Established Populations For Epidemiologic Studies Research Articles

Neuropsychiatric symptoms are Predictors of Disturbed Sleep in Mexican American Caregivers

AbstractBackgroundCaregivers of people living with dementia are more likely to experience disturbed sleep compared to non‐caregivers. Mexican‐Americans may be especially at risk due to low rates of nursing home use even in advanced dementia, when behavioral symptoms are most apparent. Few studies have evaluated predictors of disturbed sleep in this high‐risk group.MethodUsing data from the 2015 wave of the Hispanic Established Population for Epidemiologic Study of the Elderly, a representative sample of older Mexican‐Americans and their caregivers in the southwestern United States (n = 460), we examined the association of care recipient neuropsychiatric symptoms with disturbed sleep in caregivers. Care recipients’ behavioral symptoms of cognitive decline were assessed using the caregiver‐reported Neuropsychiatric Inventory. We examined caregivers’ depressive symptoms as an additional stressor. Potential “buffers” against sleep disturbances included communal support (neighbor, church, social services) and respite care. Caregivers were classified as having “highly disturbed sleep” if they reported disturbed sleep three or more days a week, and were compared to caregivers with “non‐highly disturbed sleep” (reported disturbed sleep less than three days a week). We used multivariable logistic regression to examine the association between behavioral symptoms and highly disturbed sleep, controlling for demographic factors and care buffers.ResultCaregivers in the sample were predominantly spouses or adult children of their care recipients. They had a mean age of 59.7 and7 8% were women. Care recipients were a mean age of 90 and 65% were women. Caregivers with disturbed sleep (12% of the sample) reported significantly more care recipient NPI symptoms, distress from symptoms, and more depressive symptoms. In the regression model accounting for all predictors, the number of NPI symptoms and depressive symptoms were associated with higher odds of disturbed sleep, while communal support was associated with lower odds of disturbed sleep. Use of respite care did not show associations.ConclusionBehavioral symptoms of cognitive impairment are associated with sleep disturbance in Mexican American caregivers. Though respite has been described as a crucial resource for caregiver sleep health, communal supports were more significantly associated with sleep l. These results should inform the development of culturally‐competent resources for Mexican‐Americans.

Keep it simple: comparing functional assessments in individuals with Down syndrome.

A number of assessments exist that evaluate function in ambulatory adults. However, these assessments take for granted the cognitive abilities required for the participant to understand what is being asked of them in order to demonstrate their functional abilities. It has been shown that individuals with Down syndrome (DS) demonstrate lower functional levels when asked to perform additional tasks while walking. Therefore, measurements of function may not be reflective of actual function if the assessment requires additional tasks in those with DS. It is for these reasons the current investigation sought to evaluate four common functional assessments, two with [modified Berg balance test (mBERG) and Functional Gait Assessment (FGA)] and two without [Timed Up and Go (TUG) and Established Populations for Epidemiologic Study in the Elderly (EPESE)] complex tasks. Adults with DS (n=19) completed four functional assessments, which were later compared using bivariate Pearson correlation coefficients. There were large associations between simple assessments (TUG-EPESE: r=-0.525, P=0.021) and complex assessments (FGA-mBERG: r=0.612, P=0.005), respectively. The TUG also inversely correlated with the FGA (r=-0.476, P=0.039), and the EPESE had a large association with mBERG (r=0.508, P=0.027). The mBERG may be the best test to replicate real-world scenarios through its tasks, although it may also be confounded by the cognitive load required to perform the movements as asked. The TUG and EPESE may be more appropriate as mobility assessments because they require very little cognitive attention when completing the tasks. True assessments of mobility ought to err on the side of simple so to not confuse the outcomes with executive functionality.

Longitudinal Causal Inference of Cognitive Function and Depressive Symptoms in Elderly People

Objective: the association between depressive symptoms (Center for Epidemiologic Studies Depression Scale [CES-D]) and subsequent cognitive function (Mini-Mental State Examination [MMSE]) is equivocal in literature. To examine the causal relationship between them, we use longitudinal data on MMSE and CESD and causal inference to illustrate the relationship between two health outcomes.
 Method:  Data were obtained from the Hispanic Established Populations for Epidemiologic Studies of the Elderly. Participants included 3050 noninstitutionalized Mexican Americans aged 65 and older followed from 1993-2001. Cognitive function and depressive symptoms were assessed using the MMSE and CESD at baseline and at 2, 5, and 7 years of follow-up. Independent variables were sociodemographics, CESD, medical conditions. Marginal structural causal models were employed to evaluate the extent to which cognitive function depend not only on depressive symptoms measured at a single point in time but also on an individual’s entire depressive symptoms history.
  Discussion: our results indicate that if intervention to reduce 1 points of depressive symptoms were made at two years prior to assessing cognitive function, they would result in average improvement in cognitive function of 0.12, 95% CI [0.06, 0.18],P<.0001. Conclusion: The results suggest that health intervention of depressive symptoms would be useful in prevention of cognitive impair.  

Joint Modeling of Multivariate Longitudinal Depressive Symptoms and Survival with Application to an Aging Study

Objective The primary aim in this study was to use a joint analysis approach to examine the association between longitudinal depressive symptoms and survival in Mexican Americans.
 Methods:  The separate Cox regression and joint modeling were applied to data from the Hispanic Established Population for Epidemiological Study of the Elderly (HEPESE). Depressive symptoms were measured by the Center of Epidemiological Studies Depression Scale (CES-D). The trajectories of CES-D, modeled by random effect, were used as independent variables to fit the mortality curve adjusted by other variables including demographics and physical functioning.
 Results: The separate Cox regression couldn’t identify association between depressive symptoms and survival. The joint analysis indicated that the  slope of  CES-D score was not associated with mortality in older Mexican-Americans, however the intercept had negative effects on mortality.
 Conclusion: There was significant association between baseline depression symptoms and mortality, while no association with slope in older Mexican Americans

Neuropsychiatric symptoms and caregiver relationship quality for older Mexican Americans

