1
|
Pana A, Sourtzi P, Kalokairinou A, Pastroudis A, Chatzopoulos ST, Velonaki VS. Association between self-reported or perceived fatigue and falls among older people: A systematic review. Int J Orthop Trauma Nurs 2021; 43:100867. [PMID: 34399107 DOI: 10.1016/j.ijotn.2021.100867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/18/2021] [Accepted: 04/23/2021] [Indexed: 12/12/2022]
Abstract
AIM The aim of the present review was to examine the evidence of the relationship between self-reported or perceived fatigue and falls among older adults. METHODS A systematic review, following the PRISMA recommendations, was performed. PubMed, Scopus, Web of Science, and Cinahl were searched from February 2021 until March 2021, without any limitation on publication date. The methodological quality of the recruited studies was assessed with the Newcastle-Ottawa scale. RESULTS Of the 2,296 initially retrieved records, 20 met the inclusion criteria; 11 cohort and 9 cross-sectional studies. They were classified as "good or very good" studies. Data on 59,852 older adults was reported. Most studies reported a strong association between fatigue and incidence or risk of falls, with odds ratios ranging from 1.04 to 3.53. Evidence obout the relationship between fatigue and recurrent, as well as injurious, falls is limited. CONCLUSIONS Self-reported or perceived fatigue is associated with the incidence of falls or risk of falling among older adults. Nurses could contribute to decreasing the inicdence of falls through prevention and proper geriatric assessment, including the management of fatigue in their daily clinical practice. The evidence about the potential effect of fatigue on falls-related injuries is inconclusive and on recurrent falls remains to be further defined.
Collapse
Affiliation(s)
- Anastasia Pana
- National and Kapodistrian University of Athens, Department of Nursing, Greece; Hellenic Association of Gerontology and Geriatrics, Athens, Greece; General Hospital Asklepieio, Voula, Greece.
| | - Panayota Sourtzi
- National and Kapodistrian University of Athens, Department of Nursing, Greece; Hellenic Association of Gerontology and Geriatrics, Athens, Greece
| | - Athina Kalokairinou
- National and Kapodistrian University of Athens, Department of Nursing, Greece
| | - Alexandros Pastroudis
- Hellenic Association of Gerontology and Geriatrics, Athens, Greece; General Hospital Asklepieio, Voula, Greece
| | | | - Venetia Sofia Velonaki
- National and Kapodistrian University of Athens, Department of Nursing, Greece; Hellenic Association of Gerontology and Geriatrics, Athens, Greece
| |
Collapse
|
2
|
Blinka MD, Buta B, Bader KD, Hanley C, Schoenborn NL, McNabney M, Xue QL. Developing a sensor-based mobile application for in-home frailty assessment: a qualitative study. BMC Geriatr 2021; 21:101. [PMID: 33541276 PMCID: PMC7863502 DOI: 10.1186/s12877-021-02041-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 01/20/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Frailty syndrome disproportionately affects older people, including 15% of non-nursing home population, and is known to be a strong predictor of poor health outcomes. There is a growing interest in incorporating frailty assessment into research and clinical practice, which may provide an opportunity to improve in home frailty assessment and improve doctor patient communication. METHODS We conducted focus groups discussions to solicit input from older adult care recipients (non-frail, pre-frail, and frail), their informal caregivers, and medical providers about their preferences to tailor a mobile app to measure frailty in the home using sensor based technologies. Focus groups were recorded, transcribed, and analyzed thematically. RESULTS We identified three major themes: 1) perspectives of frailty; 2) perceptions of home based sensors; and 3) data management concerns. These relate to the participants' insight, attitudes and concerns about having sensor-based technology to measure frailty in the home. Our qualitative findings indicate that knowing frailty status is important and useful and would allow older adults to remain independent longer. Participants also noted concerns with data management and the hope that this technology would not replace in-person visits with their healthcare provider. CONCLUSIONS This study found that study participants of each frailty status expressed high interest and acceptance of sensor-based technologies. Based on the qualitative findings of this study, sensor-based technologies show promise for frailty assessment of older adults with care needs. The main concerns identified related to the volume of data collected and strategies for responsible and secure transfer, reporting, and distillation of data into useful and timely care information. Sensor-based technologies should be piloted for feasibility and utility. This will inform the larger goal of helping older adults to maintain independence while tracking potential health declines, especially among the most vulnerable, for early detection and intervention.
