Targeted tDCS Mitigates Dual-Task Costs to Gait and Balance in Older Adults.

OBJECTIVE: Among older adults, the ability to stand or walk while performing cognitive tasks (ie, dual-tasking) requires coordinated activation of several brain networks. In this multicenter, double-blinded, randomized, and sham-controlled study, we examined the effects of modulating the excitability of the left dorsolateral prefrontal cortex (L-DLPFC) and the primary sensorimotor cortex (SM1) on dual-task performance "costs" to standing and walking. METHODS: Fifty-seven older adults without overt illness or disease completed 4 separate study visits during which they received 20 minutes of transcranial direct current stimulation (tDCS) optimized to facilitate the excitability of the L-DLPFC and SM1 simultaneously, or each region separately, or neither region (sham). Before and immediately after stimulation, participants completed a dual-task paradigm in which they were asked to stand and walk with and without concurrent performance of a serial-subtraction task. RESULTS: tDCS simultaneously targeting the L-DLPFC and SM1, as well as tDCS targeting the L-DLPFC alone, mitigated dual-task costs to standing and walking to a greater extent than tDCS targeting SM1 alone or sham (p < 0.02). Blinding efficacy was excellent and participant subjective belief in the type of stimulation received (real or sham) did not contribute to the observed functional benefits of tDCS. INTERPRETATION: These results demonstrate that in older adults, dual-task decrements may be amenable to change and implicate L-DPFC excitability as a modifiable component of the control system that enables dual-task standing and walking. tDCS may be used to improve resilience and the ability of older results to walk and stand under challenging conditions, potentially enhancing everyday functioning and reducing fall risks. ANN NEUROL 2021;90:428-439.

Stemming the Tide of COVID-19 Infections in Massachusetts Nursing Homes.

BACKGROUND/OBJECTIVES: In April 2020, Massachusetts nursing homes (NHs) became a hotspot for COVID-19 infections and associated deaths. In response, Governor Charles Baker allocated $130 million in additional funding for 2 months contingent on compliance with a new set of care criteria including mandatory testing of all residents and staff, and a 28-point infection control checklist. We aimed to describe the Massachusetts effort and associated outcomes. DESIGN: Longitudinal cohort study. SETTING: A total of 360 Massachusetts NHs. PARTICIPANTS: The Massachusetts Senior Care Association and Hebrew SeniorLife rapidly organized a Central Command team, targeted 123 "special focus" facilities with infection control deficiencies for on-site and virtual consultations, and offered all 360 facilities weekly webinars and answers to questions regarding infection control procedures. The facilities were also informed of resources for the acquisition of personal protective equipment (PPE), backup staff, and SARS-CoV-2 testing. MEASUREMENTS: We used two data sources: (1) four state audits of all NHs, and (2) weekly NH reports to the Massachusetts Center for Health Information and Analysis. Primary independent process measures were the checklist scores and adherence to each of its six core competencies. Primary outcomes were the average weekly rates of new infections, hospitalizations, and deaths in residents and staff. We used a hurdle mixed effects model adjusted for county COVID-19 prevalence to estimate relationships between infection control process measures and rates of new infections or deaths. RESULTS: Both resident and staff infection rates started higher in special focus facilities, then rapidly declined to the same low level in both groups. Adherence to infection control processes, especially proper wearing of PPE and cohorting, was significantly associated with declines in weekly infection and mortality rates. CONCLUSION: This statewide effort could serve as a national model for other states to prevent the devastating effects of pandemics such as COVID-19 in frail NH residents.

When I'm 84: What Should Life Look Like in Old Age?

Housing and the built environment are well-established social determinants of healthy longevity, yet no guidelines or standards exist for the design and construction of health-promoting environments, especially for older adults who are at risk for functional decline and frailty. To envision what should be included in the design of healthy communities, it may help to reverse-engineer what each of us would like our lives to look like in old age. In this special article, a geriatrician draws on his own personal aspirations and successful models of supportive community-based programs to suggest key factors that should be considered in the design of future living environments. These include healthy housing that can enable aging in place without social isolation and loneliness; engagement in meaningful and productive work; financial, physical, transportation, food, and housing security; and affordable high-quality home- and community-based healthcare. By conceptualizing what we would like our later years to look like, future leaders can be more deliberate in creating living environments that promote a long and productive health span. J Am Geriatr Soc 68:967-969, 2020.

