Hebrew SeniorLife Research Articles

TMS Targets for Multiple Sclerosis Related Depression Derived Using a Precomputed Functional Connectome (P11-3.014)

TMS Targets for Multiple Sclerosis Related Depression Derived Using a Precomputed Functional Connectome (P11-3.014)

Building community and resilience in Massachusetts nursing homes during the COVID-19 pandemic.

During the COVID‐19 pandemic, frontline nursing home staff faced extraordinary stressors including high infection and mortality rates and ever‐changing and sometimes conflicting federal and state regulations. To support nursing homes in evidence‐based infection control practices, the Massachusetts Senior Care Association and Hebrew SeniorLife partnered with the Agency for Healthcare Research and Quality AHRQ ECHO National Nursing Home COVID‐19 Action Network (the network). This educational program provided 16 weeks of free weekly virtual sessions to 295 eligible nursing homes, grouped into nine cohorts of 30–33 nursing homes. Eighty‐three percent of eligible nursing homes in Massachusetts participated in the Network, and Hebrew SeniorLife's Training Center served the vast majority. Each cohort was led by geriatrics clinicians and nursing home leaders, and coaches trained in quality improvement. The interactive sessions provided timely updates on COVID‐19 infection control best practices to improve care and also created a peer‐to‐peer learning community to share ongoing challenges and potential solutions. The weekly Network meetings were a source of connection, emotional support, and validation and may be a valuable mechanism to support resilience and well‐being for nursing home staff.

Stemming the Tide of COVID-19 Infections in Massachusetts Nursing Homes.

BACKGROUND/OBJECTIVESIn April 2020, Massachusetts nursing homes (NHs) became a hotspot for COVID‐19 infections and associated deaths. In response, Governor Charles Baker allocated $130 million in additional funding for 2 months contingent on compliance with a new set of care criteria including mandatory testing of all residents and staff, and a 28‐point infection control checklist. We aimed to describe the Massachusetts effort and associated outcomes.DESIGNLongitudinal cohort study.SETTINGA total of 360 Massachusetts NHs.PARTICIPANTSThe Massachusetts Senior Care Association and Hebrew SeniorLife rapidly organized a Central Command team, targeted 123 “special focus” facilities with infection control deficiencies for on‐site and virtual consultations, and offered all 360 facilities weekly webinars and answers to questions regarding infection control procedures. The facilities were also informed of resources for the acquisition of personal protective equipment (PPE), backup staff, and SARS‐CoV‐2 testing.MEASUREMENTSWe used two data sources: (1) four state audits of all NHs, and (2) weekly NH reports to the Massachusetts Center for Health Information and Analysis. Primary independent process measures were the checklist scores and adherence to each of its six core competencies. Primary outcomes were the average weekly rates of new infections, hospitalizations, and deaths in residents and staff. We used a hurdle mixed effects model adjusted for county COVID‐19 prevalence to estimate relationships between infection control process measures and rates of new infections or deaths.RESULTSBoth resident and staff infection rates started higher in special focus facilities, then rapidly declined to the same low level in both groups. Adherence to infection control processes, especially proper wearing of PPE and cohorting, was significantly associated with declines in weekly infection and mortality rates.CONCLUSIONThis statewide effort could serve as a national model for other states to prevent the devastating effects of pandemics such as COVID‐19 in frail NH residents.

The Feasibility of a Low Sodium Meal Plan for Residents of a Subsidized Senior Housing Facility: The SOTRUE Pilot Study