Collapse
Affiliation(s)
- Marcela D Blinka
- Center on Aging and Health, Johns Hopkins University, 2024 E. Monument Street, Suite 2-700, Baltimore, MD, 21205, USA.
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Brian Buta
- Center on Aging and Health, Johns Hopkins University, 2024 E. Monument Street, Suite 2-700, Baltimore, MD, 21205, USA
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kevin D Bader
- The Johns Hopkins University Applied Physics Laboratory, Laurel, MD, USA
| | - Casey Hanley
- The Johns Hopkins University Applied Physics Laboratory, Laurel, MD, USA
| | - Nancy L Schoenborn
- Center on Aging and Health, Johns Hopkins University, 2024 E. Monument Street, Suite 2-700, Baltimore, MD, 21205, USA
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew McNabney
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Qian-Li Xue
- Center on Aging and Health, Johns Hopkins University, 2024 E. Monument Street, Suite 2-700, Baltimore, MD, 21205, USA.
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
3
|
Bandeen-Roche K, Gross AL, Varadhan R, Buta B, Carlson MC, Huisingh-Scheetz M, Mcadams-Demarco M, Piggott DA, Brown TT, Hasan RK, Kalyani RR, Seplaki CL, Walston JD, Xue QL. Principles and Issues for Physical Frailty Measurement and Its Clinical Application. J Gerontol A Biol Sci Med Sci 2021; 75:1107-1112. [PMID: 31287490 DOI: 10.1093/gerona/glz158] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION "Frailty" has attracted attention for its promise of identifying vulnerable older adults, hence its potential use to better tailor geriatric health care. There remains substantial controversy, however, regarding its nature and ascertainment. Recent years have seen a proliferation of frailty assessment methods. We argue that the development of frailty assessments should be grounded in "validation"-the process of substantiating that a measurement accurately and precisely measures what it intends, identify unresolved measurement issues, and highlight measurement-related considerations for clinical practice. METHODS Principles for validating frailty measures are elucidated. We follow principles-articulated, for example, by Borsboom-in which a construct must be clearly defined and then analyses undertaken to substantiate that a measurement accurately and precisely measures what it intends. Key elements are content validity, criterion validity, and construct validity, with an emphasis on the latter. RESULTS We illustrate the principles for a physical frailty phenotype construct. CONCLUSIONS Unresolved conceptual issues include the roles of intersecting concepts such as cognition, disease severity, and disability in frailty measurement, conceptualization of frailty as a state versus a continuum, and the potential need for dynamic measures and systems concepts in furthering understanding of frailty. Clinical considerations include needs to distinguish interventions designed to address frailty "symptoms" versus underlying physiology, improve "prefrailty" measures intended to screen individuals early in their frailty progression, address feasibility demands, and further visioning followed by rigorous efficacy research to address the landscape of potential uses of frailty assessment in clinical practice.
