Is strength training associated with mortality benefits? A 15year cohort study of US older adults.

BACKGROUND: The relationship between strength training (ST) behavior and mortality remains understudied in large, national samples, although smaller studies have observed that greater amounts of muscle strength are associated with lower risks of death. We aimed to understand the association between meeting ST guidelines and future mortality in an older US adult population. METHODS: Data were analyzed from the 1997-2001 National Health Interview Survey (NHIS) linked to death certificate data in the National Death Index. The main independent variable was guideline-concordant ST (i.e. twice each week) and dependent variable was all-cause mortality. Covariates identified in the literature and included in our analysis were demographics, past medical history, and other health behaviors (including other physical activity). Given our aim to understand outcomes in older adults, analyses were limited to adults age 65years and older. Multivariate analysis was conducted using multiple logistic regression analysis. RESULTS: During the study period, 9.6% of NHIS adults age 65 and older (N=30,162) reported doing guideline-concordant ST and 31.6% died. Older adults who reported guideline-concordant ST had 46% lower odds of all-cause mortality than those who did not (adjusted odds ratio: 0.64; 95% CI: 0.57, 0.70; p<0.001). The association between ST and death remained after adjustment for past medical history and health behaviors. CONCLUSIONS: Although a minority of older US adults met ST recommendations, guideline-concordant ST is significantly associated with decreased overall mortality. All-cause mortality may be significantly reduced through the identification of and engagement in guideline-concordant ST interventions by older adults.

Is exercise used as medicine? Association of meeting strength training guidelines and functional limitations among older US adults.

OBJECTIVE: To determine the association between meeting strength training guidelines (≥2 times per week) and the presence of functional limitations among older adults. METHODS: This cross-sectional study used data from older adult participants (N=6763) of the National Health Interview Survey conducted in 2011 in the United States. RESULTS: Overall, 16.1% of older adults reported meeting strength training guidelines. For each of nine functional limitations, those with the limitation were less likely to meet strength training recommendations than those without the limitation. For example, 20.0% of those who reported no difficulty walking one-quarter mile met strength training guidelines, versus only 10.1% of those who reported difficulty (p<.001). In sum, 21.7% of those with no limitations (33.7% of sample) met strength training guidelines, versus only 15.9% of those reporting 1-4 limitations (38.5% of sample) and 9.8% of those reporting 5-9 limitations (27.8% of sample) (p<.001). CONCLUSION: Strength training is uncommon among older adults and even less common among those who need it the most. The potential for strength training to improve the public's health is therefore substantial, as those who have the most to gain from strength training participate the least.

Validity of the brief inpatient screen for intimate partner violence among adult women.

BACKGROUND: Identifying intimate partner violence in healthcare settings is becoming the standard of care. The Brief Inpatient Screen was designed to assess recent emotional, physical, and sexual abuse in a general inpatient medical-surgical setting and compared to the Composite Abuse Scale. METHODS: Researchers matched "cases" (inpatients screening Brief Inpatient Screen-positive) to up to four "controls" (inpatients screening Brief Inpatient Screen-negative). Forty-six female hospital inpatients ages 18-64 years completed a self-administered survey. The sensitivity and specificity of the Brief Inpatient Screen and its subscales were compared to the Composite Abuse Scale. Researchers examined the performance of the Brief Inpatient Screen when used as a verbal screen versus an anonymous written screen. RESULTS: Twelve of 46 participants (26%) had a positive screen. Compared to the Composite Abuse Scale, the overall sensitivity and specificity of the verbal Brief Inpatient Screen were 52.6% (95% CI 28.9-75.6) and 92.6% (95% CI 75.7-99.1), respectively. The written Brief Inpatient Screen showed improved sensitivity overall (68.4%, 95% CI 43.5-87.4) for the most severe intimate partner violence. Subscale analysis revealed greater sensitivity for emotional and severe combined intimate partner violence. CONCLUSIONS: The verbal Brief Inpatient Screen, when compared to the Composite Abuse Scale, was limited in its ability to identify intimate partner violence. An anonymous written format improved sensitivity. Future research should optimize intimate partner violence screening among inpatients.

Feasibility and impact of a 1-minute daily functional exercise regimen prescribed to older adults by their primary care physician.

