Gray Matter Regions Associated With Functional Mobility in Community‐Dwelling Older Adults - American Geriatric Society

BACKGROUND/OBJECTIVES

Neuroimaging indicators of reduced brain health in the form of lower gray matter volume (GMV), lower fractional anisotropy (FA), and higher white matter hyperintensity volume (WMHV) have been related to global mobility measures, such as gait speed, in older adults. The purpose was to identify associations between brain regions and specific mobility functions to provide a greater understanding of the contribution of the central nervous system to independent living.

DESIGN

Cross‐sectional study.

SETTING

Research laboratory.

PARTICIPANTS

Seventy community‐ambulating healthy older adults (mean age = 76 ± 5 years).

MEASUREMENTS

Participants performed the following tests: gait speed, Five Times Sit to Stand, Four Square Step Test (FSST), and Dynamic Gait Index (DGI). Structural magnetic resonance imaging of each participantʼs brain was collected. Measures of regional GMV, tract‐specific WMHV, and FA were extracted. Correlational analyses between the mobility measures and neuroimaging measures were conducted using whole brain and regional and tract‐specific measures. This was followed by linear regression models relating the mobility measures to regions or tracts identified in the correlation analysis, and adjusting for age, sex, and body mass index.

RESULTS

Significant associations were found between higher GMV in multiple regions, primarily the parietal and temporal lobes, and better performance in gait speed, DGI, and FSST. After adjusting for personal factors, greater parahippocampus GMV was independently associated with greater gait speed. Greater inferior parietal lobe, supramarginal gyrus, and superior temporal gyrus GMVs were associated with gait function. Greater postcentral gyrus, parahippocampus, and superior temporal gyrus GMVs were associated with faster FSST performance. The WMHV and FA were not significantly correlated with the mobility measures.

CONCLUSIONS

Gray matter regions associated with higher performance in mobility measures serving gait function and multidirectional stepping were those structures related to vestibular sensation, spatial navigation, and somatosensation.

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Validity of Cognitive Assessment Tools for Older Adult Hispanics: A Systematic Review - American Geriatric Society

OBJECTIVES

A higher prevalence and incidence of dementia is found in Hispanic/Latino older adults. Therefore, valid instruments are necessary to assess cognitive functioning in this population group. Our aim was to review existing articles that have examined and reported on the validity of cognitive assessment tools in Hispanic/Latino population groups in the United States.

DESIGN

Systematic literature review according to the Preferred Reporting Items for Systematic Reviews and Meta‐analysis.

MEASUREMENTS

We systematically searched in the PubMed and Web of Science databases and assessed the quality of the search results using the Standards for the Reporting of Diagnostic Accuracy Studies. We included evidence from within the United States as well as from Spanish‐speaking countries of origin (Mexico, Central and South America, and the Caribbean).

RESULTS

The literature search revealed 27 studies with adequate quality that investigated 13 instruments. The Mini‐Mental Status Examination (MMSE) was the most frequently investigated instrument in Hispanic/Latino groups in the United States with high sensitivity for dementia but also with significant differences for ethnicity and education. The Addenbrooke Cognitive Examination‐Revised, Montreal Cognitive Assessment, 10/66 short diagnostic schedule, clock‐drawing test, Phototest, Eurotest, and Executive Battery 25 had good diagnostic performance in Spanish‐speaking countries. The naming test and verbal fluency tests have a higher risk of misclassifying US Hispanics/Latinos who have dementia.

CONCLUSION

Evidence on validity suggests that the MMSE may be an appropriate cognitive assessment tool for Hispanics. More research is needed to confirm the validity of cognitive tools to assess Hispanic/Latino groups for Alzheimer's disease and other related dementias in the United States to reduce current trends of culturally biased under‐ or overdiagnosis of cognitive impairments.

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A National Study of End‐of‐Life Care among Older Veterans with Hearing and Vision Loss - American Geriatric Society

OBJECTIVES

Hearing and visual sensory loss is prevalent among older adults and may impact the quality of healthcare they receive. Few studies have examined sensory loss and end‐of‐life (EOL) care quality. Our aim was to describe hearing and vision loss and their associations with the quality of EOL care and family perception of care in the last 30 days of life among a national sample of veteran decedents.

DESIGN

Retrospective medical record review and Bereaved Family Survey (BFS).

SETTING

Veterans Affairs (VA) Medical Centers (N = 145).

PARTICIPANTS

Medical record review of all veterans who died in an inpatient VA Medical Center between October 2012 and September 2017 (N = 96 424). Survey results included 42 428 individuals.

MEASUREMENTS

Three indicators of high‐quality EOL care were measured: palliative consultation in the last 90 days of life, death in a non‐acute setting, and contact with a chaplain. The BFS reflects a global evaluation of quality of EOL care; pain and posttraumatic stress disorder management; and three subscales characterizing perceptions regarding communication, emotional and spiritual support, and information about death benefits in the last month of life.

RESULTS

In adjusted models, EOL care quality indicators and BFS outcomes for veterans with hearing loss were similar to those for veterans without hearing loss; however, we noted slightly lower scores for pain management and less satisfaction with communication. Veterans with vision loss were less likely to have received a palliative care consult or contact with a chaplain than those without vision loss. Although BFS respondents for veterans with vision loss were less likely than respondents for veterans without vision loss to report excellent overall care and satisfaction with emotional support, other outcomes did not differ.

CONCLUSION

In general, the VA is meeting the EOL care needs of veterans with hearing and vision loss through palliative care practices.

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Personality and Motoric Cognitive Risk Syndrome - American Geriatric Society

OBJECTIVES

To examine whether five major personality traits are related to the motoric cognitive risk (MCR) syndrome, a pre‐dementia syndrome characterized by cognitive complaints and slow gait speed.

