The SPEER: An interprofessional team behavior rubric to optimize geriatric clinical care.

Geriatric patients with complex health care needs can benefit from interprofessional (IP) care; however, a major gap in health professional education is determining how to prepare future providers for IP collaboration. Effective IP team behavior assessment tools are needed to teach, implement, and evaluate IP practice skills. After review of IP evaluation tools, the Standardized Patient Encounter Evaluation Rubric (SPEER) was created to evaluate team dynamics in IP practice sites.Independent sample t-tests between faculty and learner SPEER scores showed learners scored themselves 15 points higher than their faculty scores (p < .001). Cronbach's α showed high internal consistency (α = 0.91). Paired t-tests found that learners identified improvements in the team's ability to address the patient's education needs and to allow the patients to voice their expectations. Faculty identified improvements in the teams' ability to make recommendations. Faculty evaluations of learner teams showed improvements in raw ratings on all but two items. Qualitative data analysis for emergent themes showed learners desired team functioning feedback and how teamwork could improve to provide optimal IP care.In conclusion, the SPEER can help faculty and learners identify growth in their teams' ability to perform key IP skills in clinical sites.

Prevalence and Prevention of Reproducibility Deficiencies in Life Sciences Research: Large-Scale Meta-Analyses.

BACKGROUND Studies have found that many published life sciences research results are irreproducible. Our goal was to provide comprehensive risk estimates of familiar reproducibility deficiencies to support quality improvement in research. MATERIAL AND METHODS Reports included were peer-reviewed, published between 1980 and 2016, and presented frequency data of basic biomedical research deficiencies. Manual and electronic literature searches were performed in seven bibliographic databases. For deficiency concepts with at least four frequency studies and with a sample size of at least 15 units in each, a meta-analysis was performed. RESULTS Overall, 68 publications met our inclusion criteria. The study identified several major groups of research quality defects: study design, cell lines, statistical analysis, and reporting. In the study design group of 3 deficiencies, missing power calculation was the most frequent (82.3% [95% Confidence Interval (CI): 69.9-94.6]). Among the 6 cell line deficiencies, mixed contamination was the most frequent (22.4% [95% CI: 10.4-34.3]). Among the 3 statistical analysis deficiencies, the use of chi-square test when expected cells frequency was <5 was the most prevalent (15.7% [95% CI: -3.2-34.7]). In the reporting group of 12 deficiencies, failure to state the number of tails was the most frequent (65% [95% CI: 39.3-90.8]). CONCLUSIONS The results of this study could serve as a general reference when consistently measurable sources of deficiencies need to be identified in research quality improvement.

Does Including Dexmedetomidine Improve Outcomes After Intravenous Sedation for Outpatient Dentoalveolar Surgery?

PURPOSE: Dexmedetomidine represents an intriguing adjunct to outpatient intravenous (IV) sedation owing to its decreased risk of respiratory depression. The purpose of the present study was to measure the incremental effect of incorporating dexmedetomidine (DXM) into an established IV sedation regimen compared with control IV sedation without the DXM infusion. MATERIALS AND METHODS: We designed a prospective, controlled trial in which American Society of Anesthesiologists Class 1 and 2 patients requiring both maxillary and mandibular dentoalveolar surgery would undergo 2 sedation appointments: 1 arch treated with surgery with control sedation (DXM-) using midazolam, fentanyl, and propofol as needed, and a second surgery on the opposite arch using the experimental sedation regimen (DXM+) of midazolam, fentanyl, and propofol, as needed, and a DXM infusion at 4 µg/kg/hr. The surgeon was the same for every appointment, and the patients were kept unaware regarding which sedation had included the experimental regimen. Whether the experimental sedation was used at the first or second surgery was randomized. The primary measured outcomes were efficiency in terms of anesthesia time for each sedation, the physiologic response in terms of vital signs, and the subjective patient experience. RESULTS: A total of 12 patients completed the trial. With DXM-, the patients had significantly shorter total (∼15 minutes) and adjusted anesthesia (∼10 minutes) times. With DXM+, the patients had significantly lower average systolic blood pressure (SBP), SBP low values, diastolic blood pressure (DBP) low values, average heart rate (HR), and HR low values. None of the other continuous patient outcomes differed significantly between the 2 groups. Of the 12 patients, 10 (83.3%) reported that they preferred the experimental sedation experience with DXM (95% confidence interval, 0.52 to 0.98). CONCLUSIONS: Using a DXM infusion with outpatient dentoalveolar surgery allowed for acceptable levels of sedation, greater patient satisfaction, and longer anesthesia and appointment times and often resulted in lower BP and heart rate.

