwelling participants in the National Health and Aging Trends Study from 2011 to 2016 were analyzed.Performance-based physical capacity was measured using the Short Physical Performance Battery [(SPPB) range: 0-12, higher is better]. Self-reported physical capacity was measured using six pairs of activities with composite scores from 0 to 12 (higher is better). We then used group-based trajectory modeling to identify longitudinal patterns of each physical capacity measure over 6 years. Associations of baseline characteristics with trajectories were examined using multinomial logistic regression.The cohort was 57% female, 68% white, and 58% were ≥75 years. Six distinct trajectories of SPPB scores were identified. Two "high" groups (n = 2192, 43%) maintained high average SPPB scores. Two "moderate decline" groups (n = 1459, 29%) had a mid-range SPPB score at baseline and demonstrated gradual decline. A "low decline" group (n = 811, 16%) started with a low SPPB score and experienced a greater decline. A "very low" group (n = 590, 12%) had very low SPPB scores in all years. Six trajectories for self-reported physical capacity were also identified. Older age, worse health, lower income and education, and being Black or Hispanic were associated with lower and declining physical capacity.

Objectives To determine the prevalence and impact of common co‐occurring symptoms among community‐dwelling older adults in the United States. Design The National Health and Aging Trends Study is a nationally representative, prospective study with annual data collection between 2011 and 2017. Setting Community‐based, in‐person interviews (survey response rates, 71%–96%). Participants A total of 7,609 community‐dwelling Medicare beneficiaries, 65 years or older. Measurements Symptoms assessed at baseline include pain, fatigue, breathing difficulty, sleeping difficulty, depressed mood, and anxiety. Total symptom count ranged from zero to six. Several outcomes were examined, including grip strength, gait speed, and overall lower‐extremity function as well as incidence of recurrent falls (two or more per year), hospitalization, disability, nursing home admission, and mortality. Results Prevalence of zero, one, two, three, and four or more symptoms was 25.0%, 26.6%, 20.7%, 14.0%, and 13.6%, respectively. Symptom count increased with advancing age and was higher in women than in men. Pain and fatigue were the most common co‐occurring symptoms. Higher symptom count was associated with decreased physical capacity. For example, participants with one, two, three, and four or more symptoms had gait speeds that were 0.04, 0.06, 0.09, and 0.13 m/s slower, respectively, than those with no symptoms, adjusting for specific diseases, total number of diseases, and other potential confounders (P < .001). The risk of several adverse outcomes also increased with greater symptom count. For example, compared with those with no symptoms, the adjusted risk ratios for recurrent falls were 1.48 (95% confidence interval [CI] = 1.30–1.70), 1.54 (95% CI = 1.32–1.80), 1.90 (95% CI = 1.55–2.32), and 2.38 (95% CI = 2.00–2.83) for older adults with one, two, three, and four or more symptoms, respectively. Conclusions Symptoms frequently co‐occur among community‐dwelling older adults and are strongly associated with increased risk of a range of adverse outcomes. Symptoms represent a potential treatment target for improving outcomes and should be systematically captured in health records. J Am Geriatr Soc 67:223–231, 2019.

A third of adults over the age of 65 are estimated to fall at least once a year. Perhaps as dangerous as the fall itself is the time spent after a fall if the person is unable to move. Although there are many devices available to detect when a person has fallen, little is known about the opinions of older adults regarding these fall detection devices (FDDs). We conducted five focus groups with 27 older adults. Transcripts from sessions were coded to generate themes that captured participants’ perceptions. Themes were identified that related to two topics of interest: (a) personal influences on the participants’ desire to have a FDD, including perceived need, participant values, and cost, and (b) participant recommendations regarding specific features and functionalities of these devices such as automation, wearable versus non-wearable devices, and device customization. Together, these themes suggest ways in which FDDs may be improved so that they are suitable for their intended population.

