Medication cost-reducing behaviors in older adults with atrial fibrillation: The SAGE-AF study.

BACKGROUND: As patient prices for many medications have risen steeply in the United States, patients may engage in cost-reducing behaviors (CRBs) such as asking for generic medications or purchasing medication from the Internet. OBJECTIVE: The objective of this study is to describe patterns of CRB, cost-related medication nonadherence, and spending less on basic needs to afford medications among older adults with atrial fibrillation (AF) and examine participant characteristics associated with CRB. METHODS: Data were from a prospective cohort study of older adults at least 65 years with AF and a high stroke risk (CHA2DS2VASc ≥ 2). CRB, cost-related medication nonadherence, and spending less on basic needs to afford medications were evaluated using validated measures. Chi-square and t tests were used to evaluate differences in characteristics across CRB, and statistically significant characteristics (P < 0.05) were entered into a multivariable logistic regression to examine factors associated with CRB. RESULTS: Among participants (N = 1224; mean age 76 years; 49% female), 69% reported engaging in CRB, 4% reported cost-related medication nonadherence, and 6% reported spending less on basic needs. Participants who were cognitively impaired (adjusted odds ratio 0.69 [95% CI 0.52-0.91]) and those who did not identify as non-Hispanic white (0.66 [0.46-0.95]) were less likely to engage in CRB. Participants who were married (1.88 [1.30-2.72]), had a household income of $20,000-$49,999 (1.52 [1.02-2.27]), had Medicare insurance (1.38 [1.04-1.83]), and had 4-6 comorbidities (1.43 [1.01-2.01]) had significantly higher odds of engaging in CRB. CONCLUSION: Although CRBs were common among older adults with AF, few reported cost-related medication nonadherence and spending less on basic needs. Patients with cognitive impairment may benefit from pharmacist intervention to provide support in CRB and patient assistance programs.

Psychoactive medication therapy and delirium screening in skilled nursing facilities.

BACKGROUND: A positive delirium screen at skilled-nursing facility (SNF) admission can trigger a simultaneous diagnosis of Alzheimer's Disease or related dementia (AD/ADRD) and lead to psychoactive medication treatment despite a lack of evidence supporting use. METHODS: This was a nationwide historical cohort study of 849,086 Medicare enrollees from 2011-2013 who were admitted to the SNF from a hospital without a history of dementia. Delirium was determined through positive Confusion Assessment Method screen and incident AD/ADRD through active diagnosis or claims. Cox proportional hazard models predicted the risk of receiving one of three psychoactive medications (i.e., antipsychotics, benzodiazepines, antiepileptics) within 7 days of SNF admission and within the entire SNF stay. RESULTS: Of 849,086 newly-admitted SNF patients (62.6% female, mean age 78), 6.1% had delirium (of which 35.4% received an incident diagnosis of AD/ADRD); 12.6% received antipsychotics, 30.4% benzodiazepines, and 5.8% antiepileptics. Within 7 days of admission, patients with delirium and incident dementia were more likely to receive an antipsychotic (relative risk [RR] 3.09; 95% confidence interval [CI] 2.99 to 3.20), or a benzodiazepine (RR 1.23; 95% CI 1.19 to 1.27) than patients without either condition. By the end of the SNF stay, patients with both delirium and incident dementia were more likely to receive an antipsychotic (RR 3.04; 95% CI 2.95 to 3.14) and benzodiazepine (RR 1.32; 95% CI 1.29 to 1.36) than patients without either condition. CONCLUSION: In this historical cohort, a positive delirium screen was associated with a higher risk of receiving psychoactive medication within 7 days of SNF admission, particularly in patients with an incident AD/ADRD diagnosis. Future research should examine strategies to reduce inappropriate psychoactive medication prescribing in older adults admitted with delirium to SNFs.

Prevalence of Frailty and Associations with Oral Anticoagulant Prescribing in Atrial Fibrillation.

