Predictors of urinary incontinence in community-dwelling frail older adults with diabetes mellitus in a cross-sectional study.

BACKGROUND: Diabetes mellitus is a potent risk factor for urinary incontinence. Previous studies of incontinence in patients with diabetes have focused on younger, healthier patients. Our objective was to characterize risk factors for urinary incontinence among frail older adults with diabetes mellitus in a real-world clinical setting. METHODS: We performed a cross-sectional analysis on enrollees at On Lok (the original Program for All-Inclusive Care of the Elderly) between October 2004 and December 2010. Enrollees were community-dwelling, nursing home-eligible older adults with diabetes mellitus (N = 447). Our outcome was urinary incontinence measures (n = 2602) assessed every 6 months as "never incontinent", "seldom incontinent" (occurring less than once per week), or "often incontinent" (occurring more than once per week). Urinary incontinence was dichotomized ("never" versus "seldom" and "often" incontinent). We performed multivariate mixed effects logistic regression analysis with demographic (age, gender and ethnicity), geriatric (dependence on others for ambulation or transferring; cognitive impairment), diabetes-related factors (hemoglobin A1c level; use of insulin and other glucose-lowering medications; presence of renal, ophthalmologic, neurological and peripheral vascular complications), depressive symptoms and diuretic use. RESULTS: The majority of participants were 75 years or older (72%), Asian (65%) and female (66%). Demographic factors independently associated with incontinence included older age (OR for age >85, 3.13, 95% CI: 2.15-4.56; Reference: Age <75) and African American or other race (OR 2.12, 95% CI: 1.14-3.93; Reference: Asian). Geriatric factors included: dependence on others for ambulation (OR 1.48, 95% CI: 1.19-1.84) and transferring (OR 2.02, 95% CI: 1.58-2.58) and being cognitively impaired (OR 1.41, 95% CI: 1.15-1.73). Diabetes-related factors associated included use of insulin (OR 2.62, 95% CI: 1.67-4.13) and oral glucose-lowering agents (OR 1.81, 95% CI: 1.33-2.45). Urinary incontinence was not associated with gender, hemoglobin A1c level or depressive symptoms. CONCLUSIONS: Geriatric factors such as the inability to ambulate or transfer independently are important predictors of urinary incontinence among frail older adults with diabetes mellitus. Clinicians should address mobility and cognitive impairment as much as diabetes-related factors in their assessment of urinary incontinence in this population.

EURO-NMD registry: federated FAIR infrastructure, innovative technologies and concepts of a patient-centred registry for rare neuromuscular disorders.

BACKGROUND: The EURO-NMD Registry collects data from all neuromuscular patients seen at EURO-NMD's expert centres. In-kind contributions from three patient organisations have ensured that the registry is patient-centred, meaningful, and impactful. The consenting process covers other uses, such as research, cohort finding and trial readiness. RESULTS: The registry has three-layered datasets, with European Commission-mandated data elements (EU-CDEs), a set of cross-neuromuscular data elements (NMD-CDEs) and a dataset of disease-specific data elements that function modularly (DS-DEs). The registry captures clinical, neuromuscular imaging, neuromuscular histopathology, biological and genetic data and patient-reported outcomes in a computer-interpretable format using selected ontologies and classifications. The EURO-NMD registry is connected to the EURO-NMD Registry Hub through an interoperability layer. The Hub provides an entry point to other neuromuscular registries that follow the FAIR data stewardship principles and enable GDPR-compliant information exchange. Four national or disease-specific patient registries are interoperable with the EURO-NMD Registry, allowing for federated analysis across these different resources. CONCLUSIONS: Collectively, the Registry Hub brings together data that are currently siloed and fragmented to improve healthcare and advance research for neuromuscular diseases.

"Knowing is better": preferences of diverse older adults for discussing prognosis.

