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Gijzel SMW, Rector J, van Meulen FB, van der Loeff RS, van de Leemput IA, Scheffer M, Olde Rikkert MGM, Melis RJF. Measurement of Dynamical Resilience Indicators Improves the Prediction of Recovery Following Hospitalization in Older Adults. J Am Med Dir Assoc 2019; 21:525-530.e4. [PMID: 31836428 DOI: 10.1016/j.jamda.2019.10.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 10/07/2019] [Accepted: 10/16/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Acute illnesses and subsequent hospital admissions present large health stressors to older adults, after which their recovery is variable. The concept of physical resilience offers opportunities to develop dynamical tools to predict an individual's recovery potential. This study aimed to investigate if dynamical resilience indicators based on repeated physical and mental measurements in acutely hospitalized geriatric patients have added value over single baseline measurements in predicting favorable recovery. DESIGN Intensive longitudinal study. SETTING AND PARTICIPANTS 121 patients (aged 84.3 ± 6.2 years, 60% female) admitted to the geriatric ward for acute illness. MEASUREMENTS In addition to preadmission characteristics (frailty, multimorbidity), in-hospital heart rate and physical activity were continuously monitored with a wearable sensor. Momentary well-being (life satisfaction, anxiety, discomfort) was measured by experience sampling 4 times per day. The added value of dynamical indicators of resilience was investigated for predicting recovery at hospital discharge and 3 months later. RESULTS 31% of participants satisfied the criteria of good recovery at hospital discharge and 50% after 3 months. A combination of a frailty index, multimorbidity, Clinical Frailty Scale, and or gait speed predicted good recovery reasonably well on the short term [area under the receiver operating characteristic curve (AUC) = 0.79], but only moderately after 3 months (AUC = 0.70). On addition of dynamical resilience indicators, the AUC for predicting good 3-month recovery increased to 0.79 (P = .03). Variability in life satisfaction and anxiety during the hospital stay were independent predictors of good 3-month recovery [odds ratio (OR) = 0.24, P = .01, and OR = 0.54, P = .04, respectively]. CONCLUSIONS AND IMPLICATIONS These results highlight that measurements capturing the dynamic functioning of multiple physiological systems have added value in assessing physical resilience in clinical practice, especially those monitoring mental responses. Improved monitoring and prediction of physical resilience could help target intensive treatment options and subsequent geriatric rehabilitation to patients who will most likely benefit from them.
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Affiliation(s)
- Sanne M W Gijzel
- Department of Geriatrics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Environmental Sciences, Wageningen University, Wageningen, the Netherlands
| | - Jerrald Rector
- Department of Geriatrics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Fokke B van Meulen
- Department of Geriatrics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rolinka Schim van der Loeff
- Department of Geriatrics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Marten Scheffer
- Department of Environmental Sciences, Wageningen University, Wageningen, the Netherlands
| | - Marcel G M Olde Rikkert
- Department of Geriatrics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - René J F Melis
- Department of Geriatrics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
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Dent E, Martin FC, Bergman H, Woo J, Romero-Ortuno R, Walston JD. Management of frailty: opportunities, challenges, and future directions. Lancet 2019; 394:1376-1386. [PMID: 31609229 DOI: 10.1016/s0140-6736(19)31785-4] [Citation(s) in RCA: 675] [Impact Index Per Article: 135.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 07/03/2019] [Accepted: 07/10/2019] [Indexed: 12/13/2022]
Abstract
Frailty is a complex age-related clinical condition characterised by a decline in physiological capacity across several organ systems, with a resultant increased susceptibility to stressors. Because of the heterogeneity of frailty in clinical presentation, it is important to have effective strategies for the delivery of care that range across the continuum of frailty severity. In clinical practice, we should do what works, starting with frailty screening, case identification, and management of frailty. This process is unarguably difficult given the absence of an adequate evidence base for individual and health-system interventions to manage frailty. We advocate change towards individually tailored interventions that preserve an individual's independence, physical function, and cognition. This change can be addressed by promoting the recognition of frailty, furthering advancements in evidence-based treatment options, and identifying cost-effective care delivery strategies.