Insomnia symptoms predict both future hypertension and depression.

The prevalence of hypertension and depression is high in older populations. Moreover, their comorbidity may significantly increase morbidity and mortality. However, the risk factors contributing to both health conditions are not well understood. Older individuals are prone to insomnia; thus we hypothesized that having more insomnia symptoms increases risk for incident hypertension and depression over time. The sample consisted of a longitudinal population-based study of community-dwelling older individuals, from the 2008-2016 waves of the Health and Retirement Study, sampled across the United States. A total of 18,123 subjects, aged 50+, were stratified into three age groups, ages 50-60, 61-74, and 75 and older years. Subjects were excluded for reporting baseline hypertension or depression at the first wave 2008. Center for Epidemiologic Studies-Depression (CES-D) score ≥ 4 was the cutoff for elevated depressive symptomatology. Subjective insomnia symptoms were evaluated. Cox proportional hazards regression revealed that SBP (1.02[1.01, 1.02]) and more insomnia symptoms (1.11[1.01, 1.21]) were significant predictors of hypertension for all age groups. For depression, only insomnia symptoms were significant predictors (9.91[6.37, 15.41]). Kaplan-Meier curves revealed that 9.2% of the overall cohort had both hypertension and depression within 8 years and more insomnia symptoms predicted greater incidences of both conditions (p-values <0.001). In this older prospective cohort, insomnia symptoms are consistent predictors of future hypertension and depression in all age groups, who were not hypertensive and depressed at baseline. Insomnia may contribute to the etiology and comorbidity of hypertension and depression in older individuals.

Development and Content Validation of a Patient-Reported Sexual Risk Measure for Use in Primary Care.

BACKGROUND: Patient-provider sexual risk behavior discussions occur infrequently but may be facilitated by high-quality sexual risk screening tools. OBJECTIVE: To develop the Sexual Risk Behavior Inventory (SRBI), a brief computer-administered patient-reported measure. DESIGN: Qualitative item development/quantitative instrument validation. PARTICIPANTS: We developed SRBI items based on patient interviews (n = 128) at four geographically diverse US primary care clinics. Patients were diverse in gender identity, sex, sexual orientation, age, race/ethnicity, and HIV status. We compared sexual risk behavior identified by the SRBI and the Risk Assessment Battery (RAB) among patients (n = 422). APPROACH: We constructed an item pool based on validated measures of sexual risk, developed an in-depth interview guide based on pool content, and used interviews to elicit new sexual risk concepts. We coded concepts, matched them to item pool content, and developed new content where needed. A provider team evaluated item clinical relevance. We conducted cognitive interviews to assess item comprehensibility. We administered the SRBI and the RAB to patients. KEY RESULTS: Common, clinically relevant concepts in the SRBI included number of sex partners; partner HIV status; partner use of antiretroviral medication (ART)/pre-exposure prophylaxis (PrEP); and recent sex without barrier protection, direction of anal sex, and concern regarding HIV/STI exposure. While 90% reported inconsistent condom use on the RAB, same-day SRBI administration revealed that for over one third, all their partners were on ART/PrEP. CONCLUSION: The SRBI is a brief, skip-patterned, clinically relevant measure that ascertains sexual risk behavior across sex, sexual orientation, gender identity, partner HIV serostatus, and partner treatment status, furnishing providers with context to determine gradations of risk for HIV/STI.

A Clinical Librarian Embedded in Medical Education: Patient-Centered Encounters for Preclinical Medical Students.