OBJECTIVES: To determine the prevalence of clinically relevant falls-related outcomes according to pain status in older adults in the United States. DESIGN: Cross-sectional analysis of the 2011 National Health and Aging Trends Study, a sample of Medicare enrollees aged 65 and older (response rate 71.0%). SETTING: In-person assessments were conducted in the home or residential care facility of the sampled study participant. PARTICIPANTS: Individuals aged 65 and older (n = 7,601, representing 35.3 million Medicare beneficiaries). MEASUREMENTS: Participants were asked whether they had been "bothered by pain" and the location of pain, as well as questions about balance and coordination, fear of falling, and falls. RESULTS: Fifty-three percent of the participants reported bothersome pain. The prevalence of recurrent falls in the past year (≥ 2 falls) was 19.5% in participants with pain and 7.4% in those without (age- and sex-adjusted prevalence ratio (PR) = 2.63, 95% confidence interval (CI) = 2.28-3.05). The prevalence of fear of falling that limits activity was 18.0% in those with pain and 4.4% in those without (adjusted PR = 3.98, 95% CI = 3.24-4.87). Prevalence of balance and falls outcomes increased with number of pain sites. For example, prevalence of problems with balance and coordination that limited activity was 6.6% in participants with no pain, 11.6% in those with one site of pain, 17.7% in those with two sites, 25.0% in those with three sites, and 41.4% in those with four or more sites (P < .001 for trend). Associations were robust to adjustment for several potential confounders, including cognitive and physical performance. CONCLUSION: Falls-related outcomes were substantially more common in older adults with pain than in those without. Accordingly, pain management strategies should be developed and evaluated for falls prevention.

Purpose of the Study: To examine the components of cost that drive increased total costs after a medical fall over time, stratified by injury severity. DESIGN AND METHODS: We used 2004-2007 cost and utilization data for persons enrolled in an integrated care delivery system. We used a longitudinal cohort study design, where each individual provides 2-3 years of administrative data grouped into 3-month intervals relative to an index date. We identified 8,969 medical fallers through International Classification of Diseases, 9th Revision, codes and E-Codes and used 8,956 nonfaller controls, identified through age and gender frequency matching. Total costs were partitioned into 7 components: inpatient, outpatient, emergency, radiology, pharmacy, postacute care, and "other." RESULTS: The large increase in costs after a hospitalized fall is mainly associated with inpatient and postacute care components. The spike in costs after a nonhospitalized fall is attributable to outpatient and "other" (e.g., ambulatory surgery or community health services) components. Hospitalized fallers' inpatient, emergency, postacute care, outpatient, and radiology costs are not always greater than those for nonhospitalized fallers. IMPLICATIONS: Components associated with increased costs after a medical fall vary over time and by injury severity. Future studies should compare if delivering certain acute and postacute health services improve health and reduce cost trajectories after a medical fall more than others. Additionally, since the older adult population and the problem of falls are growing, health care delivery systems should develop standardized methodology to monitor medical fall rates. Language: en

We assessed knowledge, attitude, and provision of recommended fall prevention (FP) practices by employees of senior-serving organization and participation in FP practices by at-risk elders. The Washington State Department of Health administered structured telephone surveys to 50 employees and 101 elders in Washington State. Only 38% of employees felt “very knowledgeable” about FP, and a majority of their organizations did not regularly offer FP services. Almost half (48%) of seniors sustained a fall within the past 12 months; however, one-third perceived falling to be among their least important health concerns, and most had minimal working knowledge of proven FP practices. Seniors who perceived avoiding falls as important to their well-being were more likely to participate in practices about which they had the least knowledge (risk assessment, medication management). Increased awareness and availability of FP services might help engage older adults in FP practices and reduce the adverse effects of falls.

