Critical care beyond organ support: the importance of geriatric rehabilitation.

Very old critically ill patients pose a growing challenge for intensive care. Critical illness and the burden of treatment in the intensive care unit (ICU) can lead to a long-lasting decline of functional and cognitive abilities, especially in very old patients. Multi-complexity and increased vulnerability to stress in these patients may lead to new and worsening disabilities, requiring careful assessment, prevention and rehabilitation. The potential for rehabilitation, which is crucial for optimal functional outcomes, requires a systematic, multi-disciplinary approach and careful long-term planning during and following ICU care. We describe this process and provide recommendations and checklists for comprehensive and timely assessments in the context of transitioning patients from ICU to post-ICU and acute hospital care, and review the barriers to the provision of good functional outcomes.

Patients with low ALT levels are at increased risk for severe COVID-19.

Introduction: Frailty is a known risk factor for many diseases, including COVID-19. However, many frail patients are undiagnosed as the diagnosis can be cumbersome. Alanine transaminase (ALT) is found not only in the liver but also in the muscle tissue, and multiple studies show that frail sarcopenic patients have lower ALT. Frail patients are at increased risk for severe COVID-19. We evaluated the association between pre-infection low ALT and the risk for severe COVID-19. Methods: We collected data regarding all subjects tested for SARS-CoV-2 between 1 March 2020 and 31 December 2021 from a national state-mandatory HMO in Israel, serving more than 1.3 million patients. Clinical and laboratory data were collected, including ALT from the year prior to infection. Severe COVID-19 was defined either as death, ICU admission, or ≥10 hospitalization days. Patients with low ALT (ALT ≤ 10 IU/l) were compared with patients with normal ALT (11-40 IU/l). Patients younger than 18 years with a diagnosis of liver disease and with ALT > 40 IU/l were excluded. Results: During the study period, 58,961 patients tested positive for SARS-CoV-2. The patients in the low ALT group were younger (40.53 vs. 42.73, p < 0.001), less likely to be males (12.3 vs. 38.7%, p < 0.001), and had lower BMI (25.97 vs. 27.15, p < 0.001). The patients in the low ALT group had higher mortality (2.36 vs. 0.57%, p < 0.001), more ICU hospitalizations (0.49 vs. 0.41%, p = 0.47), and more prolonged hospitalizations [2.63% (95% CI 2-3.2%) vs. 0.98% (95% CI 0.86-1.1%) p < 0.001]. In multivariate logistic regression analyses, low ALT was associated with an increased risk of severe COVID-19, with increased mortality (OR 1.88, 95% CI 1.37-2.56) and prolonged hospitalization (OR 1.78, 95% CI 1.33-2.35). Conclusion: Low ALT level prior to infection is a significant risk factor for morbidity and mortality from COVID-19 infection. Further studies are warranted to address treatment options for this population.

Late life depression and concepts of aging: an emerging paradigm.

Late life depression (LLD) is an emerging challenge, and recognized as a significant barrier to long-term healthy aging. Viewed within the context of the medical/biological model, advances in brain sciences over the last several decades have led to a deeper understanding of the biology of LLD. These advances in current knowledge include the description of aging brain pathophysiology; the biology and biochemistry of neurotransmitters; the correspondence between changes in neurological structure, function, and neural network; the description of neural, hormonal and inflammatory biomarkers; and identification of typical phenotypic subtypes of LLD. Despite these advances, current treatment of LLD, which remains largely pharmacological with accompanying cognitive and behavioral interventions, has poor success rate for long-term remission among older people. A wider perspective, in keeping with several emerging aging concepts, is suggested as an alternative framework within which to view LLD. A growing body of research supports the important role in LLD of frailty, resilience, intrinsic capacity, and functional integrity. Similarly, important social determinants need to be addressed in the etiology of LLD, rooted largely in negative stereotypes of aging, with consequent repercussions of reduced participation and inclusion, growing social isolation, with loss of identity, meaning and hope. This perspective suggests the importance of a wider integrative conceptualization of depression, set against a background of emerging aging concepts.

Holocaust survivors: Health and longevity 70 years later.

