Handgrip Strength Asymmetry and Weakness Are Associated With Future Morbidity Accumulation in Americans.

ABSTRACT: Klawitter, L, Vincent, BM, Choi, BJ, Smith, J, Hammer, KD, Jurivich, DA, Dahl, LJ, and McGrath, R. Handgrip strength asymmetry and weakness are associated with future morbidity accumulation in americans. J Strength Cond Res 36(1): 106-112, 2022-Identifying strength asymmetries in physically deconditioned populations may help in screening and treating persons at risk for morbidities linked to muscle dysfunction. Our investigation sought to examine the associations between handgrip strength (HGS) asymmetry and weakness on accumulating morbidities in aging Americans. The analytic sample included 18,506 Americans aged ≥50 years from the 2006-2016 Health and Retirement Study. Handgrip strength was measured on each hand with a handgrip dynamometer, and persons with an imbalance in strength >10% between hands had HGS asymmetry. Men with HGS <26 kg and women with HGS <16 kg were considered as weak. Subjects reported the presence of healthcare provider-diagnosed morbidities: hypertension, diabetes, cancer, chronic lung disease, cardiovascular disease, stroke, arthritis, and psychiatric problems. Covariate-adjusted ordinal generalized estimating equations analyzed the associations for each HGS asymmetry and weakness group on future accumulating morbidities. Of those included in our study, subjects at baseline were aged 65.0 ± 10.2 years, 9,570 (51.7%) had asymmetric HGS, and 996 (5.4%) were weak. Asymmetry alone and weakness alone were associated with 1.09 (95% confidence interval [CI]: 1.04-1.14) and 1.27 (CI: 1.11-1.45) greater odds for future accumulating morbidities, respectively. Having both HGS asymmetry and weakness was associated with 1.46 (CI: 1.29-1.65) greater odds for future accumulating morbidities. Handgrip-strength asymmetry, as another potential indicator of impaired muscle function, is associated with future morbidity status during aging. Exercise professionals and related practitioners should consider examining asymmetry and weakness with handgrip dynamometers as a simple and noninvasive screening method for helping to determine muscle dysfunction and future chronic disease risk.

Hospital-specific Template Matching for Benchmarking Performance in a Diverse Multihospital System.

BACKGROUND: Hospital-specific template matching is a newer method of hospital performance measurement that may be fairer than regression-based benchmarking. However, it has been tested in only limited research settings. OBJECTIVE: The objective of this study was to test the feasibility of hospital-specific template matching assessments in the Veterans Affairs (VA) health care system and determine power to detect greater-than-expected 30-day mortality. RESEARCH DESIGN: Observational cohort study with hospital-specific template matching assessment. For each VA hospital, the 30-day mortality of a representative subset of hospitalizations was compared with the pooled mortality from matched hospitalizations at a set of comparison VA hospitals treating sufficiently similar patients. The simulation was used to determine power to detect greater-than-expected mortality. SUBJECTS: A total of 556,266 hospitalizations at 122 VA hospitals in 2017. MEASURES: A number of comparison hospitals identified per hospital; 30-day mortality. RESULTS: Each hospital had a median of 38 comparison hospitals (interquartile range: 33, 44) identified, and 116 (95.1%) had at least 20 comparison hospitals. In total, 8 hospitals (6.6%) had a significantly lower 30-day mortality than their benchmark, 5 hospitals (4.1%) had a significantly higher 30-day mortality, and the remaining 109 hospitals (89.3%) were similar to their benchmark. Power to detect a standardized mortality ratio of 2.0 ranged from 72.5% to 79.4% for a hospital with the fewest (6) versus most (64) comparison hospitals. CONCLUSIONS: Hospital-specific template matching may be feasible for assessing hospital performance in the diverse VA health care system, but further refinements are needed to optimize the approach before operational use. Our findings are likely applicable to other large and diverse multihospital systems.

Self-Reported Dementia-Related Diagnosis Underestimates the Prevalence of Older Americans Living with Possible Dementia.