Adding patient encounters and simulation to the preclinical years of medical school is becoming increasingly popular. This article describes the creation of active learning opportunities by a clinical librarian that are aimed at training preclinical students through the use of simulated patient scenarios. Scenarios for second-year students walk them through the evidence-based resources needed in clinical years and beyond through a standardized patient encounter. Scenarios for first-year students involve role-play of cases where the patient and physician bring contrasting ideas to the outpatient interaction. All scenarios are carried out under the guidance of a clinician and librarian.

Commentary on "Rehabilitation Outcomes Associated With Foreign Domestic Workers as Caregivers".

The purpose of this commentary is to illuminate the role of foreign domestic workers (FDW) as caregivers for patients undergoing rehabilitation in Asia. The authors of a published study in this issue of the Archives of Physical Medicine and Rehabilitation investigate the association between the characteristics of caregivers for patients recovering from sub-acute stroke and the rehabilitation outcomes of those patients in Singapore. The investigators examined over 4,000 caregivers and one of the findings showed that after controlling for characteristics of both caregivers and patients, there was a significant and negative association between having an FDW as a caregiver, compared to a spouse, and patient rehabilitation effectiveness. The inclusion of FDW's in this study is an important and understudied group of caregivers in the role of patient rehabilitation that is relatively new to the US, but common in other parts of the world.

Content validity of Patient-Reported Outcomes Measurement Information System (PROMIS) items in the context of HIV clinical care.

PURPOSE: To assess content validity and patient and provider prioritization of Patient-Reported Outcomes Measurement Information System (PROMIS) depression, anxiety, fatigue, and alcohol use items in the context of clinical care for people living with HIV (PLWH), and to develop and assess new items as needed. METHODS: We conducted concept elicitation interviews (n = 161), item pool matching, prioritization focus groups (n = 227 participants), and cognitive interviews (n = 48) with English-speaking (~75 %) and Spanish-speaking (~25 %) PLWH from clinical sites in Seattle, San Diego, Birmingham, and Boston. For each domain we also conducted item review and prioritization with two HIV provider panels of 3-8 members each. RESULTS: Among items most highly prioritized by PLWH and providers were those that included information regarding personal impacts of the concept being assessed, in addition to severity level. Items that addressed impact were considered most actionable for clinical care. We developed additional items addressing this. For depression we developed items related to suicide and other forms of self-harm, and for all domains we developed items addressing impacts PLWH and/or providers indicated were particularly relevant to clinical care. Across the 4 domains, 16 new items were retained for further psychometric testing. CONCLUSION: PLWH and providers had priorities for what they believed providers should know to provide optimal care for PLWH. Incorporation of these priorities into clinical assessments used in clinical care of PLWH may facilitate patient-centered care.

Cognitive functioning throughout the treatment history of clinical late-life depression.

OBJECTIVE: Previous investigations into the relationship between late-life depressive symptoms and cognitive functioning have resulted in mixed findings concerning whether or not depressive symptoms and cognitive functioning are related. The mixed reports may be due in part to differences in clinical and nonclinical samples and to inadequate consideration of the dynamic nature (i.e., fluctuating course) of depressive symptoms and cognitive functioning in older adults. The current study examined the chronic, acute, and longitudinal relationships between depressive symptoms and cognitive functioning in older adults in an ongoing treatment study of major depressive disorder (MDD). METHODS: The neurocognitive outcomes of depression in the elderly study operates in a naturalistic treatment milieu using a pharmacological treatment algorithm and regular psychiatric assessment. Four hundred and fifty-three older adults [mean age 70 years, standard deviation (SD) = 7.2] meeting criteria for MDD at study enrollment received annual neuropsychological testing and depressive symptom monitoring for an average of 8.5 years (SD = 4.5). RESULTS: Hierarchical linear modeling revealed that higher age, lower education, and higher average/chronic levels of depressive symptoms were related to lower cognitive functioning. Additionally, results revealed that when an individual's depressive symptoms are higher than is typical for a specific individual, general cognitive function was worse than average. There was no evidence of lagged/longitudinal relationships between depressive symptoms and cognitive functioning in older adults in treatment for MDD. CONCLUSIONS: Cognitive functioning and depressive symptoms are concurrently associated in older adults with MDD, highlighting the potential importance for stabilizing mood symptoms as a means to manage cognitive deficits in late-life depression.