Objectives Caregivers play a key role in supporting older Mexican Americans, who are less likely to enter nursing facilities than other racial/ethnic groups in the US. However, there is little research on how Neuropsychiatric symptoms (NPS) affect relationship quality between caregivers and care recipients. Method Using data from the 2015 wave of the Hispanic Established Populations for Epidemiologic Studies of the Elderly (H-EPESE) (n = 416) study of older (age 85+) Mexican Americans, we examined relationship quality and NPS with ordered logistic regression. Relationship quality was measured using positive (enjoyment, appreciation) and negative (nerves, argue) assessments. NPS were categorized into hyperactivity, affective, and psychosis symptoms. Results Hyperactivity symptoms were associated with appreciation, arguing, and nerves. Psychosis symptoms were associated with arguing and nerves. Spousal caregivers were more likely to report arguing and nerves and less likely to report feeling appreciated. Enjoyment assessments were not associated with NPS. Conclusion Relationship quality is related to behavioral changes in late life. Mexican American caregivers negatively evaluate their relationships, not in response to care tasks per se, but when the older person exhibits behavioral problems. The relationship between NPS and negative relationship assessments may be due to unanticipated behavior changes in late life and stigma around psychiatric symptomatology.

Trajectories of concurrent depressive symptoms and cognitive function on health outcomes and mortality among older Mexican Americans

Background: We sought to identify distinctive concurrent trajectory classes of depressive symptoms (DS) and cognitive function (CF) in Mexican Americans aged 75+ years, and to examine whether these trajectories were associated with an increased risk of adverse outcomes. Methods: We used 4 waves of Hispanic Established Populations for Epidemiologic Studies of the Elderly (H-EPESE) data from 2004 to 5 to 2013. Latent growth curve analysis was used to identify distinctive concurrent trajectory classes of DS and CF. Generalized linear mixed models were further used to examine the association between the concurrent trajectories and health outcomes. Cox proportional hazards regression model was used to examine the risk of mortality as a function of the concurrent trajectories. Results: 1,302 older adults followed-up approximately 9-years were successfully classified into 6 distinct concurrent trajectory classes of DS (low-increasing, high) and CF (high, high-declining, medium-declining). Compared to the co-occurrence of low DS and high CF trajectories, those with the high DS and declining CF trajectories were at greater risk of ADL and IADL functional limitations (1.6 − 2.9 times), more medical visits (1.3 − 1.4 times), hospital admissions (1.6 − 1.9 times), and mortality (1.7 − 2.6 times). Conclusions: Differences in adverse health outcomes across concurrent trajectory classes of DS and CF suggest that differences in underlying co-occurrence and progression have important implications for public health interventions as well as development of aging social and health policies.

Back Pain and Heart Failure in Older Adults: Findings From the Health ABC Study

Both back pain and heart failure (HF) have negative influence on all aspects of life. Little is known about the impact of back pain on older adults with HF. We include 1295 older adults who had data collected in the 11th year (2007-2008) of the Health, Aging and Body Composition (Health ABC) study to evaluate the effect of back pain on health status among older adults with and without HF. The participants aged 79-91, 54.8% were female and 34.8% were African American. Among 94 participants with HF, 63 (67.0%) had back pain; among 1201 participants without HF, 649 (54.0%) had back pain. Females reporting back pain had 4.76 (95% CI: 1.83, 12.37) times the odds of having HF compared to those without back pain. Male with back pain, compared to those without back pain, had 1.14 times (95% CI: 0.65, 2.02) the odds of having HF. Depressive symptoms were measured by the Center for Epidemiological Studies-Depression (CES-D) scale. Performance and functions were measured by the Established Populations for Epidemiologic Studies in the Elderly (EPESE) performance score, the Health ABC performance battery score and self-reported difficulty with functional tasks. These symptom and performance measures were significantly associated with both back pain and HF, but not the interaction terms of back pain and HF after adjusting demographic variables including gender, race, smoking status and BMI category. The high incidence and negative impact of back pain highlighted the needs of developing strategies in pain management among older adults with and without HF.

Determinants of Maintenance and Recovery of Function in a Representative Older Community-Resident Biracial Sample

ObjectivesFocus on decline in performance of activities of daily living (ADL) has not been matched by studies of recovery of function. Advised by a broad conceptual model of physical resilience, we ascertain characteristics that identify (1) maintenance, (2) decline, and (3) recovery of personal self-maintenance activities over six years in an older, community representative, African American and white sample. DesignLongitudinal study, analyses included descriptive statistics and repeated measures proportional hazards. Setting/ParticipantsCommunity-representative participants of the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE), unimpaired at baseline (n = 3187; 46% white, 54% African American; 64% female, 36% male), followed annually for up to 6 years. MeasuresData included information on basic activities of daily living (BADL), demographic characteristics, health status, social services provided and received, household size, neighborhood safety, and survival status. ResultsOver 6 years, ∼75% remained unimpaired, of whom 30% were unimpaired when they dropped out or died. Of ∼25% who became impaired, just under half recovered. Controlled analyses indicated that those who became impaired were in poorer health, younger, and more likely to be African American. Characteristics of recovery included younger age, not hospitalized in the previous year, and larger household size. Conclusions/ImplicationsMaintenance of health status facilitated continued unimpaired BADL. While decline was associated with poorer health, younger age, and being African American, recovery was also associated with younger age, together with larger household size, and no further deterioration in health as measured here. Maintenance of good health is preferred, but following decline in functioning, increased effort to improve health and avoid further decline, which takes into account not only physical but also personal social conditions, is needed.

FRAILTY MEDIATES SENILITY IN MEXICAN AMERICANS

The latent construct “d” (for “dementia”) offers a continuously distributed transdiagnostic dementia severity metric. Age is significantly associated with “d”. We test whether frailty mediates age’s effect on 6 year prospective change in dementia severity in Mexican-Americans (MA), using data from the Hispanic Established Population for Epidemiological Studies in the Elderly (HEPESE). Age was regressed onto the 6yr prospective slope of change in “d” in N = 880 [mean age = 77.4 (6.1) at wave 3]. Change in “d” was estimated by a latent growth curve (LGC) indicated by latent cognitive measures across three HEPESE waves (i.e., 3, 5 and 6). “Frailty” was assessed by a modified version of Fried et al.’s construct observed at wave 5, and was tested as a mediator of age’s association with change in “d”. The mediation effect was estimated by MacKinnon’s method. “d” at each wave, and the LGC of change in “d” all had acceptable model fit (e.g. RMSEA <.05). Age was significantly associated with change in “d”. 51% of their association was explained by frailty. Frailty mediates the majority of age’s association with dementia severity. Not only does this support the existence of a cognitive “frailty” syndrome in MA, it also implicates an effect of frailty on intelligence (as “d” is derived from Spearman’s general intelligence factor “g”). Their association may be mediated by blood-based serum biomarkers, including somatomedins, which may offer targets for the treatment and /or prevention of senility in frail elderly persons.