BACKGROUND: Dementia screening is an important step for appropriate dementia-related referrals to diagnosis and treat possible dementia. OBJECTIVE: We sought to estimate the prevalence of no reported dementia-related diagnosis in a nationally representative sample of older Americans with a cognitive impairment consistent with dementia (CICD). METHODS: The weighted analytical sample included 6,036,224 Americans aged at least 65 years old that were identified as having a CICD without history of stroke, cancers, neurological conditions, or brain damage who participated in at least one-wave of the 2010-2016 Health and Retirement Study. The adapted Telephone Interview of Cognitive Status assessed cognitive functioning. Those with scores≤6 were considered as having a CICD. Healthcare provider dementia-related diagnosis was self-reported. Age, sex, educational achievement, and race and ethnicity were also self-reported. RESULTS: The overall estimated prevalence of no reported dementia-related diagnosis for older Americans with a CICD was 91.4%(95%confidence interval (CI): 87.7%-94.1%). Persons with a CICD who identified as non-Hispanic black had a high prevalence of no reported dementia-related diagnosis (93.3%; CI: 89.8%-95.6%). The estimated prevalence of no reported dementia-related diagnosis was greater in males with a CICD (99.7%; CI: 99.6%-99.8%) than females (90.2%; CI: 85.6%-93.4%). Moreover, the estimated prevalence of no reported dementia-related diagnosis for non-high school graduates with a CICD was 93.5%(CI: 89.3%-96.1%), but 90.9%(CI: 84.7%-94.7%) for those with at least a high school education. CONCLUSION: Dementia screening should be encouraged during routine geriatric health assessments. Continued research that evaluates the utility of self-reported dementia-related measures is also warranted.

The Associations of Handgrip Strength and Leg Extension Power Asymmetry on Incident Recurrent Falls and Fractures in Older Men.

BACKGROUND: Evaluating asymmetries in muscle function could provide important insights for fall risk assessments. We sought to determine the associations of (i) handgrip strength (HGS) asymmetry and (ii) leg extension power (LEP) asymmetry on risk of incident recurrent falls and fractures in older men. METHOD: There were 5 730 men with HGS asymmetry data and 5 347 men with LEP asymmetry data from the Osteoporotic Fractures in Men (MrOS) study. A handgrip dynamometer measured HGS and a Nottingham Power Rig ascertained LEP. Percent difference in maximal HGS between hands was calculated, and asymmetric HGS was defined as men in the highest quartile of dissimilarity for HGS between hands. The same approach was used to determine asymmetric LEP. Participants self-reported falls every 4 months after the baseline exam, and persons with ≥2 falls in the first year were considered recurrent fallers. Fractures and their dates of occurrence were self-reported and confirmed with radiographic reports. RESULTS: Older men in the highest HGS asymmetry quartile had a 1.20 (95% confidence interval [CI]: 1.01-1.43) relative risk for incident recurrent falls. Likewise, men in the highest HGS asymmetry quartile had a higher risk for incident fractures: 1.41 (CI: 1.02-1.96) for hip, 1.28 (CI: 1.04-1.58) for major osteoporotic, and 1.24 (CI: 1.06-1.45) for nonspine. There were no significant associations between LEP asymmetry and recurrent falls or fractures. CONCLUSIONS: Asymmetric HGS could be a novel risk factor for falls and fractures that is more feasible to measure than LEP. Fall risk assessments should consider evaluating muscle function, including HGS asymmetry.

Getting better or getting by?: A qualitative study of in-hospital cardiac arrest survivors long-term recovery experiences.

In the United States, approximately 292,000 adults (>18 years old) per year suffer an in-hospital cardiac arrest (IHCA). Survival rates have increased over the last decade and many survivors return to their communities. IHCA has been recognized as a unique disease entity because the arrest happens in a medical care setting and survivors often have more medical co-morbidities. Although more individuals are surviving IHCA, very little is known about their long-term recovery experiences. Semi-structured interviews with 19 IHCA survivors were conducted to better understand their recovery experiences and identify strategies of adaptation that they felt aided their recovery. Thematic analysis indicated that IHCA survivors experience ongoing challenges to recovery. Reconceptualization of independence was necessary for some participants to re-engage in social and physical activities and a few were able to engage in new activities. Our findings suggest that IHCA survivors often develop their own strategies for adaptation in order to continue participation in their social lives and that their recovery experiences are ongoing. Intervention programs and follow-up care should continuously ask survivors what is important to them and identify resources that will support their goals. Questions should include physical, cognitive, psychological and social goals that extend beyond those specifically related to IHCA since our findings indicate that the effects of IHCA are long-lasting and encompass all aspects of survivors' lives.

Sleeping time is associated with functional limitations in a national sample of older Americans.

