Effects of Calorie Restriction in Obese Older Adults: The CROSSROADS Randomized Controlled Trial.

BACKGROUND: We lack a comprehensive assessment of the risks and benefits of calorie restriction in older adults at high risk for cardiometabolic disease. Calorie restriction may reduce visceral adipose tissue (VAT) but also have negative effects on lean mass and quality of life. METHODS: We conducted a 52-week, randomized controlled trial involving 164 older adults with obesity taking at least one medication for hyperlipidemia, hypertension, or diabetes. Interventions included an exercise intervention alone (Exercise), or with diet modification and body weight maintenance (Maintenance), or with diet modification and energy restriction (Weight Loss). The primary outcome was change in VAT at 12 months. Secondary outcomes included cardiometabolic risk factors, functional status, and quality of life. RESULTS: A total of 148 participants had measured weight at 12 months. Despite loss of -1.6% ± 0.3% body fat and 4.1% ± 0.7% initial body weight, Weight Loss did not have statistically greater loss of VAT (-192.6 ± 185.2 cm3) or lean mass (-0.4 ± 0.3 kg) compared with Exercise (VAT = -21.9 ± 173.7 cm3; lean mass = 0.3 ± 0.3 kg). Quality of life improved in all groups with no differences between groups. No significant changes in physical function were observed. Weight Loss had significantly greater improvements in blood glucose (-8.3 ± 3.6 mg/dL, p < .05) and HDL-cholesterol (5.3 ± 1.9, p < .01) compared with Exercise. There were no group differences in the frequency of adverse events. CONCLUSIONS: While moderate calorie restriction did not significantly decrease VAT in older adults at high risk for cardiometabolic disease, it did reduce total body fat and cardiometabolic risk factors without significantly more adverse events and lean mass loss.

Calorie restriction in overweight seniors: response of older adults to a dieting study: the CROSSROADS randomized controlled clinical trial.

We conducted a study designed to evaluate whether the benefits of intentional weight loss exceed the potential risks in a group of community-dwelling obese older adults who were at increased risk for cardiometabolic disease. The CROSSROADS trial used a prospective randomized controlled design to compare the effects of changes in diet composition alone or combined with weight loss with an exercise only control intervention on body composition and adipose tissue deposition (Specific Aim #1: To compare the effects of changes in diet composition alone or combined with weight loss with an exercise only control intervention on body composition, namely visceral adipose tissue), cardiometabolic disease risk (Specific Aim #2: To compare the effects of a change in diet composition alone or combined with weight loss with an exercise only control intervention on cardiometabolic disease risk), and functional status and quality of life (Specific Aim #3: To compare the effects of a change in diet composition alone or combined with weight loss with an exercise only control intervention on functional status and quality of life). Participants were randomly assigned to one of three groups: Exercise Only (Control) Intervention, Exercise + Diet Quality + Weight Maintenance Intervention, or Exercise + Diet Quality + Weight Loss Intervention. CROSSROADS utilized a lifestyle intervention approach consisting of exercise, dietary, and behavioral components. The development and implementation of the CROSSROADS protocol, including a description of the methodology, detailing specific elements of the lifestyle intervention, assurances of treatment fidelity, and participant retention; outcome measures and adverse event monitoring; as well as unique data management features of the trial results, are presented in this article.

Symptom burden predicts hospitalization independent of comorbidity in community-dwelling older adults.

