Is the Montreal cognitive assessment culturally valid in a diverse geriatric primary care setting? Lessons from the Bronx.

BACKGROUND: Efficacy and validity of the MoCA for cognitive screening in ethnoculturally and linguistically diverse settings is unclear. We sought to examine the utility and discriminative validity of the Spanish and English MoCA versions to identify cognitive impairment among diverse community-dwelling older adults. METHODS: Participants aged ≥65 with cognitive concerns attending outpatient primary care in Bronx, NY, were recruited. MoCA and neuropsychological measures were administered in Spanish or English, and a neuropsychologist determined cognitive status (normal with subjective cognitive concerns [SCC], mild cognitive impairment [MCI], and dementia). One-way ANOVA compared cognitive statuses. ROC analyses identified optimal MoCA cutpoints for discriminating possible cognitive impairment. RESULTS: There were 231 participants, with mean age 73, 72% women, 43% Hispanic; 39% Black/African American; 113 (49%) completed testing in English and 118 (51%) in Spanish. Overall MoCA mean was 17.7 (SD = 4.3). Neuropsychological assessment identified 90 as cognitively normal/SCC, average MoCA 19.9 (SD = 4.1), 133 with MCI, average MoCA 16.6 (SD = 3.7), and 8 with dementia, average MoCA 10.6 (SD = 3.1). Mean English MoCA average was 18.6 (SD = 4.1) versus Spanish 16.7 (SD = 4.3). The published cutpoint ≤23 for MCI yielded a high false-positive rate (79%). ROC analyses identified ≤18.5 as the score to identify MCI or dementia using the English MoCA (65% sensitivity; 77% specificity) and ≤16.5 for the Spanish MoCA (64% sensitivity;73% specificity) in this sample of older adults with cognitive concerns. CONCLUSIONS: Current MoCA cutpoints were inappropriately high in a culturally/linguistically diverse urban setting, leading to a high false-positive rate. Lower Spanish and English MoCA cutpoints may improve diagnostic accuracy for identifying cognitive impairment in this group, highlighting the need for the creation and validation of accurate cognitive screeners for ethnoculturally and linguistically diverse older adults.

Difference-Making Pathways to Frailty Through Social Factors: A Configurational Analysis.

BACKGROUND AND OBJECTIVES: Social disconnection is highly prevalent in older adults and is associated with frailty. It is unclear which aspects of social disconnection are most associated with frailty, which ones are difference-making, and which combination of social factors are directly linked to frailty. RESEARCH DESIGN AND METHODS: We conducted a secondary coincidence analysis (CNA) of 1,071 older adults from the Rush Memory and Aging Project (mean age 79.3 ± 7.1; 75.8% female) to identify combinations of social factors that are difference-making for frailty. We included 7 demographic (e.g., age, sex, socioeconomic status) and structural (e.g., social network), functional (e.g., social support, social activity), and quality (e.g., loneliness) aspects of social connection. An established cut score of 0.2 on a frailty index was used to define frailty as the outcome. RESULTS: CNA produced 46 solution models for the presence of frailty in the data set. The top-scoring model was underfit, leaving a final complex solution path for frailty with the highest fit-robustness score that met the fit parameter cutoffs. We found that the combination of loneliness, low social activity, and older age was present 82% of the time when frailty was present. DISCUSSION AND IMPLICATIONS: The combination of loneliness, social activity, and old age is difference-making for frailty, and supports the inclusion of social factors in frailty prevention and intervention. Further research is needed in diverse data sets to better understand the interrelationships between the 3 aspects of social connection and frailty.

Home-Based Gait Speed Assessment: Normative Data and Racial/Ethnic Correlates Among Older Adults.

