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The study attempts to evaluate and compare the efficacy of advanced dementia using Advanced Dementia Prognostic Tool (ADEPT) as against Hospice Eligibility guidelines in predicting the 6-month survival of nursing home residents with advanced dementia. The results indicate that ADEPT was significantly better than hospice eligibility guidelines in predicting dementia rate, though moderately.

The study aims to evaluate the relationship between chronic musculoskeletal pain and the occurrence of falls in the elderly. The results indicate that properly measured chronic pain was associated with an increased risk of falls in older adults.

A study was conducted to investigate the clinical course of residents with advanced dementia in a nursing home. Results indicated that those with dementia suffered from frequent complications like pneumonia, febrile episodes and eating problems, which tended to result in high mortality rates within 6 months.

Background. This study was designed to evaluate the benefits of INVEST (Increased Velocity Specific to Task) training on limb power and mobility among mobility-limited older adults. Methods. We conducted a single blinded, randomized controlled trial among 138 mobility-limited community-dwelling older adults, evaluating two 16-week supervised exercise programs. The intervention group participated in InVEST training, and the control group participated in the National Institute on Aging's (NIA) strength training program. Primary outcomes were changes in limb power per kilogram and mobility performance as measured by the Short Physical Performance Battery (SPPB). Results. After 16 weeks, INVEST produced significantly greater improvements in limb power than NIA (p = .02). There was no significant difference in strength improvements. Both groups had significant changes in SPPB of greater than 1 unit. Self-reported function was also significantly improved in both groups. Differences between groups were not statistically different. In a post hoc analysis when participants were categorized by the manifestation of baseline leg velocity impairments (N = 68), INVEST training produced effect size differences in SPPB that were clinically meaningful (SPPB Group x Time difference 0.73 units, p = .05). Conclusions. Among mobility-limited older adults, both NIA and INVEST produce robust changes in observed physical performance and self-reported function. These improvements were not meaningfully different by statistical or clinical criteria. Compared with NIA, INVEST training produced greater improvements in limb power and equivalent improvements in strength. Observed differences between NIA and INVEST based upon baseline leg impairment status are informative for futures studies. Key Words: Exercise--Rehabilitation--Mobility--Muscle power--Task performance.

Background. Little is known about the terminal trajectories of functional decline among long-term care (LTC) residents dying with different diseases. Methods. A retrospective cohort study was performed on 747 individuals aged 65 or older who died between January 1994 and December 2004 in a 675-bed LTC facility in Massachusetts. Three study groups were created: advanced dementia, n = 314 (42%); terminal cancer, n = 63 (8%); and organ failure (congestive heart failure and chronic obstructive pulmonary disease), n = 370 (50%). Quarterly scores of 7 activities of daily living (ADLs) during the last year of life derived from the Minimum Data Set were compared among the three groups. Each activity was rated from 0 to 4 (higher scores indicate more dependence; total range, 0-28). Results. The mean age of all individuals at death was 91 [+ or -] 6 (standard deviation) years. Functional decline was greatest during the last 3 months of life, but this decline was most precipitous in the terminal cancer and organ failure groups compared to the advanced dementia group. The mean change in ADL scores during the last year of life differed among the three groups (p < .001), with the greatest decline in the terminal cancer group (from initial score 13 to final score 25), followed by the organ failure group (13 to 22), and finally, the advanced dementia group (24 to 27). Conclusions. The terminal trajectories of functional decline among LTC residents vary by underlying diseases. An understanding of these trajectories may be useful to clinicians and families caring for LTC residents near the end of life.

Background. Delirium is common among hospitalized elders and may persist for months. Therefore, the adverse impact of delirium on independence often occurs in the postacute care (PAC) setting. The effect of psychomotor subtypes on delirium remains uncertain. The purpose of this study is to examine the association between psychomotor activity delirium subtypes and l-year mortality among 457 newly admitted delirious PAC patients. Methods. Patients were screened for delirium on admission to PAC facilities after an acute hospitalization, and patients with 'Confusion Assessment Method'-defined delirium were enrolled. Psychomotor activity was assessed using the Memorial Delirium Assessment Scale, and patients were classified as to their delirium subtype (hyperactive, hypoactive, mixed, or normal). One-year mortality data were obtained from the National Death Index. A Kaplan-Meier survival analysis and a proportional hazards analysis using indicator (dummy) variables with normal psychomotor activity as the referent were performed. Results. The normal psychomotor activity group had the lowest 1-year mortality rate, followed by the hyperactive, mixed, then hypoactive groups in increasing order. Independent of age, gender, comorbidity, dementia, and delirium severity, hypoactive patients were 1.60 (95% confidence interval [CI], 1.09-2.35) times more likely to die during the l-year follow-up period than were patients with normal psychomotor activity. The hyperactive (hazard ratio = 1.30; 95% CI, 0.73-2.31 ) and mixed (hazard ratio = 1.25; 95% CI, 0.72-2.17) psychomotor groups had nonsignificant elevated risks relative to the normal psychomotor behavior group. Conclusions. All three psychomotor disturbance subtypes had an elevated risk of dying during the 1-year follow-up relative to the normal psychomotor group, though the hypoactive group had the highest mortality risk and was the only group with a statistically significantly elevated risk relative to the normal group.