BACKGROUND: Frailty is often cited as a factor influencing oral anticoagulation (OAC) prescription in patients with non-valvular atrial fibrillation (NVAF). We sought to determine the prevalence of frailty and its association with OAC prescription in older veterans with NVAF. METHODS: We used ICD-9 codes in Veterans Affairs (VA) records and Medicare claims data to identify patients with NVAF and CHA2DS2VASC ≥2 receiving care between February 2010 and September 2015. We examined rates of OAC prescription, further stratified by direct oral anticoagulant (DOAC) or vitamin K antagonist (VKA). Participants were characterized into 3 categories: non-frail, pre-frail, and frail based on a validated 30-item EHR-derived frailty index. We examined relations between frailty and OAC receipt; and frailty and type of OAC prescribed in regression models adjusted for factors related to OAC prescription. RESULTS: Of 308,664 veterans with NVAF and a CHA2DS2VASC score ≥2, 121,839 (39%) were prescribed OAC (73% VKA). The mean age was 77.7 (9.6) years; CHA2DS2VASC and ATRIA scores were 4.6 (1.6) and 5.0 (2.9) respectively. Approximately a third (38%) were frail, another third (32%) were pre-frail, and the remainder were not frail. Veterans prescribed OAC were younger, had higher bleeding risk, and were less likely to be frail than participants not receiving OAC (all p's<0.001). After adjustment for factors associated with OAC use, pre-frail (OR: 0.89, 95% CI: 0.87-0.91) and frail (OR: 0.66, 95% CI: 0.64-0.68) veterans were significantly less likely to be prescribed OAC than non-frail veterans. Of those prescribed OAC, pre-frail (OR:1.27, 95% CI: 1.22-1.31) and frail (OR: 1.75, 95% CI: 1.67-1.83) veterans were significantly more likely than non-frail veterans to be prescribed a DOAC than a VKA. CONCLUSIONS: There are high rates of frailty among older veterans with NVAF. Frailty using an EHR-derived index is associated with decreased OAC prescription.

An Emergency Department Delirium Screening and Management Initiative: The Development and Refinement of the SCREENED-ED Intervention.

The current article describes an intervention aimed at emergency department (ED) nurses and physicians that was designed to address the challenges of managing delirium in the ED environment. The intervention development process followed the Medical Research Council principles paired with a user-centered design perspective. Expert clinicians and nursing staff were involved in the development process. As a result, the SCREENED-ED intervention includes four major components: screening for delirium, informing providers, an acronym (ALTERED), and documentation in the electronic health record. The acronym "ALTERED" includes seven key elements of delirium management that were considered the most evidence-based, relevant, and practical for the ED. Nurses are at the frontline of delirium recognition and management and the SCREENED-ED intervention with the ALTERED acronym holds the potential to improve nursing care in this complex clinical setting. [Journal of Gerontological Nursing, 47(12), 13-17.].

Association of Positive Delirium Screening with Incident Dementia in Skilled Nursing Facilities.

BACKGROUND AND OBJECTIVE: Early detection of delirium in skilled nursing facilities (SNFs) is a priority. The extent to which delirium screening leads to a potentially inappropriate diagnosis of Alzheimer's disease and related dementia (ADRD) is unknown. DESIGN: Nationwide retrospective cohort study from 2011 to 2013. SETTING: An SNF. PARTICIPANTS: A total of 1,175,550 Medicare enrollees who entered the SNF from a hospital and had no prior diagnosis of dementia. EXPOSURE: A positive screen for delirium using the validated Confusion Assessment Method (CAM), performed as part of the federally mandated Minimum Data Set (MDS) assessment. MEASUREMENTS: Incident all-cause dementia, ascertained through International Classification of Diseases, Ninth Revision (ICD-9), diagnosis in Medicare claims or active diagnoses in MDS. RESULTS: Positive screening for delirium was identified in 7.7% of cases (n = 90,449), and most occurred within the first 7 days of SNF admission (62.5%). The overall incidence of ADRD was 6.3% (n = 73,542). Nearly all new diagnoses of ADRD (93.5%) occurred within the first 30 days of SNF admission. Patients who screened CAM positive for delirium had a nearly threefold increased risk of receiving an incident ADRD diagnosis on the same day (hazard ratio (HR) = 2.63; 95% confidence interval (CI) = 1.50-4.63). Among patients who screened CAM positive for delirium, those who were cognitively intact or had mild cognitive impairments were, on average, six times more likely to receive an incident ADRD diagnosis (HR = 6.64; 95% CI = 1.76-25.0) relative to those testing CAM negative. CONCLUSION AND RELEVANCE: Among older adults not previously diagnosed with dementia, a positive screen for delirium was significantly associated with higher risk of ADRD diagnosis after admission to a SNF. This risk was highest for patients in the first days of their stay and with the least cognitive impairment, suggesting that the ADRD diagnosis was potentially inappropriate.