Abstract Objectives To determine the feasibility of a low sodium meal plan intervention aimed at reducing seated blood pressure (BP) in residents of a government-subsidized congregate, senior living facility. Methods The Satter House Trial of Reduced Sodium Meals (SOTRUE) was an individual-level, masked, randomized, controlled pilot study, testing the feasibility of administering a low versus typical sodium meal plan to adult residents of Jack Satter House, a section 202 congregate living facility in Revere, MA, subsidized by the Federal Department of Housing and Urban Development (HUD). Adults over age 60 years received 3 isocaloric meals with two snacks daily over a 14-day period. Both meal plans were equivalent in potassium and macronutrients, but differed in sodium density (<0.95 mg/kcal vs > 2 mg/kcal). The primary outcome was seated systolic BP (SBP) averaged over 2 visits (days 10 and 14) using an Omron HEM-907XL automated cuff. Our objective measure of compliance was morning urine sodium-creatinine ratio. Results We randomized 20 participants (95% women, 95% white, and mean age 78 +/− 8 years), beginning in October 7, 2019. Baseline characteristics were evenly distributed between groups. Dietary compliance was high (only 2 discontinued meals) and follow-up was 100% with the last participant ending November 4, 2019. Baseline SBP changed from 121 to 116 mm Hg on the typical sodium meal plan (N = 9; mean difference of −5 mm Hg; 95% CI: −18, 8) and 123 to 112 mm Hg on the low sodium meal plan (N = 11; mean difference of −11 mm Hg; 95% CI: −15.2, −7.7). Compared to the typical sodium meal plan, the low sodium meal plan non-significantly reduced SBP by 5 mm Hg (95% CI: −14, 4) and non-significantly reduced urine sodium-creatinine ratio (%-difference −36.0; 95% CI: −60.3, 3.4). Effects on SBP were greater in the subgroup using hypertension medications at baseline (−13 mm Hg; 95% CI: −26, −0) and changes in SBP from baseline were correlated with changes in urine sodium-creatinine ratio (Pearson's r = 0.31). Conclusions This trial represents an innovative, feasible, and practical approach to healthier eating by altering federally-mandated meal plans. A definitive study with a larger sample size is needed to establish the efficacy and safety of this approach in older adults who reside in section 202 housing. Funding Sources ISAC, Marcus Institute for Aging Research, Hebrew SeniorLife.

The Feasibility of Using Computrition Software for Nutrition Research

Abstract Objectives Computrition is a food service software utilized by dieticians in clinical settings to create recipes, design menus, and scale the menus to larger quantities, yet it is underutilized in the research setting. The objective was to determine the practicality of administering two meal plans (low sodium vs typical sodium) designed with Computrition in a double-blind, randomized pilot study in older adult residents of a congregate housing facility. Methods This pilot study included 19 females and 1 male aged ≥65y residing at Jack Satter House, Revere, MA. Participants were randomized to low sodium or typical sodium meals (<0.95 or >2 mg/kcal), designed with Computrition. A base 7-day meal plan (with breakfast, lunch, dinner, and two snacks) was generated. Recipes entered in Computrition were modified to reach three calorie levels (1750, 2000, 2250 kcal/d) and two sodium densities, while keeping potassium levels constant at ∼3500 mg/d. Finally, Computrition labels were generated to execute meals while maintaining blinding. To determine efficacy of these meal plans, compliance was evaluated by comparing change in urinary sodium (mmol/L) over 2-weeks between low sodium vs. typical sodium groups. These comparisons were also assessed in sub-groups by calorie intake (≤1750 kcal/d, n = 12 and ≥2000 kcal/d, n = 8). Results Mean age was 77 ± 6y and calorie intake was 1849 kcal (low sodium group, n = 11) and 80 ± 9y and 1785 kcal (typical sodium group, n = 9). Over 2-weeks, urinary sodium decreased by −30.6 mmol/L in the low sodium diet, compared to 2.4 mmol/L in the typical sodium diet (P = 0.003). In those consuming ≤ 1750 kcal/d on the low sodium diet, urinary sodium decreased non-significantly by −18.3 mmol/L, compared to −2.3 mmol/L in the typical sodium diet (P = 0.16). In those consuming ≥2000 kcal/d on the low sodium diet, urinary sodium decreased non-significantly by −22.0 mmol/L, compared to no change in the typical sodium diet (P = 0.26). Conclusions In this study, two sodium meal plans designed using Computrition altered urinary sodium over 2 weeks. Similar trends in reduction were seen in the sub-groups by calorie intake, although results were not significant due to small sample sizes. Future work should evaluate testing and standardization of this software for a multi-site nutrition intervention study. Funding Sources ISAC, Marcus Institute, Hebrew SeniorLife.

KENT AND KLEEMEIER AWARD LECTURES

The Donald P. Kent Award is given annually to a member of the The Gerontological Society of America who best exemplifies the highest standards of professional leadership in gerontology through teaching, service, and interpretation of gerontology to the larger society. The Kent lecture will feature an address by the 2018 recipient, Lewis Lipsitz, MD, Hebrew Senior Life. The Robert W. Kleemeier Award is given annually to a member of The Gerontological Society of America in recognition for outstanding research in the field of gerontology. The Kleemeier lecture will feature an address by the 2018 recipient, Keith Whitfield, PhD, Wayne State University.

Recipients, Staff Provide Insights on Person-Centered Care

Recipients, Staff Provide Insights on Person-Centered Care

Evaluation of an Automated Falls Detection Device in Nursing Home Residents.

