A Mobile Intervention Designed Specifically for Older Adults With Frailty to Support Healthy Eating: Pilot Randomized Controlled Trial

BACKGROUND

Frailty, a common geriatric syndrome, predisposes older adults to functional decline. No medications can alter frailty's trajectory, but nutritional interventions may aid in supporting independence.

OBJECTIVE

This paper presents a pilot randomized controlled trial to investigate the feasibility and efficacy of a mobile health intervention, "Olitor," designed to enhance adherence to the Mediterranean diet among older adults with frailty, requiring no external assistance.

METHODS

The study sample consisted of 15 participants aged 66-77 (mean 70.5, SD 3.96) years randomized into intervention (n=8; 8 females; mean 72.4, SD 4.8 years) and control groups (n=7; 6 females, 1 male; mean 70.0, SD 3.9 years). The intervention involved a patient-facing mobile app called "Olitor" and a secure web-based administrative dashboard. Participants were instructed to use the app at least weekly for 3 months, which provided feedback on their food choices, personalized recipe recommendations, and an in-app messaging feature. Using Mann-Whitney tests to compare change scores and Hedges g statistics to estimate effect sizes, the primary efficacy outcomes were adherence to the Mediterranean diet score and insulin resistance measures. Secondary outcomes included retention as a measure of feasibility, engagement level and user app quality ratings for acceptability, and additional metrics to evaluate efficacy. Models were adjusted for multiple comparisons.

RESULTS

The findings demonstrated a significant improvement in the Mediterranean diet adherence score in the intervention group compared to the control (W=50.5; adjusted P=.04) with median change scores of 2 (IQR 2-4.25) and 0 (IQR -0.50 to 0.50), respectively. There was a small and insignificant reduction in homeostasis model assessment of insulin resistance measure (W=23; adjusted P=.85). Additionally, there were significant increases in legume intake (W=54; adjusted P<.01). The intervention's effect size was large for several outcomes, such as Mediterranean diet adherence (Hedges g=1.58; 95% CI 0.34-2.67) and vegetable intake (Hedges g=1.14; 95% CI 0.08-2.21). The retention rate was 100%. The app's overall quality rating was favorable with an average interaction time of 12 minutes weekly.

CONCLUSIONS

This pilot study revealed the potential of the mobile intervention "Olitor" in promoting healthier eating habits among older adults with frailty. It demonstrated high retention rates, significant improvement in adherence to the Mediterranean diet, and increased intake of recommended foods. Insulin resistance showed a minor nonsignificant improvement. Several secondary outcomes, such as lower extremity function and Mediterranean diet knowledge, had a large effect size. Although the app's behavior change features were similar to those of previous digital interventions, the distinctive focus on theory-informed mechanistic measures involved in behavioral change, such as self-regulation, self-efficacy, and expected negative outcomes, may have enhanced its potential. Further investigations in a more diverse and representative population, focusing on individuals with impaired insulin sensitivity, are warranted to validate these preliminary findings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05236712; https://clinicaltrials.gov/study/NCT05236712.

Risk factors and early prevention of skin cancer in rural older outdoor workers: A scoping review

Skin cancer risk increases with age and prolonged exposure to ultraviolet radiation (UVR), particularly in rural geographical locations and for individuals with light skin complexions. However, the impact of UVR-induced skin cancer risk and sun-protective behaviors in rural older populations working outdoors has yet to be explored. A scoping review was conducted to fill this gap, with 12 articles meeting the inclusion criteria of aged 50 years and older among rural outdoor workers. Skin cancer risk factors, prevention strategies, and barriers to sun-protective behaviors were summarized for each study. The scoping review addressed some key differences in age-related effects of UVR among rural older outdoor workers compared to studies among adults in general. Findings have policy and research implications that highlight the need to design feasible preventive strategies to reduce rural disparities in cancer care and enhance access to preventive services for this high-risk population.

Associations of Health-Related Quality of Life and Sleep Disturbance With Cardiovascular Disease Risk in Postmenopausal Breast Cancer Survivors

BACKGROUND

Breast cancer (BC) survivors are at an increased risk of long-term cardiovascular disease (CVD), often attributed to cancer treatment. However, cancer treatment may also negatively impact health-related quality of life (HRQoL), a risk factor of CVD in the general population.

OBJECTIVE

We examined whether sleep disturbance, and physical or mental HRQoL were associated with CVD risk in BC survivors.

METHODS

We conducted a longitudinal analysis in the Women's Health Initiative of postmenopausal women given a diagnosis of invasive BC during follow-up through 2010 with no history of CVD before BC. The primary outcome was incident CVD, defined as physician-adjudicated coronary heart disease or stroke, after BC. Physical and mental HRQoL, measured by the Short-Form 36 Physical and Mental Component Summary scores, and sleep disturbance, measured by the Women's Health Initiative Insomnia Rating Scale, were recorded post BC. Time-dependent Cox proportional hazards models were used starting at BC diagnosis until 2010 or censoring and adjusted for relevant confounders.

RESULTS

In 2884 BC survivors, 157 developed CVD during a median follow-up of 9.5 years. After adjustment, higher Physical Component Summary scores were significantly associated with a lower risk of CVD (hazard ratio, 0.90 [95% confidence interval, 0.81-0.99]; per 5-point increment in Physical Component Summary). No associations with CVD were found for Mental Component Summary or Insomnia Rating Scale.

CONCLUSION

In BC survivors, poor physical HRQoL is a significant predictor of CVD.

IMPLICATIONS FOR PRACTICE

Our findings highlight the importance for nurses to assess and promote physical HRQoL as part of a holistic approach to mitigating the risk of CVD in BC survivors.

Examining Engagement and Usability in an Online Discussion Platform for Older Adults: Findings From Pilot Studies

Social media may facilitate older adults' ability to engage socially and explore health information, but it can present difficulties for older adults. Therefore, it is important to explore older adults' experience of usability and user engagement. We conducted two rounds of pilot studies where we used Facebook to engage older adults. We performed a mixed-methods evaluation of user engagement and usability. A directed content analysis of qualitative data from the pilot studies was used to explore engagement and perceived usability, and the Mann-Whitney U test was used to examine differences in feature usage and engagement. We analyzed qualitative data from 13 participants. Qualitative data analysis yielded themes pertaining to three main domains: user engagement , usability , and usability related to aging-related changes . In terms of user engagement and usability, participants in both pilot studies reported positive feedback on felt involvement and endurability, and the second pilot group reported more positive comments regarding perceived usefulness compared with the first pilot group. There was no statistically significant difference in usage over the two studies. The findings of this study suggest opportunities to improve older adults' experience of online discussion platforms. Considering changes that improve perceived aesthetic appeal and focused attention will be helpful.

A THEORETICAL FRAMEWORK FOR UTI PREVENTION AND MANAGEMENT IN COMMUNITY-DWELLING OLDER PERSONS WITH DEMENTIA

UTI admission rates are 3.4 times higher among persons with dementia (PWD) than among those without dementia. The hospitalizations often result in adverse health complications such as the increased risk of delirium, cognitive decline, and higher mortality. To date, several UTI guidelines exist for specific populations, including women, children, people with catheters, and long-term care patients; however, there has been little focus on non-pharmacological prevention and management in PWD. The goal of this work is to propose a theoretical framework for UTI prevention and management in community-dwelling older PWD with the following three aims: 1) identify factors and outcomes of UTIs in community-dwelling older PWD; 2) generate a conceptual framework informed by Bronfenbrenner’s 1977 ecological model; 3) integrate preventive measures to the adapted framework. We conducted a scoping literature review utilizing the following keywords and concepts: risk factors, UTI management and prevention, community-dwelling older adults, and dementia. The UTIP framework was generated with four levels of risk factors (individual, interpersonal, community, and national) and four domains of affected outcomes (PWD, caregivers, PWD and their caregivers, and community/national). Additionally, seven themes of preventive measures emerged: physical activity and mobility, behavioral therapy, personal hygiene, phytotherapy, dietary, compound, and hormone. Finally, a table of care management opportunities was proposed according to dementia severity and caregivers’ involvement. In conclusion, the UTIP framework synthesizes exciting and is flexible to accommodate new evidence. As such, the framework is informative for programs, practices, and policies to lower the risks of preventable admission in PWD.