Selecting optimal screening items for delirium: an application of item response theory.

BACKGROUND: Delirium (acute confusion), is a common, morbid, and costly complication of acute illness in older adults. Yet, researchers and clinicians lack short, efficient, and sensitive case identification tools for delirium. Though the Confusion Assessment Method (CAM) is the most widely used algorithm for delirium, the existing assessments that operationalize the CAM algorithm may be too long or complicated for routine clinical use. Item response theory (IRT) models help facilitate the development of short screening tools for use in clinical applications or research studies. This study utilizes IRT to identify a reduced set of optimally performing screening indicators for the four CAM features of delirium. METHODS: Older adults were screened for enrollment in a large scale delirium study conducted in Boston-area post-acute facilities (n = 4,598). Trained interviewers conducted a structured delirium assessment that culminated in rating the presence or absence of four features of delirium based on the CAM. A pool of 135 indicators from established cognitive testing and delirium assessment tools were assigned by an expert panel into two indicator sets per CAM feature representing (a) direct interview questions, including cognitive testing, and (b) interviewer observations. We used IRT models to identify the best items to screen for each feature of delirium. RESULTS: We identified 10 dimensions and chose up to five indicators per dimension. Preference was given to items with peak psychometric information in the latent trait region relevant for screening for delirium. The final set of 48 indicators, derived from 39 items, maintains fidelity to clinical constructs of delirium and maximizes psychometric information relevant for screening. CONCLUSIONS: We identified optimal indicators from a large item pool to screen for delirium. The selected indicators maintain fidelity to clinical constructs of delirium while maximizing psychometric information important for screening. This reduced item set facilitates development of short screening tools suitable for use in clinical applications or research studies. This study represents the first step in the establishment of an item bank for delirium screening with potential questions for clinical researchers to select from and tailor according to their research objectives.

Visibility and Accessibility of Hand Hygiene Stations and Fatigue Among Nurses Working in Long-Term Care (LTC) During the COVID-19 Pandemic.

OBJECTIVES: Evaluate the relationship between nurses' perception of the long-term care (LTC) environment, specifically having visible and accessible hand hygiene stations (HHS), and nurses' fatigue during the COVID-19 pandemic. BACKGROUND: LTC nurses experience not only heavy workloads and fatigue but also a high risk of infection during the COVID-19 pandemic. Few studies have evaluated the relationship between safety measures such as having visible and accessible HHS and nurses' fatigue. METHODS: The cross-sectional COVID-19 Impact on Nurses Study (COINS) was an online survey distributed to members of the American Association of Post-Acute Care Nursing through the REDCap survey platform, between June 1, 2020, and January 31, 2021. Logistic regression modeling was conducted to identify the relationship between nurses' perception of having visible and accessible HHS and fatigue among LTC nurses. RESULTS: The majority of LTC nurse respondents (78.35%) reported having moderate to very severe fatigue. Nurses who reported not having enough visible and accessible HHS in their work environment have statistically significantly higher odds (odds ratio [OR] = 0.37, 95% confidence interval [CI] [0.20, 0.70], p = .002) of reporting experiencing moderate to very severe fatigue compared to nurses who perceived there was adequate HHS. The logistic regression is significant while controlling for sociodemographic differences, guilt for family and patients, support from work, and confidence in the future of LTC. CONCLUSIONS: This study reveals the LTC environment that incorporates better considerations of more visible and accessible HHS might mitigate nurses' fatigue during the pandemic. A conceptual framework has been proposed for future studies.

Hypertension, white matter hyperintensities, and concurrent impairments in mobility, cognition, and mood: the Cardiovascular Health Study.

