Effects of restriction of activities and social isolation on risk of dementia in the community.

OBJECTIVE: Social isolation and emotional isolation, i.e. loneliness, have been associated with dementia or cognitive decline. In contrast, the relationship of restriction of physical and instrumental activities of daily living to cognitive decline and dementia has been less studied. DESIGN: We examined multiple quality of life (QoL) indicators, including isolation and restriction of activities, utilizing two validated scales in elders without dementia to determine their associations with cognitive decline and incident dementia that were followed longitudinally over 6 years. We comprehensively controlled for other symptom constellations, including depression and anergia. SETTING: A large multi-ethnic prospective study was conducted in northern Manhattan, NYC. PARTICIPANTS: An ethnically diverse sample of 855 non-demented individuals at baseline participated. MEASURES: The following QoL scales were utilized: Restriction, Anergia, Isolation, Loneliness, and Affective Suffering. RESULTS: Both Restriction (HR = 2.22, 95% CI [1.42, 3.47], P < .001) and Isolation (HR = 1.78, 95% CI [1.17, 2.70], P = 0.007) were associated with episodic memory and incident dementia, controlling for age, sex, and education. Loneliness and Affective Suffering (depression) were not associated with these outcomes (P's > .1) with both Restriction and Isolation in the same model for the prediction of dementia, only Restriction remained significant (HR = 1.97, 95% CI [1.24, 3.14], P = 0.004). In cross-lagged panel analyses, Restriction and Isolation had reciprocal influences (P's < .001), indicating that Restriction at the previous time point influenced current Isolation. Importantly, Restriction (but not Isolation) and Selective Reminding total recall memory demonstrated highly significant direct and reciprocal influences over time (P's < .001). CONCLUSIONS: Restriction and Isolation were associated with incident dementia. Restriction played a more prominent role in its impact on memory decline. The development of these impairments in QoL, particularly Restriction, may provide warning signs of future cognitive decline and dementia and provide multiple and novel avenues for therapeutic interventions with the goal of delaying the development of cognitive decline and dementia.

Quality of life impacts on 16-year survival of an older ethnically diverse cohort.

OBJECTIVE: The objective of this study is to examine the prediction of mortality, over 16 years, by the domains and domain elements underlying generic measures of quality of life (QoL). METHODS: The method used was an analysis of mortality in an older (65 + years) representative sample (N = 2130) of a multicultural community in North Manhattan. Five conventional QoL domains were measured by in-home, rater-administered, and computer-assisted questionnaire: depressed mood, pain, self-perceived health, and function and social relationships. RESULTS: Some domain scales that qualitatively express distress, such as depressed mood and widespread pain, significantly predicted lower mortality (were protective) and felt isolation trended in that direction, whereas domains indicating quantitative limitations such as impairment of functioning in daily tasks, stair climbing, as well as social disengagements and lack of support network significantly predicted higher mortality. Domain elements also mattered; contrary to their domain predictions, increased mortality was predicted by the domain elements of somatic symptoms of depression. Self-perceived poor health reflected the predictive (higher mortality) direction of the limitations cluster. CONCLUSIONS: The internal complexity of QoL is underscored by differential impacts of domains and elements on mortality. Clinical implications include setting distress domains as important clinical goals, whereas strengthening limiting domains could result in lengthening life and secondarily relieving distress. The relative weighting of these goals could be derived from patient preferences and clinical efficacy. Fundamental implications lie in the interaction between the person's qualitative evaluations of choices and the quantitative building of desired choices for a better QoL.

Management of persistent pain in the older patient: a clinical review.