Psychosocial and cognitive multimorbidity and health-related quality of life and symptom burden in older adults with atrial fibrillation: The systematic assessment of geriatric elements in atrial fibrillation (SAGE-AF) cohort study.

BACKGROUND: Depression, anxiety, and cognitive impairments occur in up to 40 % of adults with AF and are associated with poorer health-related quality of life (HRQoL) and higher symptom burden. However, it is unknown how often these impairments co-occur, or multimorbidity, and how multimorbidity effects HRQoL and symptom burden. METHODS: Patients with AF age ≥65 years with a CHA2DS2VASC risk score ≥ 2 and eligible for oral anticoagulation therapy were recruited from five clinics in a prospective cohort study. Participants completed validated measures of depression (PHQ9) and anxiety (GAD7), cognitive impairment (MoCA), and HRQOL and AF symptom burden (AFEQT). Multinomial logistic regression was used. RESULTS: Participants (N = 1244, 49 % female) were on average 76 ± 7 years; 86 % were non-Hispanic white. Approximately 35 % of participants had 1 impairment, 17 % had 2 impairments and 8% had 3 impairments; 39 % had none of the 3 impairments examined. Compared to participants with no impairments, patients with 1, 2 and 3 impairments had higher odds of poor HRQoL (adjusted OR [AOR] = 1.77, 95 % CI 1.21, 2.60; AOR = 6.64, 95 % CI 4.43, 9.96; and AOR = 7.50, 95 % CI 4.40, 12.77, respectively) and those with 2 and 3 impairments had higher odds of high symptom burden (AOR = 3.69 95 % CI 2.22, 6.13; and AOR = 5.41 95 % CI 2.85, 10.26). CONCLUSIONS: Psychosocial/cognitive multimorbidity is common among older adults with AF and is associated with poor HRQoL and high symptom burden. Clinicians might consider incorporating psychosocial and cognitive screens into routine care as this may identify a high-risk population.

Characteristics Associated With Facebook Use and Interest in Digital Disease Support Among Older Adults With Atrial Fibrillation: Cross-Sectional Analysis of Baseline Data From the Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF) Cohort.