Background. The objective of this study was to determine if level of educational attainment, a marker of cognitive reserve, was associated with the cumulative risk of delirium among hospitalized elders. Methods. We performed a secondary analysis of two hospital-based studies. The first (study 1) was an observational study involving 491 admissions. The second study (study 2) involved consecutive admissions assigned to the usual care condition in a controlled clinical trial, and included 461 persons. All participants were elderly (aged 70+) and free from delirium at admission. The outcome was the occurrence of delirium, as rated by the Confusion Assessment Method during hospitalization. Results. In study 1 and 2, 22% and 14% of persons developed delirium (cumulative incidence), respectively. In both studies, risk of delirium was higher among persons with fewer years of education. Controlling for the effect of age, sex, dementia, comorbidity, and severity of illness, each year of completed education was associated with a 0.91 lower odds of delirium (95% confidence interval: 0.87, 0.95): compared to persons with 12 years of education, persons with 7 years of education had 1.6-fold increased odds of delirium (95% confidence interval: 1.4, 2.0). Conclusion. Hospitalized older persons with low educational attainment are at increased risk for delirium relative to persons with more education. This finding may have implications for the role of cognitive reserve in characterizing individual differences in risk for delirium.

Background. Delirium is common among hospitalized elders and may persist for months. The adverse impact of delirium on independence may increasingly occur in the postacute care (PAC) setting. The purpose of this study is to examine the association between delirium resolution and functional recovery in skilled nursing facilities specializing in PAC. Methods. Patients were screened for delirium on admission after an acute hospitalization at PAC facilities. Only patients with 'Confusion Assessment Method'-defined delirium were enrolled. Delirium and activities of daily living were assessed prehospital, at PAC admission, and at four (2-week, and 1-, 3-, and 6-month) follow-up assessments to measure functional ability. Four distinct delirium resolution groups were created ranging from resolution within 2 weeks without recurrence to no resolution over 6 months. Repeated-measures analysis of covariance was used to determine if functional performance differed over time by delirium resolution slaws. Results. Among the 393 PAC patients, functional recovery differed significantly (p < .0001) by delirium resolution status. Patients who resolved their delirium by 2 weeks without recurrence regained 100% of their prehospital functional level, whereas patients who never resolved their delirium retained less than 50% of their prehospital functional level. Patients with slower resolving delirium and recurrent delirium had intermediate functional outcomes. Conclusions. Resolution of delirium among PAC patients appears to be a prerequisite for functional recovery. Delirium resolution within 2 weeks without recurrence is associated with excellent functional recovery. Effective strategies to resolve delirium promptly and prevent its recurrence in the PAC setting will likely benefit patient rehabilitation and functional recovery.

Background, Lower limb muscle power impairments are modifiable factors underlying mobility limitations in older adults. This study examined relationships between upper and lower limb muscle power and their role in predicting mobility performance among community-dwelling older adults. Methods. A cross-sectional analysis was conducted. Participants included 37 mobility-limited adults (24 women, 13 men), aged 65 to 93 years. Measures included upper (elbow extension) and lower limb (double leg press) one repetition maximum (IRM), and muscle power at both 40% and 70% one repetition maximum. Physical performance measures included stair climb time, the Short Physical Performance Battery, and 4-meter walk time. Factors commonly mediating the relationship between impairments and physical performance were analyzed as covariates. Results. Participants had a mean age of 76 years, had five chronic medical conditions, and manifested moderate mobility limitations. Although the associations between the upper and lower limbs were strong (p < .001), the magnitude of association was greater for power (r = .88-.89) as compared to strength (r = .69). Multivariate regression analyses revealed consistently strong relationships between limb muscle power and mobility performance measures. Substituting upper for lower limb power within these models did not materially weaken the relationships. Conclusion. Muscle power appears to be a more generalized attribute between the upper and lower limbs than is muscle strength, suggesting that mechanisms underlying velocity of movement, as opposed to force production, may be important factors underlying muscle power in elderly persons. Additionally, upper limb muscle power measures may serve as a useful surrogate measure of limb power having implications for clinicians and researchers.

The factors associated with 6-month mortality in newly admitted nursing home residents with advanced dementia are identified and a practical risk score to predict 6-month mortality in this population is created. Results found a risk score based on 12 variables from the Minimum Data Set (MDS) estimates 6-month mortality for nursing home residents with advanced dementia with greater accuracy than existing prognostic guidelines.