DEVELOPMENT OF A MOBILE INTERVENTION TO SUPPORT HEALTHY EATING IN PERSON WITH CO-OCCURRING FRAILTY AND DEMENTIA

New behavioral solutions are needed to improve health in persons with co-occurring frailty and dementia. Using dementia-specific principles of human-centered design, we developed a mobile intervention that includes a patient-facing app and clinician interface to promote a Mediterranean-style eating plan in this population. Our design processes were as follows. We first solicited iterative input from experts in dementia, accessible design, and technology concerning language, cognitive load, and overall accessibility needs in persons with early dementia. Next, we recruited seven people with mild dementia and their partners for interviews, experience sampling, and usability studies. Our primary findings were: 1) participants have basic knowledge of healthy eating tenets and want to learn more; 2) participants are unaware of anything specific to improve in their diet; 3) participants value simple meals with few ingredients; 4) participants strongly rely on physical cookbooks. Based on the results, we developed a high-fidelity prototype of the patient-facing mobile app, divided into tasks: 1) First time onboarding; 2) Setting the first dietary goal; 3) Finding a recipe; 4) Filter/sort for recipes; 5) Food tracking tool; 6) Mastering a dietary goal and starting a new one; 7) Reviewing progress. The resultant product was iterated in usability studies and informed a final prototype for further testing. In parallel, a web-based clinician interface was developed through individual interviews, a survey of potential end-users (n=24), and two rounds of usability studies (n=3 in each round). The online clinician product features these interactive modules: dashboard, tracking manager, patient portal, and individual patient page

THE ROLE OF MEDITERRANEAN DIET IN THE PRIMARY AND SECONDARY PREVENTION OF ATRIAL FIBRILLATION: A SCOPING REVIEW

Atrial fibrillation (AF) is the most common cardiac arrhythmia, especially in patients older than 65. The prevalence of AF increased 3-fold over the last 50 years. All treatments, such as cardioversion, ablation, and anticoagulation, are associated with risks and relapses. Besides, these strategies may not apply to all patients with AF. Adherence to the Mediterranean dietary pattern is assumed as an ideal nutritional model for AF. Yet, there is a gap on 1) how adherence to the Mediterranean diet prevents AF and 2) how the Mediterranean diet affects complications in patients with AF. A scoping review was performed in June 2022 to identify studies focusing on the Mediterranean diet and AF. A total of 334 articles were retrieved and 12 met inclusion criteria. Six studies were interventions (n=6) and six were observational studies (n=6). In the six intervention studies, five were nested within the PREDIMED (Prevención con Dieta Mediterránea) study. In AF occurrence (n=6), the results were inconsistent. The Mediterranean diet plus extra virgin olive oil was significantly and favorably related to AF, however, Mediterranean diet plus nuts was not, when compared with the low-fat diet; Mediterranean diet modified how long chain acylcarnitine affected development of AF but not how tryptophan or arginine metabolites affected AF. In patients diagnosed with AF (n=6), Mediterranean diet favorably related to adverse cardiovascular events, oxidative stress, and Mediterranean diet adherence, and did not affect anticoagulation for those taking anticoagulants. Further research is needed to examine how the Mediterranean diet affects the development of AF.

The relationship between depressive symptoms and subtypes of mild cognitive impairment in post-menopausal women: Results from the Women's Health Initiative Memory Study

BACKGROUND

Depressive symptoms are associated with age-related cognitive impairment, but the relative risk of specific subtypes of mild cognitive impairment (MCI) conferred by depressive symptoms is unclear. The purpose of this exploratory study was to determine the longitudinal association between baseline depressive symptoms and incident cases of MCI subtypes (amnestic vs. non-amnestic) and probable dementia (PD) (Alzheimer's disease, vascular, mixed) among postmenopausal women.

METHODS

Depressive symptoms were assessed at study baseline using an 8-item Burnam algorithm in 7043 postmenopausal women who participated in the Women's Health Initiative Memory Study (WHIMS) and the WHIMS-Epidemiology of Cognitive Health Outcomes (WHIMS-ECHO) extension study. During the median 9.4-year follow-up interval, the presence of MCI and PD was classified by a central adjudication committee. Classification of participants by MCI subtype (amnestic single and multi-domain, non-amnestic single and multi-domain) was done algorithmically based on established criteria using data from annual cognitive testing.

RESULTS

At baseline, 557 women (7.9%) had clinically significant depressive symptoms based on Burnam algorithm cut-point of 0.06. Depressive symptoms at baseline were associated with an increased risk of incident amnestic MCI (hazard ratio [HR] = 1.91, 95% confidence interval [CI] 1.32-2.78, p < 0.0001), but not non-amnestic MCI (HR = 1.39, 95% CI 0.91-2.14, p = 0.13) after controlling for demographic factors. This relationship between depressive symptoms and amnestic MCI remained consistent after controlling for lifestyle variables, cardiovascular risk factors, antidepressant use, and history of hormone therapy. There were no significant associations between depressive symptoms and incidence of PD.

CONCLUSION

Depressive symptoms at baseline among postmenopausal older women are associated with higher incidence of amnestic MCI, suggesting that they may be an independent risk factor or part of the early prodrome of dementia.

Association of sleep duration and insomnia with metabolic syndrome and its components in the Women's Health Initiative

BACKGROUND

Epidemiological evidence suggests that inadequate sleep duration and insomnia may be associated with increased risk of metabolic syndrome (MetS). However, longitudinal data with repeated measures of sleep duration and insomnia and of MetS are limited. We examined the association of sleep duration and insomnia with MetS and its components using longitudinal data from the Women's Health Initiative (WHI).

METHODS

The study included postmenopausal women (ages 50-79 years) diabetes-free at enrollment in the WHI, with baseline data on sleep duration (n = 5,159), insomnia (n = 5,063), MetS, and its components. Repeated measures of self-reported sleep duration and insomnia were available from years 1 or 3 of follow-up and of the MetS components from years 3, 6 and 9. Associations were assessed using logistic regression and generalized estimating equations models, and odds ratios and 95% confidence intervals (CI) adjusted for major risk factors were calculated.

RESULTS

In cross-sectional analysis, baseline sleep duration ≥ 9 h was positively associated with MetS (OR = 1.51; 95%CI 1.12-2.04), while sleep duration of 8- < 9 h was associated with waist circumference > 88 cm and triglycerides ≥ 150 mg/dL (OR = 1.18; 95%CI 1.01-1.40 and OR = 1.23; 95%CI 1.05-1.46, respectively). Insomnia had a borderline positive association with MetS (OR = 1.14; 95%CI 0.99-1.31), and significant positive associations with waist circumference > 88 cm and glucose ≥ 100 mg/dL (OR = 1.18; 95%CI 1.03-1.34 and OR = 1.17; 95%CI 1.02-1.35, respectively). In the longitudinal analysis, change from restful sleep to insomnia over time was associated with increased odds of developing MetS (OR = 1.40; 95%CI 1.01-1.94), and of a triglyceride level ≥ 150 mg/dL (OR = 1.48; 95%CI 1.08-2.03).

CONCLUSIONS

Among postmenopausal women in the WHI, sleep duration and insomnia were associated with current and future risk of MetS and some of its components.

Virtual Intervention for Caregivers of Persons With Lewy Body Dementia: Pilot Quasi-Experimental Single-Arm Study

BACKGROUND

Compared to other types of dementia, family caregivers of people with Lewy body dementia (LBD) report higher stress levels and more severe depressive symptoms. Although several digital support interventions for caregivers of persons with dementia exist, few target LBD specifically or leverage a fully remote and asynchronous approach suitable for pandemic circumstances.

OBJECTIVE

We performed a pilot evaluation of a digital intervention designed to help caregivers of people with LBD address challenges they have experienced, with the end goal of reducing psychological distress in this population.

METHODS

We recruited 15 family caregivers of people with LBD to participate in the quasi-experimental, single-arm, mixed methods study titled Virtual Online Communities for Aging Life Experience-Lewy Body Dementia (VOCALE-LBD). The study offers an 8-week web-based intervention that uses a digital discussion platform and involves moderation, peer-to-peer support, didactic training, and problem-solving skill enactment.