BACKGROUND: Engaging in healthy behaviors may help to preserve function during aging; however, it is not well understood how sleeping time is associated with functional capacity in older adults. AIMS: We sought to determine the association of sleeping time on functional limitation in a national sample of older Americans. METHODS: The analytical sample included 6020 adults aged at least 65 years who participated in the 2007-2016 waves of the National Health and Nutrition Examination Survey. Respondents indicated their hours of sleep/weeknight and were categorized as < 5, 5-6.5, 7-8, 8.5-9, and > 9 h of sleep/weeknight. Ability to complete 19 functional tasks including basic activities of daily living, instrumental activities of daily living, leisure and social activities, lower extremity mobility activities, and general physical activities were also self-reported. A covariate-adjusted logistic model analyzed the associations between each sleeping time category and functional limitation. RESULTS: Relative to those reporting 7-8 h of sleep/weeknight, older Americans reporting < 5, 5-6.5, 8.5-9, and > 9 h of sleep/weeknight had 1.66 [95% confidence interval (CI): 1.05, 2.62], 1.25 (CI: 1.02, 1.52), 1.59 (CI: 1.19, 2.12), and 2.99 (CI: 1.96, 4.56) greater odds for functional limitation, respectively. DISCUSSION: Sleep should be recognized as a health factor that may reflect functional capacity in older adults. Healthcare providers should discuss the importance of optimal sleep with their older patients and older adults should practice healthy sleeping behaviors for preserving function. CONCLUSIONS: Not meeting optimal sleep recommendations is associated with functional limitations in older Americans.

Handgrip Strength Asymmetry and Weakness Together Are Associated With Functional Disability in Aging Americans.

BACKGROUND: Evaluating handgrip strength (HGS) asymmetry may help to improve the prognostic value of HGS. This study sought to determine the associations of HGS asymmetry and weakness on future activities of daily living (ADL) disability in a national sample of aging Americans. METHODS: The analytic sample included 18,468 Americans aged ≥50 years from the 2006-2016 waves of the Health and Retirement Study. A handgrip dynamometer measured HGS. Those with HGS >10% stronger on either hand were considered as having any HGS asymmetry. Individuals with HGS >10% stronger on their dominant hand were considered as having dominant HGS asymmetry, while those with HGS >10% stronger on their nondominant hand were classified as having nondominant HGS asymmetry. Men with HGS <26 kg and women with HGS <16 kg were considered weak. ADLs were self-reported. Generalized estimating equations were used for analyses. RESULTS: Relative to those with symmetric HGS and no weakness, each HGS asymmetry and weakness group had increased odds for future ADL disability: 1.11 (95% confidence interval [CI]: 1.02-1.20) for any HGS asymmetry alone, 1.42 (CI: 1.16-1.74) for weakness alone, and 1.81 (CI: 1.52-2.16) for both any HGS asymmetry and weakness. Most weakness and HGS asymmetry dominance groups had increased odds for future ADL disability: 1.30 (CI: 1.13-1.50) for nondominant HGS asymmetry alone, 1.42 (CI: 1.16-1.74) for weakness alone, 1.72 (CI: 1.29-2.29) for both weakness and nondominant HGS asymmetry, and 1.86 (CI: 1.52-2.28) for both weakness and dominant HGS asymmetry. CONCLUSIONS: HGS asymmetry and weakness together may increase the predictive utility of handgrip dynamometers.

Seroprevalence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection among Veterans Affairs healthcare system employees suggests higher risk of infection when exposed to SARS-CoV-2 outside the work environment.

OBJECTIVE: The seroprevalence of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) IgG antibody was evaluated among employees of a Veterans Affairs healthcare system to assess potential risk factors for transmission and infection. METHODS: All employees were invited to participate in a questionnaire and serological survey to detect antibodies to SARS-CoV-2 as part of a facility-wide quality improvement and infection prevention initiative regardless of clinical or nonclinical duties. The initiative was conducted from June 8 to July 8, 2020. RESULTS: Of the 2,900 employees, 51% participated in the study, revealing a positive SARS-CoV-2 seroprevalence of 4.9% (72 of 1,476; 95% CI, 3.8%-6.1%). There were no statistically significant differences in the presence of antibody based on gender, age, frontline worker status, job title, performance of aerosol-generating procedures, or exposure to known patients with coronavirus infectious disease 2019 (COVID-19) within the hospital. Employees who reported exposure to a known COVID-19 case outside work had a significantly higher seroprevalence at 14.8% (23 of 155) compared to those who did not 3.7% (48 of 1,296; OR, 4.53; 95% CI, 2.67-7.68; P < .0001). Notably, 29% of seropositive employees reported no history of symptoms for SARS-CoV-2 infection. CONCLUSIONS: The seroprevalence of SARS-CoV-2 among employees was not significantly different among those who provided direct patient care and those who did not, suggesting that facility-wide infection control measures were effective. Employees who reported direct personal contact with COVID-19-positive persons outside work were more likely to have SARS-CoV-2 antibodies. Employee exposure to SARS-CoV-2 outside work may introduce infection into hospitals.