To determine the concordance between falls recorded using an investigational fall detection device and falls reported by nursing staff in a nursing home. Six-month prospective study. Hebrew SeniorLife nursing home units in Boston, Massachusetts. Nursing home residents with a documented history of at least one fall within 12 months before consent (N = 62, mean age 86.2 ± 8.1, 66% female). Subjects continuously wore an automated falls detection device on a pendant around their neck. The device contained triaxial accelerometers set to detect a rapid change in position that was interpreted as a fall. Healthcare staff reported daily falls, defined as unexpected events in which residents were found on the floor, and the number of these falls was compared with the number of falls recorded according to the device. Seven of 37 residents whom nursing staff found on the floor had a fall recorded according to the device (19%). The device did not identify any of the clinical fall events in 23 of the 37 fallers (62%). The device detected 17 of 89 total falls that nursing staff recorded (sensitivity 19%) within an 8-hour time window. Of 128 fall events that the device recorded, 17 were concordant with nursing reports (13%) within an 8-hour time window, and 111 (87%) were false positives. There is poor concordance between falls recorded using the investigational fall detection device and falls to the floor that nursing home staff report.

Implantable Cardioverter-Defibrillator Use in Older Adults: Proceedings of a Hartford Change AGEnts Symposium.

Since their initial clinical demonstration in 1980, implantable cardioverter–defibrillators (ICDs) have prolonged countless lives with successful treatment of sudden cardiac arrest.1 No other therapy has proved as effective in preventing death from ventricular arrhythmias, and important advances in ICD technology continue to improve outcomes for well-selected patients.2 Although indicated for a wide range of inherited and acquired conditions,3 ICDs are predominantly placed in older patients with left ventricular systolic dysfunction and either previous myocardial infarction or congestive heart failure.4 In the United States alone, >50 000 ICDs are placed annually in patients aged > 65 years, and nearly 500 000 more may meet current guidelines for device implantation.5 However, decision making for older patients considering ICD implantation is particularly challenging. Subjects in the landmark trials had average ages in the 60s, and thus the survival benefits of ICDs in older age groups is less well-established.6 In addition, compared with the younger participants in most clinical trials, older adults have a lower ratio of arrhythmic death to nonarrhythmic death because of competing risks for mortality, resulting in a potentially lower absolute risk reduction. At the same time, living and eventually dying with an ICD introduces potential risks, including a lower quality of life (QoL), hospitalizations, and potential suffering at the end of life.7 A rigorous consideration of the benefits, risks, and ongoing care surrounding ICD use in older patients is long overdue. On April 22, 2014, we convened a conference of multidisciplinary experts in cardiac electrophysiology, heart failure, geriatrics, ethics, and palliative care in Boston, supported by the Hartford Change AGEnts and Paul B. Beeson Career Development Award programs, and the Hebrew SeniorLife Institute for Aging Research. The objectives of the conference were (1) to review what is currently known about ICD use in …