RESULTS

Participants' baseline characteristics were the following: mean age 66 (SD 8) years; 14 of 15 (93%) of them were female; all (15/15, 100%) were White; and 8 (53%) of them had at least a postgraduate degree. Throughout the intervention, participants engaged in weekly web-based discussions, generating a total of 434 posts (average 4 posts per week). Attrition was 20% (3/15). Upon study exit, participants showed the following average improvements: 3.0 (SD 6.0) in depression, 8.3 (SD 16.7) in burden, 2.9 (SD 6.8) in stress, and 0.3 (SD 0.8) in loneliness. When looking at the proportion of participants with clinically significant improvement versus those with a worsening of ≥0.5 SD for each outcome, we observed net improvements of 50% (6/12), 33% (4/12), 25% (3/12), and 25% (3/12) in depression, loneliness, burden, and stress, respectively. In terms of the benefits of participation, participants reported that participation helped them "a great deal" to (1) improve their understanding of LBD (9/12, 75%), (2) gain confidence in dealing with difficult behaviors of the care recipient (6/12, 50%), and (3) improve in one's abilities to provide care to the care recipient (4/12, 33%).

CONCLUSIONS

The study generated promising feasibility and preliminary efficacy data for a low-cost, web-based intervention designed for caregivers of persons with LBD. Though the study was not powered for significance, we observed nominal average and net improvements in important psychological outcomes. Moreover, many caregivers reported that study participation helped them better understand the disease, feel more confident in dealing with difficult behaviors of the care recipient, and improve their ability to care for the care recipient. If validated in future studies, the intervention could be an accessible, on-demand resource for caregivers, enabling them to engage in moderated remote discussions with peers at their own convenience in terms of location, time of the day, and frequency.

Behavioral Change Factors and Retention in Web-Based Interventions for Informal Caregivers of People Living With Dementia: Scoping Review

BACKGROUND

Web-based interventions aimed at supporting informal caregivers of people living with dementia have the potential to improve caregivers' well-being and psychological health. However, few interventions are widely implemented for this population, and none of the prior reviews have systematically examined the use of behavior change techniques (BCTs), theories, and agents in web-based interventions for informal caregivers of people living with dementia. To better understand this implementation gap, we reviewed the literature to map behavioral factors (BCTs, theories, and agents) deployed in the studies. Furthermore, because there is an emerging consensus that retention could be shaped by participant characteristics and behavioral factors, we explored relationships between these features and retention rates across studies.

OBJECTIVE

We pursued 3 objectives: to map behavioral factors involved in the web-based interventions for informal caregivers of people living with dementia; to examine the relationship between behavioral change elements and retention in the studies; and to examine the relationship between participant characteristics (gender, age, and spouse or adult children caregiver proportion) and study retention.

METHODS

We conducted a literature review using the following keywords and their corresponding Medical Subject Headings terms: dementia, caregivers, and web-based intervention. The time limits were January 1998 to March 2022. Using the BCTv1 taxonomy, which specifies active behavioral components in interventions, 2 coders collected, summarized, and analyzed the frequency distributions of BCTs. Similarly, they abstracted and analyzed participant characteristics, behavior change theories, behavior change agents, and retention rates in the studies.

RESULTS

The average age was 61.5 (SD 7.4) years, and the average proportion of spousal informal caregivers, adult children informal caregivers, and retention rates were 51.2% (SD 24.8%), 44.8% (SD 22%), and 70.4% (SD 17%), respectively. Only 53% (17/32) of the studies used behavior change theories, but 81% (26/32) included behavior change agents. The most common BCTv1 clusters were shaping knowledge and social support. The median number of BCTv1 clusters was 5 (IQR 3). We observed a negative correlation between the proportion of spousal informal caregivers and the retention rate (r=-0.45; P=.02) and between the number of BCTv1 clusters and retention rates (r=-0.47; P=.01). We also found that the proportion of adult children informal caregivers in the study was significantly and positively correlated with the retention rate (r=0.5; P=.03). No other participant characteristics or behavioral factors were associated with retention rates.

CONCLUSIONS

We found that almost half of the studies were not informed by behavior change theories. In addition, spousal involvement and a higher number of BCTs were each associated with lower retention rates, while the involvement of adult children caregivers in the study was associated with higher retention. In planning future studies, researchers should consider matching participant characteristics with their intended intervention as the alignment might improve their retention rates.

Feeling Younger, Rehabilitating Better: Reciprocal and Mediating Effects between Subjective Age and Functional Independence in Osteoporotic Fracture and Stroke Patients

INTRODUCTION

The current study aimed to find reciprocal effects between subjective age and functional independence during rehabilitation from osteoporotic fractures and stroke and whether these effects can be mediated by indicators of well-being.

METHODS

Participants were 194 older adults (mean age = 78.32 years, SD = 7.37; 64.8% women) who were hospitalized following an osteoporotic fracture or stroke. Participants completed measures of subjective age and well-being (i.e., optimism, self-esteem, and life satisfaction) several times during rehabilitation. Functional Independence Measure (FIM) was completed by nursing personnel at admission and at discharge.

RESULTS

Younger subjective age at admission predicted higher FIM scores at discharge. The reverse effect, that is, of FIM scores at admission on subjective age at discharge, was nonsignificant. Optimism during hospitalization mediated the effect of subjective age on subsequent FIM scores while self-esteem and life satisfaction did not. Sensitivity analyses further showed that the effect of subjective age on FIM was significant for both fracture and stroke patients.

DISCUSSION

The findings highlight the effect of subjective age on rehabilitation outcomes among osteoporotic fractures and stroke patients and suggest several potential mechanisms behind this effect. Rehabilitation outcomes following osteoporotic fractures or strokes could improve if subjective age and an optimistic outlook are taken into consideration.

Association between having a family member with dementia and perceptions of dementia preventability

BACKGROUND

One's experience with dementia may affect their perceptions about dementia preventability, which in turn could influence preventive health behaviors. We aimed to examine how having a family history of dementia and caregiving experience are associated with perceptions about and self-efficacy for dementia preventability.

METHODS

Cross-sectional, self-administered survey. Participants reported whether they have had a family member with dementia and, among those who reported having a family member with dementia, whether they served as a caregiver. Outcomes were perceptions about the likelihood of dementia preventability, self-efficacy for dementia prevention, and benefits of specific dementia prevention strategies. Associations were assessed via partial proportional odds model for ordinal outcome variables and logistic regression for binary outcome variables.

RESULTS

Of 1,575 respondents, 71% had a family member with dementia, of which 42% served as a caregiver. People with a family member with dementia were less likely to believe that dementia is preventable (aOR = 0.75, 95% CI: 0.58, 0.96) and had lower self-efficacy for dementia prevention (aOR = 0.71, 95% CI: 0.56, 0.90). The subgroup analysis among those with caregiving experience was consistent with the primary findings, showing less belief in the likelihood of dementia preventability (aOR = 0.69, 95% CI: 0.46, 1.03) and self-efficacy (aOR = 0.75, 95% CI: 0.56, 1.00).

CONCLUSION

Having a family member with dementia is associated with unfavorable perceptions about dementia preventability. Incorporating family history of dementia into communication efforts about dementia risk reduction may help address potential barriers to preventive health behaviors.

Mediterranean Diet and Fatigue among Community-Dwelling Postmenopausal Women

We investigated cross-sectional relationships between the Mediterranean diet and overall fatigue, energy, and weariness scores among 4,563 women aged 65+ from the Women's Health Initiative study. We also used the Isocaloric Substitution approach to explore whether the substitution of fish for red and processed meat, whole for non-whole grains, and whole fruit for fruit juice relate to RAND-36 measured overall fatigue and its subdomains. The alternate Mediterranean Diet (aMED) Index quintiles (Q1-Q5) and selected Mediterranean foods available on a Food Frequency Questionnaire were exposure measures. Results showed aMED Q5 was associated with 2.99 (95% CI: 0.88, 5.11), 4.01 (95% CI: 1.51, 6.53), and 2.47 (95% CI: 0.24, 4.70) point improvements in fatigue, energy, and weariness scores, respectively, compared with aMED Q1. Substituting fish for red and processed meat and whole for non-whole grains was associated with more favorable fatigue scores, whereas substituting whole fruit for juice was not.