Association of Blood Chemistry Quantifications of Biological Aging With Disability and Mortality in Older Adults.

Quantification of biological aging has been proposed for population surveillance of age-related decline in system integrity and evaluation of geroprotective therapies. However, methods of quantifying biological aging have been little studied in geriatric populations. We analyzed three clinical-biomarker-algorithm methods to quantify biological aging. Klemera-Doubal method Biological Age and homeostatic dysregulation algorithms were parameterized from analysis of U.S. National Health and Nutrition Examination Surveys (NHANES) data (N = 36,207) based on published methods. Levine method Biological Age was adapted from published analysis of NHANES data. Algorithms were applied to biomarker data from the Duke Established Populations for Epidemiologic Studies of the Elderly (Duke-EPESE) cohort of older adults (N = 1,374, aged 71-102 years, 35% male, 52% African American). We tested associations of biological aging measures with participant reported Activities of daily living (ADL), instrumental activities of daily living (IADL) dependencies, and mortality. We evaluated the sensitivity of results to the demographic composition of reference samples and biomarker sets used to develop biological aging algorithms. African American and white Duke-EPESE participants with more advanced biological aging reported dependence in more ADLs and IADLs and were at increased risk of death over follow-up through 2017. Effect sizes were similar across algorithms, but were strongest for Levine method Biological Age (per-quintile increase in ADL incidence rate ratio = 1.25, 95% confidence interval [1.17-1.37], IADL incidence rate ratio = 1.23 [1.15-1.32], mortality hazard ratio = 1.12 [1.08-1.16]). Results were insensitive to demographic composition of reference samples, but modestly sensitive to the biomarker sets used to develop biological aging algorithms. Blood-chemistry-based quantifications of biological aging show promise for evaluating the effectiveness of interventions to extend healthy life span in older adults.

Cumulative Inequality at the End of Life?: Racial Disparities in Impairment in the Time Before Death.

Drawing from cumulative inequality (CI) theory, the current study examined racial disparities in impairment as individuals approached death to determine whether proposed mechanisms hypothesized to fuel or diminish racial disparities at late ages were at work at the end of individualized life spans. Black-white disparities were analyzed among decedents using latent growth curves based on the data from the North Carolina Established Populations for Epidemiologic Studies of the Elderly (EPESE) (N = 1,926). Consistent with previous literature, racial inequalities in functional disparities diminish at late ages. However, significant black-white disparities emerge as older adults approach death, exponentially increasing within the 2 years immediately preceding death. Further, these disparities are not fully mediated by socioeconomic status. The results confirm that CI in health outcomes is observable in late life among individual life spans, suggesting the years surrounding death may be a particularly vulnerable period for health inequality. Future research should examine how advantaged statuses translate to increased access to health-related resources that aid in maintaining greater functional independence until the last stage of life.

Limited English Proficiency and Trajectories of Depressive Symptoms Among Mexican American Older Adults.

This study examined the effect of limited English proficiency (LEP) on trajectories of depressive symptoms among Mexican American older adults in the United States. The sample was drawn from Waves 1 to 6 (1993-2007) of the Hispanic Established Population for Epidemiological Studies of the Elderly (H-EPESE). A total of 2,945 Mexican American older adults were included in the analyses. A latent growth curve modeling was conducted. After adjusting for covariates, results show that Mexican American older adults with LEP had higher levels of depressive symptoms than those with English proficiency (EP) at baseline as well as over a 14-year period. Differential trajectories were observed between those with LEP and EP over time, indicating that those with LEP had a significantly steeper curve of depressive symptom trajectories over time than those with EP. These results suggest that LEP is a risk factor not merely for greater depressive symptomatology at each time point, but for an accelerated trajectory of depressive symptoms over time among Mexican American older adults. Overall, the findings emphasize the need to assist not only the informal support system of Mexican American older adults with LEP, but also the formal system.

Physical Performance Trajectories and Mortality Among Older Mexican Americans.

We sought to identify distinct trajectory classes of physical performance in Mexican Americans aged 75 years and older and to examine whether these trajectories predict mortality. We used four waves of Hispanic Established Populations for Epidemiologic Studies of the Elderly (H-EPESE) data for adults 75 years and older from 2004-2005 to 2013. Latent growth curve analysis was used to identify distinct trajectory classes. Multinomial logistic regression analysis was used to examine the association between baseline characteristics and the newly constructed trajectories. Cox proportional hazards regression models examined the hazard of mortality as a function of Short Physical Performance Battery (SPPB) trajectories. The study follow-up period was approximately 9.5 years. One thousand four hundred and eleven adults were successfully classified into three (low-declining, high-declining, and high-stable) physical performance trajectory classes. Depressive symptoms (relative risk ratio = 1.94, 95% confidence interval [CI] = 1.17-3.22), diabetes (relative risk ratio = 2.44, 95% CI = 1.63-3.65), number of other comorbid health conditions (relative risk ratio = 1.40, 95% CI = 1.16-1.68), and obesity (relative risk ratio = 2.83, 95% CI = 1.67-4.80), increased the relative risk of classification into the low, relative to high-stable trajectory class. Male gender and foreign-born status significantly reduced risk of classification in the low-declining and high-declining trajectory classes. We observed a statistically significant association between low-declining (hazard ratio = 3.01, 95% CI = 2.34-3. 87) and high-declining (hazard ratio = 1.64, 95% CI = 1.32-2.03) trajectories and increased risk of mortality. Differences in mortality across physical performance trajectory classes suggest that these physical performance classes represent differences in underlying disease progression, and thus differences in mortality risk among older Mexican Americans, which warrants additional research to better understand differential physical performance trajectories and their effects on morbidity and mortality in heterogeneous aging populations.