OBJECTIVES: To determine home-based gait speed performance and its associations with sociodemographic and health-related factors among older adults. DESIGN: Cross-sectional analysis of a nationally representative US population sample. SETTING AND PARTICIPANTS: Homes of Health and Retirement Study (HRS) participants. METHODS: Walk test data measured at home over 2.5 m were aggregated for 6983 individuals, aged ≥65 years (mean age 74.8 ± 6.9 years, 54.2% women), from the 2006 and 2008 HRS waves. Means for gait speed at normal pace were determined for demographic and clinical groupings; association of gait speed with demographic, socioeconomic status, and health factors were examined. Four-year mortality was predicted from baseline slow gait status defined using demographic-based cutoff scores as well as commonly recommended cutoff scores (100 or 60 cm/s). RESULTS: Home-based gait speed (cm/s) means were lower for female than male (9.6% difference), older than younger (18.0% difference), African American than white (20.5% difference), and Hispanic than Non-Hispanic (10.3% difference) participants. Differences by age group, race, and ethnicity remained significant within sexes (P < .001). Lower speed was associated with African American race and all health problems; higher speed was associated with higher socioeconomic status and alcohol consumption. Four-year mortality was predicted by slow gait status. Predictive validity was, in general, higher for slow gait cutoff scores defined by demographic characteristics. CONCLUSIONS AND IMPLICATIONS: Mean gait speed measured at home differs among older (aged ≥65 years) US resident population groups defined by sex, age, race, ethnicity, health status, and combinations of these factors, and predicts 4-year mortality when substantially slower than group-based norms. These findings may assist researchers and clinicians in determining normal and abnormal gait performance in older adults in community settings.

Gray matter volume covariance networks associated with dual-task cost during walking-while-talking.

We studied gray matter volume covariance networks associated with normal pace walking (NPW) speed and dual-task costs (DTCs) during walking-while-talking (WWT)-a mobility stress test that involves walking while reciting alternate letters of the alphabet. Using a multivariate covariance-based analytic approach, we identified gray matter networks associated with NPW speed (mean 102.1 cm/s ±22.5 cm/s) and DTC (percent difference in gait speed between NPW and WWT, mean 25.9% ± 18.8%) in 139 older adults without dementia (M = 75.3 ± 6.1 years). The gray matter network associated with NPW was primarily composed of supplementary motor area, precuneus cortex, and the middle frontal gyrus. Greater expression of this NPW network was associated with better processing speed (trail-making test A [r = -0.30, p = 0.005]) and executive function (trail-making test B - A [r = -0.43, p < 0.0001]). The gray matter network associated with DTC was primarily composed of medial prefrontal, cingulate, and thalamic regions. Greater expression of this DTC network was associated with better episodic memory performance on the free and cued selective reminding test (r = 0.30, p = 0.007). These results suggest that NPW speed and DTC are supported by different networks, and are associated with different cognitive domains.

Guidelines for Assessment of Gait and Reference Values for Spatiotemporal Gait Parameters in Older Adults: The Biomathics and Canadian Gait Consortiums Initiative.

Background: Gait disorders, a highly prevalent condition in older adults, are associated with several adverse health consequences. Gait analysis allows qualitative and quantitative assessments of gait that improves the understanding of mechanisms of gait disorders and the choice of interventions. This manuscript aims (1) to give consensus guidance for clinical and spatiotemporal gait analysis based on the recorded footfalls in older adults aged 65 years and over, and (2) to provide reference values for spatiotemporal gait parameters based on the recorded footfalls in healthy older adults free of cognitive impairment and multi-morbidities. Methods: International experts working in a network of two different consortiums (i.e., Biomathics and Canadian Gait Consortium) participated in this initiative. First, they identified items of standardized information following the usual procedure of formulation of consensus findings. Second, they merged databases including spatiotemporal gait assessments with GAITRite® system and clinical information from the "Gait, cOgnitiOn & Decline" (GOOD) initiative and the Generation 100 (Gen 100) study. Only healthy-free of cognitive impairment and multi-morbidities (i.e., ≤ 3 therapeutics taken daily)-participants aged 65 and older were selected. Age, sex, body mass index, mean values, and coefficients of variation (CoV) of gait parameters were used for the analyses. Results: Standardized systematic assessment of three categories of items, which were demographics and clinical information, and gait characteristics (clinical and spatiotemporal gait analysis based on the recorded footfalls), were selected for the proposed guidelines. Two complementary sets of items were distinguished: a minimal data set and a full data set. In addition, a total of 954 participants (mean age 72.8 ± 4.8 years, 45.8% women) were recruited to establish the reference values. Performance of spatiotemporal gait parameters based on the recorded footfalls declined with increasing age (mean values and CoV) and demonstrated sex differences (mean values). Conclusions: Based on an international multicenter collaboration, we propose consensus guidelines for gait assessment and spatiotemporal gait analysis based on the recorded footfalls, and reference values for healthy older adults.

Short Physical Performance Battery and all-cause mortality: systematic review and meta-analysis.