Fatigue in community-dwelling older adults: A review of definitions, measures, and related factors

Fatigue is a common age-related symptom among community-dwelling adults aged 65 years and older. Yet, a systematic approach has rarely been applied to review definitions, measures, related factors, and consequences of fatigue in this population. A scoping review was conducted in December 2020 to fill the gap, and 36 articles met the inclusion criteria. Definitions, albeit diverse, included at least one of the following attributes: an early indicator of disablement, subjective, a lack of energy, multidimensional, impaired daily activities, and temporal. A summary of fatigue measures used in this population was provided, including a brief overview, number of items, reliability, and validity. In general, different measures were used with considerable variability in the content. Additionally, most measures had limited information on test-retest reliability and validity. Fatigue-related factors mapped into biological, psychological, social, and behavioral factors. Fatigue consequences were primarily declines in physical and cognitive functions. (100-150 words).

An Online Community Intervention for Older Persons with Pre-Frailty and Frailty: Pilot Studies

Online community interventions can support self-management in older populations but have rarely targeted symptomology of pre-frailty and frailty. To support older adults’ pre-frailty/frailty symptom management, we iteratively refined an approach entitled Virtual Online Community for Aging Life Experience (VOCALE) in three consecutive pilot studies (2018-2020). These studies employed asynchronous online discussions in which participants were asked to respond to weekly prompts. A study facilitator moderated the discussion, encouraging participants to respond to both the prompts and comments of other participants. In the first pilot (n=8), participants engaged in a collective exploration of different symptoms of pre-frailty and frailty. The second (n=10) and third (n=10) pilots employed a hybrid approach including collaborative exploration and learning of different problem-solving therapy skills over eight weeks. The mean age of participants of the three pilots combined was 80.6 (SD = 7.0). Most participants were female (71%). Participant attrition ranged from 20-25%. Many participants who completed the study noted that they enjoyed the discussions. The participants also found the moderators' follow-up questions and support timely and engaging. Additionally, we observed small but positive changes in self-efficacy measures. These pilot studies have confirmed that older adults with pre-frailty and frailty are interested, and can successfully engage in online community interventions, with the technical support and moderation provided, even during the initial stages of the COVID-19 pandemic, when lockdown policies were rolled out. Participation in the intervention was also associated with increased awareness of the need to be proactive in self-management concerning frailty-related symptoms.

DXA Versus Clinical Measures of Adiposity as Predictors of Cardiometabolic Diseases and All-Cause Mortality in Postmenopausal Women

OBJECTIVE

To investigate whether dual-energy x-ray absorptiometry (DXA) estimates of adiposity improve risk prediction for cardiometabolic diseases over traditional surrogates, body mass index (BMI), waist circumference (WC), and waist-to-hip ratio (WHR) in older women.

PATIENTS AND METHODS

We analyzed up to 9744 postmenopausal women aged 50 to 79 years participating in the Women's Health Initiative who underwent a DXA scan and were free of cardiovascular disease and diabetes at baseline (October 1993 to December 1998) and followed through September 2015. Baseline BMI, WC, WHR, and DXA-derived percent total-body and trunk fat (%TrF) were incorporated into multivariable Cox proportional hazards models to estimate the risk of incident diabetes, atherosclerosis-related cardiovascular diseases (ASCVDs), heart failure, and death. Concordance probability estimates assessed the relative discriminatory value between pairs of adiposity measures.

RESULTS

A total of 1327 diabetes cases, 1266 atherosclerotic cardiovascular disease (ASCVD) cases, 292 heart failure cases, and 1811 deaths from any cause accrued during a median follow-up of up to 17.2 years. The largest hazard ratio observed per 1 standard deviation increase of an adiposity measure was for %TrF and diabetes (1.77; 95% CI, 1.66-1.88) followed by %TrF and broadly defined ASCVD (1.22; 95% CI, 1.15-1.30). These hazard ratios remained significant for both diabetes (1.47; 95% CI, 1.37-1.57) and ASCVD (1.22; 95% CI, 1.14-1.31) even after adjusting for the best traditional surrogate measure of adiposity, WC. Percentage of trunk fat was also the only adiposity measure to demonstrate statistically significant improved concordance probability estimates over BMI, WC, and WHR for diabetes and ASCVD (all P<0.05).

CONCLUSION

DXA-derived estimates of abdominal adiposity in postmenopausal women may allow for substantially improved risk prediction of diabetes over standard clinical risk models. Larger DXA studies with complete lipid biomarker profiles and clinical trials are needed before firm conclusions can be made.

Frailty measurements in hospitalised orthopaedic populations age 65 and older: A scoping review

Aims and Objectives

To identify and compare frailty instruments used with hospitalised orthopaedic patients aged over 65.

Background

Frailty predicts clinical events in orthopaedic patients aged over 65. However, the strengths and limitations of different approaches to measuring frailty in this population are rarely discussed. As such, a comprehensive review to address the gap is needed.

Design

Scoping review using Arksey and O’Malley framework.

Methods

PubMed, CINAHL, PsycINFO, Scopus and EMBASE databases were searched to identify studies published from 2006 to 2020 regarding frailty instruments in older orthopaedic patients. The Preferred Reporting Items for Systematic Reviews and Meta‐analyses were followed.

Results

The initial search resulted in 1,471 articles. After review against inclusion and exclusion criteria, a final set of 31 articles containing 15 unique frailty instruments were evaluated. Most of the articles were from Western countries. Fried's phenotype and Frailty Index were commonly used. The frailty index was mostly modified to measure frailty. In hip fracture, physical function items were frequently modified in the measurement of frailty. Trained physicians and nurses administered most frailty instruments. Frailty screening was commonly conducted at hospital admission and used to prognosticate both postoperative complications and hospital outcomes. Most instruments could be completed within 10 min. Reported psychometrics had acceptable reliability and validity.

Conclusion

Many reliable frailty measures have been used in the inpatient orthopaedic settings; however, evidence is still lacking for a gold standard frailty instrument. More research is needed to identify the best‐performing measure. Frailty evaluation in patients with physical limitations is challenging with existing instruments. Clinical context, resources required and instrument quality are essential factors in selecting a frailty instrument.

Relevance to clinical practice

Musculoskeletal symptoms in older patients may bias frailty assessment. Proactive frailty screening with valid and practical instruments is vital to strengthen preoperative risk stratification and improve post‐surgical outcomes.

Associations of inflammatory, oxidative stress, and cardiac damage biomarkers and radiation-induced fatigue in breast cancer survivors

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Background: Radiation-induced fatigue (RIF) is common in breast cancer (BC) survivors and can last years after treatment. Despite the known physiological consequences of radiation, information on biomarkers of RIF is limited. Therefore, we examined the longitudinal association between serum biomarkers and post-BC fatigue in BC survivors treated with radiation: [oxidative stress] 8-hydroxyguanosine (8-OH-dG), myeloperoxidase (MPO); [inflammation] interleukin-6 (IL-6), C-reactive protein (CRP), growth differentiation factor-15 (GDF-15), placental growth factor (PGF), transforming growth factor-beta (TGF-B); [cardiac damage] cystatin-C, troponin-I (TnI). Methods: In an ancillary study in the Women’s Health Initiative (WHI), participants with incident BC (stages I-III) treated with radiation were followed for the development of fatigue post-BC. Women were eligible if they 1) had no prior cardiovascular disease and 2) had pre-and post-BC serum samples drawn approximately three years apart with fatigue measured using the Short-Form 36 (SF-36) vitality subscale at the same times. Biomarkers were analyzed using enzyme-linked immunosorbent assays. Higher SF-36 vitality scores correspond to lesser fatigue. Weighted linear regression adjusted for relevant demographic, lifestyle, and psychosocial factors, as well as pre-cancer fatigue. Each biomarker was modeled as the post-BC to pre-BC ratio and log transformed to base 2, thus, the effect estimates correspond to a doubling in value compared to pre-BC. Results: A total of 180 women with a mean (SD) age of 67.0 (5.5) were included. The mean (SD) vitality score was 66.2 (17.2) and 59.7 (19.7) pre- and post-BC, respectively. The median (IQR) time between pre-BC serum collection to BC was 1.9 (0.8, 2.6) years and 1.4 (0.7, 2.3) years between BC and the post-BC serum collection. After adjustment, a higher biomarker ratio of cystatin-C, IL-6, and GDF-15 were all associated with a lower SF-36 vitality score (i.e., higher fatigue) (Table). As an example, for a 2-fold difference in the cystatin-C biomarker ratio, the SF-36 vitality score was lower by 7.31 points (95% CI: -14.2, -0.45). Conclusions: Inflammatory and cardiac damage biomarkers are associated with RIF in BC survivors. Biomarkers could be measured in clinical practice or be included in risk prediction models to help identify patients at high risk for RIF. [Table: see text]

Behavior change factors and retention in dietary interventions for older adults: scoping review

BACKGROUND AND OBJECTIVES

Although poor diet is a major driver of morbidity and mortality in people 60 and older, few dietary interventions are widely implemented for this population. We mapped behavior change theories, agents, and techniques in dietary interventions for adults 60+ and explored relationships between these factors and ability to retain at least 80% of the study participants.