The ACTIVE Study

In response to data indicating that persons over age 65 account for almost half of all days of care in short stay hospitals (Graves & Kozak, 1999), constitute the majority of residents of nursing homes (Strahan, 1997), and account for over 75% of required formal home-based care supports (Levit et al., 1997; Office, 1996), the National Institute on Aging and the National Institute for Nursing Research funded an initiative to test the effectiveness of cognitive interventions in maintaining cognitive health and functional independence in older adults. This initiative was based on evidence that the cognitive performance of older adults can be improved through systematic training focused on cognitive skills (Baltes, Kuhl, Gutzmann, & Sowarka, 1995; Caprio-Prevette & Fry, 1996; Hayslip, Maloy, & Kohl, 1995; Kramer, Larish, & Strayer, 2002; Mohs et al., 1998; Neely & Backman, 1995; Noice, Noice, & Staines, 2004; Oswald, Rupprecht, Gunzelmann, & Tritt, 1996) paired with evidence of the importance of cognitive functioning for performing activities of daily living (Allaire & Marsiske, 1999; Backman & Hill, 1996; Burdick et al., 2005; Cahn-Weiner, Malloy, Boyle, Marran, & Salloway, 2000; Owsley, Sloane, McGwin, & Ball, 2002) and maintaining health related quality of life among older adults (Hultsch, Hammer, & Small, 1993; Swan, Carmelli, & LaRue, 1995; Wolinsky & Johnson, 1991). At that time, essentially no research had been conducted demonstrating training transfer to real-world functional outcomes in later adulthood. The Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) trial addressed this gap. The goal of ACTIVE was to test the effectiveness of three cognitive interventions (memory, reasoning, and visual speed of processing) in maintaining cognitive health and functional independence in older adults. The targeted abilities-- memory, reasoning, and speed of processing—were selected based on evidence that they exhibit relatively early age-related decline, beginning on average in the mid-sixties (Schaie, 1996), that interventions have been shown to be effective in training these abilities (K Ball, 1997; K. Ball & Owsley, 2000; Kliegl, Smith, & Baltes, 1990; Lachman, Weaver, Bandura, Elliott, & Lewkowicz, 1992; McDougal, 1999; Mohs et al., 1998; Oswald et al., 1996; Rasmusson, Rebok, Bylsma, & Brandt, 1999; Rebok & Balcerak, 1989; S. Willis, 1990; S. Willis, Cornelius, Blow, & Baltes, 1983; S. Willis & Nesselroade, 1990; S. Willis & Schaie, 1986, 1994), and that performance on these abilities is associated with performance of cognitively demanding instrumental activities of daily living, critical for independent living (K. Ball & Owsley, 2000; K. Ball, Owsley, Sloane, Roenker, & Bruni, 1993; Diehl, Willis, & Schaie, 1995; S. L. Willis, 1996; S. L. Willis, Jay, Diehl, & Marsiske, 1992). ACTIVE began in September, 1996 at six field centers: the University of Alabama at Birmingham, the Boston Hebrew Rehabilitation Center for Aged (now Hebrew Senior Life), the Indiana University School of Medicine, the Johns Hopkins University, the Pennsylvania State University, and Wayne State University, with a data coordinating center at the New England Research Institutes. The conceptual model that informed the design of ACTIVE (Figure 1) was based on prior evidence showing that cognitive training would be domain specific. That is, each intervention was expected to result in specific improvement on measures of the trained ability relative to the other interventions and control group. For example, training in memory was expected to improve memory function (the proximal outcome) but was not expected to improve reasoning or speed of processing skills. On the other hand, intervention effects were expected to show some level of general transfer to daily function (the primary outcome) based on the critical assumption that declines in cognitive function lead to declines in activities in daily living. In other words, improvement in cognitive ability should result in maintenance of functional independence. In turn, maintained functional independence could result in a positive cascade of effects including improvements in quality of life, mobility, and health service utilization. Figure 1 Hypothesized mode of effects in ACTIVE trial. Influence of intervention on primary and secondary outcomes is mediated through trained abilities. Bold lines represent specific effects of training. Dashed lines represent non-specific effects of training ...

Zoledronic Acid Cut Older Men's Fractures

Zoledronic Acid Cut Older Men's Fractures

Characteristics of Chronic Pain Associated with Sleep Difficulty in Older Adults: The Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly (MOBILIZE) Boston Study

To evaluate pain severity and distribution in relation to sleep difficulty in older adults. Population-based cross-sectional study. Community within a 5-mile radius of the study center at the Institute for Aging Research, Hebrew SeniorLife (HSL), Boston. Seven hundred sixty-five participants of the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly (MOBILIZE) Boston Study aged 64 and older. Pain severity was measured using the Brief Pain Inventory (BPI) Pain Severity Subscale. Musculoskeletal pain distribution was grouped according to no pain, single site, two or more sites, and widespread pain (upper and lower extremities and back pain). Three aspects of sleep difficulty were measured using items from the Center for Epidemiologic Studies Depression Scale, Revised (trouble getting to sleep, sleep more than usual, and restless sleep). Prevalence of trouble getting to sleep according to BPI severity was 17.8%, 19.7%, 32.0%, and 37.0% for the lowest to highest pain severity quartiles, respectively. Similar relationships between pain and sleep were observed across sleep measures according to pain severity and distribution. Adjusted for sociodemographic characteristics, chronic conditions, and health behaviors, chronic pain was strongly associated with trouble sleeping (≥ 1 d/wk) (single-site pain, odds ratio (OR)=1.77, 95% confidence interval (CI)=1.10-2.87; multisite pain, OR=2.38, 95% CI=1.48-3.83; widespread pain, OR=2.55, 95% CI=1.43-4.54, each compared with no pain). Similar associations were observed for restless sleep and sleeping more than usual. For specific pain sites alone or in combination with other sites of pain, only modest associations were observed with sleep problems. Widespread or other multisite pain and moderate to severe pain are strongly associated with sleep difficulty in older adults. Further research is needed to better understand the burden and consequences of pain-related sleep problems in older adults.