BACKGROUND: Online support groups for atrial fibrillation (AF) and apps to detect and manage AF exist, but the scientific literature does not describe which patients are interested in digital disease support. OBJECTIVE: The objective of this study was to describe characteristics associated with Facebook use and interest in digital disease support among older patients with AF who used the internet. METHODS: We used baseline data from the Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF), a prospective cohort of older adults (≥65 years) with AF at high stroke risk. Participants self-reported demographics, clinical characteristics, and Facebook and technology use. Online patients (internet use in the past 4 weeks) were asked whether they would be interested in participating in an online support AF community. Mobile users (owns smartphone and/or tablet) were asked about interest in communicating with their health care team about their AF-related health using a secure app. Logistic regression models identified crude and multivariable predictors of Facebook use and interest in digital disease support. RESULTS: Online patients (N=816) were aged 74.2 (SD 6.6) years, 47.8% (390/816) were female, and 91.1% (743/816) were non-Hispanic white. Roughly half (52.5%; 428/816) used Facebook. Facebook use was more common among women (adjusted odds ratio [aOR] 2.21, 95% CI 1.66-2.95) and patients with mild to severe depressive symptoms (aOR 1.50, 95% CI 1.08-2.10) and less common among patients aged ≥85 years (aOR 0.27, 95% CI 0.15-0.48). Forty percent (40.4%; 330/816) reported interest in an online AF patient community. Interest in an online AF patient community was more common among online patients with some college/trade school or Bachelors/graduate school (aOR 1.70, 95% CI 1.10-2.61 and aOR 1.82, 95% CI 1.13-2.92, respectively), obesity (aOR 1.65, 95% CI 1.08-2.52), online health information seeking at most weekly or multiple times per week (aOR 1.84, 95% CI 1.32-2.56 and aOR 2.78, 95% CI 1.86-4.16, respectively), and daily Facebook use (aOR 1.76, 95% CI 1.26-2.46). Among mobile users, 51.8% (324/626) reported interest in communicating with their health care team via a mobile app. Interest in app-mediated communication was less likely among women (aOR 0.48, 95% CI 0.34-0.68) and more common among online patients who had completed trade school/some college versus high school/General Educational Development (aOR 1.95, 95% CI 1.17-3.22), sought online health information at most weekly or multiple times per week (aOR 1.86, 95% CI 1.27-2.74 and aOR 2.24, 95% CI 1.39-3.62, respectively), and had health-related apps (aOR 3.92, 95% CI 2.62-5.86). CONCLUSIONS: Among older adults with AF who use the internet, technology use and demographics are associated with interest in digital disease support. Clinics and health care providers may wish to encourage patients to join an existing online support community for AF and explore opportunities for app-mediated patient-provider communication.

Burden of Psychosocial and Cognitive Impairment in Patients With Atrial Fibrillation.

BACKGROUND: Impairments in psychosocial status and cognition relate to poor clinical outcomes in patients with atrial fibrillation (AF). However, how often these conditions co-occur and associations between burden of psychosocial and cognitive impairment and quality of life (QoL) have not been systematically examined in patients with AF. METHODS: A total of 218 patients with symptomatic AF were enrolled in a prospective study of AF and psychosocial factors between May 2013 and October 2014 at the University of Massachusetts Medical Center. Cognitive function, depression, and anxiety were assessed at baseline and AF-specific QoL was assessed 6 months after enrollment using validated instruments. Demographic and clinical information were obtained from a structured interview and medical record review. RESULTS: The mean age of the study participants was 63.5 ± 10.2 years, 35% were male, and 81% had paroxysmal AF. Prevalences of impairment in 1, 2, and 3 psychosocial/cognitive domains (eg, depression, anxiety, or cognition) were 75 (34.4%), 51 (23.4%), and 16 (7.3%), respectively. Patients with co-occurring psychosocial/cognitive impairments (eg, >1 domain) were older, more likely to smoke, had less education, and were more likely to have heart failure (all P < 0.05). Compared with participants with no psychosocial/cognitive impairments, AF-specific QoL at 6 months was significantly poorer among participants with baseline impairment in 2 (B = -13.6, 95% CI: -21.7 to -5.4) or 3 (B = -15.1, 95% CI: -28.0 to -2.2) psychosocial/cognitive domains. CONCLUSION: Depression, anxiety, and impaired cognition were common in our cohort of patients with symptomatic AF and often co-occurred. Higher burden of psychosocial/cognitive impairment was associated with poorer AF-specific QoL.

Derivation and Validation of a Severity Scoring Method for the 3-Minute Diagnostic Interview for Confusion Assessment Method--Defined Delirium.