RESEARCH DESIGN AND METHODS

We conducted a scoping review using MEDLINE, CINAHL, and Web of Science through April 2021 for dietary interventions in adults 60 and older. We collated, summarized, and calculated frequency distributions of behavior change theories, behavior change agents, and behavior change techniques (BCTs) using BCTv1 taxonomy with regard to participant retention across 43 studies.

RESULTS

Only 49% and 30% of the studies reported behavior theory and change agents respectively. Of the studies reporting on theory and agents, the most common were social cognitive theory and the related mechanism of self-efficacy. The most common BCTv1 were "shaping knowledge" and "goals and planning." Several BCTv1 such as "antecedents" and "reward and threat" and evidence for concordance between BCTs and change agents were more common in interventions with higher retention rates.

DISCUSSION AND IMPLICATIONS

Mechanistically concordant studies with BCTs that involve resource allocation and positive reinforcement through rewards may be advantageous for retention in dietary intervention for older adults. Future studies should continue developing theory and mechanism-oriented research. Furthermore, future studies should consider diversifying the portfolio of currently deployed BCTs and strengthening a concordance between BCTs and mechanisms of change.

Patient Digital Technologies to Support Primary Care across Disorders: Survey of Primary Care Providers, Behavioral Health Consultants, and Nurses (Preprint)

Background

Objective

Methods

Results

Conclusions

Incident Dementia, Glycated Hemoglobin (HbA1c) Levels and Potentially Preventable Hospitalizations in People Age 65 and Older with Diabetes

BACKGROUND

To determine whether incident dementia and HbA1c levels are associated with increased rates of potentially preventable hospitalizations (PPH) in persons with diabetes.

METHODS

565 adults age 65+ ever treated for diabetes were from ACT study. PPH were from principal discharge diagnoses and included diabetes PPH (dPPH), respiratory PPH (rPPH), urinovolemic PPH (uPPH), cardiovascular, and other PPH. Poisson generalized estimating equations estimated rate ratios (RR) and 95% confidence intervals (CI) for the associations between dementia or HbA1c measures and rate of PPH.

RESULTS

562 individuals contributed 3602 dementia-free years, and 132 individuals contributed 511 dementia follow-up years. 128 (23%) dementia-free individuals had 210 PPH admissions and a crude rate of 58 per 1000 person-years while 55 (42%) individuals with dementia had 93 PPH admissions, a rate of 182 per 1000 person-years. The adjusted RR (95% CI) comparing rates between dementia and dementia-free groups were 2.27 (1.60, 3.21) for overall PPH; 5.90 (2.70, 12.88) for dPPH; 5.17 (2.49, 10.73) for uPPH, and 2.01 (1.06, 3.83) for rPPH. Compared with HbA1c of 7-8% and adjusted for dementia, the RR (95% CI) for overall PPH was 1.43 (1.00, 2.06) for >8% and 1.18 (0.85, 1.65) for <7% HbA1c. The uPPH RR was also increased, comparing >8% and <7% HbA1c levels.

CONCLUSION

Incident dementia is associated with higher rates of PPH among people with diabetes, especially PPHs due to diabetes, UTI, and dehydration. Potential evidence suggested that HbA1c levels of >8% vs. lower levels are associated with higher rates of overall, UTI and dehydration-related PPHs.

Promoting Problem Solving About Health Management: A Mixed-Methods Pilot Evaluation of a Digital Health Intervention for Older Adults With Pre-Frailty and Frailty

Background: There is a need for interventions to promote health management of older adults with pre-frailty and frailty. Technology poses promising solutions, but questions exist about effective delivery. Objectives: We present the results of a mixed-methods pilot evaluation of Virtual Online Communities for Older Adults (VOCALE), an 8-week intervention conducted in the northwestern United States, in which participants shared health-related experiences and applied problem solving skills in a Facebook group. Methods: We performed a mixed-methods process evaluation, integrating quantitative and qualitative data, to characterize the intervention and its effects. We focus on four areas: health-related measures (health literacy and self-efficacy), participation, problem solving skills enacted, and subjective feedback. Results: Eight older adults with pre-frailty and frailty (age = 82.7 ± 6.6 years) completed the study. There was an upward trend in health literacy and health self-efficacy post-intervention. Participants posted at least two times per week. Content analysis of 210 posts showed participants were able to apply the problem solving skills taught, and exit interviews showed participants' increased awareness of the need to manage health, and enjoyment in learning about others. Conclusion: This mixed-methods evaluation provides insight into feasibility and design considerations for online interventions to promote health management among vulnerable older adults.

Artificial Intelligence: An Interprofessional Perspective on Implications for Geriatric Mental Health Research and Care

Artificial intelligence (AI) in healthcare aims to learn patterns in large multimodal datasets within and across individuals. These patterns may either improve understanding of current clinical status or predict a future outcome. AI holds the potential to revolutionize geriatric mental health care and research by supporting diagnosis, treatment, and clinical decision-making. However, much of this momentum is driven by data and computer scientists and engineers and runs the risk of being disconnected from pragmatic issues in clinical practice. This interprofessional perspective bridges the experiences of clinical scientists and data science. We provide a brief overview of AI with the main focus on possible applications and challenges of using AI-based approaches for research and clinical care in geriatric mental health. We suggest future AI applications in geriatric mental health consider pragmatic considerations of clinical practice, methodological differences between data and clinical science, and address issues of ethics, privacy, and trust.

Risk of metabolic syndrome and metabolic phenotypes in relation to biomarker-calibrated estimates of energy and protein intakes: an investigation from the Women's Health Initiative

BACKGROUND

Metabolic syndrome (MetS) is associated with increased mortality independent of BMI, resulting in discordant metabolic phenotypes, such as metabolically healthy obese and metabolically unhealthy normal-weight individuals. Studies investigating dietary intake in MetS have reported mixed results, due in part to the limitations of self-reported measures.

OBJECTIVES

To investigate the role of biomarker-calibrated estimates of energy and protein in MetS and metabolic phenotypes.

METHODS

Postmenopausal participants from the Women's Health Initiative (WHI) study who were free of MetS at baseline, had available data from FFQs at baseline, and had components of MetS at Year 3 (n = 3963) were included. Dietary energy and protein intakes were estimated using biomarker calibration methods. MetS was defined as 3 or more of the following: elevated serum triglycerides (≥150 mg/dL), low HDL cholesterol (<50 mg/dL), hypertension [systolic blood pressure (BP) ≥130 or diastolic BP ≥85 mmHg], elevated serum glucose (>100 mg/dL), and abdominal adiposity (waist circumference > 89 cm). Models were adjusted for age, WHI study component, race/ethnicity, education, income, smoking, recreational physical activity, disease history, and parity.

RESULTS

For every 10% increment in total calibrated energy intake, women were at a 1.37-fold elevated risk of MetS (95% CI, 1.15-1.63); a 10% increment in calibrated total protein intake was associated with a 1.21-fold elevated risk of MetS (95% CI, 1.00-1.47). Specifically, animal protein intake was associated with MetS (OR, 1.08; 95% CI, 1.02-1.14), whereas vegetable protein intake was not (OR, 0.99; 95% CI, 0.95-1.03). No differences were seen when examining metabolic phenotypes.