OBJECTIVES: To determine whether cumulative symptom burden predicts hospitalization or emergency department (ED) visits in a cohort of older adults. DESIGN: Prospective, observational study with a baseline in-home assessment of symptom burden. SETTING: Central Alabama. PARTICIPANTS: Nine hundred eighty community-dwelling adults aged 65 and older (mean 75.3 ± 6.7) recruited from a random sample of Medicare beneficiaries stratified according to sex, race, and urban/rural residence. MEASUREMENTS: Symptom burden score (range 0-10). One point was given for each symptom reported: shortness of breath, tiredness or fatigue, problems with balance or dizziness, leg weakness, poor appetite, pain, stiffness, constipation, anxiety, and loss of interest in activities. Dependent variables were hospitalizations and ED visits, assessed every 6 months during the 8.5-year follow-up period. Using Cox proportional hazards models, time from the baseline in-home assessment to the first hospitalization and first hospitalization or ED visit was determined. RESULTS: During the 8.5-year follow-up period, 545 (55.6%) participants were hospitalized or had an ED visit. Participants with greater symptom burden had higher risk of hospitalization (hazard ratio (HR) = 1.09, 95% confidence interval (CI) = 1.05-1.14) and hospitalization or ED visit (HR = 1.10, 95% CI = 1.06-1.14) than those with lower scores. Participants living in rural areas had significantly lower risk of hospitalization (HR = 0.83, 95% CI = 0.69-0.99) and hospitalization or ED visit (HR = 0.80, 95% CI = 0.70-0.95) than individuals in urban areas, independent of symptom burden and comorbidity. CONCLUSION: Greater symptom burden was associated with higher risk of hospitalization and ED visits in community-dwelling older adults. Healthcare providers treating older adults should consider symptom burden to be an additional risk factor for subsequent hospital utilization.

The E-coach transition support computer telephony implementation study: protocol of a randomized trial.

BACKGROUND: Patients requiring complex care are at high risk during the transition from one setting of care to another. Effective interventions to support care transitions have been designed but are very resource intensive. Telemonitoring has been considered as an approach to enhance care transition support, but many telemonitoring systems require special equipment or web-based interfaces to interact with patients and caregivers. METHODS/DESIGN: In this paper we report our protocol for developing and testing E-Coach, an interactive voice response (IVR)-enhanced care transition intervention that monitors patients at home using their personal phone. The elements described include 1) development of an IVR monitoring system that will be based on Coleman's four pillars of care transition support; 2) development of a web-based "dashboard" of IVR responses that alert care transition nurses (CTN) of patient/caregiver concerns after discharge and allow documentation by the CTN when patients/caregivers are called; 3) pilot testing of the IVR system by patients and providers with refinement of the system based on patient/provider input; and 4) a pragmatic protocol for formal testing through a randomized controlled trial (RCT) of the E-Coach intervention in congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) patients admitted to a large tertiary hospital. TRIAL REGISTRATION: CT.gov#: NCT01135381.

Inflammatory biomarkers as predictors of hospitalization and death in community-dwelling older adults.

Individuals with multimorbidity may be at increased risk of hospitalization and death. Comorbidity indexes do not capture severity of illness or healthcare utilization; however, inflammation biomarkers that are not disease-specific may predict hospitalization and death in older adults. We sought to predict hospitalization and mortality of older adults using inflammation biomarkers. From a prospective, observational study, 370 community-dwelling adults 65 years or older from central Alabama participated in an in-home assessment and provided fasting blood samples for inflammation biomarker testing in 2004. We calculated an inflammation summary score (range 0-4), one point each for low albumin, high C-reactive protein, low cholesterol, and high interleukin-6. Utilizing Cox proportional hazards models, inflammation summary scores were used to predicted time to hospitalization and death during a 4-year follow up period. The mean age was 73.7 (±5.9 yrs), and 53 (14%) participants had summary scores of 3 or 4. The rates of dying were significantly increased for participants with inflammation summary scores of 2, 3, or 4 (hazard ratio (HR) 2.22, 2.78, and 7.55, respectively; p<0.05). An inflammation summary score of 4 significantly predicted hospitalization (HR 5.92, p<0.05). Community-dwelling older adults with biomarkers positive for inflammation had increased rates of being hospitalized or dying during the follow up period. Assessment of the individual contribution of particular inflammation biomarkers in the prediction of health outcomes in older populations and the development of validated summary scores to predict morbidity and mortality are needed.

Visual acuity's association with levels of leisure-time physical activity in community-dwelling older adults.