BACKGROUND: Our objective was to investigate the association between hypertension and concurrent impairments in mobility, cognition, and mood; the role of brain white matter hyperintensities in mediating this association; and the impact of these impairments on disability and mortality in elderly hypertensive individuals. METHODS AND RESULTS: -Blood pressure, gait speed, digit symbol substitution test, and the Center for Epidemiological Studies Depression Scale were measured yearly (1992-1999) on 4700 participants in the Cardiovascular Health Study (age: 74.7, 58% women, 17% blacks, 68% hypertension, 3600 had brain magnetic resonance imaging in 1992-1993, survival data 1992-2005). Using latent profile analysis at baseline, we found that 498 (11%) subjects had concurrent impairments and 3086 (66%) were intact on all 3 measures. Between 1992 and 1999, 651 (21%) became impaired in all 3 domains. Hypertensive individuals were more likely to be impaired at baseline (odds ratio 1.23, 95% confidence interval 1.04 to 1.42, P=0.01) and become impaired during the follow-up (hazard ratio=1.3, 95% confidence interval 1.02 to 1.66, P=0.037). A greater degree of white matter hyperintensities was associated with impairments in the 3 domains (P=0.007) and mediated the association with hypertension (P=0.19 for hypertension after adjusting for white matter hyperintensities in the model, 21% hazard ratio change). Impairments in the 3 domains increased subsequent disability with hypertension (P<0.0001). Hypertension mortality also was increased in those impaired (compared with unimpaired hypertensive individuals: HR=1.10, 95% confidence interval 1.04 to 1.17, P=0.004). CONCLUSIONS: Hypertension increases the risk of concurrent impairments in mobility, cognition, and mood, which increases disability and mortality. This association is mediated in part by microvascular brain injury.

Racial/ethnic differences in responses to the everyday discrimination scale: a differential item functioning analysis.

The authors examined the impact of race/ethnicity on responses to the Everyday Discrimination Scale, one of the most widely used discrimination scales in epidemiologic and public health research. Participants were 3,295 middle-aged US women (African-American, Caucasian, Chinese, Hispanic, and Japanese) from the Study of Women's Health Across the Nation (SWAN) baseline examination (1996-1997). Multiple-indicator, multiple-cause models were used to examine differential item functioning (DIF) on the Everyday Discrimination Scale by race/ethnicity. After adjustment for age, education, and language of interview, meaningful DIF was observed for 3 (out of 10) items: "receiving poorer service in restaurants or stores," "being treated as if you are dishonest," and "being treated with less courtesy than other people" (all P's < 0.001). Consequently, the "profile" of everyday discrimination differed slightly for women of different racial/ethnic groups, with certain "public" experiences appearing to have more salience for African-American and Chinese women and "dishonesty" having more salience for racial/ethnic minority women overall. "Courtesy" appeared to have more salience for Hispanic women only in comparison with African-American women. Findings suggest that the Everyday Discrimination Scale could potentially be used across racial/ethnic groups as originally intended. However, researchers should use caution with items that demonstrated DIF.

Neuropsychological test performance and cognitive reserve in healthy aging and the Alzheimer's disease spectrum: a theoretically driven factor analysis.

Accurate measurement of cognitive function is critical for understanding the disease course of Alzheimer's disease (AD). Detecting cognitive change over time can be confounded by level of premorbid intellectual function or cognitive reserve and lead to under- or over-diagnosis of cognitive impairment and AD. Statistical models of cognitive performance that include cognitive reserve can improve sensitivity to change and clinical efficacy. We used confirmatory factor analysis to test a four-factor model composed of memory/language, processing speed/executive function, attention, and cognitive reserve factors in a group of cognitively healthy older adults and a group of participants along the spectrum of amnestic mild cognitive impairment to AD (aMCI-AD). The model showed excellent fit for the control group (χ(2) = 100; df = 78; CFI = .962; RMSEA = .049) and adequate fit for the aMCI-AD group (χ(2) = 1750; df = 78; CFI = .932; RMSEA = .085). Although strict invariance criteria were not met, invariance testing to determine if factor structures are similar across groups yielded acceptable absolute model fits and provide evidence in support of configural, metric, and scalar invariance. These results provide further support for the construct validity of cognitive reserve in healthy and memory impaired older adults.