IMPORTANCE: Persistent pain is highly prevalent, costly, and frequently disabling in later life. OBJECTIVE: To describe barriers to the management of persistent pain among older adults, summarize current management approaches, including pharmacologic and nonpharmacologic modalities; present rehabilitative approaches; and highlight aspects of the patient-physician relationship that can help to improve treatment outcomes. This review is relevant for physicians who seek an age-appropriate approach to delivering pain care for the older adult. EVIDENCE ACQUISITION: Search of MEDLINE and the Cochrane database from January 1990 through May 2014, using the search terms older adults, senior, ages 65 and above, elderly, and aged along with non-cancer pain, chronic pain, persistent pain, pain management, intractable pain, and refractory pain to identify English-language peer-reviewed systematic reviews, meta-analyses, Cochrane reviews, consensus statements, and guidelines relevant to the management of persistent pain in older adults. FINDINGS: Of the 92 identified studies, 35 evaluated pharmacologic interventions, whereas 57 examined nonpharmacologic modalities; the majority (n = 50) focused on older adults with osteoarthritis. This evidence base supports a stepwise approach with acetaminophen as first-line therapy. If treatment goals are not met, a trial of a topical nonsteroidal anti-inflammatory drug, tramadol, or both is recommended. Oral nonsteroidal anti-inflammatory drugs are not recommended for long-term use. Careful surveillance to monitor for toxicity and efficacy is critical, given that advancing age increases risk for adverse effects. A multimodal approach is strongly recommended-emphasizing a combination of both pharmacologic and nonpharmacologic treatments to include physical and occupational rehabilitation, as well as cognitive-behavioral and movement-based interventions. An integrated pain management approach is ideally achieved by cultivating a strong therapeutic alliance between the older patient and the physician. CONCLUSIONS AND RELEVANCE: Treatment planning for persistent pain in later life requires a clear understanding of the patient's treatment goals and expectations, comorbidities, and cognitive and functional status, as well as coordinating community resources and family support when available. A combination of pharmacologic, nonpharmacologic, and rehabilitative approaches in addition to a strong therapeutic alliance between the patient and physician is essential in setting, adjusting, and achieving realistic goals of therapy.

The Stroud/ADI dementia quality framework: a cross-national population-level framework for assessing the quality of life impacts of services and policies for people with dementia and their family carers.

OBJECTIVES: To generate an internationally applicable framework for the systematic assessment of the quality of life impacts of services and policies for people with dementia and their family carers. DESIGN: A qualitative analysis of text. SETTING: Open groups at six consecutive Alzheimer's Disease International (ADI) Conferences (1999-2005) lasting between 1.5 and 2 h. Data were: presenters' texts, transcribed points made during discussion and written contributions. PARTICIPANTS: Three hundred and twelve contributors of text. RESULTS: From 2246 chunks of text, eight interacting domains relating to quality of life emerged: Public Attitudes and Understanding; Government and Social Policy; Funding for Services; Health; Communication; Choice and Personhood; Environment; and Quality of Care leading to the development of the Stroud/ADI Dementia Quality Framework. CONCLUSIONS: The Stroud/ADI Dementia Quality Framework helps to structure assessment of the quality of life impacts of population level approaches in dementia impacts of population-level approaches in dementia. Information available can be mapped onto the framework. With its international approach, the Stroud/ADI Dementia Quality Framework has validity across cultures within and between countries. It is intended as a useful aid for the assessment of services and policies for people with dementia and their family carers.

The choices, choosing model of quality of life: linkages to a science base.

BACKGROUND: A previous paper began with a critical review of current models and measures of quality of life and then proposed criteria for judging the relative merits of alternative models: preference was given to finding a model with explicit mechanisms, linkages to a science base, a means of identifying deficits amenable to rational restorative interventions, and with embedded values of the whole person. A conjectured model, based on the processes of accessing choices and choosing among them, matched the proposed criteria. The choices and choosing (c-c) process is an evolved adaptive mechanism dedicated to the pursuit of quality of life, driven by specific biological and psychological systems, and influenced also by social and environmental forces. OBJECTIVE: In this paper the c-c model is examined for its potential to strengthen the science base for the field of quality of life and thus to unify many approaches to concept and measurement. CONCLUSIONS: A third paper in this set will lay out a guide to applying the c-c model in evaluating impairments of quality of life and will tie this evaluation to corresponding interventions aimed at relieving restrictions or distortions of the c-c process; thus helping people to preserve and improve their quality of life. The fourth paper will demonstrate empirical analyses of the relationship between health imposed restrictions of options for living and conventional indicators of diminished quality of life.

The choices, choosing model of quality of life: description and rationale.