OBJECTIVES: To compare longitudinal changes in healthcare costs between fallers admitted to the hospital at the time of the fall (admitted), those not admitted to the hospital (nonadmitted), and nonfaller controls; test hypotheses related to differences in mean costs between and within these groups over time; and estimate the costs attributable to falling. DESIGN: Longitudinal cohort. SETTING: Group Health Cooperative of Puget Sound. PARTICIPANTS: Seven thousand nine hundred ninety-three nonadmitted fallers, 976 admitted fallers, and 8,956 nonfallers aged 67 and older enrolled in an integrated healthcare delivery system. Fallers were identified according to fall-related E-Codes and International Classification of Diseases, Ninth Revision codes recorded between January 1, 2004, and December 31, 2006. Nonfallers were frequency matched on age group and sex. MEASUREMENTS: Quarterly costs during a 3-year period were modeled using generalized estimating equations. Covariates included index age, sex, RxRisk (a comorbidity adjuster), fall status, time, and interactions between fall status and time. RESULTS: Cost differences between the faller cohorts and nonfallers were greatest in quarters closest to the fall (all P Language: en

Although multifactorial fall prevention interventions have been shown to reduce falls and injurious falls, their translation into clinical settings has been limited. This article describes a hospital-based fall prevention clinic established to increase availability of preventive care for falls. Outcomes for 43 adults aged 65 and older seen during the clinic's first 6 months of operation were compared with outcomes for 86 age-, sex-, and race-matched controls; all persons included in analyses received primary care at the hospital's geriatrics clinic. Nonsignificant differences in falls, injurious falls, and fall-related healthcare use according to study group in multivariate adjusted models were observed, probably because of the small, fixed sample size. The percentage experiencing any injurious falls during the follow-up period was comparable for fall clinic visitors and controls (14% vs 13%), despite a dramatic difference at baseline (42% of clinic visitors vs 15% of controls). Fall-related healthcare use was higher for clinic visitors during the baseline period (21%, vs 12% for controls) and decreased slightly (to 19%) during follow-up; differences in fall-related healthcare use according to study group from baseline to follow-up were nonsignificant. These findings, although preliminary because of the small sample size and the baseline difference between the groups in fall rates, suggest that being seen in a fall prevention clinic may reduce injurious falls. Additional studies will be necessary to conclusively determine the effects of multifactorial fall risk assessment and management delivered by midlevel providers working in real-world clinical practice settings on key outcomes, including injurious falls, downstream fall-related healthcare use, and costs.

In a pair of randomized controlled trials in the Kaiser Permanente delivery system in Colorado in the 1990s, group visits for older adults (monthly non-disease-specific group medical appointments for a cohort of patients led by primary care teams) were proven to reduce costs, decrease hospitalizations, and improve patient and provider satisfaction. As part of a translational effort, this group visit intervention was replicated in a delivery system in Seattle, Washington, and the log of total healthcare costs was measured in the first year of the intervention. Utilization and patient and physician satisfaction were secondary outcomes. For the cost and utilization analysis, a retrospective case-control design compared 221 case patients aged 65 and older with high outpatient usage in the previous 18 months with 1,015 control patients selected randomly from clinics not participating in the intervention. Controls were matched to cases on the number of primary care visits in the prior 18 months. Total costs were not statistically different for intervention patients and controls ($8,845 vs $10,288, P=.11), nor were there statistically significant differences in utilization, including hospital admissions and outpatient visits, but patient and provider satisfaction with the intervention was high. This translational effort did not demonstrate the cost savings of the original efficacy trials. Possible explanations for these divergent results may have to do with differences between those who participated and differences between the two delivery systems.

Objectives To determine whether outpatient care by fellowship-trained geriatricians is distinguishable from that of generalists caring for older patients.

Optimizing duration of participation in health promotion programs has important implications for program reach and costs. We examine data from 355 participants in EnhanceWellness to determine whether improvements in disability risk factors (depression, physical inactivity) occurred early or late in the enrollment period. Participants had a mean age of 74 years; 76% were women, and 16% were non-White. The percentage depressed declined from enrollment to 6 months (35% to 28%, p = .001) and from 6 to 12 months (28% to 22%, p = .03). The percentage physically inactive declined over the first 6 months, without substantial change thereafter (47%, 29%, and 29%). Those remaining inactive at 6 months had worse self-rated health and more depressive symptoms initially; a subset of those increased their physical activity by 12 months. These data suggest that enrollment could be reduced from 12 to 6 months without compromising favorable effects of EW participation, although additional benefits may accrue beyond 6 months.