BACKGROUND: Holocaust survivors (HS) alive today form a unique and disappearing population, whose exposure to systematic genocide occurred over 70 years ago. Negative health outcomes were widely documented prior to age 70. We examine the hypothesis that the experience of remote trauma continues to negatively affect health, functional status, and survival between the ages of 85-95. METHODS: The Jerusalem Longitudinal Study (1990-2022) followed a representative sample of Jerusalem residents born 1920-1921, at ages 85, 90 and 95. Home assessment included medical, social, functional, and cognitive status, and mortality data. Subjects were classified: (1) HS-Camp (HS-C): survived slave-labor, concentration, or death camps; (2) HS-Exposed (HS-E): survived Nazi occupation of Europe; (3) Controls: European descent, outside Europe during WWII. We determined Hazards Ratios (HR), adjusting for gender, loneliness, financial difficulty, physical activity, ADL dependence, chronic ischemic heart disease, cancer, cognitive deficits, chronic joint pain, self-rated health. RESULTS: At ages 85 (n = 496), 90 (n = 524), and 95 (n = 383) the frequency of HS-C versus HS-E versus Controls was 28%/22%/50%, 19%/19%/62%, and 20%/22%/58%, respectively. No consistent significant morbidity differences were observed. Mortality between ages 85-90 and 90-95 years was 34.9% versus 38% versus 32.0%, and 43.4% versus 47.3% versus 43.7%, respectively, with no significant differences in survival rates (log rank p = 0.63, p = 0.81). Five-year mortality adjusted HRs were insignificant for HS-C and HS-E between ages 85-90 (HR 0.87, 95% CI 0.54-1.39; HR 1.14, 95% CI 0.73-1.78) and ages 90-95 (HR 0.72, 95% CI 0.39-1.32; HR 1.38, 95% CI 0.85-2.23). CONCLUSIONS: Seventy years following their trauma and suffering during the Holocaust, the significant impairments of health, function, morbidity, and mortality which have accompanied survivors throughout their entire adult life, were no longer observed. Indeed, it is likely that survivors living >85 years old represent a uniquely resilient population of people, whose adaptation to adversity has accompanied them throughout their lives.

Prolonged mechanical ventilation and caregiver strain: Home vs. long-term care facility.

OBJECTIVE: The number of patients treated with prolonged mechanical ventilation (PMV) is steadily rising. Traditionally treated within specialized long-term care facilities (LTCFs), healthcare providers are increasingly promoting homecare as a technologically safe, humane, and cheaper alternative. Little is known concerning their informal caregivers (ICGs), despite their crucial role in facilitating care. This study examines caregiver strain among the primary ICG of PMV patients treated at home vs. LTCF. METHOD: This study was an observational cross-sectional study. The study enrolled 120/123 PMV patients ≥18 years within the study region (46 treated with homecare/74 treated at the LTCF) and 106 ICGs (34 ICGs/46 homecare patients and 72 ICGs/74 LTCF patients). Caregiver assessment included the 13-item Modified Caregiver Strain Index (Mod CSI) (0-26 maximum); patient assessment included symptom burden (the revised Edmonton Symptom Assessment System). RESULTS: The mean age of ICGs was 58.9 years old; 60.4% were females; 82.1% were married; 29.2% were patient's spouses; and 40.6% were patient's children. The total Mod CSI was 13.58 (SD 6.52) and similar between home vs. LTCF (14.30 SD 7.50 vs. 13.26 SD 6.03, p = 0.50), or communicative vs. non-communicative patients (13.50 SD 7.12 vs. 13.64 SD 6.04, p = 0.93). Hierarchical analysis identified three clusters of caregiver strain, with ICGs at home vs. LTCF reporting significantly lower mood strain, higher burden, and similar levels of lifestyle disturbance. In adjusted models, homecare was significantly associated with reduced mood strain and increased burden, while increased patient symptomatology was significantly associated with total strain, mood, and burden strain clusters. SIGNIFICANCE OF RESULTS: Recognizing the different patterns of caregiver strain at home or LTCF is a prerequisite for addressing their palliative care needs and improving the wellbeing and resilience of informal caregivers, who often play a critical role in deciding whether to treat the PMV patient at home or LTCF.

Myocardial contraction fraction predicts mortality in the oldest old.