Handgrip Weakness and Asymmetry Independently Predict the Development of New Activity Limitations: Results from Analyses of Longitudinal Data from the US Health and Retirement Study.

OBJECTIVES: Examining strength asymmetries in assessments of muscle function may improve screenings for limitations in independent living tasks such as instrumental activities of daily living (IADL). We sought to determine the associations between handgrip strength (HGS) asymmetry and future IADL limitations in aging Americans. DESIGN: Longitudinal panel. SETTING AND PARTICIPANTS: Secondary analyses of data from participants aged at least 50 years from the 2006-2016 waves of the Health and Retirement Study. The analytic sample included 18,235 Americans who identified hand dominance and had measures of HGS for both hands in a single wave. METHODS: Hand dominance was self-reported, and a handgrip dynamometer measured HGS on each hand. The highest HGS values on each hand were used to calculate the HGS asymmetry ratio: (nondominant HGS/dominant HGS). Individuals with HGS asymmetry ratio <0.80 or >1.20 had HGS asymmetry. Persons with HGS asymmetry ratio <0.80 had dominant HGS asymmetry, whereas participants with HGS asymmetry ratio >1.20 had nondominant HGS asymmetry. Persons with HGS asymmetry ratio <1.0 also had their ratio inversed to make all HGS asymmetry ratios ≥1.0. IADL were self-reported. Covariate-adjusted generalized estimating equations were used for the analyses. RESULTS: Participants with HGS asymmetry had 1.12 [95% confidence interval (CI): 1.03-1.20] greater odds for future IADL limitations. Each HGS asymmetry dominance group also had greater odds for future IADL limitations: 1.09 (CI: 1.01-1.18) for individuals with dominant HGS asymmetry and 1.29 (CI: 1.09-1.52) for persons with nondominant HGS asymmetry. Every 0.10 increase in inverted HGS asymmetry ratio was associated with 1.30 (CI: 1.07-1.57) greater odds for future IADL limitations. CONCLUSIONS AND IMPLICATIONS: Assessing HGS asymmetry, as another potential biomarker of impaired muscle function, may provide novel insights for predicting IADL limitations. Future research should continue examining how strength asymmetries, and other aspects of muscle function beyond maximal strength, factor into the disabling cascade.

Handgrip Strength Asymmetry and Weakness May Accelerate Time to Mortality in Aging Americans.

OBJECTIVES: Assessing handgrip strength (HGS) asymmetry may provide insights into HGS as a prognostic assessment of strength capacity and vitality. This study sought to determine the associations of HGS asymmetry and weakness on time to mortality in aging Americans. DESIGN: Longitudinal panel. SETTING: Secondary analyses of data from participants aged ≥50 years from the 2006‒2014 waves of the Health and Retirement Study. PARTICIPANTS: The analytic sample included 19,325 Americans who identified hand dominance and had measures of HGS for both hands in a single wave. MEASURES: A handgrip dynamometer was used to measure HGS. Men and women who were considered weak had HGS <26 kg and <16 kg, respectively. The highest HGS values from the dominant and nondominant hands were used to calculate HGS ratio: (nondominant HGS/dominant HGS). Those with HGS ratio <0.90 or >1.10 had any HGS asymmetry. Moreover, participants with HGS ratio <0.90 had dominant HGS asymmetry, whereas those with HGS ratio >1.10 had nondominant HGS asymmetry. The National Death Index and postmortem interviews verified date of death. Covariate-adjusted Cox models were used for analyses. RESULTS: Those with any HGS asymmetry had a 1.10 [95% confidence interval (CI) 1.03‒1.17] higher hazard for mortality, while those with weakness had a 1.44 (CI 1.32‒1.58) higher hazard for mortality. Likewise, participants with dominant HGS asymmetry had a 1.11 (CI 1.03‒1.18) higher hazard for mortality, and those with weakness had a 1.45 (CI 1.32‒1.58) higher hazard for mortality; however, the association was not significant for those with nondominant HGS asymmetry (hazard ratio: 1.07; CI 0.96‒1.18). CONCLUSIONS AND IMPLICATIONS: HGS asymmetry and weakness are markers of impaired strength capacity that independently accelerate time to mortality, but the magnitude of these associations was more prominent for weakness. Nevertheless, assessments of asymmetric HGS are a simple adjunct analysis that may show promise for increasing the prognostic value of handgrip dynamometers.