AIM: This introductory paper offers a critical review of current models and measures of quality of life, and describes a choices and choosing (c-c) process as a new model of quality of life. METHOD: Criteria are proposed for judging the relative merits of models of quality of life with preference being given to explicit mechanisms, linkages to a science base, a means of identifying deficits amenable to rational restorative interventions, and with embedded values of the whole person. RESULT: A conjectured model, based on the processes of gaining access to choices and choosing among them, matches the proposed criteria. The c-c process is an evolved adaptive mechanism dedicated to the pursuit of quality of life, driven by specific biological and psychological systems, and influenced by social and environmental forces. CONCLUSIONS: This model strengthens the science base for the field of quality of life, unifies approaches to concept and measurement, and guides the evaluation of impairments of quality of life. Corresponding interventions can be aimed at relieving restrictions or distortions of the c-c process; thus helping people to preserve and improve their quality of life. RELATED WORK: Companion papers detail relevant aspects of the science base, present methods of identifying deficits and distortions of the c-c model so as to open opportunities for rational restorative interventions, and explore empirical analyses of the relationship between health imposed restrictions of c-c and conventional indicators of diminished quality of life. [corrected]

The choices, choosing model of quality of life: clinical evaluation and intervention.

Two previous papers presented a conjectured model of quality of life featuring the personal management of accessing choices and choosing among them (the c-c process). Those papers made the case that this model unifies the pathways leading to impaired quality of life, especially with regard to age associated multiple co-morbidities, changes in perception and functioning, and the effects of long term care environments; it also introduces a science base for understanding and guiding interventions that can assist people to achieve their quality-of-life goals. Our aim in this paper is to outline interprofessional strategies that could relieve restrictions or distortions of the c-c process imposed by aging, ill-health, or a restricting environment. We do so by outlining potential deficits in the c-c process and matching these with restorative person-centered interprofessional interventions including interprofessional teamwork. Findings suggest that interprofessional assessment and team work is well suited to assisting the c-c process. We conclude that the groundwork has been prepared for developing training programs and clinical trials for interprofessional interventions targeting the c-c process.

Self-reported lack of energy (anergia) among elders in a multiethnic community.

BACKGROUND: Lack of energy, "anergia," is a possible central feature for identifying, evaluating, and treating elders with health-related problems in quality of life. METHODS: A survey was conducted on a randomly selected stratified sample (N = 2130) of three ethnic groups of community-residing elders in a defined urban geographic area: the Northern Manhattan Aging Project (NMAP). The participants were Medicare beneficiaries living north of 150(th) Street in Manhattan. The criteria for anergia were based on the presence of the major criterion "sits around a lot for lack of energy" and any two of six minor criteria. Self-reports were gathered using a computer-assisted, rater-administered interview (the Comprehensive Assessment and Referral Interview; CARE) covering: function (basic activities of daily living [ADL] and instrumental ADL [IADL]); features of geriatric syndromes such as self-rated physical health, depression, pain, respiratory distress, trouble sleeping, cognitive impairment, and cardiovascular syndromes; social isolation; and healthcare utilization. Short-term (18-month) and long-term (6-year) mortality were derived from the National Death Index. RESULTS: Three hundred eighty-six people (18% of the sample) met criteria for anergia. Anergia was more common in women than men (22% vs 12%, p <.01), in unmarried than in married persons (21% vs 13%, p <.001), and with advancing age. People with anergia used more hospitalizations, office visits, emergency room visits, and home care services and, had higher mortality rates. In multivariate analyses, the following factors had independent associations with anergia: female gender, impaired physical function and IADL, depression, pain, respiratory symptoms, urinary incontinence, hearing difficulty, feeling dizzy or weak, and social isolation and disengagement. These factors could be the initial candidates for clinical investigation of anergia of undetermined origin. Among people with anergia at baseline, 31.3% (n = 121) had persistent anergia and 33.9% (n = 131) recovered over a follow-up period of 18 months. CONCLUSIONS: Anergia in multiethnic older adults is associated with a range of clinical symptoms and diseases, with extensive health services use, and with increased mortality.

A Link between Subjective Perceptions of Memory and Physical Function: Implications for Subjective Cognitive Decline.

