Impact of Bedside Rounding on Attending Teaching Evaluations.

OBJECTIVE: To examine associations between bedside rounding (BSR) and other rounding strategies (ORS) with resident evaluations of teaching attendings and self-reported attending characteristics. METHODS: Faculty from three academic medical centers who attended resident teaching services for ≥4 weeks during the 2018-2019 academic year were invited to complete a survey about personal and rounding characteristics. The survey instrument was iteratively developed to assess rounding strategy as well as factors that could affect choosing one rounding strategy over another. Survey results and teaching evaluation scores were linked, then deidentified and analyzed in aggregate. Included evaluation items assessed resident perceptions of autonomy, time management, professionalism, and teaching effectiveness, as well as a composite score (the numeric average of each attending's scores for all of the items at his or her institution). BSR was defined as spending >50% of rounding time in patients' rooms with the team. Hallway rounding and conference room rounding were combined into the ORS category and defined as >50% of rounding time in these settings. All of the scores were normalized to a 10-point scale to allow aggregation across sites. RESULTS: A total of 105 attendings were invited to participate, and 65 (62%) completed the survey. None of the resident evaluation scores significantly differed based on rounding strategy. Composite scores were similar for BSR and ORS (difference of <0.1 on a 10-point scale). Spearman correlation coefficients identified no statistically significant correlation between rounding strategy and evaluation scores. An exploratory analysis of variance model identified no single factor that was significantly associated with composite teaching scores (P > 0.45 for all) or the domains of teaching efficacy, professionalism, or autonomy (P > 0.13 for all). Having a formal educational role was significantly associated with better evaluation scores for time management, and the number of lectures delivered per year approached statistical significance for the same domain. CONCLUSIONS: Conducting BSR did not significantly affect resident evaluations of teaching attendings. Resident perception of teaching effectiveness based on rounding strategy should be neither a motivator nor a barrier to widespread institution of BSR.

Holiday Discharges Are Associated with Higher 30-Day General Internal Medicine Hospital Readmissions at an Academic Medical Center.

OBJECTIVE: Academic medical centers face unique challenges in educating physician trainees in effective discharge practices to prevent readmissions. Meanwhile, residents must handle high workloads coupled with frequent rotations to different services. This study aimed to determine whether daily service census, service turnover, time of discharge, and day of discharge increase the risk of 30-day readmission. METHODS: All of the discharges from two academic general internal medicine teaching services between October 1, 2013 and September 30, 2014 were included in this observational data analysis. Variables were fit to a 30-day, all-cause readmission outcome using multiple logistic regression with inverse probability of treatment weighting and multiple imputations with chained equations. The following potential confounding variables were included in the model: health system utilization, demographics, laboratory values, and comorbidities. RESULTS: Among 1935 total discharges, 258 patients (13.3%) were readmitted within 30 days of the index discharge. Turnover, service census, weekend discharge, and time of discharge were not significantly associated with the risk of readmission. Patients discharged during holiday periods had higher odds of readmission (odds ratio 2.56, 95% confidence interval 2.01-3.25), whereas patients discharged on an intern switch day had lower odds of readmission (odds ratio 0.33, 95% confidence interval 0.27-0.41). CONCLUSIONS: Patients who are discharged during holiday periods are at a higher risk of readmission after adjusting for potential confounders. These results also suggest that discharge on an intern switch day had a protective effect on readmission. Further work is needed to examine whether these findings can be replicated, and, if confirmed, to determine to what extent these associations are causal.

Preclinical medical student observations associated with later professionalism concerns.

PURPOSE: Professionalism is a core physician competency and identifying students at risk for poor professional development early in their careers may allow for mentoring. This study identified indicators in the preclinical years associated with later professionalism concerns. METHODS: A retrospective analysis of observable indicators in the preclinical and clinical years was conducted using two classes of students (n = 226). Relationships between five potential indicators of poor professionalism in the preclinical years and observations related to professional concerns in the clinical years were analyzed. RESULTS: Fifty-three medical students were identified with at least one preclinical indicator and one professionalism concern during the clinical years. Two observable preclinical indicators were significantly correlated with unprofessional conduct during the clinical years: Three or more absences from attendance-required sessions (odds ratio 4.47; p=.006) and negative peer assessment (odds ratio 3.35; p=.049). CONCLUSIONS: We identified two significant observable preclinical indicators associated with later professionalism concerns: excessive absences and negative peer assessments. Early recognition of students at risk for future professionalism struggles would provide an opportunity for proactive professional development prior to the clinical years, when students' permanent records may be affected. Peer assessment, coupled with attention to frequent absences, may be a method to provide early recognition.