OBJECTIVES: To derive and validate a method for scoring delirium severity using a recently validated, brief, structured diagnostic interview for Confusion Assessment Method (CAM)-defined delirium (3D-CAM) and to demonstrate its agreement with the CAM Severity short form (CAM-S SF) as the reference standard. DESIGN: Derivation and validation analysis in a prospective cohort study. SETTING: Two academic medical centers. PARTICIPANTS: Individuals aged 70 and older enrolled in the Successful Aging after Elective Surgery Study undergoing major elective noncardiac surgery (N = 566). MEASUREMENTS: The sample was randomly divided into a derivation dataset (n = 377) and an independent validation dataset (n = 189). These datasets were used to develop a severity scoring method using the 3D-CAM based on the four-item CAM-S SF (3D-CAM-S) and evaluate agreement between the 3D-CAM-S and the traditional CAM-S SF using weighted kappa statistics. RESULTS: A method for scoring severity using 3D-CAM items was developed that achieved good agreement with the CAM-S SF in the derivation dataset (κ = 0.94, 95% confidence interval (CI) = 0.93-0.95). The 3D-CAM-S achieved nearly identical agreement in the independent validation dataset (κ = 0.93, 95% CI = 0.92-0.95), and 100% of 3D-CAM-S scores were within 1 point of the CAM-S SF score in both datasets. The 3D-CAM-S also strongly predicts clinical outcomes. CONCLUSION: A newly developed method for scoring delirium severity using the 3D-CAM (the 3D-CAM-S) has excellent agreement with the CAM-S SF. This new methodology enables clinicians and researchers using the 3D-CAM for surveillance to measure delirium severity and monitor its course simultaneously by tracking changes over time. The 3D-CAM-S expands the utility of the 3D-CAM as an important tool for delirium recognition and management.

Reliability of Predicting Early Hospital Readmission After Discharge for an Acute Coronary Syndrome Using Claims-Based Data.

Early rehospitalization after discharge for an acute coronary syndrome, including acute myocardial infarction (AMI), is generally considered undesirable. The Centers for Medicare and Medicaid Services (CMS) base hospital financial incentives on risk-adjusted readmission rates after AMI, using claims data in its adjustment models. Little is known about the contribution to readmission risk of factors not captured by claims. For 804 consecutive patients >65 years discharged in 2011 to 2013 from 6 hospitals in Massachusetts and Georgia after an acute coronary syndrome, we compared a CMS-like readmission prediction model with an enhanced model incorporating additional clinical, psychosocial, and sociodemographic characteristics, after principal components analysis. Mean age was 73 years, 38% were women, 25% college educated, and 32% had a previous AMI; all-cause rehospitalization occurred within 30 days for 13%. In the enhanced model, previous coronary intervention (odds ratio [OR] = 2.05, 95% confidence interval [CI] 1.34 to 3.16; chronic kidney disease OR 1.89, 95% CI 1.15 to 3.10; low health literacy OR 1.75, 95% CI 1.14 to 2.69), lower serum sodium levels, and current nonsmoker status were positively associated with readmission. The discriminative ability of the enhanced versus the claims-based model was higher without evidence of overfitting. For example, for patients in the highest deciles of readmission likelihood, observed readmissions occurred in 24% for the claims-based model and 33% for the enhanced model. In conclusion, readmission may be influenced by measurable factors not in CMS' claims-based models and not controllable by hospitals. Incorporating additional factors into risk-adjusted readmission models may improve their accuracy and validity for use as indicators of hospital quality.

The Montreal Cognitive Assessment: Creating a Crosswalk with the Mini-Mental State Examination.

OBJECTIVES: To establish Montreal Cognitive Assessment (MoCA) scores that correspond to well-established cut-points on the Mini-Mental State Examination (MMSE). DESIGN: Cross-sectional observational study. SETTING: General medical service of a large teaching hospital. PARTICIPANTS: Individuals aged 75 and older (N = 199; mean age 84, 63% female). MEASUREMENTS: The MoCA (range 0-30) and the MMSE (range 0-30) were administered within 2 hours of each other. The Abbreviated MoCA (A-MoCA; range 0-22) was calculated from the full MoCA. Scores from the three tests were analyzed using equipercentile equating, a statistical method for determining comparable scores on different tests of a similar construct by estimating percentile equivalents. RESULTS: MoCA scores were lower (mean 19.3 ± 5.8) than MMSE scored (mean 24.1 ± 6.6). Traditional MMSE cut-points of 27 for mild cognitive impairment and 23 for dementia corresponded to MoCA scores of 23 and 17, respectively. CONCLUSION: Scores on the full and abbreviated versions of the MoCA can be linked directly to the MMSE. The MoCA may be more sensitive to changes in cognitive performance at higher levels of functioning.