Collapse
Affiliation(s)
- Karen Bandeen-Roche
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alden L Gross
- Department of Epidemiology, Baltimore, Maryland.,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ravi Varadhan
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Brian Buta
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Michelle C Carlson
- Department of Epidemiology, Baltimore, Maryland.,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Megan Huisingh-Scheetz
- Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago Medicine, Illinois
| | | | - Damani A Piggott
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of Epidemiology, Baltimore, Maryland
| | - Todd T Brown
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rani K Hasan
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rita R Kalyani
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Jeremy D Walston
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Qian-Li Xue
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of Epidemiology, Baltimore, Maryland
| |
Collapse
|
4
|
Atkins JL, Delgado J, Pilling LC, Bowman K, Masoli JAH, Kuchel GA, Ferrucci L, Melzer D. Impact of Low Cardiovascular Risk Profiles on Geriatric Outcomes: Evidence From 421,000 Participants in Two Cohorts. J Gerontol A Biol Sci Med Sci 2019; 74:350-357. [PMID: 29982474 PMCID: PMC6376108 DOI: 10.1093/gerona/gly083] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Individuals with low cardiovascular risk factor profiles experience lower rates of cardiovascular diseases, but associations with geriatric syndromes are unclear. We tested whether individuals with low cardiovascular disease risk, aged 60-69 years old at baseline in two large cohorts, were less likely to develop aging-related adverse health outcomes. METHODS Data were from population representative medical records (Clinical Practice Research Datalink [CPRD] England, n = 239,591) and healthy volunteers (UK Biobank [UKB], n = 181,820), followed for ≤10 years. A cardiovascular disease risk score (CRS) summarized smoking status, LDL-cholesterol, blood pressure, body mass index, fasting glucose and physical activity, grouping individuals as low (ie, all factors near ideal), moderate, or high CRS. Logistic regression, Cox models, and Fine and Grey risk models tested the associations between the CRS and health outcomes. RESULTS Low CRS individuals had less chronic pain (UKB: baseline odds ratio = 0.52, confidence interval [CI] = 0.50-0.54), lower incidence of incontinence (CPRD: subhazard ratio [sub-HR] = 0.75, 0.63-0.91), falls (sub-HR = 0.82, CI = 0.73-0.91), fragility fractures (sub-HR = 0.78, CI = 0.65-0.93), and dementia (vs. high risks; UKB: sub-HR = 0.67, CI = 0.50-0.89; CPRD: sub-HR = 0.79, CI = 0.56-1.12). Only 5.4% in CPRD with low CRS became frail (Rockwood index) versus 24.2% with high CRS. All-cause mortality was markedly lower in the low CRS group (vs. high CRS; HR = 0.40, 95% CI = 0.35-0.47). All associations showed dose-response relationships, and results were similar in both cohorts. CONCLUSIONS Persons aged 60-69 years with near-ideal cardiovascular risk factor profiles have substantially lower incidence of geriatric conditions and frailty. Optimizing cardiovascular disease risk factors may substantially reduce the burden of morbidity in later life.
Collapse
Affiliation(s)
- Janice L Atkins
- Epidemiology and Public Health Group, University of Exeter Medical School, UK
| | - João Delgado
- Epidemiology and Public Health Group, University of Exeter Medical School, UK
| | - Luke C Pilling
- Epidemiology and Public Health Group, University of Exeter Medical School, UK
| | - Kirsty Bowman
- Epidemiology and Public Health Group, University of Exeter Medical School, UK
| | - Jane A H Masoli
- Epidemiology and Public Health Group, University of Exeter Medical School, UK.,Healthcare for Older People, Royal Devon and Exeter NHS Foundation Trust, UK
| | - George A Kuchel
- Department of Geriatric Medicine, Center on Aging, University of Connecticut, Farmington
| | | | - David Melzer
- Epidemiology and Public Health Group, University of Exeter Medical School, UK
| |
Collapse
|
5
|
Shardell M, Semba RD, Kalyani RR, Bandinelli S, Prather AA, Chia CW, Ferrucci L. Plasma Klotho and Frailty in Older Adults: Findings From the InCHIANTI Study. J Gerontol A Biol Sci Med Sci 2019; 74:1052-1057. [PMID: 29053774 PMCID: PMC6580690 DOI: 10.1093/gerona/glx202] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 10/16/2017] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The hormone klotho, encoded by the gene klotho, is primarily expressed in the kidney and choroid plexus of the brain. Higher klotho concentrations have been linked to better physical performance; however, it is unknown whether klotho relates to frailty status in older adults. METHODS Plasma klotho was measured in 774 participants aged ≥65 years enrolled in InCHIANTI, a prospective cohort study comprising Italian adults. Frailty status was assessed at 3 and 6 years after enrollment. Frailty was defined as presence of at least three out of five criteria of unintentional weight loss, exhaustion, sedentariness, muscle weakness, and slow walking speed; prefrailty was defined as presence of one or two criteria; and robustness was defined as zero criteria. We assessed whether plasma klotho concentrations measured at the 3-year visit related to frailty. RESULTS Each additional natural logarithm of klotho (pg/mL) was associated with lower odds of frailty versus robustness after adjustment for covariates (odds ratio [OR] 0.46; 95% confidence interval 0.21, 0.98; p-value = .045). Higher klotho was particularly associated with lower odds of exhaustion (OR 0.57; 95% CI 0.36, 0.89; p-value = .014). Participants with higher klotho also had lower estimated odds of weight loss and weakness, but these findings were not statistically significant. CONCLUSIONS Higher plasma klotho concentrations were associated with lower likelihoods of frailty and particularly exhaustion. Future studies should investigate modifiable mechanisms through which klotho may affect the frailty syndrome.