Intern Boot Camp: Feasibility and impact of a 1-hour session to ensure graduating medical student competency in falls risk assessment.

The authors evaluated the feasibility of a 1-hour session to ensure competency in gait and falls risk assessment for medical students at their institution. The session included a history and exam with faculty and staff as standardized patients, gait recognition videos, and case evaluation for falls risk assessment and prevention. Student perceptions were evaluated using a retrospective pre-post survey, scored on a 5-point Likert-type scale. Wilcoxon signed-rank tests were used to assess change and Kruskal-Wallis tests were used to analyze differences by residency choice. A range of five to 11 faculty and staff certified 238 medical students during eight 1-hour sessions. Overall self-perception of competence in falls risk assessment and prevention improved (p ≤ .001), and did not differ by residency choice, both before and after the training program (p = .73 and p = .25). Feedback was positive. This session is a feasible way to teach and assess the competency for falls risk assessment with modest time commitment.

Intensive blood pressure control, falls, and fractures in patients with type 2 diabetes: the ACCORD trial.

BACKGROUND: There are few rigorous studies to confirm or refute the commonly cited concern that control of blood pressure to lower thresholds may result in an increased risk of falls and fractures. OBJECTIVE: To compare falls and fractures in participants with type 2 diabetes in the intensive (targeting a systolic blood pressure of < 120 mmHg) and standard (targeting a systolic blood pressure of < 140 mmHg) blood pressure control arms of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) randomized trial (N = 4,733). PARTICIPANTS: A subset of 3,099 participants self-reported annually on the occurrence of falls and non-spine fractures. Fractures were centrally adjudicated. MAIN MEASURES: The incidence of falls in the two treatment groups was compared using a random-effects negative binomial model, and fracture risk was compared using Cox proportional hazards models. KEY RESULTS: At enrollment in both groups, the mean age was 62 years, 44% were women, 25% were Black, and mean blood pressure was 138/75 mmHg. During follow-up, all classes of medications, particularly thiazide diuretics, were more commonly prescribed in the intensive group. After 1 year of follow-up, the mean systolic blood pressure was 133 ± 15 mmHg in the standard group and 119 ± 14 mmHg in the intensive group. The adjusted rate of falls did not differ in the intensive and standard groups (62.2/100 person-years vs. 74.1/100 person-years, RR = 0.84, 95% CI 0.54-1.29, p = 0.43). The risk of non-spine fractures was nonsignificantly lower in the intensive than in the standard blood pressure group (HR 0.79, 95% CI 0.62-1.01, p = 0.06). CONCLUSIONS: We conclude that intensive antihypertensive treatment that lowered mean systolic blood pressure to below 120 mmHg was not associated with an increased risk of falls or non-spine fractures in patients age 40 to 79 years with type 2 diabetes.

Utilizing a Meals on Wheels program to teach falls risk assessment to medical students.

Falls are a critical public health issue for older adults, and falls risk assessment is an expected competency for medical students. The aim of this study was to design an innovative method to teach falls risk assessment using community-based resources and limited geriatrics faculty. The authors developed a Fall Prevention Program through a partnership with Meals-on-Wheels (MOW). A 3rd-year medical student accompanies a MOW client services associate to a client's home and performs a falls risk assessment including history of falls, fear of falling, medication review, visual acuity, a Get Up and Go test, a Mini-Cog, and a home safety evaluation, reviewed in a small group session with a faculty member. During the 2010 academic year, 110 students completed the in-home falls risk assessment, rating it highly. One year later, 63 students voluntarily completed a retrospective pre/postsurvey, and the proportion of students reporting moderate to very high confidence in performing falls risk assessments increased from 30.6% to 87.3% (p < .001). Students also reported using most of the skills learned in subsequent clerkships. A single educational intervention in the MOW program effectively addressed geriatrics competencies with minimal faculty effort and could be adopted by many medical schools.