CONCLUSIONS

We found that higher calibrated total energy, total protein, and total animal protein intakes were strongly associated with MetS. If replicated in clinical trials, these results will have implications for the promotion of energy and animal protein restrictions for the reduction of MetS risks.

Predicting Hospital Outcomes Using the Reported Edmonton Frail Scale-Thai Version

Backgrounds Frailty is a common geriatric condition leading to poor surgical outcomes. Having a valid frailty measure has the potential to improve surgical care quality. Objectives To test the ability of the Reported Edmonton Frailty Scale-Thai version (REFS-Thai) in predicting hospital outcomes compared with the American Society of Anesthesiologists physical status classification (ASA) and the Elixhauser Comorbidity Measure (EMC) in older Thai orthopedic patients. Methods A prospective study was conducted on hospitalized older adults scheduled for elective orthopedic surgery. Multiple Firth logistic regression modeled the effect of frailty on postoperative complications, postoperative delirium (POD), and discharge disposition, while the length of stay (LOS) was examined by Poisson regression. The area under the receiver operating characteristic curve (AUC) and mean squared errors (MSE) were used to compare the predictive ability of the instruments. Results Two hundred participants with mean age of 72 (range 60-94 years) were mostly female, 23% were frail. Adjusting for other variables, frailty was significantly associated with postoperative complications (OR = 2.38, p = 0.049), POD (OR = 3.52, p = 0.034), and prolonged LOS (relative risk [RR] = 1.42, p = 0.043). The REFS-Thai alone shows good performance in predicting postoperative complications (AUC = 0.81, 95% CI = 0.74-0.88) and POD (AUC = 0.81, 95% CI = 0.72-0.90). The combination of REFS-Thai with ASA and EMC demonstrates an improved predictability. Conclusion The REFS-Thai was useful in predicting adverse outcomes in surgical orthopaedic older adults. Integrating the REFS-Thai for preoperative assessment may be useful for enhancing care quality.

Predicting hospital outcomes with the reported edmonton frail scale-Thai version in orthopaedic older patients

AIMS AND OBJECTIVES

To test the ability of the Reported Edmonton Frail Scale-Thai version to predict hospital outcomes compared with standard preoperative assessment measures (American Society of Anesthesiologists physical status classification and the Elixhauser Comorbidity Measure) in older Thai orthopaedic patients.

BACKGROUND

Frailty is a common geriatric condition. No previous studies have assessed frailty among orthopaedic patients in Thailand. Effective frailty screening could enhance quality of care.

DESIGN

Prospective cohort study in a university hospital.

METHODS

Two hundred hospitalised patients, aged 60 years or older and scheduled for orthopaedic surgery, participated in the study. Frailty was evaluated using the Reported Edmonton Frail Scale-Thai version. Multiple Firth logistic regression was used to model the effect of frailty on postoperative complications, postoperative delirium and discharge disposition. Length of stay was examined using Poisson regression. Comparing predictability of the instruments, the area under the receiver operating characteristic curve and mean squared errors were evaluated. The STROBE guideline was used.

RESULTS

Participants' mean age was 72 years; mostly were female, frail and underwent knee, spine and/or hip surgery. Poor health outcomes including postoperative complications, postoperative delirium, and not being discharged to the home were commonly identified. The length of stay varied from three days to more than ten weeks. Frailty was significantly associated with postoperative complications, postoperative delirium and prolonged length of stay. The Reported Edmonton Frail Scale-Thai version revealed good performance for predicting postoperative complications and postoperative delirium and was improved by combining with standard assessments.

CONCLUSION

The Reported Edmonton Frail Scale-Thai version, alone or combined with standard assessment, was useful for predicting adverse outcomes in older adults undergoing orthopaedic surgery.

RELEVANCE TO CLINICAL PRACTICE

These findings indicate that nurse professionals should apply culturally sensitive frailty screening to proactively identify patients' risk of frailty, improve care quality and prevent adverse outcomes.

Accelerometer-Measured Physical Activity Levels and Fatigue in Older Women

The authors examined whether the associations between physical activity (PA) levels and fatigue vary by body mass index and physical performance, and whether substituting sedentary time (ST) with low light PA, high light PA, and moderate to vigorous PA (MVPA) was associated with better mean fatigue scores. In total, 6,111 participants (aged 65 years and older) were from the Women's Health Initiative Objective Physical Activity and Cardiovascular Health Study. PA levels were from a hip-worn GT3X accelerometer. Overall fatigue, energy, and weariness subdomains were from the RAND-36 Vitality subscale. Isotemporal substitution models examined the time-substitution effects. Interactions were observed between MVPA and short physical performance battery performance measure (p < .05). Substituting ST with 34.3 min of MVPA was associated on average with a 1.63-point improvement in fatigue score. Substituting ST with 50.2 min of low light PA and 34.3 min of MVPA was associated on average with an energy score improvement of 1.18 and 2.06 points respectively. Substituting ST with 34.3 min of MVPA was associated on average with a 1.08-point improvement in weariness score (p < .05 for all).

Association of Prediagnostic Frailty, Change in Frailty Status, and Mortality After Cancer Diagnosis in the Women's Health Initiative

IMPORTANCE

Understanding changes in frailty in relation to cancer diagnosis can inform optimal selection of cancer treatments and survivorship care.

OBJECTIVE

To investigate associations of prediagnostic frailty and change in frailty status with mortality after a cancer diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter, prospective cohort study included 7257 community-dwelling, postmenopausal women in the United States who had frailty assessed at the Women's Health Initiative (WHI) enrollment (1993-1998) and the 3-year visit who were subsequently diagnosed as having invasive cancer. The data were analyzed from January 7, 2019, to June, 8, 2020.

EXPOSURE

Frailty scores were defined from validated questionnaire items conceptually aligned with the Fried frailty phenotype, including at least 3 of the following characteristics: self-reported unintentional weight loss, exhaustion, low physical activity, and muscle weakness or impaired walking. Physical function components of the frailty score were updated a median of 10 (range, 1-18) times.

MAIN OUTCOMES AND MEASURES

Using multivariable-adjusted Cox proportional hazards models, this study examined associations of prediagnostic frailty (at the 3-year visit, before cancer diagnosis) and prediagnostic changes in frailty (from enrollment to the 3-year visit) with mortality. Women were followed up beginning from cancer diagnosis for mortality outcomes through March 2018. In linear mixed-effects models with frailty scores as a function of time since cancer diagnosis, this study evaluated whether the time slope, ie, the rate of change in frailty score, increased after cancer diagnosis.

RESULTS

This study included 7257 women in the WHI cohort who completed frailty assessments at enrollment and the 3-year WHI visit before cancer diagnosis and subsequently developed cancer. Cancer cases included 2644 breast cancers (36%), 822 lung cancers (11%), 691 colorectal cancers (10%), 445 endometrial cancers (6%), and 286 ovarian cancers (4%). At the 3-year visit, prior to cancer diagnosis, the mean (SD) age was 63 (7) years, and 1161 of 7257 (16%) of participating women met criteria for frailty; 2129 of 7257 (29%) were prefrail, and 3967 of 7257 (55%) were nonfrail. Over a median follow-up of 5.8 years after cancer diagnosis (range, 1 day to 19.9 years), 3056 women died. After multivariable adjustment, women who were frail (vs nonfrail) before cancer diagnosis had an increased risk of mortality after cancer diagnosis (hazard ratio [HR], 1.40; 95% CI, 1.26-1.55; P for trend <.001). Sustained frailty (21% [1537 of 7257] of women) or worsening frailty (22% [1578 of 7257]) vs being consistently nonfrail (45% [3266 of 7257]) before cancer diagnosis increased the risk of mortality after cancer diagnosis (HR, 1.25; 95% CI, 1.14-1.38 and 1.22; 95% CI, 1.11-1.34, respectively; P for trend <.001). In linear mixed-effects models, the rate of increase in physical frailty over time was statistically significantly higher after cancer diagnosis.

CONCLUSIONS AND RELEVANCE

Sustained and worsening frailty before cancer diagnosis was associated with an increased risk of mortality after cancer diagnosis in postmenopausal women. Furthermore, the rate of decline in physical function accelerated after cancer diagnosis. Frailty assessment could provide valuable information and perhaps prompt interventions to reduce and preempt worsening of physical frailty after cancer diagnosis.