Characteristics of contemporary patients discharged from the hospital after an acute coronary syndrome.

BACKGROUND: Limited contemporary data compare the clinical and psychosocial characteristics and acute management of patients hospitalized with an initial vs a recurrent episode of acute coronary disease. We describe these factors in a cohort of patients recruited from 6 hospitals in Massachusetts and Georgia after an acute coronary syndrome. MATERIALS AND METHODS: We performed structured baseline in-person interviews and medical record abstractions for 2174 eligible and consenting patients surviving hospitalization for an acute coronary syndrome between April 2011 and May 2013. RESULTS: The average patient age was 61 years, 64% were men, and 47% had a high school education or less; 29% had a low general quality of life, and 1 in 5 were cognitively impaired. Patients with a recurrent coronary episode had a greater burden of previously diagnosed comorbidities. Overall, psychosocial burden was high, and more so in those with a recurrent vs those with an initial episode. Patients with an initial coronary episode were as likely to have been treated with all 4 effective cardiac medications (51.6%) as patients with a recurrent episode (52.3%), but were significantly more likely to have undergone cardiac catheterization (97.9% vs 92.9%) and a percutaneous coronary intervention (73.7% vs 60.9%) (P < .001) during their index hospitalization. CONCLUSIONS: Patients with a first episode of acute coronary artery disease have a more favorable psychosocial profile, less comorbidity, and receive more invasive procedures but similar medical management, than patients with previously diagnosed coronary disease. Implications of the high psychosocial burden on various patient-related outcomes require investigation.

The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts.

BACKGROUND: Quantifying the severity of delirium is essential to advancing clinical care by improved understanding of delirium effect, prognosis, pathophysiology, and response to treatment. OBJECTIVE: To develop and validate a new delirium severity measure (CAM-S) based on the Confusion Assessment Method. DESIGN: Validation analysis in 2 independent cohorts. SETTING: Three academic medical centers. PATIENTS: The first cohort included 300 patients aged 70 years or older scheduled for major surgery. The second included 919 medical patients aged 70 years or older. MEASUREMENTS: A 4-item short form and a 10-item long form were developed. Association of the maximum CAM-S score during hospitalization with hospital and posthospital outcomes related to delirium was evaluated. RESULTS: Representative results included adjusted mean length of stay, which increased across levels of short-form severity from 6.5 days (95% CI, 6.2 to 6.9 days) to 12.7 days (CI, 11.2 to 14.3 days) (P for trend < 0.001) and across levels of long-form severity from 5.6 days (CI, 5.1 to 6.1 days) to 11.9 days (CI, 10.8 to 12.9 days) (P for trend < 0.001). Representative results for the composite outcome of adjusted relative risk of death or nursing home residence at 90 days increased progressively across levels of short-form severity from 1.0 (referent) to 2.5 (CI, 1.9 to 3.3) (P for trend < 0.001) and across levels of long-form severity from 1.0 (referent) to 2.5 (CI, 1.6 to 3.7) (P for trend < 0.001). LIMITATION: Data on clinical outcomes were measured in an older data set limited to patients aged 70 years or older. CONCLUSION: The CAM-S provides a new delirium severity measure with strong psychometric properties and strong associations with important clinical outcomes. PRIMARY FUNDING SOURCE: National Institute on Aging.

A systematic review of validated methods for identifying heart failure using administrative data.