Angiotensin-converting enzyme inhibition and novel cardiovascular risk biomarkers: results from the Trial of Angiotensin Converting Enzyme Inhibition and Novel Cardiovascular Risk Factors (TRAIN) study.

BACKGROUND: Beneficial effects of angiotensin-converting enzyme (ACE) inhibitors seem to be mediated by mechanisms that are partly independent of blood pressure lowering. The present study evaluates effects of an ACE inhibitor (ie, fosinopril) intervention on novel cardiovascular risk factors. METHODS: Data are from the Trial of Angiotensin Converting Enzyme Inhibition and Novel Cardiovascular Risk Factors (TRAIN) study, a double-blind, crossover, randomized, placebo-controlled trial enrolling subjects > or =55 years old with high cardiovascular disease risk profile. Biomarkers of hemostasis (ie, plasminogen activator inhibitor 1, D-dimer), inflammation (ie, C-reactive protein, interleukin-6), and endothelial function (ie, endothelin 1, vascular cell adhesion molecule 1) were measured at the baseline, at the midterm, and at end of follow-up (after 1 year) clinic visits. Paired t test analyses (after Sidak's adjustment, P < .009) were performed to compare biomarkers modifications after fosinopril/placebo interventions. RESULTS: Mean age of the sample (n = 290, women 43.4%) was 66.0 years old. No significant differences were reported for C-reactive protein, interleukin 6, plasminogen activator inhibitor 1, vascular cell adhesion molecule 1, and endothelin 1 levels in the comparisons between fosinopril and placebo interventions. D-dimer was the only biomarker showing a significant difference between fosinopril intervention (median 0.32 microg/mL, interquartile range 0.22-0.52 microg/mL) and placebo (median 0.29 microg/mL, interquartile range 0.20-0.47 microg/mL, P = .007) when analyses were restricted to participants with higher compliance to treatment and receiving the maximum ACE inhibitor dosage. CONCLUSIONS: Angiotensin-converting enzyme inhibition does not significantly modify major biomarkers of inflammation, hemostasis, and endothelial function. Further studies should confirm the possible effect of ACE inhibitors on the fibrinolysis pathway.

A 360-degree assessment of teaching effectiveness using a structured-videorecorded observed teaching exercise for faculty development.

BACKGROUND: Filming teaching sessions were reported in the medical literature in the 1980s and 1990s but appear to have been an underreported and/or underutilized teaching tool since that time. National faculty development programs, such as the Harvard Macy Institute (HMI) Program for Educators in Health Professions and the Stanford Faculty Development Center for Medical Teachers program, have attempted to bridge this gap in formal instruction in teaching skills through microteaching sessions involving videos for self- and peer-assessment and feedback. OBJECTIVE: Current video-feedback faculty development initiatives are time intensive and impractical to implement broadly at an institutional level. Further, results of peer feedback have not been frequently reported in the literature at the institutional level. Our research aims to propose a convenient and effective process for incorporating video analysis into faculty devleopment programs. DESIGN: Our work describes a novel technique using video-recorded, simulated teaching exercises to compile multi-dimensional feedback as an aid in faculty development programs that promote teaching-skill development. This research evaluated the effectiveness of a focused teaching practicum designed for faculty in multiple specialty departments with large numbers of older patients into a geriatrics-based faculty development program. Effectiveness of the practicum is evaluated using quantitative scoring and qualitative analysis of self-reflection as well as peer and trainee input. RESULTS: VOTE sessions demonstrate an important exportable product which enable faculty to receive a detailed 360-degree assessment of their teaching. CONCLUSION: This intervention can be easily replicated and revised, as needed, to fit into the educational curriculum at other academic medical centers.

Patient-Centered Bedside Rounds and the Clinical Examination.

Bedside hospital rounds promote patient-centered care in teaching and nonteaching settings. Patients and families prefer bedside rounds and provider acceptance is increasing. Efficient bedside rounds with an interprofessional team or with learners requires preparation of the patient and the rounding team. Bedside "choreography" provides structure and sets expectations for time spent in the room. By using relationship-centered communication, rounds can be both patient proximate and patient centered. The clinical examination can be integrated into the flow of the presentation and case discussion. Patient and provider experience can be enhanced through investing time at the bedside.