Developing a template matching algorithm for benchmarking hospital performance in a diverse, integrated healthcare system.

Template matching is a proposed approach for hospital benchmarking, which measures performance based on matching a subset of comparable patient hospitalizations from each hospital. We assessed the ability to create the required matched samples and thus the feasibility of template matching to benchmark hospital performance in a diverse healthcare system.Nationwide Veterans Affairs (VA) hospitals, 2017.Observational cohort study.We used administrative and clinical data from 668,592 hospitalizations at 134 VA hospitals in 2017. A standardized template of 300 hospitalizations was selected, and then 300 hospitalizations were matched to the template from each hospital.There was substantial case-mix variation across VA hospitals, which persisted after excluding small hospitals, hospitals with primarily psychiatric admissions, and hospitalizations for rare diagnoses. Median age ranged from 57 to 75 years across hospitals; percent surgical admissions ranged from 0.0% to 21.0%; percent of admissions through the emergency department, 0.1% to 98.7%; and percent Hispanic patients, 0.2% to 93.3%. Characteristics for which there was substantial variation across hospitals could not be balanced with any matching algorithm tested. Although most other variables could be balanced, we were unable to identify a matching algorithm that balanced more than ∼20 variables simultaneously.We were unable to identify a template matching approach that could balance hospitals on all measured characteristics potentially important to benchmarking. Given the magnitude of case-mix variation across VA hospitals, a single template is likely not feasible for general hospital benchmarking.

Statin discontinuation and new antipsychotic use after an acute hospital stay vary by hospital.

INTRODUCTION: Patients are at risk for medication problems after hospital admissions, particularly those with critical illness. Medication problems include continuation of acute medications and discontinuation of chronic medications after discharge. Little is known across a national integrated health care system about the extent of these two medication problems. OBJECTIVE: To examine the extent of statin medication discontinuation and new antipsychotic medication use after hospital discharge. DESIGN: Retrospective cohort study. SETTING: Veterans Affairs healthcare system. PARTICIPANTS: Veterans with an inpatient hospitalization from January 1, 2014-December 31, 2016, survived at least 180 days post-discharge, and received at least one medication through the VA outpatient pharmacy within one year around admission were included. Hospitalizations were grouped into: 1) direct admission to the intensive care unit (ICU) and a diagnosis of sepsis, 2) direct admission to the ICU without sepsis diagnosis, and 3) no ICU stay during the hospitalization. MAIN OUTCOME MEASURES: Statin medication discontinuation and new antipsychotic use at six months post-hospital discharge. RESULTS: A total of 520,187 participants were included in the statin medication and 910,629 in the antipsychotic medication cohorts. Statin discontinuation ranged from 10-15% and new antipsychotic prescription fills from 2-4% across the three hospitalization groups, with highest rates in the ICU admission and sepsis diagnosis group. Statin discontinuation and new antipsychotic use after a hospitalization varied by hospital, with worse performing hospitals having 11% higher odds of discontinuing a statin (median odds ratio at hospital-level, adjusted for patient differences, aMOR: 1.11 (95% CI: 1.09, 1.13)) and 29% higher odds of new antipsychotic use (aMOR, 1.29 (95% CI: 1.24, 1.34)). Risk-adjusted hospital rates of these two medication changes were not correlated (p = 0.49). CONCLUSIONS: Systemic variation in the rates of statin medication continuation and new antipsychotic use were found.

Absolute and Body Mass Index Normalized Handgrip Strength Percentiles by Gender, Ethnicity, and Hand Dominance in Americans.

BACKGROUND: Gender and ethnicity are factors which influence strength, and hand dominance could be a critical component of handgrip strength (HGS) testing. Providing such HGS percentiles across the lifespan may help to identify weakness-related health concerns. We sought to generate growth charts and curves for HGS by gender and ethnicity in a nationally-representative sample of Americans aged 6-80 years. METHODS: Data from 13,617 participants in the 2011-2012 and 2013-2014 waves of the National Health and Nutrition Examination Survey were analyzed. HGS was measured with a handgrip dynamometer. Age, gender, ethnicity, and hand dominance were self-reported. Body Mass Index (BMI) was calculated from height and body mass. Measures of absolute HGS and HGS normalized to BMI were separately included in parametric quantile regression analyses for determining the 10th-90th percentiles across ages by gender and ethnicity. Similar models were also conducted by hand dominance. RESULTS: Differences in absolute HGS and HGS normalized to BMI quantiles across ages existed for each ethnicity regardless of gender. In men, absolute HGS generally increased until about 25 years of age, began to decline around age 30 years, and regressed into older adulthood. In women, absolute HGS appeared to rise starting at age 6 years, peaked between 20 and 30 years of age, but was maintained into mid-life before declining in older adulthood. Similar results were found for HGS normalized to BMI. CONCLUSIONS: Our findings provide percentile charts for HGS capacity that could be utilized for comparing individual measures of HGS to those from a United States population-representative sample.