Background: People over the age of 85 are the world's most rapidly growing age group. Ejection fraction (EF) may be limited prognostically in this population and myocardial contraction fraction (MCF) may be more accurate. The objective of this longitudinal study was to assess the prognosis of MCF in an age-homogenous, community-dwelling population of subjects. Methods: Subjects were recruited from the Jerusalem Longitudinal Cohort Study. Echocardiography was performed with a portable echocardiograph at the subjects place of residence. Standard echocardiographic assessment of cardiac structure and function including MCF was performed. Values of EF and MCF above and below the median for males and females were defined as normal and abnormal in categorical analysis. 5-year mortality was assessed via a centralized government database. Results: 418 subjects (199 males, 219 females) were enrolled in the study of whom 113 (27 %) died at the time of 5-year follow-up. Subjects who died had significantly lower MCF (32 ± 14 % vs 36 ± 12 %; p < 0.004) and EF (51.6 ± 11.6 % vs 56.3 ± 9.4 %; p < 0.0001) than survivors. The association between MCF and mortality remained significant on clinical multivariate analysis as both a categorical and continuous variable while EF was only significant as a continous variable. When both EF and MCF were added to the model only MCF as a categorical variable remained significant. Conclusions: MCF assessed by home echocardiography provides additional prognostic information to EF and may be a superior predictor of 5-year mortality in a community-dwelling population of the oldest old.

Exploring the Multidimensional Participation of Adults Living in the Community in the Chronic Phase following Acquired Brain Injury.

This exploratory study aimed to examine multiple aspects of the participation of adults in the chronic phase following acquired brain injury (ABI), considering different disability levels. Our study included 25 adults ≥6 months after ABI (predominantly stroke), living at home, without severe cognitive decline. Primary measures included the Canadian Occupational Performance Measure (subjective participation) and the Mayo-Portland Adaptability Inventory-4 Participation Index (objective participation). The results indicated subjective participation problems in all of the International Classification of Functioning, Disability and Health participation domains. In addition, objective participation was reported as most limited in the areas of leisure and recreational activities, residence, and employment. Both subjective and objective participation profiles varied according to the disability level except for the social and leisure areas, which were found to be similar across all subgroups. However, only partial compatibility was found between the subjective and objective participation aspects. To conclude, our findings indicated that chronic ABI survivors report a variety of subjective and objective participation concerns that varied according to their disability levels. Moreover, the incongruity between the participation aspects suggests that the level of limitation may not necessarily correspond to the importance of a particular participation area. This highlights the need for comprehensive assessments to determine unique individual participation profiles in order to facilitate client-centered interventions supporting the rehabilitation of community-dwelling ABI survivors.

Static Balance Digital Endpoints with Mon4t: Smartphone Sensors vs. Force Plate.

Static balance tests are conducted in various clinics for diagnosis and treatment adjustment. As a result of population aging, the accessibility of these tests should be increased, in the clinic, and for remote patient examination. A number of publications have already conducted static balance evaluations using the sensors embedded in a smartphone. This study focuses on the applicability of using smartphone-based balance assessment on a large scale while considering ease of use, safety, and reliability. The Mon4t® app was used to acquire the postural motion using different smartphone devices, different smartphone locations, and various standing postures. The signals derived from the app were compared to the center of pressure displacement derived from a force plate. The results showed moderate to high agreement between the two methods, particularly at the tandem stance (0.69 ≤ r ≤ 0.91). Preliminary data collection was conducted on three healthy participants, followed by 50 additional healthy volunteers, aged 65+. The results demonstrated that the Mon4t app can serve as an accessible and inexpensive static balance assessment tool, both in clinical settings and for remote patient monitoring, which is key for enabling telehealth.

Personalized Exercise Programs Based upon Remote Assessment of Motor Fitness: A Pilot Study among Healthy People Aged 65 Years and Older.