Health-related quality of life and cost-effectiveness components of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial: rationale and design.

Diabetes mellitus affects not only life expectancy but also quality of life. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial's health-related quality of life (HRQOL) and cost-effectiveness components will enable the assessment of the relative importance of the various outcomes from the point of view of patients, provide an understanding of the balance between the burdens and benefits of the intervention strategies, and offer valuable insights into adherence. The HRQOL measures used include the Diabetes Symptoms Distress Checklist; the 36-Item Short Form Health Survey, Version 2 (SF-36) (RAND Corporation, Santa Monica, CA); the Patient Health Questionnaire (PHQ) depression measure (Pfizer Inc, New York, NY); the World Health Organization (WHO) Diabetes Treatment Satisfaction Questionnaire (DTSQ); and the EuroQol Feeling Thermometer (EuroQol Group, Rotterdam, Netherlands). The cost-effectiveness analysis (CEA) in ACCORD will provide information about the relative economic efficiency of the different interventions being compared in the trial. Effectiveness will be measured in terms of cardiovascular event-free years gained and quality-adjusted life-years gained (using the Health Utilities Index Mark 3 [HUI-3] [Health Utilities Inc., Dundas, Ontario, Canada] to measure health-state utility). Costs will be direct medical costs assessed from the perspective of a single-payer health system collected by means of patient and clinic cost forms and hospital discharge summaries. The primary HRQOL and CEA hypotheses mirror those in the main ACCORD trial, addressing the effects of the 3 main ACCORD interventions considered separately. There are also secondary (pairwise reference case) comparisons that do not assume independence of treatment effects on HRQOL. CEA will be done on a subsample of 4,311 ACCORD participants and HRQOL on a subsample of 2,053 nested within the CEA subsample. Most assessments will occur through questionnaires at baseline and at 12, 36, and 48 months.

Associations of gait speed and other measures of physical function with cognition in a healthy cohort of elderly persons.

BACKGROUND: Recent evidence suggests that physical decline and slower gait may be associated with early signs of dementia, but more information on healthy older adults is needed. METHODS: We determined associations between cognitive function, gait speed, and self-reported measures of physical function in 3035 healthy mobile participants of the Ginkgo Evaluation of Memory Study evaluated in 2000-2001. Gait speed was measured over a 15-foot course with participants walking at both their usual and rapid pace. Self-reported difficulties with Activities of Daily Living (ADLs) and other physical function tasks were also collected. Results of the Modified Mini-Mental State Examination (3MSE) determined cognitive function. RESULTS: The average age of the cohort was 78.6 years (standard deviation [SD] 3.3), and 53.9% of participants were men. Mean gait speed was 0.95 (SD 0.23) m/s at a usual pace and 1.35 (SD 0.58) m/s at a rapid pace. More than three-fourths of participants had 3MSE scores > 90. In multiple logistic models adjusted for demographics and comorbidities, risk of low cognition (defined as 3MSE score of 80-85) was almost twice as great for participants in the slowest quartile of the rapid-paced walking task than for the fastest walkers (odds ratio: 1.96, 95% confidence interval, 1.25-3.08). Associations between cognition and usual-paced walking were borderline, and no relationships were found with self-reported measures of physical function, including ADLs. CONCLUSIONS: In very healthy older adults, performance-based measures better predict early cognitive decline than do subjective measures, and tasks requiring greater functional reserve, such as fast-paced walking, appear to be the most sensitive in assessing these relationships.

Cognitive function, gait speed decline, and comorbidities: the health, aging and body composition study.