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Affiliation(s)
- Elsa Dent
- Torrens University Australia, Adelaide, SA, Australia; Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.
| | | | - Howard Bergman
- Department of Family Medicine, McGill University, Montréal, QC, Canada
| | - Jean Woo
- Department of Medicine, Chinese University of Hong Kong, Hong Kong, Special Administrative Region, China
| | - Roman Romero-Ortuno
- Discipline of Medical Gerontology and Global Brain Health Institute, Trinity College, Dublin, Ireland; Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Jeremy D Walston
- Division of Geriatric Medicine and Gerontology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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53
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Gijzel SMW, Whitson HE, van de Leemput IA, Scheffer M, van Asselt D, Rector JL, Olde Rikkert MGM, Melis RJF. Resilience in Clinical Care: Getting a Grip on the Recovery Potential of Older Adults. J Am Geriatr Soc 2019; 67:2650-2657. [PMID: 31498881 PMCID: PMC6916426 DOI: 10.1111/jgs.16149] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 07/23/2019] [Accepted: 07/26/2019] [Indexed: 12/12/2022]
Abstract
Background Geriatricians are often confronted with unexpected health outcomes in older adults with complex multimorbidity. Aging researchers have recently called for a focus on physical resilience as a new approach to explaining such outcomes. Physical resilience, defined as the ability to resist functional decline or recover health following a stressor, is an emerging construct. Methods Based on an outline of the state‐of‐the‐art in research on the measurement of physical resilience, this article describes what tests to predict resilience can already be used in clinical practice and which innovations are to be expected soon. Results An older adult's recovery potential is currently predicted by static tests of physiological reserves. Although geriatric medicine typically adopts a multidisciplinary view of the patient and implicitly performs resilience management to a certain extent, clinical management of older adults can benefit from explicitly applying the dynamical concept of resilience. Two crucial leads for advancing our capacity to measure and manage the resilience of individual patients are advocated: first, performing multiple repeated measurements around a stressor can provide insight about the patient's dynamic responses to stressors; and, second, linking psychological and physiological subsystems, as proposed by network studies on resilience, can provide insight into dynamic interactions involved in a resilient response. Conclusion A big challenge still lies ahead in translating the dynamical concept of resilience into clinical tools and guidelines. As a first step in bridging this gap, this article outlines what opportunities clinicians and researchers can already exploit to improve prediction, understanding, and management of resilience of older adults. J Am Geriatr Soc 67:2650–2657, 2019
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Affiliation(s)
- Sanne M W Gijzel
- Department of Geriatrics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Environmental Sciences, Wageningen University, Wageningen, The Netherlands
| | - Heather E Whitson
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina.,Duke Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina.,Geriatrics Research Education and Clinical Center, Durham Veteran Affairs (VA) Medical Center, Durham, North Carolina
| | | | - Marten Scheffer
- Department of Environmental Sciences, Wageningen University, Wageningen, The Netherlands
| | - Dieneke van Asselt
- Department of Geriatrics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jerrald L Rector
- Department of Geriatrics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel G M Olde Rikkert
- Department of Geriatrics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - René J F Melis
- Department of Geriatrics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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54
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Dekhtyar S, Vetrano DL, Marengoni A, Wang HX, Pan KY, Fratiglioni L, Calderón-Larrañaga A. Association Between Speed of Multimorbidity Accumulation in Old Age and Life Experiences: A Cohort Study. Am J Epidemiol 2019; 188:1627-1636. [PMID: 31274148 DOI: 10.1093/aje/kwz101] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 04/16/2019] [Accepted: 04/17/2019] [Indexed: 11/14/2022] Open
Abstract
Rapidly accumulating multiple chronic conditions (multimorbidity) during aging are associated with many adverse outcomes. We explored the association between 4 experiences throughout life-childhood socioeconomic circumstances, early-adulthood education, midlife occupational stress, and late-life social network-and the speed of chronic disease accumulation. We followed 2,589 individuals aged ≥60 years from the Swedish National Study on Aging and Care in Kungsholmen for 9 years (2001-2013). Information on life experiences was collected from detailed life-history interviews. Speed of disease accumulation was operationalized as the change in the count of chronic conditions obtained from clinical examinations, medical histories, laboratory data, drug use, and register linkages over 9 years. Linear mixed models were used to analyze the data. Speed of disease accumulation was lower in individuals with more than elementary education (for secondary, β × time = -0.065, 95% CI: -0.126, -0.004; for university, β × time = -0.118, 95% CI: -0.185, -0.050); for active occupations compared with high-strain jobs (β × time = -0.078, 95% CI: -0.138, -0.017); and for richer social networks (for moderate tertile, β × time = -0.102, 95% CI: -0.149, -0.055; for highest tertile, β × time = -0.135, 95% CI: -0.182, -0.088). The association between childhood circumstances and speed of disease accumulation was attenuated by later-life experiences. Diverse experiences throughout life might decelerate chronic disease accumulation during aging.