Associated factors with the use of dentures or reported dental and gum problems with oral prosthesis use among Mexican American older adults

The objective of this study was to determine factors associated with using dental prosthesis or oral problems related to their use among older Mexican Americans of the Hispanic Established Populations for Epidemiologic Studies of the Elderly EPESE) in the United States. A cross-sectional analysis was made with data of 2992 men and women aged 65 years and older inter-viewed during 1993-1994. Forty four % of subjects reported the use of partial or total dental prosthesis. Among those using dental prosthesis, 21% reported problems with teeth or gums when eating. In multivariate analyses, instrumental activities of daily living (IADL) limitations were associated with using dental prosthesis (OR = 1.23, 95% confidence interval - CI =1.04-1.45). Also, among subjects using dental pros-thesis, increased depressive symptoms (OR = 1.42, 95% CI 1.04-1.95) and IADL limitations (OR = 1.58, 95% CI 1.15-2.17) were associated with problems with teeth or gums when eating. In conclusion, factors usually affecting quality of life in older persons such as functional dependency and depression are associated with using dental prosthesis or oral problems with teeth or gums when eating.

Relations of established aging biomarkers (IL-6, D-dimer, s-VCAM) to glomerular filtration rate and mortality in community-dwelling elderly adults.

ABSTRACTBackgroundBiomarkers improving risk prediction for elderly populations with chronic kidney disease (CKD), an independent predictor of mortality, could be particularly useful. We previously observed that interleukin-6 (IL-6), D-dimer and soluble vascular adhesion molecule (s-VCAM) were independent biomarkers of mortality in elderly individuals. Therefore, we investigated whether these established biomarkers were independently associated with both estimated glomerular filtration rate (eGFR) and mortality.MethodsThe Established Populations for Epidemiologic Studies of the Elderly (EPESE) is a longitudinal cohort of community-dwelling elderly individuals. We investigated the association among eGFR, the biomarkers (IL-6, D-dimer and s-VCAM) and 4-year all-cause mortality using restricted cubic splines within Cox proportional hazards models.ResultsAmong 1907 participants in EPESE, 1342 had available creatinine and biomarker measures. Incidence of all-cause mortality was 21.6%. eGFR was associated with all-cause mortality (P < 0.01); individuals at the lowest (<30 mL/min/1.73 m2) levels had the highest mortality rates. D-dimer and s-VCAM were associated (P < 0.01) with mortality, and after adjustment for IL-6, D-dimer and s-VCAM, the mortality risk varied by eGFR level.ConclusionsIn community-dwelling elderly individuals, we observed an association among eGFR, 4-year mortality and IL-6, D-dimer and s-VCAM. eGFR was independently associated with mortality, and the relation between eGFR and mortality was modified by IL-6, D-dimer and s-VCAM, which was most notable in individuals with severely reduced eGFR. These findings suggest that IL-6, D-dimer and s-VCAM may be useful biomarkers for improving risk prediction, but further studies are needed examining the role of these biomarkers in elderly individuals with CKD.

A Cumulative Deficit Laboratory Test-based Frailty Index: Personal and Neighborhood Associations.

To explore the association between a newly developed cumulative laboratory-based frailty index (FI) and intrinsic (personal) and extrinsic (social, environmental) characteristics. Cross-sectional longitudinal study. The third and fourth waves of the community-representative, five-county, 10-year Duke Established Populations for Epidemiologic Studies of the Elderly study, carried out in a health service-rich area. Cognitively intact survivors of the third wave (N = 1,740), who provided blood samples for standard laboratory work. Biomarkers (n = 28) were measured to develop a cumulative deficit laboratory test-based FI (Duke FI) derived from standard laboratory tests: SMAC-24 chemistry panel, high-density lipoprotein cholesterol panel, and complete blood count. Information was gathered on scales assessing intrinsic characteristics (personal locus of control, life satisfaction, self-esteem, depressive symptomatology) and extrinsic characteristics (support received from and provided to family and friends, stressful life events, neighborhood disadvantage). The newly developed Duke FI had content, construct, concurrent, and predictive validity. In addition to sex, race, and income, the Duke FI was associated at the intrinsic level with locus of control, self-esteem, life satisfaction, and depressive symptomatology (each P < .01) and at the extrinsic level with provision (P < .01) and with receipt of instrumental help (P < .10), social stressors (P < .03), and neighborhood disadvantage (P < .01) in unadjusted analysis; race fully explained neighborhood disadvantage. Intrinsic (personality) characteristics and personally close extrinsic characteristics (contacts with family and friends, personal stressors) are associated with laboratory test-based frailty, as is neighborhood disadvantage, although in this accessible, health service-rich environment, race fully explained association with neighborhood disadvantage, suggesting that interventions to reduce frailty in residents in such an environment should pay particular attention to characteristics that immediately affect the individual.

Influence of Studies Published by the Journal of the American Geriatrics Society: Top 20 Articles from 2000-2015.