BACKGROUND: The Short Physical Performance Battery (SPPB) is a well-established tool to assess lower extremity physical performance status. Its predictive ability for all-cause mortality has been sparsely reported, but with conflicting results in different subsets of participants. The aim of this study was to perform a meta-analysis investigating the relationship between SPPB score and all-cause mortality. METHODS: Articles were searched in MEDLINE, the Cochrane Library, Google Scholar, and BioMed Central between July and September 2015 and updated in January 2016. Inclusion criteria were observational studies; >50 participants; stratification of population according to SPPB value; data on all-cause mortality; English language publications. Twenty-four articles were selected from available evidence. Data of interest (i.e., clinical characteristics, information after stratification of the sample into four SPPB groups [0-3, 4-6, 7-9, 10-12]) were retrieved from the articles and/or obtained by the study authors. The odds ratio (OR) and/or hazard ratio (HR) was obtained for all-cause mortality according to SPPB category (with SPPB scores 10-12 considered as reference) with adjustment for age, sex, and body mass index. RESULTS: Standardized data were obtained for 17 studies (n = 16,534, mean age 76 ± 3 years). As compared to SPPB scores 10-12, values of 0-3 (OR 3.25, 95%CI 2.86-3.79), 4-6 (OR 2.14, 95%CI 1.92-2.39), and 7-9 (OR 1.50, 95%CI 1.32-1.71) were each associated with an increased risk of all-cause mortality. The association between poor performance on SPPB and all-cause mortality remained highly consistent independent of follow-up length, subsets of participants, geographic area, and age of the population. Random effects meta-regression showed that OR for all-cause mortality with SPPB values 7-9 was higher in the younger population, diabetics, and men. CONCLUSIONS: An SPPB score lower than 10 is predictive of all-cause mortality. The systematic implementation of the SPPB in clinical practice settings may provide useful prognostic information about the risk of all-cause mortality. Moreover, the SPPB could be used as a surrogate endpoint of all-cause mortality in trials needing to quantify benefit and health improvements of specific treatments or rehabilitation programs. The study protocol was published on PROSPERO (CRD42015024916).

Frailty Assessment in Advanced Heart Failure.

BACKGROUND: Several studies have recently demonstrated the value of frailty assessment in a general heart failure (HF) population; however, it is unknown whether these findings are also applicable in advanced HF. We investigated the utility of frailty assessment and its prognostic value in elderly patients with advanced HF. METHODS: Forty consecutive elderly subjects aged ≥65 years, with left ventricular ejection fraction ≤35%, New York Heart Association class III or IV, and a 6-minute walk test <300 m were enrolled from the HF clinic at Montefiore Medical Center between October 2012 and July 2013. Subjects were assessed for frailty with the Fried Frailty Index, consisting of 5 components: hand grip strength, 15-foot walk time, weight loss, physical activity, and exhaustion. All subjects were prospectively followed for death or hospitalization. RESULTS: At baseline, the mean age of the cohort was 74.9 ± 6.5 years, 58% female, left ventricular ejection fraction 25.6 ± 6.4%, 6-minute walk test 195.8 ± 74.3 m and length of follow-up 454 ± 186 days. Thirty-five percent were prefrail and 65% were frail. Frailty status was associated with the combined primary endpoint of mortality and all-cause hospitalization (hazard ratio [HR] 1.93, 95% confidence interval [CI] 1.15-3.25, P = .013). On individual analysis, frailty was associated with all-cause hospitalizations (HR 1.92, 95% CI 1.12-3.27, P = .017) and non-HF hospitalizations (HR 3.31, 95% CI 1.14- 9.6, P = .028), but was not associated with HF hospitalizations alone (HR 1.31, 95% CI 0.68-2.49, P = .380). CONCLUSIONS: Frailty assessment in patients with advanced HF is feasible and provides prognostic value. These findings warrant validation in a larger cohort.

Multiple modes of assessment of gait are better than one to predict incident falls.