Collapse
Affiliation(s)
- Michelle Shardell
- Translational Gerontology Branch, National Institute on Aging, Baltimore, Maryland
| | - Richard D Semba
- Wilmer Eye Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Rita R Kalyani
- Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | | | - Aric A Prather
- Department of Psychiatry, University of California San Francisco, San Francisco, California
| | - Chee W Chia
- Translational Gerontology Branch, National Institute on Aging, Baltimore, Maryland
| | - Luigi Ferrucci
- Translational Gerontology Branch, National Institute on Aging, Baltimore, Maryland
| |
Collapse
|
6
|
McAdams-DeMarco MA, Chu NM, Segev DL. Frailty and Long-Term Post-Kidney Transplant Outcomes. CURRENT TRANSPLANTATION REPORTS 2019; 6:45-51. [PMID: 31768307 PMCID: PMC6876846 DOI: 10.1007/s40472-019-0231-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW To highlight recent research about frailty and its role as a predictor of adverse, long-term post-kidney transplant (KT) outcomes. RECENT FINDINGS Frailty is easily measured using the physical frailty phenotype (PFP) developed by gerontologist Dr. Linda Fried and colleagues. In recent studies, >50% of KT recipients were frail (20%) or intermediately frail (32%) at KT admission. Frail recipients were at 1.3-times higher risk of immunosuppression intolerance and 2.2-times higher risk of mortality, even after accounting for recipient, donor, and transplant factors; these findings were consistent with those on short-term post-KT outcomes. Pilot data suggests that prehabilitation may be an intervention that increases physiologic reserve in frail KT recipients. SUMMARY The PFP is a effective tool to measure frailty in ESRD that improves risk stratification for short-term and long-term post-KT outcomes. Interventions to improve physiologic reserve and prevent adverse KT outcomes, particularly among frail KT recipients, are needed.
Collapse
Affiliation(s)
- Mara A. McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of
Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg
School of Public Health, Baltimore, MD
| | - Nadia M. Chu
- Department of Surgery, Johns Hopkins University School of
Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg
School of Public Health, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of
Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg
School of Public Health, Baltimore, MD
| |
Collapse
|
7
|
Wu C, Geldhof GJ, Xue QL, Kim DH, Newman AB, Odden MC. Development, Construct Validity, and Predictive Validity of a Continuous Frailty Scale: Results From 2 Large US Cohorts. Am J Epidemiol 2018; 187:1752-1762. [PMID: 29688247 DOI: 10.1093/aje/kwy041] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 02/27/2018] [Indexed: 01/10/2023] Open
Abstract
Frailty is an age-related clinical syndrome of decreased resilience to stressors. Among numerous assessments of frailty, the frailty phenotype (FP) scale proposed by Fried et al. has been the most widely used. We aimed to develop a continuous frailty scale that could overcome limitations facing the categorical FP scale and to evaluate its construct validity, predictive validity, and measurement properties. Data were from the Cardiovascular Health Study (n = 4,243) and Health and Retirement Study (n = 7,600), both conducted in the United States. Frailty was conceptualized as a continuous construct, assessed by 5 measures used in the FP scale: gait speed, grip strength, exhaustion, physical activity, and weight loss. We used confirmatory factor analysis to investigate the relationship between the 5 indicators and the latent frailty construct. We examined the association of the continuous frailty scale with mortality and disability. The unidimensional model fit the data satisfactorily; similar factor structure was observed across 2 cohorts. Gait speed and weight loss were the strongest and weakest indicators, respectively; grip strength, exhaustion, and physical activity had similar strength in measuring frailty. In each cohort, the continuous frailty scale was strongly associated with mortality and disability and continued to be associated with outcomes among robust and prefrail persons classified by the FP scale.