As the tenure of Dr. Thomas T. Yoshikawa comes to a close on July 1, 2016, after 16 years as editor in chief of the Journal of the American Geriatrics Society (JAGS), the editorial board members (which includes the editors) felt it would be valuable to determine which of the published manuscripts would be rated as the most important articles in terms of clinical influence on patient care and improving the health and quality of life of older adults from 2000 to 2015. In addition, such information would provide some level of perspective on how the field of aging (geriatrics, gerontology, and long-term care) has evolved over 15 years and how that progress continues to affect our focus and priorities for the present and future of care for older adults. The process of determining which of the articles published from 2000 to 2015 would be worthy of consideration involved objective and subjective assessments. JAGS publisher, Wiley-Blackwell, provided a spreadsheet of the 10 published JAGS articles that other journals cited most for each year between 2000 and 2015, which yielded 155 articles for consideration. (There were more than 150 articles because a few articles had the same rating scores.) This information was organized according to year and included the title, authors, publication date, volume, and total citations for each article. The data were then shared with 96 JAGS editorial board members. Editorial board members were asked to vote on their top two articles for each year based on what they believed the article's influence has been on clinical care, research and education. The editorial board members were also invited to recommend any additional articles that they felt should be considered but were not included in the spreadsheet data. From the votes obtained on the 155 articles, a rank order of articles from the most to fewest votes was generated. Thirty-six editors submitted their votes. These votes were tallied and shared with the selection committee: Thomas T. Yoshikawa, MD (outgoing JAGS editor in chief), William B. Applegate, MD (incoming JAGS editor in chief), and Joseph G. Ouslander, MD (JAGS executive editor). The selection committee met in a conference call to determine the final list of top articles for 2000 to 2015 from the ranking of the 155 articles. A cutoff of the top 20 articles was arbitrarily agreed upon. Each of the selection committee members was assigned an equal number of articles to review and provide a brief summary (100 words or fewer) that included study objective, relevance of the findings, and effect on current practice. Selection committee members were also allowed to contact experts in the field to obtain their opinions on the merits and influence of the articles assigned to them. The following are the summaries of the top 20 articles listed according to rank order of votes received, beginning with the articles with the highest votes and in decreasing order. Many articles received the same number of votes. The articles will be listed by title, first author's name, year, volume, and pages. (See Reference section for complete citations.) The Montreal Cognitive Assessment, MoCA: A Brief Screening Tool for Mild Cognitive Impairment. Nasreddine ZS et al. 2005;53:695–699.1 Study Objective: To report on a new screening test to detect mild cognitive impairment (MCI). Relevance: The MoCA is an excellent bedside measure that performs well in discriminating MCI from normal cognition as an initial test. Effect on Current Practice: MCI is more common than dementia in older adults, and the MoCA's more-challenging tasks, all of which are directly related to clinical cognitive status, produce greater sensitivity for MCI than other screening tests, making the MoCA an attractive measure for use in clinical and research settings where detection of MCI is desired and use of longer neuropsychological batteries is not feasible. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. American Geriatrics Society. 2012;60:616–631. 2 Study Objective: To update the previous Beers Criteria using a comprehensive, systematic review and grading of the evidence on drug-related problems and adverse drug events. Relevance: Fifty-three medications or medication classes were divided into three categories: potentially inappropriate medications or medication classes to avoid in older adults, potentially inappropriate medications or medication classes to avoid in older adults with certain diseases and syndromes that the drugs listed can exacerbate, and medications or medication classes to be used with caution in older adults. Effect on Current Practice: In recent years, the Beers Criteria has been one of the most widely used clinical tools for determining medications that could be harmful to older persons. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. Naylor MD et al. 2004;52:675–684. 3 Study Objective: To examine the effectiveness of a transitional care intervention delivered by advanced practice nurses to older adults hospitalized with heart failure. Relevance: The study involved 259 participants (mean age 76, 43% male, 36% African American) in six academic and community hospitals followed for 52 weeks after index hospital discharge. Time to first admission or death was longer in intervention participants (P = .026). At 52 weeks, intervention group participants had fewer admissions than controls (104 vs 162, P = .047) and lower mean total costs ($7,363 vs $12,481, P = .002). For intervention participants, only short-term improvements were demonstrated in overall quality of life, physical dimension of quality of life, and participant satisfaction. It was concluded that a comprehensive transitional care intervention for older adults hospitalized with heart failure increased the length of time between hospital discharge and readmission or death, reduced total number of rehospitalizations, and decreased healthcare costs. Effect on Current Practice: This study formed the basis of Dr. Mary Naylor's Transitional Care Model, which is being disseminated widely throughout the United States as a result of evolving Medicare payment models. Potentially Avoidable Hospitalizations of Nursing Home Residents: Frequency, Causes and Costs. Ouslander JG et al. 2010;58:627–635. 4 Study Objective: To examine the frequency of and reasons for potentially avoidable hospitalizations (PAHs) of nursing home (NH) residents. Relevance: Ten hospitalizations each per NH of long- and short-stay residents were randomly selected—10 from Georgia NHs with high and 10 with low hospitalization rates. Expert clinicians performed ratings of avoidability using a structured review. Of the 200 hospitalizations, 134 (67%) were rated as potentially avoidable. The expert clinicians cited lack of on-site availability of primary care clinicians, inability to obtain timely laboratory tests and intravenous fluids, problems with quality of care in assessing acute changes, and uncertain benefits of hospitalization as causes of these potentially avoidable hospitalizations. Results suggested that support for NH infrastructure, attention to reducing the frequency of medically futile care, and financial and other incentives for NHs and their affiliated hospitals are needed to improve care, reduce PAHs, and avoid unnecessary healthcare expenditures in this population. Effect on Current Practice: This study provided the data for an expert panel to make recommendations that evolved into the Interventions to Reduce Acute Care Transfers quality improvement program, which is being widely used in many NHs in the United States, as well as in several other countries. Ten-Year Effects of the Advanced Cognitive Training for Independent and Vital Elderly Cognitive Training Trial on Cognition and Everyday Functioning in Older Adults. Rebok GW et al. 2014;62:16–24. 5 Study Objective: To assess the effect of 10 cognitive training sessions with or without two later booster sessions on cognitive performance and self-reported function at 10 years compared to controls. Relevance: This is the seminal randomized clinical trial of cognitive training for older adults. Effects were specific to the domain trained (memory, speed of processing, reasoning), and gains in speed and reasoning were still evident after 10 years relative to controls, when participants' average age was 82. Training was associated with small to moderate benefits in long-term maintenance of self-reported activities of daily living. Effect on Current Practice: This study confirmed that cognitive performance of older adults can improve with structured training and hinted at possible transfer of training benefits to everyday function. The results seeded commercialization and expansion of cognitive training tools and new studies demonstrating important practical benefits, such as better driving performance in older adults. Geriatric Syndromes: Clinical, Research, and Policy Implications of a Core Geriatric Concept. Inouye SK et al. 2007;55:780–791. 6 Study Objective: To review criteria for defining geriatric syndromes and propose a balanced approach of developing preliminary criteria based on peer-reviewed evidence. Relevance: Based on a review of the literature, four shared risk factors (old age, baseline cognitive impairment, baseline functional impairment, impaired mobility) were identified for five common geriatric syndromes (pressure ulcers, incontinence, falls, functional decline, delirium). It was asserted that understanding basic mechanisms involved in geriatric syndromes will be critical to advancing research and developing targeted therapeutic options and that, given the complexity of these multifactorial conditions, attempts to define relevant mechanisms will need to incorporate more-complex models, including a focus on synergistic interactions between risk factors. There was a call for national strategic initiatives to overcome barriers and to achieve clinical, research, and policy advances that will improve quality of life for older adults. Effect on Current Practice: This is a seminal article that has formed the basis of many current clinical care and research initiatives on multimorbidity. Guideline for the Prevention of Falls in Older Persons. American Geriatrics Society et al. 2001;49:664–672. 