Despite the inverse relationship between physical activity (PA) and physical function, few older adults achieve PA recommendations. In response to observations that "lack of time" underlies reduced PA among older adults, recent work suggests even short bouts of PA can improve health and fitness. In addition, because they are frequently visited by older adults, an important conduit for PA promotion could be the primary care physician (PCP). However, most PCPs receive little training related to PA, rendering it difficult for them to offer meaningful counseling. Therefore, we explored the feasibility and impact of a PCP-prescribed one-minute daily functional exercise program, consisting of 30 s each of bodyweight push-ups and squats, among 24 patients 60 years of age or older. 42% of patients who were contacted started the exercise prescription and, over 24-weeks, completed approximately 114 sessions, while 75% completed at least half of the possible daily exercise sessions. As a group, the patients demonstrated increases in both maximal push-up and squat performance, though these increases plateaued following week-12. These preliminary results suggest that a PCP prescription of one-minute of daily functional exercise among older adult patients was feasible, acceptable, and effective for improving functional physical fitness. Given these findings, formal controlled research with recruitment from multiple clinics, random assignment to treatment conditions, and blinded assessments of objective functional physical performance should be pursued.

Working to Increase Stability through Exercise (WISE): screening, recruitment, and baseline characteristics.

BACKGROUND: The aim of this paper is to describe the utility of various recruitment modalities utilized in the Working to Increase Stability through Exercise (WISE) study. WISE is a pragmatic randomized trial that is testing the impact of a 3-year, multicomponent (strength, balance, aerobic) physical activity program led by trained volunteers or delivered via DVD on the rate of serious fall-related injuries among adults 65 and older with a past history of fragility fractures (e.g., vertebral, fall-related). The modified goal was to recruit 1130 participants over 2 years in three regions of Pennsylvania. METHODS: The at-risk population was identified primarily using letters mailed to patients of three health systems and those over 65 in each region, as well as using provider alerts in the health record, proactive recruitment phone calls, radio advertisements, and presentations at community meetings. RESULTS: Over 24 months of recruitment, 209,301 recruitment letters were mailed, resulting in 6818 telephone interviews. The two most productive recruitment methods were letters (72% of randomized participants) and the research registries at the University of Pittsburgh (11%). An average of 211 letters were required to be mailed for each participant enrolled. Of those interviewed, 2854 were ineligible, 2,825 declined to enroll and 1139 were enrolled and randomized. Most participants were female (84.4%), under age 75 (64.2%), and 50% took an osteoporosis medication. Not having a prior fragility fracture was the most common reason for not being eligible (87.5%). The most common reason provided for declining enrollment was not feeling healthy enough to participate (12.6%). CONCLUSIONS: The WISE study achieved its overall recruitment goal. Bulk mailing was the most productive method for recruiting community-dwelling older adults at risk of serious fall-related injury into this long-term physical activity intervention trial, and electronic registries are important sources and should be considered.

Working to Increase Stability through Exercise (WISE): Study protocol for a pragmatic randomized controlled trial of a coached exercise program to reduce serious fall-related injuries.

Approximately one-third of older adults fall each year and fall-related injuries are a leading cause of death and disability among this rapidly expanding age group. Despite the availability of bisphosphonates to reduce fractures, concerns over side effects have dramatically reduced use, suggesting that other treatment options are needed. Though many smaller studies have shown that physical activity programs can reduce falls, no study has been adequately powered to detect a reduction in fall-related injuries. We present the design of a three-year randomized controlled clinical trial of 1130 adults age 65 and older with a past history of fragility fractures (e.g., vertebral, fall-related). The main aim is to determine the impact of a community-based multicomponent (strength, balance, aerobic) physical activity program led by trained volunteers (or delivered via DVD) and accompanied by coaching and oversight, by telephone and in-person, by a fitness professional. The main outcome measure is serious fall-related injuries. Secondary outcomes include health care utilization, bone and muscle mass, loneliness, health-related quality of life and mood. The study represents the first large clinical trial of a comprehensive physical activity program to reduce secondary injuries among patients with a history of fragility fracture.

Light therapy for seniors in long term care.