A Cluster Randomized Trial of Tai Chi vs Health Education in Subsidized Housing: The MI-WiSH Study.

OBJECTIVES: Tai Chi (TC) may benefit older adults with a variety of diseases and disabilities. We tested the hypothesis that TC improves physical function in older adults living in low-income housing facilities. DESIGN: Cluster randomized controlled trial. SETTING: Subsidized housing facilities in Boston, Massachusetts, and neighboring communities. PARTICIPANTS: Volunteers were recruited from 15 facilities. The 180 randomized participants were 60 years of age or older, able to understand English and participate in TC, expected to remain in the facility for 1 year, and able to walk independently. INTERVENTION: TC classes were conducted in the housing facilities twice/week for 1 year and compared with monthly health promotion educational classes and social calls. MEASUREMENTS: The primary outcome was physical function measured by the Short Physical Performance Battery (SPPB). Secondary outcomes included other aspects of physical and cognitive function, and falls. RESULTS: An interim analysis revealed less improvement over 12 months in SPPB scores among TC participants (+.20 units; 95% confidence interval [CI] = -.20 to +.60; P = .69) vs control participants (+.51 units; 95% CI = +.15 to +.87; P = .007), a difference of -.31 units (95% CI = -.66 to .04; P = .082). This met the criterion for futility, and the Data Safety Monitoring Board recommended trial termination. No differences were found in 6- or 12-month changes favoring TC in any secondary outcomes or adverse events. CONCLUSION: In older adults with multiple chronic conditions living in subsidized housing facilities, 6 and 12 months of twice/week TC classes were not associated with improvements in functional health. J Am Geriatr Soc 67:1812-1819, 2019.

Validation of a Claims-Based Frailty Index Against Physical Performance and Adverse Health Outcomes in the Health and Retirement Study.

BACKGROUND: A claims-based frailty index (CFI) was developed based on a deficit-accumulation approach using self-reported health information. This study aimed to independently validate the CFI against physical performance and adverse health outcomes. METHODS: This retrospective cohort study included 3,642 community-dwelling older adults who had at least 1 health care encounter in the year prior to assessments of physical performance in the 2008 Health and Retirement Study wave. A CFI was estimated from Medicare claims data in the past year. Gait speed, grip strength, and the 2-year risk of death, institutionalization, disability, hospitalization, and prolonged (>30 days) skilled nursing facility (SNF) stay were evaluated for CFI categories (robust: <0.15, prefrail: 0.15-0.24, mildly frail: 0.25-0.34, moderate-to-severely frail: ≥0.35). RESULTS: The prevalence of robust, prefrail, mildly frail, and moderate-to-severely frail state was 52.7%, 38.0%, 7.1%, and 2.2%, respectively. Individuals with higher CFI had lower mean gait speed (moderate-to-severely frail vs robust: 0.39 vs 0.78 m/s) and weaker grip strength (19.8 vs 28.5 kg). Higher CFI was associated with death (moderate-to-severely frail vs robust: 46% vs 7%), institutionalization (21% vs 5%), activity of daily living disability (33% vs 9%), instrumental activity of daily living disability (100% vs 22%), hospitalization (79% vs 23%), and prolonged SNF stay (17% vs 2%). The odds ratios per 1-SD (=0.07) difference in CFI were 1.46-2.06 for these outcomes, which remained statistically significant after adjustment for age, sex, and a comorbidity index. CONCLUSION: The CFI is useful to identify individuals with poor physical function and at greater risks of adverse health outcomes in Medicare data.

Measuring Frailty in Medicare Data: Development and Validation of a Claims-Based Frailty Index.