7 Study Objective: To provide a guideline for clinicians for prevention of falls in older adults. Relevance: This guideline was a collaborative effort between the American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons. It includes a review of the literature on risk factors for falls, general recommendations for the assessment of individuals who have fallen, and an evidence-based review of multiple types of interventions for fall prevention. The guideline also outlines an ambitious research agenda for the future. Effect on Current Practice: This guideline formed the basis for current fall prevention guidelines and provided a research agenda, some elements of which have been accomplished, and much of which is still ongoing. The Hospital Elder Life Program: A Model of Care to Prevent Cognitive and Functional Decline in Hospitalized Older Patients. Inouye SK et al. 2000;48:1697–1706. 8 Study Objective: To describe the Hospital Elder Life Program (HELP), a new model of care designed to prevent delirium. Relevance: In 1,507 participants, HELP substantially decreased rates of cognitive and functional decline. HELP was the first in-hospital delirium-prevention model and has subsequently been demonstrated to be clinically effective and cost-effective through reductions in delirium, falls, sitter use, hospital length of stay, institutionalization, and readmission. Effect on Current Practice: The program has been implemented in more than 200 hospitals in the United States and other countries. HELP interventions and protocols have also had widespread influence on many adaptations, guidelines, pathways, and standing order sets for delirium worldwide. Reducing Delirium After Hip Fracture: A Randomized Trial. Marcantonio ER et al. 2001;49:516–522. 9 Study Objective: To conduct a randomized trial of a proactive geriatrics consultation to reduce delirium after hip fracture surgery. Relevance: One hundred twenty-six participants were randomized. All proactive consultation participants were seen within 24 hours of admission and had good adherence to recommendations. The incidence of delirium in the proactive consultation group was two-thirds that of the usual care group, and the incidence of severe delirium was half that of the usual care group. Effect on Current Practice: This study provided a model for improving outcomes of a vulnerable hospitalized population and has led to the widespread adoption of geriatrics–orthopedics co-management services in many medical centers today. Pharmacological Management of Persistent Pain in Older Persons. American Geriatrics Society. 2009;57:1331–1346. 10 Study Objective: To update the 2002 American Geriatrics Society pain guideline and provide recommendations regarding use of newer pharmacological approaches to managing persistent pain in older adults. Relevance: This guideline provided general principles on the assessment and management of persistent pain, principles of pharmacological management, and a summary of nonopioid and opioid analgesics with an emphasis on recommending acetaminophen as initial and ongoing pharmacotherapy for most cases of persistent pain. Effect on Current Practice: The guideline continues to remain an important management tool for treating older adults with persistent pain. Physical Performance Measures in the Clinical Setting. Studenski S et al. 2003;51:314–322. 11 Study Objective: To assess the ability of gait speed alone and a three-item lower extremity performance battery to predict 12-month rates of hospitalization, decline in health, and decline in function in primary care settings serving older adults. Relevance: Gait speed alone and the Established Populations for Epidemiological Study of the Elderly (EPESE) battery predicted hospitalizations; 41% (21/51) of slow walkers (gait speed <0.6 m/sec), 26% (70/266) of intermediate walkers (0.6–1.0 m/sec) and 11% (15/136) of fast walkers (>1.0 m/sec) were hospitalized at least once (P < .001). It was concluded that gait speed and a physical performance battery are brief, quantitative estimates of future risk of hospitalization and decline in health and might serve as easily accessible “vital signs” to screen older adults in clinical settings. Effect on Current Practice: In the years since this article was published, gait speed and physical performance have been shown to have clinical utility in risk stratifying older adults. Effective Exercise for the Prevention of Falls: A Systematic Review and Meta-Analysis. Sherrington C et al. 2008;56:2234–2243. 12 Study Objective: To determine the effects of exercise on fall prevention. Relevance: Randomized controlled trials were included that compared fall rates in older adults who undertook exercise programs with fall rates in older adults who did not exercise in the general community and residential care. The pooled estimate of the effect of exercise was that it reduced the rate of falling by 17% (44 trials with 9,603 participants; rate ratio = 0.83, 95% confidence interval = 0.75–0.91, P < .001). The greatest relative effects of exercise on fall rates were seen in programs that had a combination of a higher total dose of exercise (450 hours over the trial period) and challenging balance exercises (exercises conducted while standing in which people aimed to stand with their feet closer together or on one leg, minimize use of their hands to assist, and practice controlled movements of the center of mass) and did not include a walking program. It was concluded that exercise can prevent falls in older adults, with greater relative effects seen in programs that include exercises that challenge balance, use a higher dose of exercise, and do not include a walking program. Effect on Current Practice: This study reinforces the use of tai chi and similar balance training that is commonly used in fall prevention today. Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons. American Geriatrics Society and British Geriatrics Society. 2011;59:148–157. 13 Study Objective: To provide a summary of the updated American Geriatrics Society/British Geriatrics fall guideline, the guideline process, and the differences between the updated guideline and the 2001 version of fall guideline. Relevance: The algorithm is clear and simple to follow, and the text of the article highlights a comprehensive set of recommendations on screening and assessment and interventions for falls, with ratings of the evidence supporting them. Separate sections are included on managing falls in long-term care facilities and in older persons with cognitive impairment. Updates of the 2001 guideline include more-specific recommendations on fall risk assessment and the circumstances of the fall and new recommendations on a variety of interventions studied since the older guideline was published. Effect on Current Practice: This guideline should form the basis of all initiatives to manage fall risk and prevent falls in older adults. Low Relative Skeletal Mass (Sarcopenia) in Older Persons Is Associated with Functional Impairment and Physical Disability. Jansen I et al. 2002;58:889–896. 14 Study Objective: To establish the prevalence of sarcopenia in older Americans and to test the hypothesis that sarcopenia is related to functional impairment and physical disability in older adults. Relevance: The prevalence of Class I (59% vs 45%) and Class II (10% vs 7%) sarcopenia was greater in older (≥60) women than older men (P < .001). The likelihood of functional impairment and disability was approximately two times as great in older men and three times as great in older women with Class II sarcopenia than in those with Class I sarcopenia. Some of the associations between Class II sarcopenia and functional impairment remained significant after adjustment for age, race, body mass index, health behaviors, and comorbidity. Effect on Current Practice: This study demonstrates the independent association between sarcopenia and functional impairment and disability and hypothesizes that sarcopenia may be a potentially reversible cause of disability, particularly in older women. The Mini-Cog as a Screen for Dementia: Validation in a Population-Based Sample. Borson S et al. 2003;51:1451–1454. 15 Study Objective: To compare performance of a 2–3-minute screen for dementia, the Mini-Cog, compared with that of the Mini-Mental State Examination and a research neuropsychological battery in a population with low rates of dementia. Relevance: The Mini-Cog was as effective as longer tests in detecting dementia diagnosed by research criteria, making dementia detection simple and feasible in primary care settings. Effect on Current Practice: This study provided evidence to support adoption of the Mini-Cog in healthcare and clinical training settings and electronic medical record systems, its endorsement in evidence reviews and best practice statements, and its use to evaluate the combined effects of cognitive impairment and comorbid chronic conditions on healthcare outcomes. Effects of Exercise Training on Frailty in Community-Dwelling Older Adults: Results of a Randomized, Controlled Trial. Binder EF et al. 2002;50:1921–1928. 