OBJECTIVES: To assess the effect of a team of geriatrics specialists on the practice style of primary care providers (PCPs) and the functioning of their patients aged 75 and older. DESIGN: Randomized, controlled trial. SETTING: Two primary care clinics in the Seattle, Washington, area. PARTICIPANTS: Thirty-one PCPs and 874 patients aged 75 and older. INTERVENTION: An interdisciplinary team of geriatrics specialists worked with patients and providers to enhance the geriatric focus of care. MEASUREMENTS: Main outcomes were a practice style reflecting a geriatric orientation and patient scores on the physical and affect subscales of the Arthritis Impact Measurement Scale 2—Short Form. Secondary outcomes were hospitalizations, incident disability in activities of daily living (ADLs), and PCP perceptions of the intervention. Death rates were also assessed. RESULTS: Intervention providers screened significantly more for geriatric syndromes at 12 months, but this finding did not persist at 24 months. There were no significant differences in adequate hypertension control or high-risk prescribing at 12 or 24 months of follow-up. There were no significant differences in patient functioning or significant differences in hospitalization rates at either time point. Meaningful differences were observed in ADL disability at 12 but not 24 months. PCPs viewed the intervention favorably. Seventy-eight participants died over the 24 months of follow-up; the proportion dying was higher in the intervention group (11.4% in intervention group vs 7.1% of controls, P=.03). CONCLUSION: The addition of an interdisciplinary geriatric team was acceptable to PCPs and had some effect on care of geriatric conditions but little effect on patient function or the use of inpatient care and was associated with greater mortality.

OBJECTIVES: To determine whether positive affect, defined as emotional contentment and happiness, remains stable in late life and to identify predictors of longitudinal change in positive affect. DESIGN: Longitudinal observational study. SETTING: Community. PARTICIPANTS: Six hundred sixty-three individuals aged 70 and older without disability at baseline and free of chronically depressed mood. MEASUREMENTS: Positive affect, social network, social activity, chronic health conditions, activities of daily living, instrumental activities of daily living (IADLs), cognitive functioning, and negative affect measured over 54 months, at 18-month intervals, up to four times. RESULTS: Positive affect remained relatively stable over 4.5 years of follow-up. Higher average levels of social activity and lower levels of negative affect were associated with higher positive affect. An increase of 1 point in negative affect (on a 7-point scale) was associated with a 0.23-point concurrent decrease in positive affect (on a 5-point scale). Needing help in an additional IADL was associated with a decrease in positive affect of 0.04 points. A greater number of chronic conditions at enrollment was associated with lower positive affect. CONCLUSION: Positive affect is directly correlated with social involvement and inversely correlated with negative affect, IADL functioning, and comorbidity. Positive affect was mostly related to factors that do not change over time, although it showed some sensitivity to short- and long-term changes in physical health and functioning.

This study examined the effectiveness of participation in EnhanceFitness (EF) (formerly the Lifetime Fitness Program), an established community-based group exercise program for older adults. EF incorporated performance and health status measure testing in year 2000. Initial performance was compared to age and gender-based norms to classify participants as within or at or above normal limits (WNL) or below (BNL). In 2,889 participants who participated in outcomes testing, improvements were observed at 4 and 8 months on performance tests for both subgroups. Participants’ self-rating of health improved at 8 months. All participants improved on performance tests. Implementation of performance-based measures in community studies is possible. Challenges included selecting measures, staff training, collecting performance measures, and deciding on time points for data collection. Older adults can maintain and/or improve physical function through participation in EnhanceFitness.