BACKGROUND: Emerging evidence indicates an association between cognitive function and physical performance in late life. This study examines the relationship between cognitive function and subsequent gait speed decline among high-functioning older adults. METHODS: Measures of global cognitive function (Modified Mini Mental State Examination [3MS]) and executive control function (ECF) (a clock drawing task [CLOX 1] and the 15-item Executive Interview [EXIT 15]) were obtained in the Health, Aging, and Body Composition Study in 1999-2000. Gait-speed (meters/second) was assessed over 20 meters at usual pace. Using a mixed model, we assessed the relationship between baseline cognitive function and gait-speed change over 3 years. RESULTS: Two thousand, three hundred forty-nine older adults (mean age 75.6 +/- 2.9 years) completed the assessments. After adjustment for baseline gait speed, a 1-standard-deviation (SD) lower performance on each cognitive test was associated with greater gait-speed decline over 3 years: 0.016 m/s for the 3MS (SD = 8.1), 0.009 m/s for CLOX 1 (SD = 2.4), and 0.012 m/s for EXIT 15 (SD = 4.1) (p <.0005 for all). After adjustment for comorbidities, the effect size was attenuated for 3MS and CLOX 1, and the association for EXIT 15 was no longer significant. Depression score was most strongly associated with the EXIT 15 effect reduction. CONCLUSION: Global and executive cognitive functions predict declines in gait speed. The association of ECF with gait speed decline is attenuated by comorbid conditions, particularly depression. Elucidation of the mechanisms underlying these associations may point to new pathways for the treatment of physical decline associated with diminished cognitive function.

Internal Medicine Residents' Ambulatory Management of Core Geriatric Conditions.

BACKGROUND: Adults aged 65 years and older account for more than 33% of annual visits to internal medicine (IM) generalists and specialists. Geriatrics experiences are not standardized for IM residents. Data are lacking on IM residents' continuity experiences with older adults and competencies relevant to their care. OBJECTIVE: To explore patient demographics and the prevalence of common geriatric conditions in IM residents' continuity clinics. METHODS: We collected data on age and sex for all IM residents' active clinic patients during 2011-2012. Academic site continuity panels for 351 IM residents were drawn from 4 academic medical center sites. Common geriatric conditions, defined by Assessing Care of Vulnerable Elders measures and the American Geriatrics Society IM geriatrics competencies, were identified through International Classification of Disease, ninth edition, coded electronic problem lists for residents' patients aged 65 years and older and cross-checked by audit of 20% of patients' charts across 1 year. RESULTS: Patient panels for 351 IM residents (of a possible 411, 85%) were reviewed. Older adults made up 21% of patients in IM residents' panels (range, 14%-28%); patients ≥ 75 (8%) or 85 (2%) years old were relatively rare. Concordance between electronic problem lists and chart audit was poor for most core geriatric conditions. On chart audit, active management of core geriatric conditions was variable: for example, memory loss (10%-25%), falls/gait abnormality (26%-42%), and osteoporosis (11%-35%). CONCLUSIONS: The IM residents' exposure to core geriatric conditions and management of older adults was variable across 4 academic medical center sites and often lower than anticipated in community practice.

Sarcopenia, obesity, and inflammation--results from the Trial of Angiotensin Converting Enzyme Inhibition and Novel Cardiovascular Risk Factors study.

BACKGROUND: Age-related body-composition changes are associated with health-related outcomes in elders. This relation may be explained by inflammation and hemostatic abnormalities. OBJECTIVES: Our objectives were to evaluate the relation between body-composition measures [body mass index (BMI), total fat mass, and appendicular lean mass (aLM)] and C-reactive protein (CRP), interleukin 6 (IL-6), and plasminogen activator inhibitor 1 (PAI-1) and to explore the effect of obesity and sarcopenia on CRP, IL-6, and PAI-1 concentrations. DESIGN: The data are from the Trial of Angiotensin Converting Enzyme Inhibition and Novel Cardiovascular Risk Factors (TRAIN) study baseline visit (n = 286; mean age = 66.0 y). Total fat mass and aLM were assessed with a dual-energy X-ray absorptiometry scan. Linear regressions were performed between body-composition measures and CRP, IL-6, or PAI-1 concentrations. The effect of sarcopenia and obesity (defined as the percentage of fat mass) on CRP, IL-6, and PAI-1 concentrations was evaluated with the use of analyses of covariance. RESULTS: CRP and IL-6 were positively associated with both BMI [beta = 0.027 (P = 0.03) and beta = 0.048 (P < 0.001), respectively] and total fat mass [beta = 0.049 (P < 0.001) and beta = 0.055 (P < 0.001), respectively] and were inversely associated with fat-adjusted aLM [beta = -0.629 (P = 0.002) and beta = -0.467 (P = 0.02), respectively]. PAI-1 was positively associated with both BMI (beta = 0.038, P = 0.005) and total fat mass (beta = 0.032, P = 0.007). No significant interaction was found between either obesity or sarcopenia and CRP, IL-6, and PAI-1 concentrations. Obesity remained significantly associated with high CRP and IL-6 concentrations after adjustments for sarcopenia. CONCLUSIONS: CRP and IL-6 are positively associated with total fat mass and negatively associated with aLM. Obesity-associated inflammation may play an important role in the age-related process that leads to sarcopenia. The relation of inflammation with sarcopenia was not independent of any of the considered obesity indexes.