BACKGROUND: The World Health Organization has recently updated exercise guidelines for people aged >65 years, emphasizing the inclusion of multiple fitness components. However, without adequate recognition of individual differences, these guidelines may be applied using an approach that "one-size-fits-all." Within the shifting paradigm toward an increasingly personalized approach to medicine and health, it is apparent that fitness components display a significant age-related increase in variability. Therefore, it is both logical and necessary to perform an accurate individualized assessment of multiple fitness components prior to optimal prescription for a personalized exercise program. OBJECTIVE: The aim of the study was to test the feasibility and effectiveness of a novel tool able to remotely assess balance, flexibility, and strength using smartphone sensors (accelerometer/gyroscope), and subsequently deliver personalized exercise programs via the smartphone. METHODS: We enrolled 52 healthy volunteers (34 females) aged 65+ years, with normal cognition and low fall risk. Baseline data from remote smartphone fitness assessment were analyzed to generate 42 fitness digital markers (DMs), used to guide personalized exercise programs (×5/week for 6 weeks) delivered via smartphone. Programs included graded exercises for upper/lower body, flexibility, strength, and balance (dynamic, static, and vestibular). Participants were retested after 6 weeks. RESULTS: Average age was 74.7 ± 6.4 years; adherence was 3.6 ± 1.7 exercise sessions/week. Significant improvement for pre-/posttesting was observed for 10/12 DMs of strength/flexibility for upper/lower body (sit-to-stand repetitions/duration; arm-lift duration; torso rotation; and arm extension/flexion). Balance improved significantly for 6/10 measures of tandem stance, with consistent (nonsignificant) trends observed across 20 balance DMs of tandem walk and 1 leg stance. Balance tended to improve among the 37 participants exercising ≥3/week. DISCUSSION: These preliminary results provide a proof of concept, with high adherence and improved fitness confirming the benefits of remote fitness assessment for guiding home personalized exercise programs among healthy adults aged >65 years. Further examination of the application within a randomized control study is necessary, comparing the personalized exercise program to general guidelines among healthy older adults, as well as specific populations, such as those with frailty, deconditioning, cognitive, or functional impairment. The study tool offers the opportunity to collect big data, including additional variables, with subsequent utilization of artificial intelligence to optimize the personalized exercise program.

Depression, hope and social support among older people with cancer: a comparison of Muslim Palestinian and Jewish Israeli cancer patients.

OBJECTIVES: Studies of depression in older Muslim Palestinians diagnosed with cancer are scarce. To gain insight into the psychological response and coping ability of this very large, globally distributed population, we collected data from older Muslim Palestinian people diagnosed with cancer concerning depression hope and perceived social support. Both hope and social support were selected because they can be manipulated through intervention and education, as shown in the geriatric literature. Data were compared to data collected from older Jewish Israeli people diagnosed with cancer. DESIGN: The study sample comprised 143 Muslim Palestinian and 110 Jewish Israeli people diagnosed with cancer, aged ≥ 65. All participants were either in treatment for active disease or within 6 months of such treatment. Self-administered measures included depression (the Five-Item Geriatric Depression Scale), perceived social support (Cancer Perceived Agents of Social Support Questionnaire) and hope (Snyder's Adult Hope Scale). RESULTS: Hope and depression were both found to be significantly higher among the Muslim Palestinian patients than in the Jewish Israeli participants. In both samples, higher levels of hope were associated with lower levels of depression, with this correlation stronger in the Jewish Israeli group. CONCLUSION: To improve the psychological wellbeing of patients, healthcare providers must exercise cultural sensitivity in their interactions, respecting the perspectives of both the patients and their families. Incorporating the concept of hope into the therapeutic dialogue and language may improve psychological wellbeing and synchronize the needs and expectations of patients, caregivers, and healthcare professionals, resulting in more equitable, effective and value-oriented care.

Informal caregivers of older Muslims diagnosed with cancer: A portrait of depression, social support, and faith.

OBJECTIVE: Islamic population constitute more than 20% of the world population and is growing rapidly. Nevertheless, data concerning informal caregiving to older Muslim patients diagnosed with cancer are scarce. Improving the well-being of caregivers is a vital step to optimal care for the patients themselves throughout the Muslim community and the world. This study focuses on a sample of Palestinian caregivers of older Muslim patients diagnosed with cancer living in East Jerusalem, the West Bank, and Gaza. The study aims to describe the socio-demographic characteristics of the caregivers and to understand their social support, and identify predictors of caregivers' depression. METHODS: A cross-sectional study of a convenience sample of 99 dyads of Palestinian patients (age ≥65) and their informal caregivers. Depression and social support were measured using the five items of the Geriatric Depression Scale and the Cancer Perceived Agents of Social Support questionnaire. RESULTS: Caregivers were most frequently adult children (52%) or spouses (32%), with male patients cared for by spouses (47.5%) or sons (32%), and female patients by daughters (50%). Clinical levels of depression were reported by 76% of the caregivers and 85% of patients. The significant predictors of caregiver depression were female gender, lower education, lower perceived social support from spouse and family, and higher perceived support from faith. SIGNIFICANCE OF RESULTS: Healthcare providers serving the study population should determine the position and role of the caregiver within the social and family structure surrounding the patients' families. This understanding may facilitate overcoming barriers to effective and meaningful social support.