Objective: To describe challenges in disseminating the Health Enhancement Program (HEP), a community-based disability prevention program for community dwelling elders, and to examine program effectiveness in geographically dispersed sites. Methods: Within-group, pre-test–post-test comparisons of disability risk factors, health and functional status, and hospitalizations for 115 participants completing one year in HEP, and primary care provider awareness and perceptions of the program. Results: Most (77%) participants were women, with an average age of 73 years and an average of 3.5 chronic conditions. At one-year follow-up, compared with enrollment, fewer participants were depressed (8.8% vs 15.9%), physically inactive (15.8% vs 38.6%), at high nutritional risk (24.3% vs 44.1%), or experiencing restricted activity days (35% vs 48%). Severity scores on most measures also improved significantly. The proportion hospitalized was unchanged from the year prior to HEP, although risk factors predicted an increase in hospitalizations as for the control group in the randomized trial. Conclusions: HEP reduced participants’ disability risk factors. Sites varied on numbers enrolled and time to implement the program, likely due to differing referral bases, degree of physician awareness of HEP, and site readiness. However, the benefits of HEP participation were comparable with those reported previously.

Author(s): Phelan, Elizabeth A; Williams, Barbara; LaCroix, Andrea Z; Grothaus, Lou; LoGerfo, James P; Wagner, Edward H | Abstract: ObjectivesTo examine provider determinants of new-onset disability in basic activities of daily living (ADLs) in community-dwelling elderly.DesignObservational study.SettingKing County, Washington.ParticipantsA random sample of 800 health maintenance organization (HMO) enrollees aged 65 and older participating in a prospective longitudinal cohort study of dementia and normal aging and their 56 primary care providers formed the study population.MeasurementsIncident ADL disability, defined as any new onset of difficulty performing any of the basic ADLs at follow-up assessments, was examined in relation to provider characteristics and practice style using logistic regression and adjusting for case-mix, patient and provider factors associated with ADL disability, and clustering by provider.ResultsNeither provider experience taking care of large numbers of elderly patients nor having a certificate of added qualifications in geriatrics was associated with patient ADL disability at 2 or 4 years of follow-up (adjusted odds ratio (AOR) for experience=1.29, 95% confidence interval (CI)=0.81-2.05; AOR for added qualifications=0.72, 95% CI=0.38-1.39; results at 4 years analogous). A practice style embodying traditional geriatric principles of care was not associated with a reduced likelihood of ADL disability over 4 years of follow-up (AOR for prescribing no high-risk medications=0.56, 95% CI=0.16-1.94; AOR for managing geriatric syndromes=0.94, 95% CI=0.40-2.19; AOR for a team care approach=1.35, 95% CI=0.66-2.75).ConclusionTaking care of a large number of elderly patients, obtaining a certificate of added qualifications in geriatrics, and practicing with a traditional geriatric orientation do not appear to influence the development of ADL disability in elder, community dwelling HMO enrollees.

Objectives: To determine whether older adults have thought about aging and aging successfully and to compare their perceptions of successful aging with attributes of successful aging identified in the published literature. Design: A cross-sectional, mailed survey. Setting: King County, Washington. Participants: Nondemented participants from two cohorts. The first cohort, referred to as Kame, which means turtle, a symbol of longevity for Japanese, enrolled 1,985 Japanese Americans aged 65 and older and was established in 1992–94. The second cohort, Adult Changes in Thought, enrolled 2,581 white men and women aged 65 and older from a health maintenance organization and was established in 1994–96. Measurements: Respondents were asked whether they had ever thought about aging and aging successfully and whether these thoughts had changed over the previous 20 years and about how important specific attributes, originating from the published literature, were in characterizing successful aging. Results: Overall, 90% had previously thought about aging and aging successfully, and approximately 60% said their thoughts had changed over the previous 20 years. The Japanese-American group rated 13 attributes as important to successful aging; the white group rated the same 13 as important and added one additional attribute, learning new things. Conclusion: Older adults' definition of successful aging is multidimensional, encompassing physical, functional, psychological, and social health. In contrast, none of the published work describing attributes of successful aging includes all four dimensions. Future work would benefit from an expanded definition to adequately reflect the perceptions of older adults.