BACKGROUND: Prognosis is critical in individualizing care for older adults with late life disability. Evidence suggests that preferences for prognostic information may be culturally determined. Yet little is known about the preferences of diverse elders for discussing prognosis. OBJECTIVE: To determine the preferences for discussing prognosis of a diverse sample of older adults with late-life disability. DESIGN & PARTICIPANTS: We interviewed 60 older adults with mean age 78 and mean 2.5 Activities of Daily Living dependencies. Participants were recruited from San Francisco's On Lok program, the first Program of All-inclusive Care for the Elderly (PACE). Participants were interviewed in English, Spanish, and Cantonese, and responded to scenarios in which their doctors estimated they had 5 years and 1 year left to live. Open-ended questions explored the reasons for their responses. Results were analyzed qualitatively using grounded theory. KEY RESULTS: Sixty-five percent of participants wanted to discuss the prognosis if their doctor estimated they had <5 years to live and 75% if the estimate was <1 year. Three themes were prominent among patients who wanted to discuss prognosis: to prepare, to make the most of the life they had left, and to make medical or health-related decisions. Those who preferred not to discuss prognosis described emotional difficulty, the uncertainty of prognosis, or that it would not be useful. Nearly all participants said that doctors should not make assumptions based on race or ethnicity, though differences between ethnic groups emerged. CONCLUSIONS: Most patients in this diverse sample of disabled elders were interested in discussing prognosis, while a substantial minority was not. Among those participants who preferred to discuss prognosis, many said that prognostic information would be important as they made difficult medical and personal decisions in late-life. Clinicians should inquire about preferences for discussing prognosis before sharing prognostic estimates.

Convergence of patient- and physician-reported outcomes in the French National Registry of Facioscapulohumeral Dystrophy.

BACKGROUND: Facioscapulohumeral muscular dystrophy (FSHD) is among the most prevalent muscular dystrophies and currently has no treatment. Clinical and genetic heterogeneity are the main challenges to a full comprehension of the physiopathological mechanism. Improving our knowledge of FSHD is crucial to the development of future therapeutic trials and standards of care. National FSHD registries have been set up to this end. The French National Registry of FSHD combines a clinical evaluation form (CEF) and a self-report questionnaire (SRQ), filled out by a physician with expertise in neuromuscular dystrophies and by the patient, respectively. Aside from favoring recruitment, our strategy was devised to improve data quality. Indeed, the pairwise comparison of data from 281 patients for 39 items allowed for evaluating data accuracy. Kappa or intra-class coefficient (ICC) values were calculated to determine the correlation between answers provided in both the CEF and SRQ. RESULTS: Patients and physicians agreed on a majority of questions common to the SRQ and CEF (24 out of 39). Demographic, diagnosis- and care-related questions were generally answered consistently by the patient and the medical practitioner (kappa or ICC values of most items in these groups were greater than 0.8). Muscle function-related items, i.e. FSHD-specific signs, showed an overall medium to poor correlation between data provided in the two forms; the distribution of agreements in this section was markedly spread out and ranged from poor to good. In particular, there was very little agreement regarding the assessment of facial motricity and the presence of a winged scapula. However, patients and physicians agreed very well on the Vignos and Brooke scores. The report of symptoms not specific to FSHD showed general poor consistency. CONCLUSIONS: Patient and physician answers are largely concordant when addressing quantitative and objective items. Consequently, we updated collection forms by relying more on patient-reported data where appropriate. We hope the revised forms will reduce data collection time while ensuring the same quality standard. With the advent of artificial intelligence and automated decision-making, high-quality and reliable data are critical to develop top-performing algorithms to improve diagnosis, care, and evaluate the efficiency of upcoming treatments.

In silico prediction of horizontal gene transfer in Streptococcus thermophilus.

A combination of gene loss and acquisition through horizontal gene transfer (HGT) is thought to drive Streptococcus thermophilus adaptation to its niche, i.e. milk. In this study, we describe an in silico analysis combining a stochastic data mining method, analysis of homologous gene distribution and the identification of features frequently associated with horizontally transferred genes to assess the proportion of the S. thermophilus genome that could originate from HGT. Our mining approach pointed out that about 17.7% of S. thermophilus genes (362 CDSs of 1,915) showed a composition bias; these genes were called 'atypical'. For 22% of them, their functional annotation strongly support their acquisition through HGT and consisted mainly in genes encoding mobile genetic recombinases, exopolysaccharide (EPS) biosynthesis enzymes or resistance mechanisms to bacteriophages. The distribution of the atypical genes in the Firmicutes phylum as well as in S. thermophilus species was sporadic and supported the HGT prediction for more than a half (52%, 189). Among them, 46 were found specific to S. thermophilus. Finally, by combining our method, gene annotation and sequence specific features, new genome islands were suggested in the S. thermophilus genome.