Subjective impairment in memory is a frequently defining feature of subjective cognitive decline (SCD), a state hypothesized to precede objectively apparent cognitive symptoms of Alzheimer's disease (AD) and to hold promise as a non-invasive, inexpensive, preclinical indicator of AD. However, a full model of the factors that contribute to subjective memory (SM), and therefore to SCD, has yet to be articulated. While SM impairment is widely known to be associated with negative affect, the extent to which SM functioning may also reflect other factors, particularly subjective beliefs or perceptions about one's health, is not known. To examine the extent to which SM is associated with subjective perceptions of health more broadly, the current study investigated the link between SM and subjective physical functioning (independent of depressive affect, and objective cognitive and physical function) in an ethnically diverse sample of 471 older adults enrolled in the population-based Northern Manhattan Aging Project. 199 (42%) participants endorsed no difficulty on a 5-point SM index while 272 (58%) endorsed some degree of difficulty. As hypothesized, SM correlated with both depression and subjective physical function, but not with age, education, global cognition, or objective physical function. When objective and subjective physical function were entered in two separate, adjusted linear regressions predicting SM, only subjective physical function and depressive affect independently predicted SM. Subjective perceptions of memory appear to reflect individuals' broader health perceptions in part. Articulating the various correlates of SM will improve identification of SCD specific to preclinical AD.

Development of a Short-Form of the Medication Management Test: Evaluation of Dimensionality, Reliability, Information and Measurement Equivalence Using Latent Variable Models.

BACKGROUND AND PURPOSE: The Medication Management Test (MMT) measures higher cognitive functioning. The aim of the analyses presented was to reduce assessment burden by developing a short-form version, and describe its psychometric properties. METHODS: Factor analyses, item response theory (IRT), and differential item functioning (DIF) were performed to examine the dimensionality, reliability information, and measurement equivalence. RESULTS: The ratio of the first two extracted eigenvalues from the exploratory principal component analysis was 7.62, indicating essential unidimensionality. Although one item "needs prompting for pill regime" evidenced DIF above the threshold for education and race/ethnicity, the magnitude was relatively small and the impact minimal. IRT-based reliability estimates were high (>0.80) across all subgroups. CONCLUSIONS: Because medication management is an important task associated with independent living, it is critical to assess whether medications can be self-administered safely.

Methodological issues in measuring subjective well-being and quality-of-life: Applications to assessment of affect in older, chronically and cognitively impaired, ethnically diverse groups using the Feeling Tone Questionnaire.

Quality of life assessment includes measurement of positive affect. Methods artifacts associated with positively and negatively worded items can manifest as negative items loading on a second factor, despite the conceptual view that the items are measuring one underlying latent construct. Negatively worded items may elicit biased responses. Additionally, item-level response bias across ethnically diverse groups may compromise group comparisons. The aim was to illustrate methodological approaches to examining method factors and measurement equivalence in an affect measure with 9 positively and 7 negatively worded items: The Feeling Tone Questionnaire (FTQ). The sample included 4,960 non-Hispanic White, 1,144 non-Hispanic Black, and 517 Hispanic community and institutional residents receiving long-term supportive services. The mean age was 82 (s.d.=11.0); 73% were female. Two thirds were cognitively impaired. Methods effects were assessed using confirmatory factor analyses (CFA), and reliability with McDonald's omega and item response theory (IRT) generated estimates. Measurement equivalence was examined using IRT-based Wald tests. Methods effects associated with negatively worded items were observed; these provided little IRT information, and as a composite evidenced lower reliability. Both 13 and 9 item positive affect scales performed well in terms of model fit, reliability, IRT information, and evidenced little differential item functioning of high magnitude or impact. Both CFA and IRT approaches provided complementary methodological information about scale performance. The 9-item affect scale based on the FTQ can be recommended as a brief quality-of-life measure among frail and cognitively impaired individuals in palliative and long-term care settings.

The Columbia Cooperative Aging Program: an interdisciplinary and interdepartmental approach to geriatric education for medical interns.

Although there is a critical need to prepare physicians to care for the growing population of older adults, many academic medical centers lack the geriatric-trained faculty and dedicated resources needed to support comprehensive residency training programs in geriatrics. Because of this challenge at Columbia University, the Columbia Cooperative Aging Program was developed to foster geriatric training for medical interns. For approximately 60 interns each year completing their month-long geriatric rotations, an integral part of this training now involves conducting comprehensive assessments with "well" older people, supervised by an interdisciplinary team of preceptors from various disciplines, including cardiology, internal medicine, occupational therapy, geriatric nursing, psychiatry, education, public health, social work, and medical anthropology. Interns explore individual behaviors and social supports that promote health in older people; older people's strengths, vulnerabilities, and risk for functional decline; and strategies for maintaining quality of life and independence. In addition, a structured "narrative medicine" writing assignment is used to promote the interns' reflections on the assessment process, the data gathered, and their clinical reasoning throughout. Preliminary measures of the program's effect have shown significant improvements in attitudes toward, and knowledge of, older adults as patients, as well as in interns' self-assessed clinical skills. For academic medical centers, where certified geriatric providers are scarce, this approach may be an effective model for fostering residency geriatric education among interns.