The Reported Edmonton Frail Scale-Thai version: Development and Validation of a Culturally-Sensitive Instrument

Frailty may lead to increased vulnerability, disability, and adverse health outcomes in older adults. Early detection has been described as the best approach to manage frailty; however, frailty instruments are not widely available, particularly in the Thai language. The purpose of this cross-sectional study was to develop a culturally adapted Thai version of the Reported Edmonton Frail Scale and to validate the psychometric properties of the new instrument in hospitalized older Thai adults. Reliability and validity were examined. Participants completed questionnaires that included demographic and health information, and the Reported Edmonton Frail Scale-Thai version. Results revealed that the new instrument was reliable and had good content validity. Inter-rater reliability was strong. Confirmatory factor analysis showed a fair fit for the whole model, but most domains were strongly associated with frailty. On average, the instrument was completed under 7 minutes. The Thai version of the frailty instrument may be a practical tool for frailty evaluation, and could inform inpatient care, both locally and internationally; future research is needed to confirm predictability and feasibility in other clinical settings and populations.

Glucose control and cognitive and physical function in adults 80+ years of age with diabetes

INTRODUCTION

We modeled associations between glycated hemoglobin (HbA1c) levels (<7%, 7% to 8%, and >8%) and cognitive and physical function among adults 80+ years of age with diabetes and determined whether associations differ by frailty, multimorbidity, and disability.

METHODS

A total of 316, adults with diabetes, 80+ years of age, were from the Adult Changes in Thought Study. The Cognitive Abilities Screening Instrument Item Response Theory (CASI-IRT) measured cognition. Short performance-based physical function (sPPF) and gait speed measured physical function. Glycosylated hemoglobin (HbA1c) levels were from clinical measurements. Analyses estimated associations between average HbA1c levels (<7%, 7% to 8%, and >8%) and functional outcomes using linear regressions estimated with generalized estimating equations.

RESULTS

sPPF scores did not differ significantly by HbA1c levels. Gait speed did, but only for non-frail individuals; those with HbA1c >8% were slower (-0.10 m/s [95% CI, -0.16 to -0.04]) compared to those with HbA1c 7% to 8%. The association between HbA1c and CASI-IRT varied with age (interaction P = 0.04). At age 80, for example, relative to people with HbA1c levels of 7% to 8%, CASI-IRT scores were, on average, 0.18 points lower (95% CI, -0.35 to -0.02) for people with HbA1c <7% and 0.22 points lower (95% CI, -0.40 to -0.05) for people with HbA1c >8%. At older ages, these estimated differences were attenuated. Estimated associations were not modified by multimorbidity or disability.

DISCUSSION

Moderate HbA1c levels of 7% to 8% were associated with better cognition in early but not late octogenarians with diabetes. Furthermore, HbA1c >8% was associated with slower gait speed among those without frailty. These results add to an evidence base for determining glucose targets for very old adults with diabetes.

Reactions to COVID-19, information and technology use, and social connectedness among older adults with pre-frailty and frailty

The emergence of Coronavirus Disease 2019 (COVID-19) and social distancing measures has serious implications, particularly those age 65 and older. We performed a qualitative analysis of online discussion data generated by older adults with pre-frailty and frailty while subject to a state stay-at-home order. We provided participants with prompts relating to the public health emergency, collected 60 posts, and analyzed them using a general inductive analytic method. We report on: (1) the impact of the pandemic on daily life; (2) preparedness, perceptions, and behavior; (3) information and technology use; and (4) social impacts. Participants’ lives of changed in many ways, including the adoption of precautionary measures and altered daily routines. Participants experienced negative emotional consequences including stress, worry, and anxiety. Information and technology use kept participants informed and connected. Participants reported varying degrees of preparedness. Our study findings provide insight into ways to support vulnerable older adults in pandemic circumstances.

Postdiagnosis Physical Activity: Association With Long-Term Fatigue and Sleep Disturbance in Older Adult Breast Cancer Survivors

BACKGROUND

Physical activity is frequently proposed as an intervention to reduce fatigue and sleep disturbance in cancer survivors; however, the long-term effects of physical activity are often not reported, and older adults are typically excluded from these intervention studies.

OBJECTIVES

This article aimed to examine if postdiagnosis physical activity is associated with lower long-term fatigue and sleep disturbance in older adult breast cancer survivors.

METHODS

Data were analyzed of a prospective cohort of 440 breast cancer survivors aged 65 years or older from the Women's Health Initiative study. Multiple linear and logistic regression models were used to examine associations of physical activity with fatigue and sleep disturbance.

FINDINGS

Higher postdiagnosis physical activity was associated with lower long-term fatigue but was not associated with lower sleep disturbance after adjusting for demographics, cancer characteristics, and baseline measures.

Using an Innovative Discussion Platform to Give Voice to Aging-Related Experiences: A Pilot Study

Exchanging information with peers may support older adults' management of aging-related health changes, including frailty. The current pilot study used a mixed-methods approach to develop and evaluate an online virtual community for older adults to discuss aging-related health issues and management strategies. Eight older adults (mean age = 84) were enrolled at the start of the study. During a 10-week moderated discussion, participants contributed a total of 133 responses. Common themes included (a) symptoms (e.g., pain, weakness/tiredness, sleep difficulties) and (b) management strategies (e.g., health behavior changes, psychosocial support). A positive trend of change was noted in participants' average self-reported health and chronic disease management self-efficacy scores. This platform could facilitate information exchange among older adults, empowering them to leverage their own knowledge to improve their health management strategies. Future research should expand on this study to include older adults of diverse racial, educational, and cultural backgrounds. [Journal of Gerontological Nursing, 45(12), 33-40.].

Healthy aging through the lens of community-based practitioners: a focus group study

Background

Nearly one in every seven Americans is 65 years and older, facing day-to-day challenge of aging. Although interest in healthy aging is growing, most of the efforts are directed towards understanding the perceptions of older adults. Little is known about the perspectives of community-based practitioners who work with older adults and deliver programs to promote healthy aging. The purpose of this project was to expand knowledge on healthy aging by exploring the perspectives of community-based practitioners working directly with older adults.

Methods

We purposively sampled community-based practitioners (n = 12, including nurses, physician, social workers, and other community services professionals) working with older adults, who then participated in one of three in-depth focus group discussions conducted between March and June 2016. Each focus group discussion lasted for about 2 h. Verbatim transcript data were analyzed in Atlas.ti 7 using a conventional content analysis with an inductive approach, and consensual validation of coding was achieved.

Results

Three core categories of healthy aging were identified: (1) characteristics of healthy aging; (2) healthy aging attainment; and (3) programs and activities for healthy aging. Practitioners identified a number of characteristics of healthy aging under person-specific (physiological, basic, psych-emotional, and cognitive needs), social aspects (creating community and contributing to the community), and spiritual dimensions (cultural views and beliefs) of healthy aging. Healthy aging attainment was represented as facilitators and barriers both with respect to care recipients and care providers, and programs and activities through promoting fitness and wellness.

Conclusions

The rapidly changing demographics and aging population in the United States and their various needs suggest the implications for recognizing opportunities and developing and implementing programs to promote healthy aging. Although practitioners’ perspectives had some overlap with traditional research and medical views on healthy aging, the unique and holistic conceptual framework derived in the study might provide a more refined foundation for delivering appropriate health care services to the American aging population.

Promoting Behavioral Change in Mobile Health Interventions for Older Adults: A Scoping Review

The current study reviewed the effectiveness of mobile health interventions in eliciting behavioral change across a range of health conditions and examined integration of behavioral change theory, techniques, and agents in interventions among people age ≥60. The initial search returned 1,929 articles: 779 in PubMed, 522 in CINAHL, 633 in PsycINFO, and 131 in EMBASE. The final sample included 20 articles. Most interventions targeted and reported increases in physical activity and disease and medication management. Some studies were informed by behavioral change theories and included behavioral change agents. The most commonly used behavior change techniques were in the form of self- or external-monitoring and receiving tailored feedback on a person's progress. As the National Institutes of Health currently calls for an increased focus on mechanisms of change, future studies should specify features promoting behavioral change and consider whether interventions worked by engaging the hypothesized change mechanisms. [Research in Gerontological Nursing, 13(2), 102-116.].