Rates of acute care admissions for frail older people living with met versus unmet activity of daily living needs.

OBJECTIVES: To determine whether older people who do not have help for their activity of daily living (ADL) disabilities are at higher risk for acute care admissions and whether entry into a program that provides for these needs decreases this risk. DESIGN: A longitudinal cohort study. SETTING: Thirteen nationwide sites for the Program of All-inclusive Care for the Elderly (PACE). PACE provides comprehensive medical and long-term care to community-living older adults. PARTICIPANTS: Two thousand nine hundred forty-three PACE enrollees with one or more ADL dependencies. MEASUREMENTS: Unmet needs were defined as the absence of paid or unpaid assistance for ADL disabilities before PACE enrollment. Hospital admissions in the 6 months before PACE enrollment and acute admissions in the first 6 weeks and the 7th through 12th weeks after enrollment were determined. RESULTS: Those who lived with unmet ADL needs before enrollment were more likely to have a hospital admission before PACE enrollment (odds ratio (OR) = 1.28, 95% confidence interval (CI) = 1.01-1.63) and an acute admission in the first 6 weeks after enrollment (OR = 1.45, 95% CI = 1.00-2.09) but not after 6 weeks of receiving PACE services (OR = 0.86, 95% CI = 0.53-1.40). CONCLUSION: Frail older people who live without needed help for their ADL disabilities have higher rates of admissions while they are living with unmet ADL needs but not after their needs are met. With state governments under increasing pressure to develop fiscally feasible solutions for caring for disabled older people, it is important that they be aware of the potential health consequences of older adults living without needed ADL assistance.

Draft Genome Sequence of the Biowarfare Simulant Bacillus atrophaeus Strain 930029.

We report here the draft genome sequence of Bacillus atrophaeus strain 930029. Strain 930029 shows evidence of drift, based on a comparison to the corresponding source strain publicly available today.

Risk of hip fracture in disabled community-living older adults.

OBJECTIVES: To determine the rate of hip fracture and risk factors associated with hip fractures in disabled older persons who enroll in the Program of All-Inclusive Care for the Elderly (PACE), a program providing comprehensive care to community-living nursing-home-eligible persons. DESIGN: Prospective cohort study between January 1990 and December 1997. SETTING: The twelve PACE demonstration sites: San Francisco, California; Columbia, South Carolina; Detroit, Michigan; Denver, Colorado; East Boston, Massachusetts; El Paso, Texas; Milwaukee, Wisconsin; Oakland, California; Portland, Oregon; Rochester, New York; Sacramento, California; and the Bronx, New York. PARTICIPANTS: Five thousand one hundred eighty-seven individuals in PACE; mean age 79, 71% female, 49% white, 47% with dementia. MEASUREMENTS: Functional status, cognitive status, demographics, and comorbid conditions were recorded on all the participants, who were tracked for occurrence of a hip fracture. The goals were to determine the rate of hip fracture and identify risk factors. RESULTS: Two hundred thirty-eight hip fractures (4.6%) occurred during follow-up. The rate of hip fracture was 2.2% per person-year. Four independent predictors of hip fracture were identified using Cox proportional hazard analysis: age of 75 and older (adjusted hazard ratio (HR) = 2.0, 95% confidence interval (CI) = 1.4-2.8); white ethnicity (HR = 2.1, 95% CI = 1.6-2.8); ability to transfer independently to and from bed, chair, and toilet (HR = 3.0, 95% CI = 1.2-7.2); and five or more Short Portable Mental Status Questionnaire errors (HR = 1.6, 95% CI = 1.3-2.1). The incidence of hip fracture ranged from 0.5% per person-year in persons with zero to one independent risk factors to 4.7% per person-year in those with all four independent risk factors. CONCLUSIONS: The rate of hip fracture in this cohort of disabled community-living older adults was similar to that reported in nursing home cohorts. Older age, white race, ability to transfer independently, and cognitive impairment were independent predictors of hip fracture. Persons with these risk factors should be targeted for preventive interventions, which should include strategies for making transferring safer.

The last 2 years of life: functional trajectories of frail older people.