Socioeconomic differences in cognitive decline and the role of biomedical factors.

PURPOSE: This study examines the association between socioeconomic status and cognitive decline in a community-based cohort of well-functioning older adults and seeks to determine whether this link could be explained by biomedical factors. METHODS: Data are from 2574 men and women aged 70 to 79 years from Pittsburgh, PA, and Memphis, TN, participating in the Health, Aging and Body Composition study (Health ABC). Three indicators of socioeconomic status were used: education, income, and ownership of financial assets. Cognitive decline over 4 years was defined as a decrease of five points or more in the Modified Mini-Mental State Examination (3MS) score. Biomedical factors measured at baseline, included heart disease, cerebrovascular disease, diabetes, hypertension, poor pulmonary function, and high serum levels of inflammatory markers. RESULTS: Adjusted odds ratios were significantly higher in those with low education, low income, and few assets. Odds ratios ranged from 1.51 to 2.16 in the lowest socioeconomic groups. Additional adjustment for biomedical factors reduced the odds ratios of cognitive decline by an average of 2% for education, 5% for income, and 8% for the number of assets. CONCLUSIONS: Low socioeconomic status predicts a decline in cognitive function in older adults and this relationship is not mediated by biomedical factors.

Predictors of combined cognitive and physical decline.

OBJECTIVES: To determine the incidence and correlates of combined declines in cognitive and physical performance. DESIGN: Cohort study of community-dwelling older women with moderate to severe disability. SETTING: The community surrounding Baltimore, Maryland. PARTICIPANTS: Participants in the Women's Health and Aging Study I with Mini-Mental State Examination (MMSE) score or 24 or greater and walking speed greater than 0.4 m/s at baseline. MEASUREMENTS: Cognitive decline was defined as an MMSE score less than 24 and physical decline as a walking speed of 0.4 m/s or less in at least one of the three annual follow-up visits. Participants were stratified into groups based on cognitive or physical decline or both. Group characteristics were compared, and results were adjusted for age, race, education, and significant covariates. RESULTS: Of 558 women that met the baseline MMSE and walking speed inclusion criteria, 21% developed physical decline, 12% developed cognitive decline, and 11% experienced combined cognitive and physical decline. After adjustment, physical decline was associated with age, nonwhite race, former smoking, baseline walking speed, and instrumental activities of daily living (IADL) impairment. Cognitive decline was associated with age and baseline MMSE score. Combined decline was associated with age, baseline walking speed, MMSE score, IADL impairment, as well as current smoking (odds ratio (OR)=5.66, 95% confidence interval (CI)=1.49-21.54) and hemoglobin level (OR=0.68, 95% CI=0.47-0.98). CONCLUSION: Potential predictors of cognitive and physical performance decline were identified. The association between smoking and lower hemoglobin levels and combined cognitive and physical decline may represent potentially modifiable risk factors and should be confirmed in future studies.

Low 25-hydroxyvitamin D concentrations predict incident depression in well-functioning older adults: the health, aging, and body composition study.