16 Study Objective: To determine the effects of intensive exercise training (ET) on measures of physical frailty in older community-dwelling men and women. Relevance: One hundred fifteen sedentary men and women (mean age 83) with mild to moderate physical frailty1 were randomized to an exercise intervention (ET) or low-intensity home exercise (control group) for 9 months. ET began with 3 months of flexibility, light-resistance, and balance training. During the next 3 months, resistance training was added, and during the last 3 months, endurance training was added. ET resulted in significantly greater improvements than home exercise in three of the four primary outcome measures: a physical performance battery, a functional status questionnaire, and peak oxygen intake. Effect on Current Practice: This may be the first study to provide evidence of the efficacy of a multidimensional high-intensity training regimen in reducing frailty and improving oxygen uptake in frail community-dwelling people. Research Agenda for Frailty in Older Adults: Toward a Better Understanding of Physiology and Etiology: Summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults. Walston J et al. 2006;54:991–1001. 17 Study Objective: To report on the results of the 2004 American Geriatrics Society/National Institute on Aging conference on a research agenda on frailty in older adults. Relevance: The conference focused on evolving conceptualizations and definitions of frailty; physiological underpinnings of frailty, including the potential contributions of inflammatory, endocrine, skeletal muscle, and neurological system changes; potential molecular and genetic contributors; proposed animal models; and integrative, system biology approaches that may help to facilitate research. Several specific recommendations as to future directions were also developed, including recommendations on definition and phenotype development, methodological development to perform clinical studies of individual-system and multiple-system vulnerability to stressors, development of animal and cellular models, application of population-based studies to frailty research, and development of large collaborative networks in which populations and resources can be shared. Effect on Current Practice: Many of the conference recommendations and concepts have led to the multitude of research studies that have better defined frailty and its consequences and translated into implementation (although limited) in clinical practice. (For example, see next article summary on frailty by Theou O et al.) Operationalization of Frailty Using Eight Commonly Used Scales and Comparison of Their Ability to Predict All-Cause Mortality. Theou O et al. 2013;61:1537–1551. 18 Study Objective: To evaluate eight frailty scales and compare their validity, feasibility, prevalence estimates of frailty, and ability to predict all-cause mortality. Relevance: Frailty scales were the Groningen Frailty Indicator, Tilburg Frailty Indicator, 70-item Frailty Index (FI), 44-item FI based on a Comprehensive Geriatric Assessment (FI-CGA), Clinical Frailty Scale, Frailty Phenotype (weighted and unweighted versions), Edmonton Frail Scale, and the FRAIL scale. Substantive differences were found between scales in their content validity, feasibility, and ability to predict all-cause mortality. The major finding is that these frailty scales capture related but distinct groups of older persons. Effect on Current Practice: Over time, frailty scales are increasingly being used in clinical research and at times in clinical practice to define which older persons are most at risk of adverse clinical outcomes and disability. Delirium Is Independently Associated with Poor Functional Recovery After Hip Fracture. Marcantonio ER et al. 2000;48:618–624. 19 Study Objective: To define the role of delirium in poor functional outcomes. Relevance: After adjusting for age, preexisting cognitive and functional impairment, and comorbidity, delirium remained an independent risk factor for decline in activities of daily living, ambulatory decline, and death or new nursing home placement at 1 month. Moreover, participants with persistent delirium at 1 month had worse outcomes than those whose delirium resolved. Effect on Current Practice: This was one of the first studies to demonstrate the importance of delirium in functional recovery after hospitalization. Screening for delirium after surgery in older adults is now common practice. The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care Approach: Preliminary Data from the Implementation of a Centers for Medicare and Medicaid Services Nursing Facility Demonstration Project. Unroe KT et al. 2015;63:165–169. 20 Study Objective: To describe a preliminary report on the Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project. Relevance: This is one of seven projects that the Centers for Medicare and Medicaid Services (CMS) has funded to test interventions to reduce avoidable hospitalizations of long-stay nursing facility residents. The study places a registered nurse in each facility to implement an evidence-based quality improvement program with clinical support from nurse practitioners. Important elements include better medical care through implementation of the Interventions to Reduce Acute Care Transfers tools and chronic care management, enhanced transitional care, and better palliative care with a focus on systematic advance care planning. Root-cause analyses were performed for 910 acute transfers. The project registered nurse evaluated 29% as avoidable transfers, and opportunities for quality improvement were identified in 54%. Lessons learned included defining new clinical roles, integrating quality improvement principles into facility culture, managing competing priorities, communicating with multiple stakeholders, and developing a system for collecting and managing data. Effect on Current Practice: The success of OPTIMISTIC and other similar interventions in the CMS initiative has resulted in a second round of funding to build on these interventions that will improve care and save billions of dollars over the next decade. During the past 15 years (2000–2015), remarkable progress has been made toward improving the health and quality of life of older adults, largely through carefully designed and implemented research studies. In going through this exercise of attempting to identify the studies published in JAGS that have the greatest influence on improving clinical care delivery and achieving desirable health outcomes in older adults, it is apparent that the field of aging (geriatrics, gerontology, long-term care) has rapidly matured and become a major discipline in the public and personal health of older adults. The major (but not only) health concerns of older adults, particularly as they age into their eighth and ninth decades of life, are concerns about cognitive impairment, physical disabilities and functional incapacity, medications, and increasing vulnerability to aging-related and disease-related disorders and their effects on health outcomes. In this review, of the top 20 JAGS articles, five articles were focused on various aspects of cognition (delirium, cognitive assessment and training), five were about physical disabilities (function, performance, falls), three discussed frailty, two were about medications, and two discussed hospitalization and transitional care. Not surprisingly, these top 20 research studies address the major concerns of our older population. Despite these successes in addressing health concerns, finding therapeutic interventions, and implementing potential preventive measures for the above major health concerns, the field of aging still has monumental challenges in the area of health of older adults. We have yet to identify causes of, treatments for, and how to prevent dementing diseases and other cognitive disorders; adequately manage multimorbidity, frailty, and a variety of infectious diseases; decrease polypharmacy and drug interactions; reduce falls and unnecessary, repeated, lengthy hospitalizations; and mitigate the prevalence and complications of age-related diseases such as heart disease, stroke, cancer, diabetes mellitus, chronic obstructive lung disease, arthritis, hypertension, osteoporosis, kidney failure, and mental health disorders such as depression. As the field of aging has matured, JAGS has gained successes through its publication toward improving the health and well-being of older adults these past 15 years. We certainly hope the next 15 years will be as productive and yielding of improved healthcare practices, models, and systems of care to achieve our stated goals. The opinions expressed by the authors are not necessarily those of the U.S. Department of Veterans Affairs. Conflicts of Interest: All three authors receive a stipend from the American Geriatrics Society in their role as editors of JAGS. The authors have no other conflicts of interest to disclose relevant to this article. Authors Contributions: All three authors contributed equally to this manuscript. The authors thank Ms. Jennifer English of Wiley-Blackwell for providing the spreadsheet data of the top 10 published JAGS articles as cited by other journals from 2000 to 2015. We also thank Ms. Mary Jordan Samuel of the American Geriatrics Society for collating and organizing the spreadsheet data for each year, contacting the JAGS editors for their specific ranking of the articles, and tabulating the ranking of articles based on the votes submitted by the editors. Sponsor's Role: The American Geriatrics Society and Wiley-Blackwell had no role in the determining the final outcomes and decisions relevant to this manuscript.