OBJECTIVES: To characterize the functional trajectories during the last 2 years of life of patients with progressive frailty, with and without cognitive impairment, and to assess whether it was possible to identify discrete functional indicators that signal the end of life. DESIGN: A retrospective analysis of functional trajectories during the last 24 months of life. SETTING: Twelve demonstration sites of the Program of All-inclusive Care for the Elderly (PACE). PACE cares for frail older people who meet criteria for nursing home placement, with the goal of keeping the patient at home. PARTICIPANTS: Nine hundred seventeen patients who died while enrolled in PACE. MEASURES: At PACE entry and every 3 months thereafter, data were collected about the degree of dependence (none, partial, or full) in bathing, eating, and walking and the degree of incontinence (none, bladder, or bowel). Cognitive impairment was defined as six or more errors on the Short Portable Mental Status Questionnaire. To describe the end-of-life trajectories of patients, data were analyzed from observational windows of time, beginning with the patients' dates of death and extending backward in time to 24 months before death. Each analytical window was 3 months in duration. For each of the functional measures, the probability of functional deterioration in the last 2 years of life in patients with (64%) and without (36%) cognitive impairment was also compared. RESULTS: The mean age at death was 84; 69% of patients were women. For patients with and without cognitive impairment, a prolonged, steady increase in the rates of functional dependence that were evident at least 1 year before death, rather than sudden increases in functional dependence shortly before death, characterized the functional trajectories. It was not possible for any of the four measures to detect a time point before death at which there was an abrupt decline in function likely to signal impending death. For each measure, patients with cognitive impairment declined earlier, were more likely than patients without cognitive impairment to have the maximal level of dependence in the 0- to 3-month window before death (e.g., 56% vs 30% for mobility, P <.001), and were more likely to decline in the 2 years before death (e.g., 56% vs 36% for mobility, P <.001). CONCLUSION: Patients with advanced frailty, with or without cognitive impairment, have an end-of-life functional course marked by slowly progressive functional deterioration, with only a slight acceleration in the trajectory of functional loss as death approaches. Patients with cognitive impairment have particularly high rates of functional impairment at the time of death. These results suggest that end-of-life care systems that are targeted toward patients with functional trajectories clearly suggesting impending death (such as the Medicare hospice benefit) are poorly suited to older people dying with progressive frailty.

Differences in mortality of black and white patients enrolled in the program of all-inclusive care for the elderly.

OBJECTIVES: To examine the relationship between race and mortality in frail community-dwelling older people with access to a program providing comprehensive access and coordination of services. DESIGN: A longitudinal cohort study. SETTING: Twelve nationwide demonstration sites of the Program of All-Inclusive Care for the Elderly (PACE) from 1990 to 1996. PACE provides comprehensive medical and long-term care services for nursing home-eligible older people who live in the community. PARTICIPANTS: Two thousand two white patients and 859 black patients. MEASUREMENTS: Patients were followed after enrollment until death or the end of the follow-up period. Time from enrollment to death was measured with adjustment of the Cox proportional hazards model for comorbid conditions, functional status, site, and other demographic characteristics. RESULTS: Black patients were younger than white patients (mean age 77 vs 80, P <.001) but had worse functional status (mean activity of daily living (ADL) score 6.5 vs 7.2, P <.001) on enrollment. Survival for black and white patients was 88% and 86% at 1 year, 67% and 61% at 3 years, and 51% and 42% at 5 years, respectively (unadjusted hazard ratio (HR) for black patients = 0.77; 95% confidence interval (CI) = 0.67-0.89). After adjustment for baseline comorbid conditions, functional status, site, and demographic characteristics, black patients still had a lower mortality rate (HR = 0.77; 95% CI =.65-0.93). The survival advantage for black patients did not emerge until about 1 year after PACE enrollment (HR for first year after enrollment = 0.97; 95% CI = 0.72-1.31; HR after first year = 0.67; 95% CI = 0.54-0.85, P-value for time interaction <.001). During the first year of enrollment, black patients were more likely to improve and less likely to decline in ADL function than white patients (P <.001). CONCLUSION: In PACE, a system providing access to and coordination of comprehensive medical and long-term care services for frail older people, black patients have a lower mortality rate than white patients. This survival advantage, which emerges approximately 1 year after PACE enrollment, may be related to the comprehensive access and coordination of services provided by the PACE program.