DESIGN

Cross‐sectional.

SETTING

Health and Retirement Study (HRS) and the National Health and Aging Trends Survey (NHATS).

PARTICIPANTS

Dementia‐free older adults aged 65 to 107 years (N > 8000).

MEASUREMENTS

In both samples, participants provided data on personality, cognitive complaints, and measures of gait speed, as well as on demographic factors, physical activity, depressive symptoms, and body mass index (BMI).

RESULTS

Across the two samples and a meta‐analysis, higher neuroticism was related to higher risk of MCR (combined odds ratio [OR] = 1.32; 95% confidence interval [CI] = 1.21‐1.45; P < .001), whereas higher extraversion (combined OR = .71; 95% CI = .65‐.79; P < .001) and conscientiousness (combined OR = .70; 95% CI = .62‐.78; P < .001) were associated with a lower likelihood of MCR. Higher openness was also related to a lower risk of MCR in the HRS and the meta‐analysis (combined OR = .77; 95% CI = .70‐.85; P < .001), whereas agreeableness was protective only in the HRS (OR = .83; 95% CI = .74‐.92; P < .001). Additional analyses indicated that physical activity, depressive symptoms, and BMI partially accounted for these associations.

CONCLUSION

This study adds to existing research on the factors related to the risk of MCR by showing an association with personality traits. Personality assessment may help to identify individuals who may be targeted by interventions focused on reducing the risk of MCR and ultimately of dementia.

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Inadequate Risk Adjustment Impacts Geriatricians' Performance on Medicare Cost and Quality Measures - American Geriatric Society

OBJECTIVES

Medicare value‐based payment programs evaluate physicians' performance on their patients' annual Medicare costs and clinical outcomes. However, little is known about how geriatricians, who disproportionately provide care for medically complex older adults, perform on these measures.

DESIGN

A retrospective study using multivariable regression methods to estimate the association of geriatric risk factors with annualized Medicare costs and preventable hospitalization rates and to compare geriatricians' performance on these outcomes to other primary care physicians (PCPs) under standard Medicare risk adjustment and after adding additional adjustment for geriatric risk factors.

SETTING

Eight years (2006‐2013) of cohort data from the Medicare Current Beneficiary Survey.

PARTICIPANTS

Medicare beneficiaries, aged 65 years and older, with primary care services contributing 27 027 person‐years of data.

MEASUREMENTS

Outcomes were costs and preventable hospitalization rates; geriatric risk factors were patient frailty, long‐term institutionalization, dementia, and depression.

RESULTS

Geriatricians were more likely to care for patients with frailty (22.8% vs 14.1%), long‐term institutionalization (12.0% vs 4.7%), dementia (21.6% vs 10.2%), and depression (23.6% vs 17.4%) than other PCPs (P < .001 for each). Under standard Medicare risk adjustment, geriatricians performed more poorly on costs compared to other PCPs (observed‐expected [O‐E] ratio = 1.24 vs 0.99) and preventable hospitalizations (O‐E ratio = 1.16 vs 0.98). Adding frailty, institutionalization, dementia, and depression to risk adjustment improved geriatricians' performance on costs by 25% and on preventable hospitalization rates by 35%, relative to other PCPs. Concurrent‐year risk prediction that removed the influence of unpredictable acute events further improved geriatricians' performance vs other PCPs (O‐E ratio = 0.99 vs 1.00).

CONCLUSION

Medicare should consider risk adjusting for frailty, long‐term institutionalization, dementia, and depression to avoid inappropriately penalizing geriatricians who care for vulnerable older adults.

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Practicing Geriatrics: Mission Impossible? - American Geriatric Society

Journal of the American Geriatrics Society, EarlyView.

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Hospice Utilization in the United States: A Prospective Cohort Study Comparing Cancer and Noncancer Deaths - American Geriatric Society

OBJECTIVES

Reliable national estimates of hospice use and underuse are needed. Additionally, drivers of hospice use in the United States are poorly understood, especially among noncancer populations. Thus the objectives of this study were to (1) provide reliable estimates of hospice use among adults in the United States; and (2) identify factors predicting use among decedents and within subsamples of cancer and noncancer deaths.

DESIGN

We conducted a prospective cohort study using the Health and Retirement Study survey. Excluding sudden deaths, we used data from the 2012 survey wave to predict hospice use in general, and then separately for cancer and non‐cancer deaths.

SETTING

Study data were provided by a population‐based sample of older adults from the U.S.

PARTICIPANTS

We constructed a sample of 1,209 participants who died between the 2012 and 2014 survey waves.

MEASUREMENTS

Hospice utilization was reported by proxy. Exposure variables included demographics, functionality (activities of daily living [ADLs]), health, depression, dementia, advance directives, nursing home residency, and cause of death.

RESULTS

Hospice utilization rate was 52.4% for the sample with 70.8% for cancer deaths and 45.4% for noncancer deaths. Fully adjusted model results showed being older (odds ratio [OR] = 1.54), less healthy (OR = .79), having dementia (OR = 1.52), and having cancer (OR = 5.47) were linked to greater odds of receiving hospice. Among cancer deaths, being older (OR = 1.64) and female (OR = 2.54) were the only predictors of hospice use. Among noncancer deaths, increased age (OR = 1.58), more education (OR = 1.56), being widowed (OR = 1.55), needing help with ADLs (OR = 1.13), and poor health (OR = .77) were associated with hospice utilization.

CONCLUSION

Findings suggest hospice remains underutilized, especially among individuals with noncancer illness. Extrapolating results to the US population, we estimate that annually nearly a million individuals who are likely eligible for hospice die without its services. Most (84%) of these decedents have a noncancer condition. Interventions are needed to increase appropriate hospice utilization, particularly in noncancer care settings.

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