Weakness and cognitive impairment are independently and jointly associated with functional decline in aging Americans.

BACKGROUND: Discovering how certain health factors contribute to functional declines may help to promote successful aging. AIMS: To determine the independent and joint associations of handgrip strength (HGS) and cognitive function with instrumental activities of daily living (IADL) and activities of daily living (ADL) disability decline in aging Americans. METHODS: Data from 18,391 adults aged 50 years and over who participated in at least one wave of the 2006-2014 waves of the Health and Retirement Study were analyzed. A hand-held dynamometer assessed HGS and cognitive functioning was examined with a modified version of the Telephone Interview of Cognitive Status. IADL and ADL abilities were self-reported. Participants were stratified into four distinct groups based on their HGS and cognitive function status. Separate covariate-adjusted multilevel models were conducted for the analyses. RESULTS: Participants who were weak, had a cognitive impairment, and had both weakness and a cognitive impairment had 1.70 (95% confidence interval (CI) 1.57-1.84), 1.97 (CI 1.74-2.23), and 3.13 (CI 2.73-3.59) greater odds for IADL disability decline, respectively, and 2.26 (CI 2.03-2.51), 1.26 (CI 1.05-1.51), and 4.48 (CI 3.72-5.39) greater odds for ADL disability decline, respectively. DISCUSSION: HGS and cognitive functioning were independently and jointly associated with IADL and ADL disability declines. Individuals with both weakness and cognitive impairment demonstrated substantially higher odds for functional decline than those with either risk factor alone. CONCLUSIONS: Including measures of both HGS and cognitive functioning in routine geriatric assessments may help to identify those at greatest risk for declining functional capacity.

Muscle weakness and functional limitations in an ethnically diverse sample of older adults.

Objectives: Muscle weakness is often linked to functional limitations in older adults. However, certain demographic characteristics, such as ethnicity, may differentially impact the association between weakness and functional limitations. This investigation sought to (1) identify sex- and ethnically-specific muscle weakness thresholds associated with functional limitations among older adults, and (2) determine the odds of functional limitations for each ethnicity by sex after identifying older adults below the weakness thresholds.Design: Persons aged ≥60 years from the 2011-2012 to 2013-2014 waves of the National Health and Nutrition Examination Survey identifying as non-Hispanic white, non-Hispanic black, Hispanic, or non-Hispanic Asian were included. Handgrip strength was normalized to each participant's body weight (normalized grip strength (NGS)). Participants responded to 19-items asking them about their ability to perform certain activities of daily living, instrumental activities of daily living, leisure and social activities, lower extremity mobility functions, and general physical activities. Receiver operating characteristic curves identified the optimal NGS thresholds associated with functional limitations. Covariate-adjusted multiple logistic regression models were performed to determine the odds of functional limitations for weak vs. not-weak participants.Results: Of the 3,027 participants, the highest NGS thresholds for functional limitations were in non-Hispanic Asian males (0.41; p < 0.001) and Hispanic females (0.36; p < 0.001); whereas, the lowest NGS thresholds were in Hispanic males (0.25; p < 0.001) and non-Hispanic black females (0.23; p < 0.001). Weak non-Hispanic Asian males (odds ratio (OR): 10.42; 95% confidence interval (CI): 10.24, 10.61) and females (OR: 11.95; CI: 11.71, 12.19) had the highest odds for functional limitations compared to their non-weak counterparts.Conclusion: Preserving muscle strength, especially for certain older adult populations, may help reduce the odds of developing functional limitations. Interventions designed to increase muscle strength to preserve or improve function should consider the role of ethnicity when designing such interventions and identifying at risk populations.

Weakness May Have a Causal Association With Early Mortality in Older Americans: A Matched Cohort Analysis.