Collapse
Affiliation(s)
- Chenkai Wu
- Department of Public Health, School of Health Sciences and Practice, New York Medical College, Valhalla, New York
- School of Biological and Population Health Sciences, Oregon State University, Corvallis, Oregon
| | - G John Geldhof
- School of Social and Behavioral Health Sciences, Oregon State University, Corvallis, Oregon
| | - Qian-Li Xue
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Center on Aging and Health, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Dae H Kim
- Division of Gerontology, Beth Israel Deaconess Medical Center, Harvard University, Boston, Massachusetts
| | | | - Michelle C Odden
- School of Biological and Population Health Sciences, Oregon State University, Corvallis, Oregon
| |
Collapse
|
8
|
Rutenberg AD, Mitnitski AB, Farrell SG, Rockwood K. Unifying aging and frailty through complex dynamical networks. Exp Gerontol 2018; 107:126-129. [DOI: 10.1016/j.exger.2017.08.027] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/17/2017] [Accepted: 08/21/2017] [Indexed: 01/08/2023]
|
9
|
Lopez-Garcia E, Hagan KA, Fung TT, Hu FB, Rodríguez-Artalejo F. Mediterranean diet and risk of frailty syndrome among women with type 2 diabetes. Am J Clin Nutr 2018; 107:763-771. [DOI: 10.1093/ajcn/nqy026] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/01/2018] [Indexed: 01/05/2023] Open
Affiliation(s)
- Esther Lopez-Garcia
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid-IdiPaz, Madrid, Spain
- CIBERESP (CIBER of Epidemiology and Public Health), Madrid, Spain
- IMDEA/Food Institute. CEI UAM+CSIC, Madrid, Spain
| | - Kaitlin A Hagan
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
- Departments of Epidemiology and Nutrition, Harvard TH Chan School of Public Health, Boston, MA
| | - Teresa T Fung
- Departments of Nutrition, Harvard TH Chan School of Public Health, Boston, MA
- Department of Nutrition, Simmons College, Boston, MA
| | - Frank B Hu
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
- Departments of Nutrition, Harvard TH Chan School of Public Health, Boston, MA
| | - Fernando Rodríguez-Artalejo
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid-IdiPaz, Madrid, Spain
- CIBERESP (CIBER of Epidemiology and Public Health), Madrid, Spain
- IMDEA/Food Institute. CEI UAM+CSIC, Madrid, Spain
| |
Collapse
|
10
|
Bandeen-Roche K, Espinoza SE. Getting Underneath Observed Frailty Transitions: Meaningful Change, Prevention, and Intervention. J Am Geriatr Soc 2017; 65:2455-2456. [PMID: 28873221 DOI: 10.1111/jgs.15034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Karen Bandeen-Roche
- Department of Biostatistics and Center on Aging and Health, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland
| | - Sara E Espinoza
- Barshop Institute for Longevity & Aging Studies, University of Texas Health Science Center at San Antonio, San Antonio, Texas.,Geriatrics Research, Education and Clinical Center, South Texas Veterans Health Care System, San Antonio, Texas
| |
Collapse
|