Implementing a self-monitoring application during pregnancy and postpartum for rural and underserved women: A qualitative needs assessment study.

BACKGROUND: Georgia has one of the highest maternal mortality rates within the US. This study describes the qualitative needs assessment undertaken to understand the needs of rural and underserved women and their perspectives on implementing a self monitoring application during pregnancy and postpartum. METHODS: Qualitative methodology was used to conduct the needs assessment of 12 health care providers (nurses, nurse-midwives, patient care coordinators, and physicians) and 25 women from rural and underserved populations in Georgia was conducted to ascertain common themes on three topics: pregnancy care experiences, comfort with technology, and initial perspectives on the proposed VidaRPM application. Transcription, coding, and consensus were conducted using content analysis and a Cohen's Kappa coefficient was calculated to identify level of overall agreement between raters for the representative quotes identified for each theme. RESULTS: The overall agreement for the representative quotes that were chosen for each theme was in strong agreement (κ = 0.832). The major provider feedback included the following regarding the VidaRPM app: inclusion of questions to monitor physical well-being, embedded valid and reliable educational resources, and multiple modalities. The overall feedback from the mothers regarding the VidaRPM application was the virtual aspect helped overcome the barriers to accessing care, comfort with both WiFi and technology, and sustainable utility. DISCUSSION: The needs of rural and underserved pregnant women and their providers were assessed to develop and refine the VidaRPM app. This qualitative study on the VidaRPM app is the first step towards closing the gap between providers and patients during prenatal and postpartum periods by empowering and educating women into the first-year postpartum living in rural and underserved areas.

Support from Work and Intent to Stay Among Nurses During COVID-19: An Academic-Practice Collaboration.

The COVID-19 pandemic created stressful working conditions for nurses and challenges for leaders. A survey was conducted among 399 acute and ambulatory care nurses measuring availability of calming and safety resources, perceptions of support from work, and intent to stay. Most nurses reported intent to stay with their employer, despite inadequate safety and calming resources. High levels of support from work were significantly influenced nurses' intent to stay. Leadership actions at the study site to provide support are described, providing context for results. Nurse leaders can positively influence intent to stay through consistent implementation of supportive measures.

Effects of DSM-5 Betel-Quid-Related Symptoms, Pathological Behaviors, and Use Disorder on Oral Squamous Cell Carcinoma Risk.

The neuroactive alkaloids in betel quid (BQ) can induce BQ addiction. We conducted a case-control study to investigate the effects of BQ-associated DSM-5 symptoms, pathological behaviors, and BQ use disorder (BUD) on oral squamous cell carcinoma (OSCC) risk. A total of 233 patients with newly diagnosed and histopathologically confirmed OSCC and 301 sex- and age-matched controls were included. BQ-related DSM-5 symptoms in the 12 months prior to disease onset were used to measure psychiatric characteristics and BUD. Compared with nonchewers, chewers with the symptoms of unsuccessful cutdown of BQ consumption, neglecting major roles, social or interpersonal problems, abandoning or limiting activities, hazardous use, and continued use despite the awareness of the dangers had a 54.8-, 49.3-, 49.9-, 40.4-, 86.2-, and 42.9-fold higher risk of developing OSCC, respectively. Mild-to-moderate and severe BUD were, respectively, associated with a 8.2-8.5- and 42.3-fold higher OSCC risk, compared with BQ nonuse. Risky BQ use of pathological behavior was associated with a 12.5-fold higher OSCC risk in chewers with no BUD or mild BUD and a 65.0-fold higher risk in chewers with moderate-to-severe BUD (p for risk heterogeneity between the two BUD groups, 0.041). In conclusion, BQ-associated DSM-5 symptoms, pathological behaviors, and BUD severity are associated with the impact of BQ chewing on OSCC development. The pathological behavior of risky BQ use enhances OSCC risk in chewers with moderate-to-severe BUD. Preventing BUD in new BQ users and treating BUD in chewers who already have the disorder are two priorities in areas where BQ chewing is prevalent.