The effects of acute illness on ADL decline over 1 year in frail older adults with and without cognitive impairment.

BACKGROUND: Acute illness may lead to long-term losses in older adults' ability to independently perform activities of daily living (ADLs). The magnitude of these losses may differ for patients with and without cognitive impairment. These relationships have not been described for the frailest of older adults whose high rates of acute illness and cognitive impairment put them at the greatest risk for loss of ADL functioning. METHODS: We conducted a prospective study of 2593 patients enrolled in a nationwide medical and psychosocial program for frail, community-living, nursing home-eligible patients. We determined the independent and interactive effects of baseline cognitive impairment and admission for an acute illness on change in ADL functioning over 1 year. RESULTS: ADL decline over 1 year occurred in 53% of cognitively impaired patients who were admitted for an acute illness, 38% of cognitively impaired patients who were not admitted for an acute illness, 42% of noncognitively impaired patients who were admitted for an acute illness, and 25% of noncognitively impaired patients who were not admitted for an acute illness (p <.001). The amount of additional decline in ADLs associated with an admission for an acute illness was similar between patients with and without cognitive impairment (-.85 vs -.74; p for interaction =.86). Among patients who were admitted for an acute illness, significant decline in ADL functioning occurred only in the quarter surrounding the acute illness with no evidence of recovery in the months after the acute illness episode. CONCLUSIONS: Among frail older adults, loss of ADL functioning over 1 year is independently associated with both acute admission for an acute illness and cognitive impairment. Frail elders, especially those with cognitive impairment, are in need of interventions that reduce the long-term functional consequences of acute illness.

Hospitalizations in the Program of All-Inclusive Care for the Elderly.

OBJECTIVES: To measure the rates of hospitalization, readmission, and potentially avoidable hospitalization (PAH) in the Program of All-Inclusive Care for the Elderly (PACE). DESIGN: Retrospective study. SETTING PACE PARTICIPANTS: PACE enrollees. MEASUREMENTS: Hospitalization and PAH rates were measured per 1,000 person-years. Readmission was defined as any return to the hospital within 30 days of prior hospital discharge. PAHs were defined as hospitalizations for conditions that previously established criteria have identified as possibly preventable or manageable without hospitalization. RESULTS: Rate of hospitalization was 539/1,000, vs 962/1,000 for dually eligible aged or disabled waiver (ADW) enrollees. Thirty-day readmission was 19.3%, compared with 22.9% for the national population of dually eligible older enrollees. PAH rate was 100/1,000, compared with 250/1,000 for dually eligible ADW enrollees. Considerable variation was observed between sites. CONCLUSION: PACE enrollees experienced lower rates of hospitalization, readmission, and PAH than similar populations. Variations in hospitalization rates between PACE sites suggest opportunities for quality improvement.

Every patient is an individual: clinicians balance individual factors when discussing prognosis with diverse frail elderly adults.

BACKGROUND: To explore clinician choice of whether to discuss prognosis with their frail older patients. DESIGN: Qualitative interview study. SETTING: Primary care clinicians were recruited from nursing homes, community-based clinics, and academic medical centers. PARTICIPANTS: Three geriatric nurse practitioners, nine geriatricians, five general internists, and three family medicine physicians with a mean age of 44 and a mean 12 years in practice. Seventeen clinicians had patient panels with 80% or more community-dwelling outpatients, 13 had patient panels with 50% or more patients aged 85 and older, and 16 had patient panels with 25% or more of patients in a minority group (Asian, African American, Hispanic). MEASUREMENTS: Clinicians were asked to describe their practice of discussing long-term (<5-year) and short-term (<1-year and 3-month) prognosis. Responses were analyzed qualitatively using constant comparison until thematic saturation was reached. RESULTS: Clinicians reported individualizing the decision to discuss prognosis with their frail older patients based on clinical circumstances. Common reasons for discussing prognosis included patient had a specific condition with a limited prognosis, to give patients time to prepare, to promote informed medical decision-making, and when patients or families prompted the conversation. Common reasons not to discuss included maintaining hope and avoiding anxiety, cognitive impairment or patient unable to understand prognosis, respect for patients' cultural values, and long-term prognosis too uncertain to be useful. CONCLUSION: Clinicians caring for frail older adults are generally willing to discuss short- but not long-term prognosis. Clinicians balance individual factors when deciding whether to discuss prognosis.