OBJECTIVES: Quantifying the association between muscle weakness and mortality with carefully matched cohorts will help to better establish the impact of weakness on premature death. We used a matched cohort analysis in a national sample of older Americans to determine if those who were weak had a higher risk for mortality compared with control groups with incrementally higher strength capacities. DESIGN: Longitudinal panel. SETTING: Detailed interviews that included physical measures were conducted in person, whereas core interviews were often performed over the telephone. PARTICIPANTS: Data from 19,729 Americans aged at least 50 years from the 2006-2014 waves of the Health and Retirement Study were analyzed. MEASURES: A handgrip dynamometer was used to assess handgrip strength (HGS) in each participant. Men with HGS <26 kg were considered weak, ≥26 kg were considered not weak, and ≥32 kg were considered strong. Women with HGS <16 kg were classified as weak, ≥16 kg were classified as not-weak, and ≥20 kg were classified as strong. The National Death Index and postmortem interviews determined the date of death. The greedy matching algorithm was used to match cohorts. RESULTS: Of the 1077 weak and not-weak matched pairs, 401 weak (37.2%) and 296 not-weak (27.4%) older Americans died over an average 4.4 ± 2.5-year follow-up. There were 392 weak (37.0%) and 243 strong (22.9%) persons who died over a mean 4.5 ± 2.5-year follow-up from the 1057 weak and strong matched pairs. Those in the weak cohort had a 1.40 [95% confidence interval (CI) 1.19, 1.64] and 1.54 (CI 1.30, 1.83) higher hazard for mortality relative to persons in the not-weak and strong control cohorts, respectively. CONCLUSIONS AND IMPLICATIONS: Our findings may indicate a causal association between muscle weakness and mortality in older Americans. Health care providers should include measures of HGS as part of routine health assessments and discuss the health risks of muscle weakness with their patients.

The Longitudinal Associations of Handgrip Strength and Cognitive Function in Aging Americans.

OBJECTIVES: Factors that are responsible for age-related neurologic deterioration of noncognitive and cognitive processes may have a shared cause. We sought to examine the temporal, directional associations of handgrip strength and cognitive function in a national sample of aging Americans. DESIGN: Longitudinal panel. SETTING: Enhanced interviews that included physical, biological, and psychosocial measures were completed in person. Core interviews were often conducted over the telephone. PARTICIPANTS: The analytic sample included 14,775 Americans aged at least 50 years who participated in at least 2 waves of the 2006-2016 waves of the Health and Retirement Study. MEASURES: Handgrip strength was measured with a hand-held dynamometer. Participants were considered cognitively intact, mildly impaired, or severely impaired according to the Telephone Interview of Cognitive Status questionnaire. Separate lagged general estimating equations analyzed the directional associations of handgrip strength and cognitive function. RESULTS: The overall time to follow-up was 2.1 ± 0.4 years. Every 5 kg higher handgrip strength was associated with 0.97 [95% confidence interval (CI) 0.93, 0.99] lower odds for both future cognitive impairment and worse cognitive impairment. Those who were not weak had 0.54 (CI 0.43, 0.69) lower odds for future cognitive impairment and 0.57 (CI 0.46, 0.72) lower odds for future worse cognitive impairment. Conversely, any (ß = -1.09; CI -1.54, -0.64), mild (ß = -0.85; CI -1.34, -0.36), and severe cognitive impairment (ß = -2.34; CI -3.25, -1.42) predicted decreased handgrip strength. Further, the presence of any, mild, and severe cognitive impairment was associated with 1.82 (CI 1.48, 2.24), 1.65 (CI 1.31, 2.08), and 2.53 (CI 1.74, 3.67) greater odds for future weakness, respectively. CONCLUSIONS/IMPLICATIONS: Strength capacity and cognitive function may parallel each other, whereby losses of functioning in 1 factor may forecast losses of functioning in the other. Handgrip strength could be used for assessing cognitive status in aging Americans and strength capacity should be monitored in those with cognitive impairment.

The burden of health conditions across race and ethnicity for aging Americans: Disability-adjusted life years.