Little is known about the effect of reduced vision on physical activity in older adults. This study evaluates the association of visual acuity level, self-reported vision, and ocular disease conditions with leisure-time physical activity and calculated caloric expenditure. A cross-sectional study of 911 subjects 65 yr and older from the University of Alabama at Birmingham Study of Aging (SOA) cohort was conducted evaluating the association of vision-related variables to weekly kilocalorie expenditure calculated from the 17-item Leisure Time Physical Activity Questionnaire. Ordinal logistic regression was used to evaluate possible associations while controlling for potential confounders. In multivariate analyses, each lower step in visual acuity below 20/50 was significantly associated with reduced odds of having a higher level of physical activity, OR 0.81, 95% CI 0.67, 0.97. Reduced visual acuity appears to be independently associated with lower levels of physical activity among community-dwelling adults.

Substantial daily pain among nursing home residents.

OBJECTIVE: To evaluate the prevalence of substantial daily pain among nursing home residents aged 65 and older. DESIGN, SETTING, AND METHODS: The Minimum Data Set (MDS) annual or admission assessment, available September 2002, for Alabama nursing home residents was used. Logistic regression was used to examine the association of such pain with nursing home characteristics as well as resident-specific factors. RESULTS: The analysis is based on 27,628 nursing home residents 65 and older with mean age of 82.8 years; 20% African American; 25% male. Seventeen percent had substantial daily pain. By nursing home, reported substantial daily pain prevalence ranged from 0% to 54.7%. The prevalence of pain was less in smaller nursing homes (P < .001). Bivariate correlations were significant for all sociodemographic and mental status variables; number of medications; dementia; thyroid, musculoskeletal, neurological, pulmonary, and sensory disorders; allergies; anemia; and cancer. Factors independently correlated with substantial daily pain included (odds ratio, 95% confidence interval) sociodemographic characteristics: white race (1.5, 1.3-1.7), female (1.3, 1.2-1.5), married (1.1, 1.0-1.2), admission within year (2.0, 1.8-2.1); nursing home characteristics: nonprofit or government financing (1.3, 1.2-1.5), greater number of residents (1.4, 1.3-1.5); subject-specific conditions: no cognitive impairment (1.6, 1.5-1.7), communication ability (1.4, 1.2-1.5), sad mood/depression (1.5, 1.4-1.6), taking 10 or more medications (2.0, 1.9-2.2), musculoskeletal disease (1.9, 1.7-2.0), anemia (1.1, 1.0-1.2), and cancer (1.6, 1.4-1.8). Lower odds of substantial daily pain were associated with older age, rural locale, dementia, and thyroid, neurological, pulmonary, and sensory disorders. DISCUSSION: This study highlights within-state variation in MDS reporting by nursing home as well as resident-specific factors associated with daily substantial pain. Rural, for-profit, and low-occupancy nursing homes had less documented pain. Communication ability and not having cognitive impairment were important factors in having such pain reported.

Body mass index, weight loss, and mortality in community-dwelling older adults.

BACKGROUND: The relationship between body mass index (BMI), weight loss, and mortality in older adults is not entirely clear. The purpose of this article is to evaluate the associations between BMI, weight loss (either intentional or unintentional), and 3-year mortality in a cohort of older adults participating in the University of Alabama at Birmingham (UAB) Study of Aging. METHODS: This article reports on 983 community-dwelling older adults who were enrolled in the UAB Study of Aging, a longitudinal observational study of mobility among older African American and white adults. RESULTS: In both raw and adjusted Cox proportional hazards models, unintentional weight loss and underweight BMI were associated with elevated 3-year mortality rates. There was no association with being overweight or obese on mortality, nor was there an association with intentional weight loss and mortality. CONCLUSIONS: Our study suggests that undernutrition, as measured by low BMI and unintentional weight loss, is a greater mortality threat to older adults than is obesity or intentional weight loss.

Pain and pain medication use in community-dwelling older adults.