Medical Director Finalists Share Their Secrets to Success

Medical Director Finalists Share Their Secrets to Success

Response to “fat mass is a positive predictor of bone mass in adolescents”

Xiumei Hong , Yi-Hsiang Hsu , and Xiaobin Wang Mary Ann and J. Milburn Smith Child Health Research Program, Department of Pediatrics, Northwestern University Feinberg School of Medicine and Children’s Memorial Hospital and Children’s Memorial Research Center, Chicago, IL, USA Institute for Biomedicine, Anhui Medical University, Hefei, People’s Republic of China Hebrew SeniorLife Institute for Aging Research and Harvard Medical School, Boston, MA, USA Molecular and Integrative Physiological Sciences Program, Harvard School of Public Health, Boston, MA, USA

Medical Director of the Year Leads by Example and Design

Medical Director of the Year Leads by Example and Design

Reporting Dementia on the Death Certificates of Nursing Home Residents Dying With End-Stage Dementia

To the Editor: In 2004, the National Center for Health Statistics (NCHS) ranked Alzheimer disease as the fifth leading cause of death among US residents older than 65 years, an increase from prior years.1 NCHS data are derived from death certificates. Retrospective studies of patients who died at various stages of dementia suggest this condition is under-reported on death certificates.2,3 We prospectively observed a cohort of nursing home residents who had been diagnosed with end-stage dementia to describe which conditions were documented on their death certificates. Methods. Data were collected between 2003 and 2007 from the Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life study, a prospective study of 323 residents of 22 Boston-area nursing homes with advanced dementia, each followed up for up to 18 months.4 Eligibility criteria included age older than 60 years and advanced dementia (based on physician documentation of dementia in chart and Global Deterioration Scale stage 7 determined by a nurse).5 The Hebrew SeniorLife institutional review board approved this study. Written consent was provided by participants’ health care proxies. Descriptive data included age, sex, race (reported by proxies using predefined categories), dementia type (Alzheimer, vascular, or other, from medical records), nursing home length of stay, living in a dementia special care unit, location of death, and functional status at study entry (from nurses; Bedford Alzheimer Nursing Severity Subscale6). Descriptive variables, including race, were ascertained to allow for comparability with other samples. Massachusetts death certificates, obtained for all participants who died during follow-up, have 3 sections. In part 1, line A requests the “immediate cause of death.” Lines B through D request the “sequence of conditions resulting in the immediate cause of death.” Part 2 asks for “other significant conditions contributing to death” (no limit on number). Two research assistants who were unaware of the study aims independently abstracted causes of death verbatim from the death certificates. Conditions were categorized into predefined clinically relevant groups and quantified using proportions. Exact binomial 95% confidence intervals (CIs) were calculated using SAS version 9.1 (SAS Institute, Cary, North Carolina). Results. Of the 323 participants, 165 died during follow-up (Table 1). Among all decedents, dementia documentation on their death certificates was none, 37.0% (95% CI, 29.6%–44.8%); listed in part 1 line A, 15.8% (95% CI, 10.6%–22.2%); listed in part 1 lines B–D, 35.2% (95% CI, 27.9%–43.0%); and listed in part 2, 16.4% (95% CI, 11.2%–22.9%) (Table 2). Seven participants had dementia listed in parts 1 and 2. Among the 114 decedents with a premortem diagnosis of Alzheimer disease, documentation of dementia anywhere on their death certificates was none, 33.3% (95% CI, 24.8%–42.8%); Alzheimer disease, 27.2% (95% CI, 19.3%–36.8%); “dementia” without further specification, 37.7% (95% CI, 28.8%–47.3%); and vascular dementia, 0.9% (95% CI, 0.2%–4.8%). Table 1 Characteristics of Nursing Home Decedents With Advanced Dementia (N = 165) Table 2 Causes of Death of Decedents With Advanced Dementia in Nursing Homes, Recorded According to Location on Death Certificates (N = 165) Comment. In this study, dementia, and specifically Alzheimer disease, was underreported on death certificates, raising concerns about the accuracy of mortality statistics based on these documents. Despite the terminal stage of dementia in our cohort, dementia was not recorded on 37% of death certificates. The absence of Alzheimer disease on three-quarters of death certificates of decedents with this premortem diagnosis is a particular problem because among the causes of dementia, NCHS ranks only Alzheimer disease among its leading causes of death. This study is limited in that 94% of the cohort died in nursing homes where dementia is more likely to be reported on death certificates compared with hospitals.2 There may be some inaccuracies in the clinical dementia subtypes obtained from the chart. The findings may not be generalizable outside Boston; however, the study sample and nursing homes are comparable with those in the rest of the United States.4 An appreciation that patients die from and with dementia is necessary to inform end-of-life decision making. Underestimation of the burden of dementia as a major fatal illness may hamper planning of health services needed for persons dying with this condition.

Want to Promote Long-Term Care? Consider Teaching It

Want to Promote Long-Term Care? Consider Teaching It