PURPOSE To determine the safety and feasibility of using Nintendo Wii Fit exergames to improve balance in older adults. METHODS Seven older adults aged 84 (5) years with impaired balance (Berg Balance Scale [BBS] score < 52 points) were recruited from 4 continuing care retirement communities to participate in a single group pre- and postevaluation of Wii Fit exergames. Participants received individualized instructions (at least 5 home visits) on playing 4 exergames (basic step, soccer heading, ski slalom, and table tilt) and were asked to play these games in their homes at least 30 minutes 3 times per week for 3 months and received weekly telephone follow-up. They also completed a paper log of their exergame play and rated their enjoyment immediately after each session. Participants completed the BBS, 4-Meter Timed Walk test, and the Physical Activity Enjoyment Scale at baseline and 3 months. Semistructured interviews were conducted at the 3-month evaluation. RESULTS Participants safely and independently played a mean of 50 sessions, median session duration of 31 minutes. Two of the games were modified to ensure participants' safety. Participants rated high enjoyment immediately after exergame play and expressed experiencing improved balance with daily activities and desire to play exergames with their grandchildren. Berg Balance Scores increased from 49 (2.1) to 53 (1.8) points (P = .017). Walking speed increased from 1.04 (0.2) to 1.33 (0.84) m/s (P = .018). CONCLUSIONS Use of Wii Fit for limited supervised balance training in the home was safe and feasible for a selected sample of older adults. Further research is needed to determine clinical efficacy in a larger, diverse sample and ascertain whether Wii Fit exergames can be integrated into physical therapy practice to promote health in older adults.

Objective. To investigate motivational factors and barriers to participating in fall risk assessment and management programs among diverse, low-income, community-dwelling older adults who had experienced a fall.Methods. Face-to-face interviews with 20 elderly who had accepted and 19 who had not accepted an invitation to an assessment by one of two fall prevention programs. Interviews covered healthy aging, core values, attributions/consequences of the fall, and barriers/benefits of fall prevention strategies and programs.Results. Joiners and nonjoiners of fall prevention programs were similar in their experience of loss associated with aging, core values they expressed, and emotional response to falling. One difference was that those who participated endorsed that they “needed” the program, while those who did not participate expressed a lack of need.Conclusions. Interventions targeted at a high-risk group need to address individual beliefs as well as structural and social factors (transportation issues, social networks) to enhance participation.

For the past 4 decades, many studies seeking to develop a definition and identify critical determinants of successful aging have been published. To date, there is still no consensus on a standard definition or measure of “successful aging.” Most constructs have been one dimensional; although a few have been multidimensional, none has emerged as standard. The most serious limitation of contemporary successful aging constructs is the undue focus on physiologic aspects of aging. To move beyond this limited perspective that stresses disease and impairment, we postulate that successful aging may coexist with diseases and functional limitations if compensatory psychological and/or social mechanisms are used. With this premise, this article presents a new definition and conceptual framework of successful aging, together with an operational definition (measurement) that delineates our successful aging concept. We discuss how the proposed multidimensional measurement may be used as a screening tool, and address its relevance for health services research and health care delivery. (J Am Med Dir Assoc 2009; 10: 87–92) Keyword: Successful aging concept

Family caregiving is prevalent and may have adverse impacts on health, particularly for elder caregivers who tend to have chronic health conditions which need ongoing self-management. Interventions that empower family caregivers to take care of themselves are needed. This study examined the impact on caregivers of participation in a self-care skill-building, self-efficacy enhancing, community-based program called powerful tools for caregiving (PTC). We assessed health-risk behaviors, self-care, and psychological well-being among 118 adult caregivers who participated in PTC in western Washington state between July 2001 and June 2004, about half of whom were aged 65 or older. Health-risk behaviors were reduced and self-care and psychological well-being improved significantly, overall and for each stratum of age (> or =65 years of age versus