Prediction of the Uric Acid Component in Nephrolithiasis Using Simple Clinical Information about Metabolic Disorder and Obesity: A Machine Learning-Based Model.

There is a great need for a diagnostic tool using simple clinical information collected from patients to diagnose uric acid (UA) stones in nephrolithiasis. We built a predictive model making use of machine learning (ML) methodologies entering simple parameters easily obtained at the initial clinical visit. Socio-demographic, health, and clinical data from two cohorts (A and B), both diagnosed with nephrolithiasis, one between 2012 and 2016 and the other between June and December 2020, were collected before nephrolithiasis treatment. A ML-based model for predicting UA stones in nephrolithiasis was developed using eight simple parameters-sex, age, gout, diabetes mellitus, body mass index, estimated glomerular filtration rate, bacteriuria, and urine pH. Data from Cohort A were used for model training and validation (ratio 3:2), while data from Cohort B were used only for validation. One hundred and forty-six (13.3%) out of 1098 patients in Cohort A and 3 (4.23%) out of 71 patients in Cohort B had pure UA stones. For Cohort A, our model achieved a validation AUC (area under ROC curve) of 0.842, with 0.8475 sensitivity and 0.748 specificity. For Cohort B, our model achieved 0.936 AUC, with 1.0 sensitivity, and 0.912 specificity. This ML-based model provides a convenient and reliable method for diagnosing urolithiasis. Using only eight readily available clinical parameters, including information about metabolic disorder and obesity, it distinguished pure uric acid stones from other stones before treatment.

Cognitive decline in the elderly: an analysis of population heterogeneity.

BACKGROUND: studies of cognitive ageing at the group level suggest that age is associated with cognitive decline; however, there may be individual differences such that not all older adults will experience cognitive decline. OBJECTIVE: to evaluate patterns of cognitive decline in a cohort of older adults initially free of dementia. DESIGN, SETTING AND SUBJECTS: elderly Catholic clergy members participating in the Religious Orders Study were followed for up to 15 years. Cognitive performance was assessed annually. METHODS: performance on a composite global measure of cognition was analysed using random effects models for baseline performance and change over time. A profile mixture component was used to identify subgroups with different cognitive trajectories over the study period. RESULTS: from a sample of 1,049 participants (mean age 75 years), three subgroups were identified based on the distribution of baseline performance and change over time. The majority (65%) of participants belonged to a slow decline class that did not experience substantial cognitive decline over the observation period [-0.04 baseline total sample standard deviation (SD) units/year]. About 27% experienced moderate decline (-0.19 SD/year), and 8% belonged to a class experiencing rapid decline (-0.57 SD/year). A subsample analysis revealed that when substantial cognitive decline does occur, the magnitude and rate of decline is correlated with neuropathological processes. CONCLUSIONS: in this sample, the most common pattern of cognitive decline is extremely slow, perceptible on a time scale measured by decades, not years. While in need of cross validation, these findings suggest that cognitive changes associated with ageing may be minimal and emphasise the importance of understanding the full range of age-related pathologies that may diminish brain function.

Aging, brain disease, and reserve: implications for delirium.

Cognitive and brain reserve are well studied in the context of age-associated cognitive impairment and dementia. However, there is a paucity of research that examines the role of cognitive or brain reserve in delirium. Indicators (or proxy measures) of cognitive or brain reserve (such as brain size, education, and activities) pose challenges in the context of the long prodromal phase of Alzheimer disease but are diminished in the context of delirium, which is of acute onset. This article provides a review of original articles on cognitive and brain reserve across many conditions affecting the central nervous system, with a focus on delirium. The authors review current definitions of reserve. The authors identify indicators for reserve used in earlier studies and discuss these indicators in the context of delirium. The authors highlight future research directions to move the field ahead. Reserve may be a potentially modifiable characteristic. Studying the role of reserve in delirium can advance prevention strategies for delirium and may advance knowledge of reserve and its role in aging and neuropsychiatric disease generally.