Heritability of Health and Aging Limitations on Personally Desired Activities.

The aim of this study is to estimate heritability of incident limitations on personally desired activities within the eighth decade of life. We measured self-rated ability to perform ten personally desired activities in 1606 male veteran twin pairs at baseline and four years later. At follow-up, 33% of the cohort reported more limitations in desired activities. Among twins who completed both assessments, there were no statistically significant differences in incidence rates of limitations as a function of zygosity. Sensitivity tests showed the same for change scores; and that, if cognitive impairment or death are deemed to belong among limitations of desired activities, zygosity contributed 10% to new limitations at follow-up. Maintaining personally desired activities over four years in the eighth decade is not subject to substantial genetic influence. However, if death and cognitive impairment are added to incident limitations, then genetics plays a modest role. In all cases, unique environment is the predominant influence.

Use of a cane for ambulation: marker and mitigator of impairment in older people who report no difficulty walking.

OBJECTIVES: To measure disability, patients are often asked whether they have difficulty performing daily tasks. However, recent work suggests that functional problems may be detected earlier by inquiring about modifications in the way tasks are performed. We sought to describe the characteristics of older people who deny difficulty walking but nevertheless have modified the manner in which they walk, by use of a cane. We also tested the hypothesis that, among older people who deny difficulty walking, those using a cane have more mobility problems and are at greater risk for future mobility problems than those not using a cane. DESIGN: Longitudinal survey study, with measures at baseline and 2-year follow-up. SETTING: Population-based survey of urban older people. PARTICIPANTS: One thousand two hundred fifty-one community-dwelling older persons without severe cognitive impairment who reported no difficulty walking at baseline. MEASUREMENTS: Self-reported health, activities of daily living (ADL), and mobility status. RESULTS: Among older people who denied difficulty walking, those who used a cane at baseline (7 of subjects) were older and more likely to have taken medication for a heart condition or arthritis, to have an ADL deficit, and to have been hospitalized in the past year. They were less likely to have walked for pleasure in the past month and more likely to report difficulty crossing roads or intersections. Moreover, those using a cane at baseline were more likely to develop new mobility problems at follow-up. For example, 15 of those who used a cane at baseline reported new difficulty walking at follow-up, compared with 2 of those who did not use a cane. CONCLUSION: Older people who deny difficulty walking but who use a cane are at greater risk than those who do not use a cane for the development of difficulty walking and other new mobility problems. Asking patients about task modification rather than difficulty alone may be a more sensitive way to detect early or mild functional problems.

A twin study of the genetic contribution to age-related functional impairment.

BACKGROUND: A key element in the quality of later life is the prevalence of age-related functional impairments. The objective of this study was to quantify the genetic and environmental influences on age-related functional impairment in a population of white male twin elders who were fit in young adulthood when entering military service. The extent of genetic influence on functioning in later life affects the role of public health, personal initiative, and service interventions. METHODS: Indicators of functional impairment were determined by telephone survey and by twin pair responses to 10 indicators of basic, instrumental, and social activities, and mobility. Responses were analyzed using structural equation modeling. Prevalence and concordances were determined by zygosity status. Covariance was partitioned between twins in a pair into components attributable to additive genetics, common environment, and unique environment. RESULTS: Data from 2721 twin pairs (1384 monozygotic and 1337 dizygotic) were analyzed for the 10 dichotomous indicators of functional impairment and for a subscale of 8 of these indicators. For the subscale, additive genes accounted for approximately 21% of covariance in liability for a higher score, whereas unique environment accounted for approximately 78% of variance, with age accounting for a very small proportion. In two indicators there were nontrivial effects of common environment. CONCLUSIONS: Within the expressed limits on generalization, the study findings suggest a major potential role for interventions aimed at a person's unique environment to maintain good functioning in aging and to lengthen the period of active life. Genetic effects play a modest but also important role in age-related functional impairment.