Personalized multicomponent exercise programs using smartphone technology among older people: protocol for a randomized controlled trial.

BACKGROUND: Optimal application of the recently updated World Health Organization (WHO) guidelines for exercise in advanced age necessitates an accurate adjustment for the age-related increasing variability in biological age and fitness levels, alongside detailed recommendations across a range of motor fitness components, including balance, strength, and flexibility. We previously developed and validated a novel tool, designed to both remotely assess these fitness components, and subsequently deliver a personalized exercise program via smartphone. We describe the design of a prospective randomized control trial, comparing the effectiveness of the remotely delivered personalized multicomponent exercise program to either WHO exercise guidelines or no intervention. METHODS: Participants (n = 300) are community dwelling, healthy, functionally independent, cognitively intact volunteers aged ≥65 at low risk for serious fall injuries, assigned using permuted block randomization (age/gender) to intervention, active-control, or control group. The intervention is an 8-week program including individually tailored exercises for upper/lower body, flexibility, strength, and balance (dynamic, static, vestibular); active-controls receive exercising counselling according to WHO guidelines; controls receive no guidance. Primary outcome is participant fitness level, operationalized as 42 digital markers generated from 10 motor fitness measures (balance, strength, flexibility); measured at baseline, mid-trial (4-weeks), trial-end (8-weeks), and follow-up (12-weeks). Target sample size is 300 participants to provide 99% power for moderate and high effect sizes (Cohen's f = 0.25, 0.40 respectively). DISCUSSION: The study will help understand the value of individualized motor fitness assessment used to generate personalized multicomponent exercise programs, delivered remotely among older adults. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04181983.

Optimism and Longevity Beyond Age 85.

BACKGROUND: Optimism is associated with health benefits and improved survival among adults older than 65 years. Whether or not optimism beyond age 85 continues to confer survival benefits is poorly documented. We examine the hypothesis that being optimistic at ages 85 and 90 is associated with improved survival. METHOD: The Jerusalem Longitudinal Study (1990-2020) assessed comorbidity, depression, cognition, social and functional status, and 5-year mortality among a representative community sample, born during 1920-1921, at age 85 (n = 1096) and age 90 (n = 533). Overall optimism (Op-Total) was measured using a validated 7-item score from the Scale of Subjective Wellbeing for Older Persons. The 4 questions concerning positive future expectations (Op-Future) and 3 questions concerning positive experiences (Op-Happy) were also analyzed separately. We determined unadjusted mortality hazards ratios and also adjusted for gender, financial difficulty, marital status, educational status, activities of daily living dependence, physical activity, diabetes mellitus, hypertension, ischemic heart disease, cognitive impairment, and depression. RESULTS: Between ages 85-90 and 90-95 years, 33.2% (364/1096) and 44.3% (236/533) people died, respectively. All mean optimism scores declined from age 85 to 90, with males significantly more optimistic than females throughout. All measures of optimism (Op-Total, Op-Future, and Op-Happy) at ages 85 and 90 were significantly associated with improved 5-year survival from age 85 to 90 and 90 to 95, respectively, in both unadjusted and adjusted models. Findings remained unchanged after separately excluding depressed subjects, cognitively impaired subjects, and subjects dying within 6 months from baseline. CONCLUSIONS: These finding support the hypothesis that being optimistic continues to confer a survival benefit irrespective of advancing age.

Prolonged Mechanical Ventilation: Symptomatology, Well-Being, and Attitudes to Life.