BACKGROUND: Pain is a common symptom and significant problem for older adults; up to one half of community-dwelling older adults have pain that interferes with normal function. OBJECTIVE: The goal of this study was to investigate the prevalence of pain among a racially and gender-balanced sample of community-dwelling older adults and evaluate sociodemographic factors associated with the reporting of pain. Both nonprescription (over-the-counter [OTC]) and prescription pain medications used by the participants and the sociodemographic factors associated with having medication prescribed were considered. METHOD: This was a population-based, prospective, observational study. Subjects were participants in the University of Alabama at Birmingham (UAB) Study of Aging, a stratified random sample of Medicare beneficiaries who completed in-home interviews (1999-2001). Assessments included sociodemographic factors and pain; interviewers listed all prescription and OTC pain medications used. Pain medications were coded as NSAIDs, opiates, and miscellaneous pain medications. A composite ordinal measure reflecting pain severity and frequency ranged from 0 = no pain to 4 = dreadful or agonizing pain > or =4 times per week. RESULTS: There were 1000 participants in the UAB Study of Aging (mean [SD] age, 75.3 [6.7] years; 50% black; 50% male; 51% rural residence). Seventy-four percent of the subjects reported pain; among these, 52% had daily pain, with 26% reporting dreadful or agonizing pain. Logistic regression controlling for other sociodemographic factors (age, gender, race, education, income, and marital status) found that rural residence (odds ratio [OR], 1.42; 95% CI, 1.1-1.9; P = 0.02) was significantly associated with the reporting of pain. Prescription pain medications were used by 35% of persons with pain and by 17% without pain (P < 0.001); OTC pain medications were used by 52% of persons with pain and by 45% of persons without pain (P = 0.06). Of persons reporting pain, 28% were taking neither prescription nor OTC pain medications; 16% took both and 20% took only prescription pain medications. Logistic regression found that factors associated with taking a prescription pain medication were: unmarried status (OR, 1.56; 95% CI, 1.1-2.2) and pain frequency/severity (OR, 1.39; 95% CI, 1.3-1.6). Taking an OTC pain medication was associated with lower odds of taking a prescription pain medication (OR, 0.50; 95% CI, 0.4-0.7). Age, gender, race, education, rural residence, transportation difficulty, income, and being on Medicaid were not associated with prescription pain medication use. CONCLUSIONS: Prescription pain medication use was associated with pain frequency/severity after adjusting for sociodemographics and OTC pain medications in this study of community-dwelling older adults, suggesting that even with medications, individuals remained in pain.

Social isolation, support, and capital and nutritional risk in an older sample: ethnic and gender differences.

This study examines the relationships that exist between social isolation, support, and capital and nutritional risk in older black and white women and men. The paper reports on 1000 community-dwelling older adults aged 65 and older enrolled in the University of Alabama at Birmingham (UAB) Study of Aging, a longitudinal observational study of mobility among older black and white participants in the USA. Black women were at greatest nutritional risk; and black women and men were the groups most likely to be socially isolated and to possess the least amounts of social support and social capital. For all ethnic-gender groups, greater restriction in independent life-space (an indicator of social isolation) was associated with increased nutritional risk. For black women and white men, not having adequate transportation (also an indicator of social isolation) was associated with increased nutritional risk. Additionally, for black and white women and white men, lower income was associated with increased nutritional risk. For white women only, the perception of a low level of social support was associated with increased nutritional risk. For black men, not being married (an indicator of social support) and not attending religious services regularly, restricting activities for fear of being attacked, and perceived discrimination (indicators of social capital) were associated with increased nutritional risk. Black females had the greatest risk of poor nutritional health, however more indicators of social isolation, support, and capital were associated with nutritional risk for black men. Additionally, the indicators of social support and capital adversely affecting nutritional risk for black men differed from those associated with nutritional risk in other ethnic-gender groups. This research has implications for nutritional policies directed towards older adults.

Measuring life-space mobility in community-dwelling older adults.

OBJECTIVES: To evaluate the validity and reliability of a standardized approach for assessing life-space mobility (the University of Alabama at Birmingham Study of Aging Life-Space Assessment (LSA)) and its ability to detect changes in life-space over time in community-dwelling older adults. DESIGN: Prospective, observational cohort study. SETTING: Five counties (three rural and two urban) in central Alabama. PARTICIPANTS: Community-dwelling Medicare beneficiaries (N=306; 46% male, 43% African American) who completed in-home baseline interviews and 2-week and 6-month telephone follow-up interviews. MEASUREMENTS: The LSA assessed the range, independence, and frequency of movement over the 4 weeks preceding assessments. Correlations between the baseline LSA and measures of physical and mental health (physical performance, activities of daily living, instrumental activities of daily living, a global measure of health (the short form-12 question survey), the Geriatric Depression Scale, and comorbidities) established validity. Follow-up LSA scores established short-term test-retest reliability and the ability of the LSA to detect change. RESULTS: For all LSA scoring methods, baseline and 2-week follow-up LSA correlations were greater than 0.86 (95% confidence interval=0.82-0.97). Highest correlations with measures of physical performance and function were noted for the LSA scoring method considering all attributes of mobility. The LSA showed both increases and decreases at 6 months. DISCUSSION: Life-space correlated with observed physical performance and self-reported function. It was stable over a 2-week period yet showed changes at 6 months.