BACKGROUND: Cross-sectional studies suggest that low 25-hydroxyvitamin D (25[OH]D) may be a risk factor for depression; however, there are few prospective studies. We examined the association between 25(OH)D and depressive symptoms in community-dwelling persons aged 70-79 years in the Health, Aging, and Body Composition (Health ABC) Study (n = 2598). METHODS: Depressive symptoms were assessed using the Center for Epidemiologic Studies-Depression Scale (CES-D) at baseline and 2-, 3- and 4-year follow-up. Serum 25(OH)D was measured at 1-year follow-up and categorized as <20, 20-<30, and ≥30 ng/mL. Mixed models were used to examine change in CES-D scores according to 25(OH)D categories. The association between 25(OH)D categories and incident depression (CES-D short score ≥10 or antidepressant medication use) were assessed using Cox proportional hazards models. Analyses were adjusted for socio-demographic and behavioral characteristics, season, and chronic conditions. RESULTS: Thirty-three percent of participants had 25(OH)D <20ng/mL. Serum 25(OH)D was not associated with CES-D scores at baseline (p = .51); however, CES-D scores increased over time and were significantly associated with 25(OH)D at 2-year (p = .003) and 4-year follow-up (p < .001). Among 2,156 participants free of depression at the 1-year follow-up, the cumulative incidence of depression was 26.9%. Participants with 25(OH)D <20ng/mL were at greater risk of developing depression (HR [95% CI]: 1.65 [1.23-2.22]) over 4 years of follow-up compared with those with 25(OH)D ≥30ng/mL. CONCLUSION: Low 25(OH)D was independently associated with a greater increase in depressive symptom scores and incident depression in community-dwelling older adults.

Reliability of the 400-m usual-pace walk test as an assessment of mobility limitation in older adults.

OBJECTIVES: To assess the test-retest reliability of the 400-m usual-pace walk test (400-MWT), and to determine whether the 4-m walk test predicts inability to walk 400 m. DESIGN: Observational. SETTING: Community, 20-m tract course. PARTICIPANTS: Sixty study participants (aged>or=65) were enrolled from the community and met the following eligibility criteria: self-reported difficulty in two or more of four functional domains (mobility and exercise tolerance, upper extremity function, basic self-care, higher functional tasks of independent living) and a score of 18 or higher on the Mini-Mental State Examination. METHODS: The 400-MWT and 4-m walk test were each repeated within 7 days. RESULTS: The mean age+/-standard deviation of the study population was 84.3+/-6.3; 88.3% were women. Nineteen participants (31.7%) failed both 400-MWTs, and 41 successfully completed both tests (kappa=1). Mean walking speed for the 4-m test was 0.87+/-0.18 m/s for those who completed the 400-MWT and 0.53+/-0.17 m/s for those who failed (P<.001). The Spearman correlation coefficient between 4-m and 400-m walking speeds was 0.93. The estimated area under the receiver operating characteristic curve between 4-m walking speed and the ability to perform the 400-MWT was 0.91. The 4-m gait speed averaged less than 0.6 m/s in 80% of subjects who failed the 400-MWT. CONCLUSION: The test-retest reliability for inability to complete the 400-MWT is high. Four-m walking speed is highly predictive of ability to perform the 400-MWT. These findings may prove useful to future clinical trials and observational studies that involve assessment of mobility limitations in older adults.

A collaborative national model to assess competencies for medical students, residents, and other healthcare practitioners in gait and falls risk evaluation.

To ensure that the healthcare workforce is adequately prepared to care for the growing population of older adults, minimum competencies in geriatrics have been published for medical students and primary care residents. Approaches to teaching and assessing these competencies are needed to guide medical schools, residencies, and continuing medical education programs. With sponsorship by the Education Committee and Teachers Section of the American Geriatrics Society (AGS), geriatrics educators from multiple institutions collaborated to develop a model to teach and assess a major domain of student and resident competency: Gait and Falls Risk Evaluation. The model was introduced as a workshop at annual meetings of the AGS and the American College of Physicians in 2011 and 2012. Participants included medical students, residents, geriatrics fellows, practicing physicians, and midlevel practitioners. At both national meetings, participants rated the experience highly and reported statistically significant gains in overall competence in gait and falls risk evaluation. The largest gains were observed for medical students, residents, and practicing physicians (P < .001 for all); geriatrics fellows reported a higher level of baseline competence and therefore had a lower magnitude of improvement, albeit still significant (P = .02). Finally, the majority of participants reported intent to disseminate the model in their institutions. This article describes the design, implementation, and evaluation of this collaborative national model. A number of institutions have used the model, and the goal of this article is to aid in further dissemination of this successful approach to teaching and assessing geriatrics competencies.