BACKGROUND: Though gait evaluation is recommended as a core component of fall risk assessments, a systematic examination of the predictive validity of different modes of gait assessments for falls is lacking. OBJECTIVE: To compare three commonly employed gait assessments - self-reported walking difficulties, clinical evaluation, and quantitative gait - to predict incident falls. MATERIALS AND METHODS: 380 community-dwelling older adults (mean age 76.5 ± 6.8 y, 55.8% female) were evaluated with three independent gait assessment modes: patient-centered, quantitative, and clinician-diagnosed. The association of these three gait assessment modes with incident falls was examined using Cox proportional hazards models. RESULTS: 23.2% of participants self-reported walking difficulties, 15.5% had slow gait, and 48.4% clinical gait abnormalities. 30.3% had abnormalities on only one assessment, whereas only 6.3% had abnormalities on all three. Over a mean follow-up of 24.2 months, 137 participants (36.1%) fell. Those with at least two abnormal gait assessments presented an increased risk of incident falls (hazard ratio (HR): 1.61, 95% confidence interval (CI): 1.04-2.49) in comparison to the 169 participants without any abnormalities on any of the three assessments. CONCLUSIONS: Multiple modes of gait evaluation provide a more comprehensive mobility assessment than only one assessment alone, and better identify incident falls in older adults.

Alzheimer's Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting.

The Patient Protection and Affordable Care Act added a new Medicare benefit, the Annual Wellness Visit (AWV), effective January 1, 2011. The AWV requires an assessment to detect cognitive impairment. The Centers for Medicare and Medicaid Services (CMS) elected not to recommend a specific assessment tool because there is no single, universally accepted screen that satisfies all needs in the detection of cognitive impairment. To provide primary care physicians with guidance on cognitive assessment during the AWV, and when referral or further testing is needed, the Alzheimer's Association convened a group of experts to develop recommendations. The resulting Alzheimer's Association Medicare Annual Wellness Visit Algorithm for Assessment of Cognition includes review of patient Health Risk Assessment (HRA) information, patient observation, unstructured queries during the AWV, and use of structured cognitive assessment tools for both patients and informants. Widespread implementation of this algorithm could be the first step in reducing the prevalence of missed or delayed dementia diagnosis, thus allowing for better healthcare management and more favorable outcomes for affected patients and their families and caregivers.

Walking while talking: effect of task prioritization in the elderly.

OBJECTIVE: To examine the effect of 2 instructions on the same walking while talking (WWT) task on task prioritization by nondisabled subjects. DESIGN: Cross-sectional survey with within subject comparisons. SETTING: Community-based sample. PARTICIPANTS: Older adults (N=189; mean age, 80.2+/-4.9y), who did not meet criteria from the Diagnostic and Statistical Manual, Fourth Edition, for dementia and were able to independently perform activities of daily living. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Verbal and gait measures on the same WWT task with 2 different instructions: paying attention to both talking and walking (WWT-C) and paying attention only to talking (WWT-T). RESULTS: Task prioritization effects were seen on walking but not on talking. Compared with their baseline normal walking velocity (without talking), subjects slowed down more on WWT-T (median change, 28.3%) than WWT-C (median change, 26.4%). Comparing the 2 WWT conditions, velocity and cadence was slower during WWT-T compared with WWT-C, with longer stride length. Verbal output was not significantly different on the 2 conditions. CONCLUSIONS: Changing instructions while maintaining the same cognitive and motor tasks on WWT in older adults result in task prioritization effects.

Cognitive and mobility profile of older social dancers.

OBJECTIVES: To define the cognitive and physical attributes of regular social dancing so as to help establish its health benefits and help plan future dance interventions to prevent adverse outcomes in older adults such as falls, slow gait, and dementia. DESIGN: Cross-sectional survey with two-group comparison. SETTING: Bronx County, New York. PARTICIPANTS: Twenty-four cognitively normal older social dancers (OSDs) were compared with 84 age-, sex-, and education-matched older nondancers (ONDs) participating in a community-based study. MEASUREMENTS: Motor and cognitive performance was assessed using validated clinical and quantitative methods. RESULTS: There were no differences in the frequency of participation in other cognitive and physical leisure activities, chronic illnesses, or falls between OSDs and ONDs. Cognitive test performance was not different between OSDs and ONDs. OSDs had better balance but not strength than ONDs. OSDs had a longer mean stride+/-standard deviation than ONDs (117.8+/-10.5 cm vs 103.4+/-20.2 cm, P=.008) on quantitative gait assessment, with a more stable pattern during walking with reduced stance time (63.9% vs 65.9%, P=.01), longer swing time (36.1% vs 34.1%, P=.01), and shorter double support time (27.9% vs 30.9%, P=.03). CONCLUSION: The results of this study suggest that long-term social dancing may be associated with better balance and gait in older adults.