Age-related underutilization of left ventricular function evaluation in older heart failure patients.

BACKGROUND: Underutilization of left ventricular function (LVF) evaluation in older patients with heart failure has been well documented, but age-related variation in the use of LVF evaluation has not been. METHODS: We studied age-related variation of LVF evaluation in older Medicare-beneficiaries discharged with a diagnosis of heart failure in 1994 in Alabama. RESULTS: A total of 1,090 patients had a mean +/- SD age of 79 +/- 7.5 years; 60% were female and 18% were African American. Of these, 636 (58%) had LVF evaluation. Compared with patients aged 65 to 74 years, those 75 to 84 years of age and those aged 85 and older were less likely to receive LVF evaluation. Age of 85 years and older was also independently associated with lower odds of LTF evaluation. CONCLUSION: The overall rate of LVF evaluation was low, and performance of evaluation decreased with patient age. Left ventricular function evaluation should be performed in all patients with heart failure. Considerable opportunities exist for improving care among hospitalized Medicare beneficiaries diagnosed with heart failure.

Age-related underutilization of angiotensin-converting enzyme inhibitors in older hospitalized heart failure patients.

BACKGROUND: The extent to which age plays a role in the underutilization of angiotensin-converting enzyme (ACE) inhibitors in heart failure patients has not been well studied. METHODS: We studied age-related variation in the use of ACE inhibitors in older Medicare beneficiaries discharged alive in Alabama with a diagnosis of heart failure with left ventricular systolic dysfunction. RESULTS: A total of 285 patients had a mean age +/- SD of 78 +/- 6.9 years; 59% were female and 21% were African American. Of the 285 patients, 181 (63%) were prescribed ACE inhibitors at discharge. Therapy with ACE inhibitors was initiated in 47% of the patients. Compared with patients 65 to 74 years, those 85 years and older had lower odds of receiving ACE inhibitors at discharge. Among patients not admitted on an ACE inhibitor, those 85 years and older also had lower odds of ACE inhibitor therapy being initiated. CONCLUSION: The overall rate of ACE inhibitor use was low, and age of 85 years and older was independently associated with lower use and initiation of ACE inhibitors. Opportunities remain to increase the use of ACE inhibitors in older patients with heart failure.

Coordination and advocacy for rural elders (CARE): a model of rural case management with veterans.

PURPOSE: To describe a pilot initiative sponsored by the Veterans Health Administration (VHA) to improve the health and community tenure of frail older veterans living in rural counties 50-100 miles from two host VHA medical centers. DESIGN AND METHODS: Veterans aged 75 and older who scored at risk of repeated hospital admission on the PRA-Plus telephone questionnaire were targeted and visited by evaluators who administered a comprehensive health questionnaire prior to being assessed at home by the Coordination and Advocacy for Rural Elders (CARE) program clinical teams. Guided by current state-of-the-art practices, the nurse-social worker teams performed in-home standardized assessments using the MDS-HC, developed patient-specific care plans, and mobilized family, community, and VHA resources to implement plans. RESULTS: On average, eight problems were identified for each patient, most commonly falls risk, social needs, pain, and needs related to IADL disability. As a result of initial assessment, two thirds of CARE participants received referral/linkage to formal services, more than half to medical providers. IMPLICATIONS: Through CARE, the VHA is learning more about the unmet needs of older rural veterans. Further development and evaluation should guide the VHA toward providing efficient, effective community-based services to all frail older veterans.