Perceptions of successful aging among diverse elders with late-life disability.

PURPOSE: Researchers often use the term "successful aging" to mean freedom from disability, yet the perspectives of elders living with late-life disability have not been well described. The purpose of this study was to explore the meaning of successful aging among a diverse sample of community-dwelling elders with late-life disability. DESIGN AND METHODS: Using qualitative grounded theory methodology, we interviewed 56 African American, White, Cantonese-speaking Chinese, and Spanish-speaking Latino disabled elders who participate in On Lok Lifeways, a Program of All-inclusive Care for the Elderly. Through semi-structured interviews with open-ended questions, we explored the elders' perceptions of what successful aging and being old meant to them. RESULTS: Despite experiencing late-life disability, most participants felt they had aged successfully. An overarching theme was that aging results in Living in a New Reality, with two subthemes: Acknowledging the New Reality and Rejecting the New Reality. Participants achieved successful aging by using adaptation and coping strategies to align their perception of successful aging with their experiences. Themes were common across race/ethnic groups but certain strategies were more prominent among different groups. IMPLICATIONS: Across race and ethnic groups, most of these participants with late-life disability felt they had aged successfully. Thus, successful aging involves subjective criteria and has a cultural context that is not captured in objective measurements. Understanding elders' perception will help establish common ground for communication between clinicians and elders and identify the most appropriate interventions to help elders achieve and maintain the experience of successful aging.

Quality of life in late-life disability: "I don't feel bitter because I am in a wheelchair".

OBJECTIVES: To determine perceived quality of life in a diverse population of elderly adults with late-life disability. DESIGN: Qualitative cross-sectional study. SETTING: Community-dwelling participants were recruited from San Francisco's On Lok Lifeways program, the first Program of All-inclusive Care for the Elderly. On Lok enrollees meet Medicaid criteria for nursing home placement. PARTICIPANTS: Sixty-two elderly adults with a mean age of 78 and a mean 2.4 activity of daily living dependencies and 6.6 instrumental activity of daily living dependencies were interviewed. Respondents were 63% female, 24% white, 19% black, 18% Latino, 32% Chinese American, and 6% other race. MEASUREMENTS: Elderly adults who scored higher than 17 points on the Mini-Mental State Examination were interviewed. Interviews were conducted in English, Spanish, and Cantonese. Respondents were asked to rate their overall quality of life on a 5-point scale. Open-ended questions explored positive and negative aspects of participants' daily experiences. Interviews were analyzed using modified grounded theory and digital coding software. RESULTS: Eighty-seven percent of respondents rated their quality of life in the middle range of the quality-of-life spectrum (fair to very good). Themes were similar across ethnic groups. Most themes could be grouped into four domains that dependent elderly adults considered important to their quality of life: physical (e.g., pain), psychological (e.g., depression), spiritual or religious (e.g., religious coping), and social (e.g., life-space). Dignity and a sense of control were identified as themes that are the most closely tied to overall quality of life. CONCLUSION: Factors that influence quality of life in late-life disability were similar across ethnic groups. As the number of elderly adults from diverse backgrounds with late life disability increases in the United States, interventions should be targeted to maximize daily sense of control and dignity.

Glycosylated hemoglobin and functional decline in community-dwelling nursing home-eligible elderly adults with diabetes mellitus.