Background. Delirium is costly, common, and may persist for weeks or months. Therefore, the adverse impact of delirium on loss of independence may occur in the post-acute setting rather than in the hospital. The purpose of this study is to describe the rate of delirium persistence and identify baseline patient characteristics that are associated with delirium persistence at 1 month among newly admitted post-acute facility patients who were admitted with delirium. Methods. Patients were recruited from 4 Boston area skilled nursing facilities specializing in post-acute care (PAC). Assessment instruments included the Confusion Assessment Method Diagnostic Algorithm, the modified Delirium Symptom Interview, the Memorial Delirium Assessment Scale (MDAS), and the Blessed Dementia Rating Scale (BDRS). Multiple logistic regression analyses were used to identify patient characteristics associated with delirium persistence (at 1 month). Results. Nearly 51% of the 85 delirious patients enrolled in this study had delirium at their 1-month follow-up assessment. Four patient factors associated with delirium persistence were identified: older age ([greater than or equal to] 85 years), severe delirium at PAC admission (MDAS score > 15), prehospital cognitive impairment based on proxy report [BDRS], and the presence of all 8 modified Delirium Symptom Interview symptoms at PAC admission. Our model has very good predictive power (area under the receiver operating characteristic = 0.85). Conclusions. Delirium is persistent in the post-acute setting. If verified in further research, the risk factors found in this study could be used to identify patients who are likely to have delirium after 1 month, and may prove useful in developing and targeting interventions of care.

Background. In a clinical study evaluating the functioning of mobility-limited elders, muscle power accounted for more of the variation in function than strength did. There was also evidence that the power-function relationship may be described as curvilinear. However, these findings have never been confirmed in a representative population. Methods. An analysis was conducted using data from the InCHIANTI study, a population-based cohort of 1032 adults living in Italy. To assess the relationships between impairments in power and strength and mobility performance, we created separate multivariate linear and log-transformed regression models as well as separate logistic regression models. Results. Subjects were age [greater than or equal to] 65 years, predominately female (54%), with a mean age of 74.2 years, and most had mild-moderate mobility limitations (Short Physical Performance Battery score 10.5 [+ or -] 2.1). Though leg extension power and isometric hip extension strength were closely associated, in several separate multivariate linear regression models, leg power consistently explained more of the variance than strength did in several measures of physical performance. Differences were even larger when observed in curvilinear models of power and strength. Using separate multivariate logistic regression models to examine the odds ratios for mobility limitations in persons with low muscle power versus high muscle power, and in persons with low muscle strength versus high muscle strength, we found that both factors influenced risk for mobility limitations, but low power was associated with a 2-3-fold greater likelihood than low strength. Conclusion. These findings identified muscle power to be a more influential proximal determinant of physical performance than impairments in strength and emphasized muscle power as an important determinant of mobility skills in older adults.

Background. Delirium may persist for weeks or months, and discharging elderly patients quickly from acute care facilities is not uncommon. Therefore, the adverse impact of delirium on loss of independence may occur in the postacute setting rather than in the hospital. The purpose of this study is to describe the prevalence of delirium, delirium symptoms, and severity assessed at admission to postacute facilities. Methods. Subjects were recruited from seven Boston-area skilled nursing facilities specializing in postacute care. Assessment instruments included the Mini-Mental Status Exam, Delirium Symptom Interview, Memorial Delirium Assessment Scale, and Confusion Assessment Method (CAM) Diagnostic Algorithm. Delirium status was categorized into four groups: full, two or more symptoms, one symptom, and no delirium. Descriptive statistics were calculated and chi-square analyses and an analysis-of-variance were used to examine delirium characteristics by delirium group. Results. Among 2158 subjects, approximately 16% had full CAM-defined delirium at admission to the postacute facility. In addition, nearly 13% of the subjects had two or more symptoms of delirium, approximately 40% had one delirium symptom, and 32% had no symptoms of delirium. In a comparison of the group with no symptoms of delirium with that with CAM-defined delirium, there was a significant trend toward (a) older age, (b) lower scores on the Mini-Mental Status Exam, (c) more Delirium Symptom Interview symptoms, and (d) higher Memorial Delirium Assessment Scale Scores. Conclusions. Results indicate that 16% of admissions to postacute facilities have CAM-defined delirium, and over two thirds had at least one delirium symptom. It is not known whether or not postacute staff have the training necessary to detect or manage delirium. Managing delirium may require different strategies and techniques in a postacute setting, thereby requiting further research.

Background. The 6-minute walk (6mw) is a well-established measure of aerobic capacity in elders with cardiorespiratory and peripheral vascular disease and may be an accurate measure of functional performance in healthy elders. In mobility-limited elders, a population at risk for disability, impairments in strength and power are predictive of performance-based measures of function. Though commonly utilized as an outcome measure among otherwise healthy mobility-limited elders, it is not clear whether the 6mw best represents a measure of functional limitation, aerobic capacity, or both. Methods. We hypothesized that the 6mw would be strongly representative of performance-based measures of function being determined by impairments in muscle strength and power. We performed a cross-sectional analysis of 45 community-dwelling elders with mild to moderate mobility limitations. Results. The 6mw was strongly associated with established functional measures (r = .61-.83; p < .001), but was poorly associated with indirect measures of aerobic capacity (r < .25; p > .05). Multivariate linear regression models demonstrated that impairments in leg strength and power, especially those at the knee and ankle, were predictive of 6mw performance. Conclusions. These findings emphasize the 6mw as a measure of functional limitation among mobility-limited elders without cardiorespiratory or peripheral vascular disease.