OBJECTIVE: Although prolonged mechanical ventilation (PMV) is increasingly common, little is known concerning patient symptom burden or attitudes toward PMV. This study aims to describe the mood, well-being, distressing symptoms, and attitudes toward prolonged ventilation among PMV patients treated either at home or long-term acute care (LTAC). DESIGN: An observational study. SETTING AND PARTICIPANTS: 62 communicative participants treated with PMV, aged ≥18 years, insurees of a single HMO, treated at home hospital or LTAC specializing in ventilation in Jerusalem. MEASURES: Sociodemographic characteristics; chronic conditions; functional status; symptom burden measured by revised Edmonton Symptomatic Assessment System (r-ESAS); attitudes toward PVM. RESULTS: Participants were aged 61.7 ± 20.7 years, commonly suffered progressive neuromuscular disease (43.5%) or chronic lung disease (29%), were functionally dependent, treated at home (64.5%) or LTAC (35.5%), and had a mean PMV duration of 36.6 months (interquartile range 10.8-114.1). The 5-item, short Geriatric Depression Scale identified depression among 38% of participants, and was less at home vs LTAC (34% vs 44%, P < .001). Mean revised Edmonton Symptom Assessment System score was 24.5 ± 14.8 (maximum severity = 100), and participants reported severe or distressing symptoms for tiredness (27%/20%), pain (10%/25%), anxiety (16%/14%), depression (9%/21%), drowsiness (12%/17%), shortness of breath (9%/15%), poor appetite (7%/9%), and nausea (0%/10%). Impaired general well-being was reported as severe, moderate, mild, or none among 15%, 40%, 30%, and 15%, respectively. Only 1 patient had advance directives concerning ventilation prior to intubation, and when asked if they had to choose again today, 85% of patients would again opt for ventilation. CONCLUSIONS AND IMPLICATIONS: Few PMV patients reported distressing symptoms, and 85% would choose ventilation if asked again. These findings might be useful in clinical practice to assist in decision making concerning prolonged ventilation.

Prolonged Mechanical Ventilation: A Comparison of Patients Treated at Home Compared With Hospital Long-Term Care.

OBJECTIVE: To compare the characteristics of patients treated with invasive prolonged mechanical ventilation (PMV) at home or in hospital long-term care (HLTC), specifically focusing on medical and functional status, caregiver strain, 6-month outcomes, and health maintenance organization (HMO) costs. DESIGN: Observational study. SETTING: A single HLTC and home hospital, serving a defined catchment area in the greater Jerusalem area, Israel. PARTICIPANTS: A total of 120 PMV patients aged ≥18 years, all insurees of the same HMO. All PMV patients in the local HMO were approached, of whom 46 of 47 home PMV and 74/76 HLTC patients were enrolled. MEASUREMENTS: Medical and sociodemographic factors, Barthel Index, Short Geriatric Depression Score, modified Caregiver Strain Index; 6-month follow-up for hospitalization, infections, pressure sores, and mortality; HMO costs. RESULTS: Home PMV was associated with younger age, improved functional status, financial difficulty, less comorbidity, and longer duration of PMV. Primary reasons for home PMV were degenerative neuromuscular disease and chronic lung disease, compared with acute illnesses with or without resuscitation among HLTC patients. Most home patients were alert and able to communicate (n = 40/46) versus HLTC (n = 22/74), and reported less depression. Caregiver strain was similar for home and HLTC. Among HLTC versus home patients, 6-month mortality (27% vs 7%, P = .012) and frequency of pressure sores (45% vs. 29%, P = .042) were higher in HLTC, with no differences for infection rates or hospitalization. In multivariate analyses, being treated at home with PMV was significantly associated with being able to communicate, lower age, financial difficulties, and improved functional status. HMO costs were one-third for home PMV versus HLTC. CONCLUSIONS AND IMPLICATIONS: Differing profiles were described for home and HLTC PMV patients, with lower rates of depression, pressure sores, mortality, and one-third the cost to HMO at home. Caregiver strain was similar irrespective of site of care. With appropriate targeting for eligible patients, home PMV is a viable and financially beneficial option.

[LONELINESS, FUNCTION AND LONGEVITY: THE JERUSALEM LONGITUDINAL COHORT STUDY].