Despite evidence suggesting race and ethnicity are important factors in responses to environmental exposures, drug therapies, and disease risk, few studies focus on the health needs of racially- and ethnically-diverse aging adults.The objective of this study was to determine the burden of 10 health conditions across race and ethnicity for a nationally-representative sample of aging Americans.Data from the 1998 to 2014 waves of the Health and Retirement Study, an ongoing longitudinal-panel study, were analyzed.Those aged over 50 years who identified as Black, Hispanic, or White were included. There were 5510 Blacks, 3423 Hispanics, and 21,168 Whites in the study.At each wave, participants reported if they had cancer, chronic obstructive pulmonary disease, congestive heart failure, diabetes, back pain, hypertension, a fractured hip, myocardial infarction, rheumatism or arthritis, and a stroke. Disability-adjusted life years (DALYs) were calculated for each health condition by race and ethnicity. Ranked DALYs determined how race and ethnicity was differentially impacted by the burden of each health condition. Sample weights were utilized to make DALY estimates nationally-representative.Weighted DALY estimates (in thousands) ranged from 1405 to 55,631 for Blacks, 931 to 28,442 for Hispanics, and 15,313 to 295,623 for Whites. Although the health conditions affected each race and ethnicity differently, hypertension had the largest number of DALYs, and hip fractures had the fewest across race and ethnicity. In total, there were an estimated 198,621, 101,462, and 1,187,725 DALYs for older Black, Hispanic, and White aging adults.Our findings indicate that race and ethnicity may be influential on health and disease for aging adults in the United States. Monitoring DALYs may help guide the flow of health-related expenditures, improve the impact of health interventions, advance inclusive health care for diverse aging adult populations, and prepare healthcare providers for serving the health needs of aging adults.

Veterans Affairs patient database (VAPD 2014-2017): building nationwide granular data for clinical discovery.

BACKGROUND: To study patient physiology throughout a period of acute hospitalization, we sought to create accessible, standardized nationwide data at the level of the individual patient-facility-day. This methodology paper summarizes the development, organization, and characteristics of the Veterans Affairs Patient Database 2014-2017 (VAPD 2014-2017). The VAPD 2014-2017 contains acute hospitalizations from all parts of the nationwide VA healthcare system with daily physiology including clinical data (labs, vitals, medications, risk scores, etc.), intensive care unit (ICU) indicators, facility, patient, and hospitalization characteristics. METHODS: The VA data structure and database organization represents a complex multi-hospital system. We define a single-site hospitalization as one or more consecutive stays with an acute treating specialty at a single facility. The VAPD 2014-2017 is structured at the patient-facility-day level, where every patient-day in a hospital is a row with separate identification variables for facility, patient, and hospitalization. The VAPD 2014-2017 includes daily laboratory, vital signs, and inpatient medication. Such data were validated and verified through lab value range and comparison with patient charts. Sepsis, risk scores, and organ dysfunction definitions were standardized and calculated. RESULTS: We identified 565,242 single-site hospitalizations (SSHs) in 2014; 558,060 SSHs in 2015; 553,961 SSHs in 2016; and 550,236 SSHs in 2017 at 141 VA hospitals. The average length of stay was four days for all study years. In-hospital mortality decreased from 2014 to 2017 (1.7 to 1.4%), 30-day readmission rates increased from 15.3% in 2014 to 15.6% in 2017; 30-day mortality also decreased from 4.4% in 2014 to 4.1% in 2017. From 2014 to 2017, there were 107,512 (4.8%) of SSHs that met the Center for Disease Control and Prevention's Electronic Health Record-based retrospective definition of sepsis. CONCLUSION: The VAPD 2014-2017 represents a large, standardized collection of granular data from a heterogeneous nationwide healthcare system. It is also a direct resource for studying the evolution of inpatient physiology during both acute and critical illness.

Template matching for benchmarking hospital performance in the veterans affairs healthcare system.

Comparing hospital performance in a health system is traditionally done with multilevel regression models that adjust for differences in hospitals' patient case-mix. In contrast, "template matching" compares outcomes of similar patients at different hospitals but has been used only in limited patient settings.Our objective was to test a basic template matching approach in the nationwide Veterans Affairs healthcare system (VA), compared with a more standard regression approach.We performed various simulations using observational data from VA electronic health records whereby we randomly assigned patients to "pseudo hospitals," eliminating true hospital level effects. We randomly selected a representative template of 240 patients and matched 240 patients on demographic and physiological factors from each pseudo hospital to the template. We varied hospital performance for different simulations such that some pseudo hospitals negatively impacted patient mortality.Electronic health record data of 460,213 hospitalizations at 111 VA hospitals across the United States in 2015.We assessed 30-day mortality at each pseudo hospital and identified lowest quintile hospitals by template matching and regression. The regression model adjusted for predicted 30-day mortality (as a measure of illness severity).Regression identified the lowest quintile hospitals with 100% accuracy compared with 80.3% to 82.0% for template matching when systematic differences in 30-day mortality existed.The current standard practice of risk-adjusted regression incorporating patient-level illness severity was better able to identify lower-performing hospitals than the simplistic template matching algorithm.