OBJECTIVES: To determine whether glycosylated hemoglobin (HbA1c) levels predict functional decline in older adults. DESIGN: Longitudinal cohort study. PARTICIPANTS: Community-dwelling, nursing home (NH)-eligible individuals with diabetes mellitus enrolled at On Lok between October 2002 and December 2008 (367 participants, 1,579 HbA1c measurements). SETTING: On Lok Lifeways, the original model for Programs of All-Inclusive Care for the Elderly. MEASUREMENTS: The outcomes were functional decline or death at 2 years. The primary predictor was HbA1c. Age, sex, race and ethnicity, baseline function, comorbid conditions, length of time enrolled at On Lok, insulin use, and clustering of HbA1c within participants were adjusted for with mixed-effects Poisson regression. RESULTS: Mean age was 80, and 185 participants (50%) were taking insulin. Sixty-three percent of participants experienced functional decline, and 75% experienced death or functional decline during the study period. At 2 years, higher HbA1c was associated with less functional decline or death (P for trend = .006). Accounting for clustering and confounding factors, HbA1c of 8.0% to 8.9% was associated with a lower likelihood (relative risk = 0.88, 95% confidence interval = 0.79-0.99) of functional decline or death than HbA1c of 7.0% to 7.9%. CONCLUSION: In community-dwelling, NH-eligible individuals with diabetes mellitus, HbA1c of 8.0% to 8.9% is associated with better functional outcomes at 2 years than HbA1c of 7.0% to 7.9%, suggesting that the current American Geriatrics Society guideline recommending a HbA1c target of 8.0% or less for older adults with limited life expectancy may be lower than necessary to maintain function.

The risks and benefits of implementing glycemic control guidelines in frail older adults with diabetes mellitus.

OBJECTIVES: To determine the hypo- and hyperglycemic outcomes associated with implementing the American Geriatrics Society (AGS) guideline for a glycosylated hemoglobin (HbA1c) level of less than 8% in frail older adults with diabetes mellitus (DM). DESIGN: Guideline implementation. SETTING: Program of All-Inclusive Care for the Elderly. PARTICIPANTS: All participants in the before (October 2002-December 2004, n=338), early (January 2005-June 2006, n=289) and late (July 2006-December 2008, n=385) periods of guideline implementation with a diagnosis of DM and at least one HbA1c measurement. INTERVENTION: Clinician education in 2005 with annual monitoring of the proportion of each clinician's patients with DM with HbA1c less than 8%. MEASUREMENTS: Hypoglycemia (blood glucose<50 mg/dL), hyperglycemia (blood glucose>400 mg/dL), and severe hypoglycemia (emergency department (ED) visit for hypoglycemia). RESULTS: Participants in the before, early, and late periods were similar in age, race and ethnicity, comorbidities, and functional dependence. Antihyperglycemic medication use was greater in the late period, with more participants using metformin (28% before, 42% late, P<.001) and insulin (23% before, 34% late, P<.001) and achieving the AGS glycemic target of HbA1c of less than 8% (74% before, 84% late, P<.001). Episodes of hyperglycemia (per 100 person-years) were dramatically lower in the late period (159 before, 46 late, P<.001), and episodes of hypoglycemia were similar (10.1 before, 9.3 late, P=.50). There were more episodes of severe hypoglycemia in the early period (1.1 before, 2.9 early, P=.03). CONCLUSION: Implementing the AGS glycemic control guideline for frail older adults led to fewer hyperglycemic episodes but more severe hypoglycemic episodes requiring ED visits in the early implementation period. Future glycemic control guideline implementation efforts should be coupled with close monitoring for severe hypoglycemia in the early guideline implementation period.

On-site mental health services for PACE (Program of All-inclusive Care for the Elderly) centers.

On Lok Lifeways (On Lok), the original Program of All-inclusive Care for the Elderly (PACE), provides comprehensive health care for over a thousand community-dwelling frail seniors in San Francisco and Fremont, California. Prior to 2005, participants were referred to off-site contracted psychiatrists and psychologists for all mental health services. In 2005, On Lok introduced an on-site mental and behavioral health (MBH) team that included a psychologist, a bilingual psychiatric social worker, and a marriage and family therapist. Two part-time psychiatrists were added to the core team in 2006 and another full-time marriage and family therapist was added in 2008. We report our experience of implementing an on-site MBH program. In particular, we observed quadrupling of the number of appointments to mental health clinicians. There was a reduction in psychiatric inpatient utilization from 129.4 days/1000 patients in 2004 to 27.1 days/1000 patients in 2005. This reduction was sustained in 2006 and 2007 (41.2 and 23.6/1000 patients respectively). Inclusion of mental and behavioral health clinicians on geriatric interdisciplinary teams at On Lok appeared to improve the quality of care we provided by increasing timely access to mental health services, reduced the rate of psychiatric inpatient admissions, and reduced reported anxiety and stress of On Lok interdisciplinary teams caring for elders with mental health diagnoses.