Background. Disability in basic activities of daily living (ADLs) implies a loss of independence and increases the risk for hospitalization, nursing home admission, and death. Little is known about ways by which ADL disability can be prevented or reversed. The authors evaluated the efficacy of the Health Enhancement Program in preventing and reducing ADL disability in community-dwelling older adults. Methods. The authors analyzed data from a 12-month, randomized, single-blinded, controlled trial of a disability prevention, chronic disease self-management program involving 201 adults aged 70 years and older that was conducted from February 1995 to June 1996 at a senior center in western Washington state. Activities of daily living disability incidence, improvement, and worsening were assessed using intention-to-treat methods. Results. The cumulative incidence of ADL disability among those who were not ADL disabled at baseline (n = 56 in the intervention group, n = 57 in the control group) was modestly lower in the intervention group than in the control group at 12 months (14.3% vs 21.3%, p =.466). Cumulative improvement in ADL function among those who reported any ADL disability at baseline (n = 41 in the intervention group, n = 43 in the control group) was greater in the intervention group at 12 months (80.5% vs 46.5%, p = .026). The likelihood for ADL improvement was greater in the intervention group compared with controls at 12 months (adjusted hazard ratio, 1.84; 95% confidence interval, 1.05 to 3.22; p = .020). Cumulative worsening of ADL function was slightly lower in the intervention group at 12 months (18.6% vs 26.5%, p = .237). Intervention participants tended to be at lower risk for ADL worsening (adjusted hazard ratio, 0.71; 95% confidence interval, 0.38 to 1.30; p = .266) compared with control participants. Conclusion. The Health Enhancement Program intervention led to improved ADL functioning in those who were disabled initially and thereby offers a promising strategy for limiting or reversing functional decline in disabled elderly persons.

Objectives: To assess the influence of education on the association between apolipoprotein E and cognitive change. Design: Prospective cohort. Participants: HMO-based sample of 2168 non-demented community-dwelling elderly followed over 6 years. Measurements: Generalized estimating equations were used with the difference between baseline and follow-up cognitive abilities screening instrument (CASI) as the outcome variable. Results: At follow-up, 6% of the sample had a decline of 1.5 S.D. or greater on the CASI. Compared to individuals without an APOE4 allele, individuals with a single APOE4 allele did not have greater CASI decline. By contrast, individuals with two APOE4 alleles experienced greater decline in cognitive performance and the magnitude of that decline decreased as years of educational attainment increased. These relationships held after adjusting for age, gender, ethnicity, depression, diabetes, and history of vascular disease. Conclusion: Lower education was associated with steep 4-year cognitive decline for APOE4 homozygotes but not for APOE4 heterozygotes. Potentially modifiable host factors such as education could influence the association of high-risk genotypes and cognitive decline.

OBJECTIVES: We previously found in an efficacy trial that a health promotion program prevented functional decline and reduced hospitalizations in community-dwelling older people with chronic conditions. We sought to evaluate the effectiveness of the program in its dissemination phase. DESIGN: Outcome evaluation using a within-group, pretest-posttest design. SETTING: Fourteen senior centers located throughout western Washington. PARTICIPANTS: Three hundred four community-dwelling men and women aged 65 and older. INTERVENTION: A disability-prevention, chronic disease–self-management program. MEASUREMENTS: Participant characteristics, risk factors for disability, change in health and functional status, and healthcare use over 1 year of enrollment; participant satisfaction. RESULTS: Participants were 71% female, had a mean age of 76, and reported three chronic health conditions on average. The percentage of participants found to be depressed decreased (28% at time of enrollment vs 17% at 1-year follow-up, P = .005). The percentage of physically inactive participants decreased (56% vs 38%, P = .001). Physical activity level and exercise readiness improved (Physician-based Assessment and Counseling for Exercise mean score 4.3 vs 5.1, P = .001). At follow-up, 83% rated their health the same as or better than a year ago, compared with 73% at time of enrollment. The proportion with impaired functional status, as measured by bed days and restricted activity days, stayed the same. The proportion hospitalized remained stable (23% at enrollment and follow-up, P = 1.0). CONCLUSIONS: Under real world conditions, the Health Enhancement Program reaches older people at risk of functional decline. Those enrolled for 1 year experience a reduction in disability risk factors, improvement in health status, no decrements in functional status, and no increase in self-reported healthcare use.