Racial Differences in the Effect of Stress on Health and the Moderating Role of Perceived Social Support.

The current study examined racial differences in the relationship between late-life stress and health functioning and the moderating role of perceived social support (PSS) in older adults. A biracial sample of community-dwelling older adults (65+) from the first two waves of the Duke University's Established Populations for Epidemiologic Studies of the Elderly (EPESE; N = 2,952) was analyzed. Baseline levels of PSS and stress were obtained. Health status was assessed at baseline and follow-up. Analyses revealed a positive effect of PSS on health functioning. There was a three-way interaction among race, stress, and PSS on health functioning. Probing the interaction, for Caucasians, PSS was beneficial at low stress, but not high stress. For African Americans, PSS had a positive effect regardless of stress level. PSS is an important protective factor for preserving positive health in late-life; however, benefits may differ by race and intensity of stressor.

Sleep quality disturbances and cognitive functioning in elderly patients with COPD.

Information about the association between cognitive functions, such as copying function, and sleep disturbances in patients with chronic obstructive pulmonary disease (COPD) is lacking. This cross-sectional observational study aimed to investigate the association between copying function and self-reported sleep quality disturbances and disease severity in an elderly COPD population.Cognitive function performances, assessed using the Mini-Mental State Examination, were compared in 562 ambulatory COPD patients with and without sleep disturbances; assessed using the Established Populations for Epidemiologic Studies of the Elderly questionnaire; and stratified by Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades.Sleep disturbances overall were not correlated with cognitive functioning. A trend was revealed towards worse design copying in patients with sleep disturbances overall. GOLD I patients with difficulties falling asleep and nocturnal awakenings had worse copying ability compared to GOLD I patients without these sleep disturbances. Copying ability was worse for GOLD III than GOLD I, orientation was worse for GOLD II than GOLD I and language was worse for GOLD II and III than GOLD I.To conclude, sleep disturbances seem to be a weak correlate of cognitive functioning, and are not a marker of disease severity.

Association of Co-Existing Impairments in Cognition and Self-Rated Vision and Hearing With Health Outcomes in Older Adults.

Objective: The objective of this study was to assess the relationship of disability (activities of daily living [ADL] and instrumental ADL [IADL]), self-rated health (SRH), and 6-year mortality with co-existing impairments in vision (self-rated), hearing (self-rated), and/or cognition (Short Portable Mental Status Questionnaire) in older adults. Method: The study sample comprised of 3,871 participants from the North Carolina Established Populations for Epidemiologic Studies of the Elderly study (NC EPESE). Results: Persons with all three impairments had increased odds of ADL/IADL disability and low SRH. Participants with combined visual and cognitive impairments had increased odds of mortality. Whereas sensory impairments were associated with poor SRH, cognitive impairment was not unless both sensory impairments were present. Conclusion: Co-existent sensory and cognitive impairments were associated with higher risk of impaired functional status. Self-rated auditory impairment alone was not associated with higher odds of death, but mortality was linked to visual and, particularly, cognitive impairment, alone or combined.