AIMS: To assess the association between subjective loneliness among the elderly (whether an individual feels lonely) with functional status and longevity after adjustment for potential confounders. BACKGROUND: While objective measures of loneliness among older people have been found to be associated with functional decline and increased mortality, little is known concerning the relationship between subjective loneliness, function, morbidity and longevity. METHODS: Subjective loneliness, health variables, functional status and mortality were assessed through the Jerusalem Longitudinal Cohort Study (1990-2015), a prospective longitudinal study. Participants born between the years 1920-1921 were assessed at home at ages 70, 78, 85 and 90. Depressed participants were excluded from the statistical analyses. Participants were asked how often they felt lonely, with answers dichotomized to never versus rarely/often/very often. RESULTS: At age 70, 78, 80 and 90, overall prevalence of loneliness was 27.8% , 23.7% , 23.9% and 26.7% respectively. Male gender and not being married were consistently associated at all ages with increased likelihood of loneliness. After adjusting for baseline variables, we found no association between subjective loneliness and subsequent deterioration in functional status, cognitive function (decline in mini-mental score<24) or chronic pain in any age groups. Furthermore, loneliness was not associated with mortality among the participants between ages 70-78, 78-85, 85-90 and 90-95. We repeated all the analyses, this time including depressed subjects, with no significant change in the overall findings. CONCLUSIONS: Loneliness was not associated with subsequent poor health outcomes or decline in functional status up to the age of 95. Furthermore, no association was found between subjective loneliness and mortality at any age.

Longitudinal changes in cardiac function in the very elderly: the Jerusalem longitudinal cohort study.

BACKGROUND: People over the age of 85 are a rapidly growing age group with a high incidence of congestive heart failure (CHF), in particular heart failure with preserved ejection fraction (HFpEF). The diagnosis of CHF is challenging and longitudinal data assessing cardiac structure and function are necessary to distinguish physiologic from pathologic cardiac aging. The objective of the study was to determine longitudinal changes in cardiac struture and function from ages 85 to 94 years using home echocardiography. METHODS: Subjects were recruited from the Jerusalem Longitudinal Cohort Study. Sixty three members of the initial cohort (32F, 31M) who underwent home echocardiography at age 85 were the subjects of the current study and underwent repeat home 2-D and Doppler echocardiographic assessment at age 94. RESULTS: There were no significant longitudinal changes in left ventricular mass index (LVMI), however LV end-diastolic volume significantly decreased from 113.4 ± 30 to 103.6 ± 35.5 mL (P < 0.02). Ejection fraction (EF) remained stable, however longitudinal systolic function significantly decreased with age from 7.9 ± 1.8 to 6.6 ± 1.4 cm/s2 (P < 0.0001). Diastolic function as assessed by increased E: e' (11.2 ± 3.4 to 16 ± 7.5, P < 0.0001) and increased left atrial volume index (34.1 ± 11.3 to 42.4 ± 13.7 mL/m2, P < 0.0001) was reduced with aging. CONCLUSIONS: This study demonstrated preserved EF with decreased longitudinal systolic function and diastolic function without significant change in LV mass. Changes in LV function in the very elderly may be independent of changes in LV geometry.

Activity Performance, Participation, and Quality of Life Among Adults in the Chronic Stage After Acquired Brain Injury-The Feasibility of an Occupation-Based Telerehabilitation Intervention.

Objective: Acquired brain injury (ABI) is a leading cause of long-term disability. This calls for effective and accessible interventions to support participation in the community over time. One promising avenue to answer this need is telerehabilitation. Prior to conducting a larger trial, the main objective of this pilot study is to explore the feasibility, acceptability, and preliminary efficacy of a metacognitive occupation-based intervention in a telerehabilitation format with adults and older adults in the chronic phase after ABI. Methods: Five community dwelling participants (ages 65-72), 6-10 months post-ABI, with scores 2-4 on the modified Rankin scale and without dementia, completed the teleintervention. The intervention included ~10 weekly videoconferencing sessions administered by an occupational therapist using the Cognitive Orientation to Daily Occupational Performance approach. Each participant defined five functional goals and three were trained and two were not trained during the intervention. Evaluations were conducted at pre, post, and 3-month follow-up. The primary outcome measures included activity performance (The Canadian Occupational Performance Measure; COPM), participation (the Mayo-Portland Adaptability Inventory-4 Participation Index; MPAI-4-P), and quality of life (QoL) (stroke impact scale; SIS). Other measures included a feedback interview, satisfaction questionnaire, field notes, and a treatment fidelity checklist. Results: The teleintervention was found to be feasible and the participants expressed a high degree of satisfaction with the intervention and the technology use. A Wilcoxon Signed-Ranks test indicated statistically significant improvements post intervention in COPM performance (z = -2.023, p = 0.043) and satisfaction (z = -2.023, p = 0.043) ratings. Additionally, clinically significant improvements (≥2 points) in both performance and satisfaction with performance were found for each participant in at least three of their five defined functional goals. Trends toward significant improvement were found in MPAI-4-P ratings post intervention (z = -1.826, p = 0.068). Furthermore, clinically significant improvements (≥15 points) post intervention were found for each participant in some subscales of the SIS. Results were partially maintained at 3-month follow-up. Conclusions: This pilot study demonstrated the feasibility of a metacognitive occupation-based telerehabilitation intervention and its potential benefits in activity performance, participation, and QoL for older adults coping with long-term disability following ABI. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03048708.