Background: Frailty is a key determinant of health status and outcomes of health care interventions in older adults that is not readily measured in Medicare data. This study aimed to develop and validate a claims-based frailty index (CFI). Methods: We used data from Medicare Current Beneficiary Survey 2006 (development sample: n = 5,593) and 2011 (validation sample: n = 4,424). A CFI was developed using the 2006 claims data to approximate a survey-based frailty index (SFI) calculated from the 2006 survey data as a reference standard. We compared CFI to combined comorbidity index (CCI) in the ability to predict death, disability, recurrent falls, and health care utilization in 2007. As validation, we calculated a CFI using the 2011 claims data to predict these outcomes in 2012. Results: The CFI was correlated with SFI (correlation coefficient: 0.60). In the development sample, CFI was similar to CCI in predicting mortality (C statistic: 0.77 vs. 0.78), but better than CCI for disability, mobility impairment, and recurrent falls (C statistic: 0.62-0.66 vs. 0.56-0.60). Although both indices similarly explained the variation in hospital days, CFI outperformed CCI in explaining the variation in skilled nursing facility days. Adding CFI to age, sex, and CCI improved prediction. In the validation sample, CFI and CCI performed similarly for mortality (C statistic: 0.71 vs. 0.72). Other results were comparable to those from the development sample. Conclusion: A novel frailty index can measure the risk for adverse health outcomes that is not otherwise quantified using demographic characteristics and traditional comorbidity measures in Medicare data.

Improving Transitions to Postacute Care for Elderly Patients Using a Novel Video-Conferencing Program: ECHO-Care Transitions.

PURPOSE: Within 30 days of hospital discharge to a skilled nursing facility, older adults are at high risk for death, re-hospitalization, and high-cost health care. The purpose of this study was to examine whether a novel videoconference program called Extension for Community Health Outcomes-Care Transitions (ECHO-CT) that connects an interdisciplinary hospital-based team with clinicians at skilled nursing facilities reduces patient mortality, hospital readmission, skilled nursing facility length of stay, and 30-day health care costs. METHODS: We undertook a prospective cohort study comparing cost and health care utilization outcomes between ECHO-CT facilities and matched comparisons from January 2014-December 2014. RESULTS: Thirty-day readmission rates were significantly lower in the intervention group (odds ratio 0.57; 95% CI, 0.34-0.96; P-value .04), as were the 30-day total health care cost ($2602.19 lower; 95% CI, -$4133.90 to -$1070.48; P-value <.001) and the average length of stay at the skilled nursing facility (-5.52 days; 95% CI, -9.61 to -1.43; P = .001). The 30-day mortality rate was not significantly lower in the intervention group (odds ratio 0.38; 95% CI, 0.11-1.24; P = .11). CONCLUSION: Patients discharged to skilled nursing facilities participating in the ECHO-CT program had shorter lengths of stay, lower 30-day rehospitalization rates, and lower 30-day health care costs compared with those in matched skilled nursing facilities delivering usual care. ECHO-CT may improve patient transitions to postacute care at lower overall cost.

Preoperative Frailty Assessment and Outcomes at 6 Months or Later in Older Adults Undergoing Cardiac Surgical Procedures: A Systematic Review.