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Affiliation(s)
- Serhiy Dekhtyar
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Davide Liborio Vetrano
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
- Department of Geriatrics, Università Cattolica del Sacro Cuore, Rome, Italy
- Centro di Medicina dell’Invecchiamento, Istituto Di Ricovero e Cura a Carattere Scientifico Fondazione Policlinico “A. Gemelli”, Rome, Italy
| | - Alessandra Marengoni
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Hui-Xin Wang
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
- Stress Research Institute, Stockholm University, Stockholm, Sweden
| | - Kuan-Yu Pan
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Laura Fratiglioni
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
- Stockholm Gerontology Research Center, Stockholm, Sweden
| | - Amaia Calderón-Larrañaga
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
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55
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Colón-Emeric C, Whitson HE, Pieper CF, Sloane R, Orwig D, Huffman KM, Bettger JP, Parker D, Crabtree DM, Gruber-Baldini A, Magaziner J. Resiliency Groups Following Hip Fracture in Older Adults. J Am Geriatr Soc 2019; 67:2519-2527. [PMID: 31469411 DOI: 10.1111/jgs.16152] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/12/2019] [Accepted: 07/30/2019] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Defining common patterns of recovery after an acute health stressor (resiliency groups) has both clinical and research implications. We sought to identify groups of patients with similar recovery patterns across 10 outcomes following hip fracture (stressor) and to determine the most important predictors of resiliency group membership. DESIGN Secondary analysis of three prospective cohort studies. SETTING Participants were recruited from various hospitals in the Baltimore Hip Studies network and followed for up to 1 year in their residence (home or facility). PARTICIPANTS Community-dwelling adults aged 65 years or older with recent surgical repair of a hip fracture (n = 541). MEASUREMENTS Self-reported physical function and activity measures using validated scales were collected at baseline (within 15-22 d of fracture), 2, 6, and 12 months. Physical performance tests were administered at all follow-up visits. Stressor characteristics, comorbidities, and psychosocial and environmental factors were collected at baseline via participant report and chart abstraction. Latent class profile analysis was used to identify resiliency groups based on recovery trajectories across 10 outcome measures and logistic regression models to identify factors associated with those groups. RESULTS Latent profile analysis identified three resiliency groups that had similar patterns across the 10 outcome measures and were defined as "high resilience" (n = 163 [30.1%]), "medium resilience" (n = 242 [44.7%]), and "low resilience" (n = 136 [25.2%]). Recovery trajectories for the outcome measures are presented for each resiliency group. Comparing highest with the medium- and low-resilience groups, self-reported pre-fracture function was by far the strongest predictor of high-resilience group membership with area under the curve (AUC) of .84. Demographic factors, comorbidities, stressor characteristics, environmental factors, and psychosocial characteristics were less predictive, but several factors remained significant in a multivariable model (AUC = .88). CONCLUSION These three resiliency groups following hip fracture may be useful for understanding mediators of physical resilience. They may provide a more detailed description of recovery patterns in multiple outcomes for use in clinical decision making. J Am Geriatr Soc 67:2519-2527, 2019.