Is age a risk factor for depression among the oldest old with cancer?

INTRODUCTION: Age is negatively related to depression among young and middle age patients with cancer. Nevertheless the relationship between age and depression among older patients with cancer is unclear. The goal of the current study is to assess the association of depression with increasing age among older patients with cancer. MATERIALS AND METHODS: Participants were 243 oncology out-patients, aged ≥65, either receiving treatment for active disease or within 6 months of completing treatment for active disease, with a Karnofsky score ≥70. Participants were grouped by age: "Younger-Old" - age 65-74 (N = 125); "Old" - age 75-84 (N = 49); and "Oldest-Old" -age ≥ 85 years (N = 69). Background data included: socio-demography; cancer type/staging/treatment; Charlson comorbidity index (CCI); Eastern Cooperative Oncology Group (ECOG) performance. Psychological data included: the 5-item Geriatric Depression Scale (GDS); "Distress Thermometer" (single item); and Cancer Perceived Agents of Social Support (12-item). RESULTS: Depression levels were significantly higher among oldest-old participants in comparison to the old and younger-old groups: mean GDS scores were 0.93 ±â€¯1.13, 1.27 ±â€¯1.41 and 3.91 ±â€¯1.35 respectively. After controlling for all potential confounders in a hierarchical logistic regression model, age-group significantly predicted both depression and distress. Receiver operating characteristic (ROC) analysis determined age 86 as the optimal cutoff for both clinical depression and distress. DISCUSSION: Depression among older patients with cancer rises with increasing age, being extremely common among the oldest old. Age independently predicted depression, irrespective of medical variables, social support, or functional status. Findings highlight the importance of addressing the potentially unmet psychological needs of this rapidly growing patient population.

Breast cancer among older women: The influence of age and cancer stage on survival.

PURPOSE OF STUDY: To describe the association between increasing age and survival among women aged over 65 years, diagnosed with breast cancer. MATERIALS AND METHODS: A historical prospective cohort study, comparing 3270 breast cancer patients to 13,163 non cancer age matched controls. Baseline characteristics and cancer data gathered from the Israeli Central Bureau of Statistics (1995), the Israel Cancer Registry (2000-2010). Baseline measurements included age, socioeconomic status. Cancer stage at diagnosis was clustered as stage I, stage II-III and metastatic. Cox Proportional Hazards regression models were used to determine Hazards Ratios (HR) for mortality. RESULTS: Between ages 65-69 and ≥85, metastatic disease rose from 3.9% to 23.4% and stage I disease declined from 58.6% to 30.1%. At age 80-84, 50% life expectancy among controls, stage I, and stage II-III disease was 95,92 and 90 months respectively, compared to 2 months for metastatic disease. Compared to controls, between the age 65-69 to ≥85, adjusted HR's progressively decreased among subjects with stage I from HR 0.96 (95% CI 0.69-1.33) to 0.60 (95%CI 0.36-1.01), stage II-III from HR 3.26 (95%CI2.58-4.12) to HR 1.60 (95%CI 1.22-2.09), and metastatic disease from HR 57.40 (95%CI 39.56-83.29) to HR 20.76 (95%CI 14.73-29.24). CONCLUSIONS: This study describes the increasingly poor prognosis and short life expectancy observed among women aged ≥80 diagnosed with metastatic breast. In contrast, our findings confirm the positive prognosis associated with rising age, among older women presenting with stage I breast cancer, among whom survival was similar, if not slightly better, than non-cancer age matched controls.