BACKGROUND: Frailty assessment may inform surgical risk and prognosis not captured by conventional surgical risk scores. PURPOSE: To evaluate the evidence for various frailty instruments used to predict mortality, functional status, or major adverse cardiovascular and cerebrovascular events (MACCEs) in older adults undergoing cardiac surgical procedures. DATA SOURCES: MEDLINE and EMBASE (without language restrictions), from their inception to 2 May 2016. STUDY SELECTION: Cohort studies evaluating the association between frailty and mortality or functional status at 6 months or later in patients aged 60 years or older undergoing major or minimally invasive cardiac surgical procedures. DATA EXTRACTION: 2 reviewers independently extracted study data and assessed study quality. DATA SYNTHESIS: Mobility, disability, and nutrition were frequently assessed domains of frailty in both types of procedures. In patients undergoing major procedures (n = 18 388; 8 studies), 9 frailty instruments were evaluated. There was moderate-quality evidence to assess mobility or disability and very-low- to low-quality evidence for using a multicomponent instrument to predict mortality or MACCEs. No studies examined functional status. In patients undergoing minimally invasive procedures (n = 5177; 17 studies), 13 frailty instruments were evaluated. There was moderate- to high-quality evidence for assessing mobility to predict mortality or functional status. Several multicomponent instruments predicted mortality, functional status, or MACCEs, but the quality of evidence was low to moderate. Multicomponent instruments that measure different frailty domains seemed to outperform single-component ones. LIMITATION: Heterogeneity of frailty assessment, limited generalizability of multicomponent frailty instruments, few validated frailty instruments, and potential publication bias. CONCLUSION: Frailty status, assessed by mobility, disability, and nutritional status, may predict mortality at 6 months or later after major cardiac surgical procedures and functional decline after minimally invasive cardiac surgery. PRIMARY FUNDING SOURCE: National Institute on Aging and National Heart, Lung, and Blood Institute.

Waiving the three-day rule: admissions and length-of-stay at hospitals and skilled nursing facilities did not increase.

The traditional Medicare program requires an enrollee to have a hospital stay of at least three consecutive calendar days to qualify for coverage of subsequent postacute care in a skilled nursing facility. This long-standing policy, implemented to discourage premature discharges from hospitals, might now be inappropriately lengthening hospital stays for patients who could be transferred sooner. To assess the implications of eliminating the three-day qualifying stay requirement, we compared hospital and postacute skilled nursing facility utilization among Medicare Advantage enrollees in matched plans that did or did not eliminate that requirement in 2006-10. Among hospitalized enrollees with a skilled nursing facility admission, the mean hospital length-of-stay declined from 6.9 days to 6.7 days for those no longer subject to the qualifying stay but increased from 6.1 to 6.6 days among those still subject to it, for a net decline of 0.7 day when the three-day stay requirement was eliminated. The elimination was not associated with more hospital or skilled nursing facility admissions or with longer lengths-of-stay in a skilled nursing facility. These findings suggest that eliminating the three-day stay requirement conferred savings on Medicare Advantage plans and that study of the requirement in traditional Medicare plans is warranted.

Prevention Program Lowered The Risk Of Falls And Decreased Claims For Long-Term Services Among Elder Participants.

The LIFT (Living Independently and Falls-free Together) Wellness Program is a multifactorial fall-prevention intervention developed for community-dwelling elders. Its effectiveness was tested in a randomized controlled trial of consenting people who were ages seventy-five and older and who held long-term care insurance policies with one of three major insurers. The study was conducted during 2008-12. In the first year following the intervention, participants in the intervention group had an 11 percent reduction in risk of falling and an 18 percent reduction in risk of injurious falls, compared to participants in the active control group. In the three years after the intervention, participants in the intervention group had a significantly (33 percent) lower incidence of claims for long-term services and supports than those in the administrative control group, for an estimated return of $1.68 on every dollar invested in program delivery. The results of this evaluation are unique in demonstrating that a multifactorial fall prevention program can do more than reduce falls in this population; they suggest that the broader availability of LIFT could benefit long-term care insurers and policyholders alike.

Fall Risk is Not Black and White.