PURPOSE: To identify and describe the validity of algorithms used to detect heart failure (HF) using administrative and claims data sources. METHODS: A systematic review of PubMed and Iowa Drug Information Service searches of the English language was performed to identify studies published between 1990 and 2010 that evaluated the validity of algorithms for the identification of patients with HF using and claims data. Abstracts and articles were reviewed by two study investigators to determine their relevance on the basis of predetermined criteria. RESULTS: The initial search strategy identified 887 abstracts. Of these, 499 full articles were reviewed and 35 studies included data to evaluate the validity of identifying patients with HF. Positive predictive values (PPVs) were in the acceptable to high range, with most being very high (>90%). Studies that included patients with a primary hospital discharge diagnosis of International Classification of Diseases, Ninth Revision, code 428.X had the highest PPV and specificity for HF. PPVs for this algorithm ranged from 84% to 100%. This algorithm, however, may compromise sensitivity because many HF patients are managed on an outpatient basis. The most common 'gold standard' for the validation of HF was the Framingham Heart Study criteria. CONCLUSIONS: The algorithms and definitions used to identify HF using administrative and claims data perform well, particularly when using a primary hospital discharge diagnosis. Attention should be paid to whether patients who are managed on an outpatient basis are included in the study sample. Including outpatient codes in the described algorithms would increase the sensitivity for identifying new cases of HF.

Multiple imputation for estimating the risk of developing dementia and its impact on survival.

Dementia, Alzheimer's disease in particular, is one of the major causes of disability and decreased quality of life among the elderly and a leading obstacle to successful aging. Given the profound impact on public health, much research has focused on the age-specific risk of developing dementia and the impact on survival. Early work has discussed various methods of estimating age-specific incidence of dementia, among which the illness-death model is popular for modeling disease progression. In this article we use multiple imputation to fit multi-state models for survival data with interval censoring and left truncation. This approach allows semi-Markov models in which survival after dementia depends on onset age. Such models can be used to estimate the cumulative risk of developing dementia in the presence of the competing risk of dementia-free death. Simulations are carried out to examine the performance of the proposed method. Data from the Honolulu Asia Aging Study are analyzed to estimate the age-specific and cumulative risks of dementia and to examine the effect of major risk factors on dementia onset and death.

Exploring the effects of an "everyday" activity program on executive function and memory in older adults: Experience Corps.

PURPOSE: There is little empirical translation of multimodal cognitive activity programs in "real-world" community-based settings. This study sought to demonstrate in a short-term pilot randomized trial that such an activity program improves components of cognition critical to independent function among sedentary older adults at greatest risk. DESIGN AND METHODS: We randomized 149 older adults to Experience Corps (EC) or a wait-list control arm. Participants randomized to EC trained in teams to help elementary school children with reading achievement, library support, and classroom behavior for 15 hr/week during an academic year. We compared baseline and follow-up assessments of memory, executive function (EF), and psychomotor speed at 4 to 8 months by intervention arm, adjusting for exposure duration. We observed a range of EF abilities at baseline and stratified analyses according to the presence of baseline impairment using established norms. RESULTS: Overall, EC participants tended to show improvements in EF and memory relative to matched controls (ps < .10). EC participants with impaired baseline EF showed the greatest improvements, between 44% and 51% in EF and memory at follow-up, compared to declines among impaired-EF controls (ps < .05). IMPLICATIONS: Short-term participation in this community-based program designed to increase cognitive and physical activity in a social, real-world setting may train memory and, particularly, executive functions important to functional independence. This community-based program represents one potentially effective model to bring high doses of sustainable cognitive exercise to the greatest proportion of older adults, particularly those sedentary individuals at elevated risk for health disparities.

The Revised Observed Tasks of Daily Living: A Performance-Based Assessment of Everyday Problem Solving in Older Adults.

The Revised Observed Tasks of Daily Living (OTDL-R), a performance-based test of everyday problem solving, was administered to a sample of community-dwelling older adults. The OTDL-R included nine tasks, representing medication use, telephone use, and financial management. The OTDL-R had a desirable range of difficulty and satisfactory internal consistency and showed a relatively invariant pattern of relations between measured tasks and the underlying latent dimensions they represent across White and non-White subsamples. The OTDL-R also correlated significantly with age, education, self-rated health, a paper-and-pencil measure of everyday problem solving, and measures of basic cognitive functioning. Thus, the OTDL-R is a reliable and valid objective measure of everyday problem solving that has great practical utility for assessing performance in diverse populations.