Relative Rates of Dementia By Multiple Case Definitions, Over Two Prevalence Periods, In Three Sociocultural Groups.

The North Manhattan Aging Project registry, using both Reporting and Survey Components, identifies dementia cases among Latino, African-American, and non-Latino white sociocultural groups (9,349 persons 65 years of age or older) in contiguous census tracts. During a 2-year prevalence period of the reporting component, 1,592 persons were reported to the Registry and screened with five widely used brief cognitive measures; 844 were evaluated in a "clinical core," and 452 met research criteria for dementia, covering all subtypes, according to DSM-III-R criteria. Thirteen different case definitions for dementia were applied to the sociocultural groups at three levels of educational achievement, examining for associations with rates of dementia cases and controlling for age. The following findings were robust across case definitions: sociocultural membership was not associated, but lower education was associated, with increased rates of recorded dementia; however, the patterns of the association with education varied across sociocultural groups.

Operating Characteristics of Brief Screens for Dementia in a Multicultural Population.

Operating characteristics of seven screens for dementia were compared across various groups for 795 persons who had received a criterion diagnostic evaluation. Area under the curve (AUC), based on receiver operating characteristics, was compared between and within scales as an indication of their efficiency. Differences in AUC were only 5% across all the scales for the entire sample, but increased to 11% across sociocultural groups and scales and to 20% across education groups and scales. Two scales (the Mini-Mental State Exam and the Short Portable Mental Status Questionnaire) misclassified most nondementias for the entire sample, and all scales misclassified most nondementias among persons with less than 5 years of education. Findings could support a recommendation that certain shorter scales be used because they perform as well as longer ones, are more consistent across cultural and educational groups, and can be more easily modified to improve performance in culturally diverse populations.

Prevalence and characteristics of anergia (lack of energy) in patients with acute coronary syndrome.

Anergia, a commonly occurring syndrome in older adults and patients with cardiovascular diseases, is associated with functional and clinical limitations. To date, the prevalence and clinical-demographic characteristics of anergia in patients with acute coronary syndrome (ACS) have not been elucidated. We examined the prevalence and clinical-demographic characteristics of anergia in a multiethnic sample of patients with ACS. Hospitalized patients with ACS (n = 472), enrolled in the Prescription Usage, Lifestyle, and Stress Evaluation (PULSE) prospective cohort study, completed assessments of demographic, behavioral, and clinical characteristics within 7 days of hospitalization for an ACS event. Current depressive disorder was ascertained using a structured psychiatric interview 3 to 7 days after discharge. Anergia was assessed at baseline and defined using patients' binary responses (yes/no) to 7 items related to energy level. At least 1 complaint of anergia was reported by 79.9% of patients (n = 377) and 32% of patients (n = 153) met criteria for anergia. In a multivariable logistic regression model, anergia was independently associated with being a woman, being white (compared to black), having bodily pain, participating in exercise, having current depressive disorder, and having higher values on the Charlson Co-morbidity Index. In conclusion, anergia is a highly prevalent syndrome in patients with ACS. It is distinct from depression and is associated with modifiable clinical factors such as participation in exercise and bodily pain that may be appropriate targets for intervention.

Health-related restrictions of choices and choosing: implications for quality of life and clinical interventions.

BACKGROUND: The process of "accessing choices and choosing among them" (c-c) has been proposed as a model for understanding, evaluating, and assisting a patient's management of quality of life. If desired choices are freely accessible, and the act of choosing is efficient and unconstrained, then the outcome is optimized quality of life. The c-c model fits many clinical situations where improved quality of life is a goal, and interventions may be aimed at relieving health-related restrictions of the patient's desired activities. AIMS: To determine the impact of health restrictions of choices and choosing on indicators and outcomes reflecting quality of life. METHOD: Secondary analysis of a community-based health survey of three ethnic groups, 65 years and older (n = 2,130), repeated after 18 months, with mortality over 6 years. FINDINGS: Complaints of health restrictions of desired activities accounted for about half the variance of all determinants of a quality of life proxy indicator, and had a high frequency. Such complaints also predicted declines in mood and function, higher death rates, and increased service use. CONCLUSIONS: Clinical trials are warranted of the efficacy for quality of life improvement of interventions that focus on the relief of health-induced restrictions of desired activities.