OBJECTIVES: To investigate the effects of light therapy on cognition, depression, sleep, and circadian rhythms in a general, nonselected population of seniors living in a long term care facility. DESIGN: A double-blind, placebo-controlled trial. SETTING: The experiment took place at a long term care facility in Pennsylvania. PARTICIPANTS: Study participants (15 treatment, 13 placebo) were residents receiving either personal care or skilled nursing care. INTERVENTION: Treatment consisted of approximately 400 lux of blue light administered for 30 minutes per day, Monday through Friday, for 4 weeks. The placebo was approximately 75 lux of red light generated from the same device. MEASUREMENTS: Behavioral assessments were made using the MicroCog Assessment of Cognitive Functioning, Geriatric Depression Scale, and Profile of Mood States. Daytime sleepiness was evaluated using the Epworth Sleepiness Scale. RESULTS: Three of the 4 composite scores from the MicroCog as well as the mean Tension/Anxiety score from the Profile of Mood States showed a significant treatment versus placebo effect. CONCLUSION: Blue light treatment led to significant cognitive improvements compared with placebo red light and may be a promising environmental intervention to reduce cognitive symptoms in elderly, long-term care residents.

Coding and documentation: Medicare severity diagnosis-related groups and present-on-admission documentation.

Effective October 1, 2007, the Centers for Medicare and Medicaid Services has changed its methodology for determining the diagnosis-related group for hospitalized patients. In an effort to more accurately reflect severity of illness, the 538 diagnosis-related groups have been converted to 745 new Medicare severity diagnosis-related groups. In addition, selected hospital-acquired complications not identified as present on admission will no longer be reimbursed. The changes will have profound effects on reimbursement for hospitalizations. To minimize financial losses under the new rules, hospitals and physicians will have to devote significant resources and attention to improved documentation. This article will discuss the new payment system, the physician's role in ensuring that all clinically important diagnoses are captured by coding specialists, and strategies that can be employed to respond proactively to the challenge.

Polypharmacy in the elderly: maximizing benefit, minimizing harm.

The purpose of this article is to define our current understanding of appropriate prescribing and outline the potential hazards of overprescribing, while acknowledging the benefits of modern pharmacologic treatment. Finally, we discuss practical strategies to attempt to achieve optimal prescribing patterns for the elderly. Polypharmacy, as well as inappropriate prescribing, for the elderly is a major problem and a challenge that contributes to costs, adverse drug events, confusion, compliance issues, and errors in management. A systematic approach to drug monitoring is an important aspect of appropriate prescribing. Attention to prescribing of medications, consistent review of medication lists, and reevaluation of indications and outcomes of prescribing are essential to ensure that polypharmacy is minimized and safety for patients is maximized. This article acts as a practical review for caregivers in multiple practice situations including acute care hospitals, outpatient settings, long-term care, and home care.

Unawareness of cognitive deficit (cognitive anosognosia) in probable AD and control subjects.

OBJECTIVE: To develop a quantitative method of assessing cognitive anosognosia in six cognitive and two noncognitive domains. METHODS: Control (n = 32) and probable Alzheimer disease (pAD) (n = 14) subjects self-estimated memory, attention, generative behavior, naming, visuospatial skill, limb praxis, mood, and uncorrected vision, both before and after these abilities were assessed. Based on this estimate and their performance the authors calculated an anosognosia ratio (AR) by dividing the difference between estimated and actual performance by an estimated and actual performance sum. With perfect awareness, AR = 0. Overestimating abilities would yield a positive AR (< or =1); underestimation would yield a negative AR (> or =-1). RESULTS: Relative to controls, pAD subjects demonstrated anosognosia. Pre-testing (off-line), pAD subjects overestimated their visuospatial skill; post-testing (on-line), pAD subjects overestimated their memory. Control subjects also made self-rating errors, underestimating their attention pre-testing and overestimating limb praxis and vision post-testing. CONCLUSIONS: This anosognosia assessment method may allow more detailed examination of distorted self-awareness. These results suggest that screening for anosognosia in probable Alzheimer disease (pAD) should include self-estimates of visuospatial function, and that, in pAD, it may be useful to assess anosognosia for amnesia both before and after memory testing.