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Affiliation(s)
- Cathleen Colón-Emeric
- Division of Geriatrics, Duke University Medical Center, Durham, North Carolina.,Geriatric Research Education Clinical Center, Durham Veteran Affairs Medical Center, Durham, North Carolina.,Duke University Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina
| | - Heather E Whitson
- Division of Geriatrics, Duke University Medical Center, Durham, North Carolina.,Geriatric Research Education Clinical Center, Durham Veteran Affairs Medical Center, Durham, North Carolina.,Duke University Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina
| | - Carl F Pieper
- Division of Geriatrics, Duke University Medical Center, Durham, North Carolina.,Geriatric Research Education Clinical Center, Durham Veteran Affairs Medical Center, Durham, North Carolina.,Duke University Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina
| | - Richard Sloane
- Division of Geriatrics, Duke University Medical Center, Durham, North Carolina.,Geriatric Research Education Clinical Center, Durham Veteran Affairs Medical Center, Durham, North Carolina.,Duke University Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina
| | - Denise Orwig
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kim M Huffman
- Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, North Carolina
| | - Janet Prvu Bettger
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Daniel Parker
- Division of Geriatrics, Duke University Medical Center, Durham, North Carolina.,Duke University Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina
| | - Donna M Crabtree
- Duke Office of Clinical Research, School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Ann Gruber-Baldini
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jay Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
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56
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Heart rate variability: a possible marker of resilience. Eur Geriatr Med 2019; 10:529-530. [DOI: 10.1007/s41999-019-00192-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 04/03/2019] [Indexed: 10/27/2022]
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Falutz J, Kirkland S, Guaraldi G. Geriatric Syndromes in People Living with HIV Associated with Ageing and Increasing Comorbidities: Implications for Neurocognitive Complications of HIV Infection. Curr Top Behav Neurosci 2019; 50:301-327. [PMID: 31907879 DOI: 10.1007/7854_2019_119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Long-term survival of treated people living with HIV (PLWH) currently approaches that of the general population. The average age of PLWH is currently in the mid-50s in resource-rich countries and is predicted that over 40% of PLWH will be older than 60 within a decade. Similar trends have been confirmed in all communities of PLWH with access to antiretroviral therapies. However, the positive impact on survival has been challenged by several developments. Ageing PLWH have clinical features similar to the general population about 5-10 years older. In addition to the earlier occurrence of common age-related conditions common geriatric syndromes have also impacted this population prematurely. These are often difficult to evaluate and manage conditions usually of multifactorial aetiology. They include polypharmacy, frailty, impaired mobility and falls, sarcopenia, sensory impairment, and increasingly, non-dementing cognitive decline. Cognitive decline is of particular concern to PLWH and their care providers. In the general geriatric population cognitive impairment increases with age and occurs in all populations with a prevalence of over 25% in people over 80. Effective treatments are lacking and therefore minimizing risk factors plays an important role in maintaining healthspan. In the general population geriatric syndromes may increase the risk of cognitive decline. The corollary is that decreasing the risk of their development may limit cognitive impairment. Whether a similar status holds in PLWH is uncertain. This chapter will address the question of whether common geriatric syndromes in PLWH contribute to cognitive impairment. Common risk factors may provide clues to limit or delay cognitive decline.
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Affiliation(s)
- Julian Falutz
- McGill University Health Centre, Montreal, QC, Canada.