OBJECTIVE: To determine whether previously reported racial differences in fall rates between White and Black/African American is explained by differences in health status and neighborhood characteristics. DESIGN: Prospective cohort. SETTING: Community. PARTICIPANTS: The study included 550 White and 116 Black older adults in the Greater Boston area (mean age: 78 years; 36% men) who were English-speaking, able to walk across a room, and without severe cognitive impairment. MEASUREMENTS: Falls were prospectively reported using monthly fall calendars. The location of each fall and fall-related injuries were asked during telephone interviews. At baseline, we assessed risk factors for falls, including sociodemographic characteristics, physiologic risk factors, physical activity, and community-level characteristics. RESULTS: Over the mean follow-up of 1,048 days, 1,539 falls occurred (incidence: 806/1,000 person-years). Whites were more likely than Blacks to experience any falls (867 versus 504 falls per 1,000 person-years; RR [95% CI]: 1.77 [1.33, 2.36]), outdoor falls (418 versus 178 falls per 1,000 person-years; 1.78 [1.08, 2.92]), indoor falls (434 versus 320 falls per 1,000 person-years; 1.44 [1.02, 2.05]), and injurious falls (367 versus 205 falls per 1,000 person-years; 1.79 [1.30, 2.46]). With exception of injurious falls, higher fall rates in Whites than Blacks were substantially attenuated with adjustment for risk factors and community-level characteristics: any fall (1.24 [0.81, 1.89]), outdoor fall (1.57 [0.86, 2.88]), indoor fall (1.08 [0.64, 1.81]), and injurious fall (1.77 [1.14, 2.74]). CONCLUSION: Our findings suggest that the racial differences in fall rates may be largely due to confounding by individual-level and community-level characteristics.

Predicting risk of hospital and emergency department use for home care elderly persons through a secondary analysis of cross-national data.

BACKGROUND: Older adults remain the highest utilization group with unplanned visits to emergency departments and hospital admissions. Many have considered what leads to this high utilization and the answers provided have depended upon the independent measures available in the datasets used. This project was designed to further understanding of the reasons for older adult ED visits and admissions to acute care hospitals. METHODS: A secondary analysis of data from a cross-national sample of community residing elderly, 60 years of age or older, and most of whom received services from a local home-care program was conducted. The assessment instrument used in this study is the interRAI HC (home care), designed for use in assessing elderly home care recipients. The model specification stage of the study identified the baseline independent variables that do and do not predict the follow-up measure of hospitalization and ED use. Stepwise logistic regression was used next to identify characteristics that best identified elders who subsequently entered a hospital or visited an ED. The items generated from the final multivariate logistic equation using the interRAI home care measures comprise the interRAI Hospital-ED Risk Index. RESULTS: Independent measures in three key domains of clinical complications, disease diagnoses and specialized treatments were related to subsequent hospitalization or ED use. Among the eighteen clinical complication measures with higher, meaningful odds ratios are pneumonia, urinary tract infection, fever, chest pain, diarrhea, unintended weight loss, a variety of skin conditions, and subject self-reported poor health. Disease diagnoses with a meaningful relationship with hospital/ED use include coronary artery disease, congestive heart failure, cancer, emphysema and renal failure. Specialized treatments with the highest odds ratios were blood transfusion, IV infusion, wound treatment, radiation and dialysis. Two measures, Alzheimer's disease and day care appear to have a protective effect for hospitalization/ED use with lower odds ratios. CONCLUSIONS: Examination into "preventable" hospitalizations and re-hospitalizations for older adults who have the highest rates of utilization are occurring beneath an umbrella of assuring the highest quality of care and controlling costs. The interRAI Hospitalization-ED Risk Index offers an effective approach to predicting hospitalization utilization among community dwelling older adults.

Long-term exposure to ambient air pollution and serum leptin in older adults: results from the MOBILIZE Boston study.

OBJECTIVE: Long-term exposure to traffic-related air pollution has been linked to increased risk of obesity and diabetes and may be associated with higher serum levels of the adipokine leptin, but this hypothesis has not been previously evaluated in humans. METHODS: In a cohort of older adults, we estimated the association between serum leptin concentrations and two markers of long-term exposure to traffic pollution, adjusting for participant characteristics, temporal trends, socioeconomic factors, and medical history. RESULTS: An interquartile range increase (0.11 µg/m) in annual mean residential black carbon was associated with 12% (95% confidence interval: 3%, 22%) higher leptin levels. Leptin levels were not associated with residential distance to major roadway. CONCLUSIONS: If confirmed, these findings support the emerging evidence suggesting that certain sources of traffic pollution may be associated with adverse cardiometabolic effects.