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58
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Kuchel GA. Frailty and Resilience as Outcome Measures in Clinical Trials and Geriatric Care: Are We Getting Any Closer? J Am Geriatr Soc 2018; 66:1451-1454. [PMID: 30094816 DOI: 10.1111/jgs.15441] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 04/24/2018] [Accepted: 04/24/2018] [Indexed: 12/13/2022]
Affiliation(s)
- George A Kuchel
- University of Connecticut Health Center, University of Connecticut Center on Aging, Farmington, CT
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59
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Morey MC, Manning KM, Guo Y, McDonald SR, Heflin MT, Porter Starr KN, Sloane R, Loyack NL, Lagoo-Deenadayalan S. Physical Activity Trackers: Promising Tools to Promote Resilience in Older Surgical Patients. ACTA ACUST UNITED AC 2018; 9. [PMID: 31106298 DOI: 10.29011/2575-9760.001156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Objectives Impending surgery presents a high risk for older adults given their vulnerability to adverse outcomes. New approaches to peri-operative care bring together surgeons, geriatricians, and other Multidisciplinary specialties to co-manage the geriatric surgical patient. However, few have incorporated interventions to promote physical activity (PA) throughout this period. We describe findings from two quality improvement (QI) initiatives that adopted the use of PA trackers to monitor and promote PA during the peri-operative period. Methods QI project within Perioperative Optimization of Senior Health (POSH) clinic at two medical centers (Duke and Durham Veterans Healthcare System (VA)) in Durham, North Carolina. Participants included 38 adults, ages 65+. Participants from POSH-at-Duke received PA trackers with one-time bundled advice from the provider team on nutrition, activity, pain management, medications and other relevant education prior to surgery. Participants from POSH-at-VA received the same one time bundled advice in addition to a visit with an exercise health coach who provided PA guidance followed by weekly PA telephone counseling throughout entire peri-operative period to 4-weeks post-surgery. Primary outcome was daily step counts. Results Ninety three percent of participants approached agreed to use PA trackers. POSH-at-Duke had mean daily step counts of 3,951 at baseline, 4,437 two days prior to surgery, and 1,838 at 4-week post-operative visit as opposed to POSH-at-VA with 2,063 steps at baseline, 5,452 two days prior to surgery, and 4,236 at 4-week post-operative visit, p=0.049 for trajectory differences. Conclusion PA trackers coupled with appropriate continuous PA counseling has a potential utility in promoting resilience in the geriatric surgical candidate.
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Affiliation(s)
- Miriam C Morey
- Geriatric Research, Education and Clinical Center, Durham VA Healthcare System, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Center for the Study of Aging and Human Development/OAIC, Duke University Medical Center, Durham, North Carolina
| | - Kenneth M Manning
- Geriatric Research, Education and Clinical Center, Durham VA Healthcare System, Durham, North Carolina
| | - Ying Guo
- Duke Center for the Study of Aging and Human Development/OAIC, Duke University Medical Center, Durham, North Carolina.,Duke- National University of Singapore Medical School, Singapore
| | - Shelley R McDonald
- Geriatric Research, Education and Clinical Center, Durham VA Healthcare System, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Center for the Study of Aging and Human Development/OAIC, Duke University Medical Center, Durham, North Carolina
| | - Mitchell T Heflin
- Geriatric Research, Education and Clinical Center, Durham VA Healthcare System, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Center for the Study of Aging and Human Development/OAIC, Duke University Medical Center, Durham, North Carolina
| | - Kathryn N Porter Starr
- Geriatric Research, Education and Clinical Center, Durham VA Healthcare System, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Center for the Study of Aging and Human Development/OAIC, Duke University Medical Center, Durham, North Carolina
| | - Richard Sloane
- Geriatric Research, Education and Clinical Center, Durham VA Healthcare System, Durham, North Carolina.,Duke Center for the Study of Aging and Human Development/OAIC, Duke University Medical Center, Durham, North Carolina
| | - Nancy L Loyack
- Surgery, Durham VA Healthcare System, Durham, North Carolina
| | - Sandhya Lagoo-Deenadayalan
- Duke Center for the Study of Aging and Human Development/OAIC, Duke University Medical Center, Durham, North Carolina.,Department of Surgery, Duke University Medical Center, Durham, North Carolina.,Surgery, Durham VA Healthcare System, Durham, North Carolina
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