Beliefs about benefits and harms of medications and supplements for brain health

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Respondents were unaware of benefits/harms of pharmaceuticals for brain health.

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Fish oil and vitamin E were most commonly thought to improve brain health.

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Nearly one-third thought over-the-counter sleep aids were harmful to brain health.

The role of medications and supplements for brain health is a fast-changing and growing field, making it difficult for patients to receive updated and accurate information. The objective of this study was to assess patients’ beliefs about the helpfulness or harmfulness of various medications and supplements on brain health. A convenience sample of adults from an integrated healthcare system completed a web-based survey. Descriptive statistics were used for this hypothesis-generating study. A total of 1661 respondents completed the survey. The majority of respondents were female (77%), between the ages of 51–70 (64%), and white (89%). Across the selected medications and supplements purported to improve a person’s brain health (vitamin E, ginkgo biloba, hormones such as estrogen or testosterone, fish oil, and statins), 46–64% of respondents reported not knowing or skipped the item regarding their helpfulness to improve brain health. One out of four respondents reported benefits of vitamin E and nearly half reported benefits of fish oil on brain health; neither benefit is supported by current evidence. For the two medication classes evaluated for increasing dementia risk (proton pump inhibitors and anticholinergics used as sleep aids), 63–77% of respondents reported not knowing or skipped the item regarding their harmfulness to brain health. Survey respondents largely reported not knowing the potential benefits and harms of different medications and supplements for brain health. Improved health communication on pharmaceutical effects on dementia risk is greatly needed, and its development and dissemination should involve healthcare providers, patients, and media outlets.

Short Sleep Is Associated With Low Bone Mineral Density and Osteoporosis in the Women's Health Initiative

Short sleep duration, recognized as a public health epidemic, is associated with adverse health conditions, yet little is known about the association between sleep and bone health. We tested the associations of usual sleep behavior and bone mineral density (BMD) and osteoporosis. In a sample of 11,084 postmenopausal women from the Women's Health Initiative (WHI; mean age 63.3 years, SD = 7.4), we performed a cross-sectional study of the association of self-reported usual hours of sleep and sleep quality (WHI Insomnia Rating Score) with whole body, total hip, femoral neck, and spine BMD using linear regression models. We also studied the association of sleep duration and quality with dual-energy X-ray absorptiometry (DXA)-defined low bone mass (T-score < -2.5 to <-1) and osteoporosis (T-score ≤ -2.5) using multinomial regression models. We adjusted for age, DXA machine, race, menopausal symptoms, education, smoking, physical activity, body mass index, alcohol use, physical function, and sleep medication use. In adjusted linear regression models, women who reported sleeping 5 hours or less per night had on average 0.012 to 0.018 g/cm² significantly lower BMD at all four sites compared with women who reported sleeping 7 hours per night (reference). In adjusted multinomial models, women reporting 5 hours or less per night had higher odds of low bone mass and osteoporosis of the hip (odds ratio [OR] = 1.22; 95% confidence interval [CI] 1.03-1.45, and 1.63; 1.15-2.31, respectively). We observed a similar pattern for spine BMD, where women with 5 hours or less per night had higher odds of osteoporosis (adjusted OR = 1.28; 95% CI 1.02-1.60). Associations of sleep quality and DXA BMD failed to reach statistical significance. Short sleep duration was associated with lower BMD and higher risk of osteoporosis. Longitudinal studies are needed to confirm the cross-sectional effects of sleep duration on bone health and explore associated mechanisms. © 2019 American Society for Bone and Mineral Research.

High glycemic index and glycemic load diets as risk factors for insomnia: analyses from the Women's Health Initiative

BACKGROUND

Previous studies have shown mixed results on the association between carbohydrate intake and insomnia. However, any influence that refined carbohydrates have on risk of insomnia is likely commensurate with their relative contribution to the overall diet, so studies are needed that measure overall dietary glycemic index (GI), glycemic load, and intakes of specific types of carbohydrates.

OBJECTIVE

We hypothesized that higher GI and glycemic load would be associated with greater odds of insomnia prevalence and incidence.

METHODS

This was a prospective cohort study with postmenopausal women who participated in the Women's Health Initiative Observational Study, investigating the relations of GI, glycemic load, other carbohydrate measures (added sugars, starch, total carbohydrate), dietary fiber, and specific carbohydrate-containing foods (whole grains, nonwhole/refined grains, nonjuice fruits, vegetables, dairy products) with odds of insomnia at baseline (between 1994 and 1998; n = 77,860) and after 3 y of follow-up (between 1997 and 2001; n = 53,069).

RESULTS

In cross-sectional and longitudinal analyses, higher dietary GI was associated with increasing odds of prevalent (fifth compared with first quintile OR: 1.11; CI: 1.05, 1.16; P-trend = 0.0014) and incident (fifth compared with first quintile OR: 1.16; CI: 1.08, 1.25; P-trend < 0.0001) insomnia in fully adjusted models. Higher intakes of dietary added sugars, starch, and nonwhole/refined grains were each associated with higher odds of incident insomnia. By contrast, higher nonjuice fruit and vegetable intakes were significantly associated with lower odds of incident insomnia. Also, higher intakes of dietary fiber, whole grains, nonjuice fruit, and vegetables were significantly associated with lower odds of prevalent insomnia.

CONCLUSIONS

The results suggest that high-GI diets could be a risk factor for insomnia in postmenopausal women. Substitution of high-GI foods with minimally processed, whole, fiber-rich carbohydrates should be evaluated as potential treatments of, and primary preventive measures for, insomnia in postmenopausal women.

Postmenopausal Breast Cancer and Physical Function Change: A Difference-in-Differences Analysis

BACKGROUND/OBJECTIVES

While breast cancer and associated therapies can influence physical function (PF), findings for breast cancer's effects on PF among postmenopausal women are not consistent. This research evaluates the effect of breast cancer on change in PF.

DESIGN

Longitudinal cohort study analyzed using difference-in-differences (DID) method to compare the changes in PF over time between women with and without breast cancer, by invasive status, stage, and age.

SETTING AND PARTICIPANTS

Women's Health Initiative participants, aged 50 to 79 years at baseline, with four completed functional status assessments were eligible for inclusion (mean age = 62.1 ± 6.9 years). Women with breast cancer diagnosed between the 3rd and 11th enrollment year (n = 1636) were compared to women without breast cancer (n = 35 660).

MEASUREMENTS

PF was measured using the Medical Outcomes Study Short Form 36 at baseline and years 3, 11, and 12.

RESULTS

Compared with women without breast cancer, women with breast cancer experienced greater PF decline (P < .0001), after adjustment for age, race, education, income, study/trial arm, and body mass index. Overall, functional declines were greatest among women with invasive breast cancer (DID = -4.87; 95% confidence interval = -7.12 to -2.62). In stratified analyses, the breast cancer effect on PF was greater among women in older age groups.

CONCLUSION

Women diagnosed with breast cancer experienced a significant decline in PF beyond what is observed in typical aging in this cohort. To optimally address survivorship issues, disease sequelae need to be distinguished from normal aging in studies incorporating a cancer-free comparison group. J Am Geriatr Soc 68:1029-1036, 2020.

Modeling the cardiometabolic benefits of sleep in older women: exploring the 24-hour day

STUDY OBJECTIVES

Activities throughout the day, including sleep, sedentary behavior (SB), light-intensity physical activity (LIPA), and moderate to vigorous physical activity (MVPA) are independently associated with cardiometabolic health. Few studies have examined interrelationships between sleep and 24-hour activity and associations with cardiometabolic risk. The objective of this study is to understand how replacing time in SB, LIPA, or MVPA with sleep impacts cardiometabolic risk.

METHODS

Women's Health Initiative OPACH Study participants (N = 3329; mean age = 78.5 ± 6) wore ActiGraph GT3X+ accelerometers 24 hours/7 days. Adjusted linear regression estimated the relationship between sleep duration and cardiometabolic markers. Separately for shorter (<8 hours) and longer (≥8 hours) sleepers, isotemporal substitution models estimated the cross-sectional associations with cardiometabolic markers with reallocating time in daytime activities to or from sleep.

RESULTS

Longer sleep duration was associated with higher insulin, HOMA-IR, glucose, total cholesterol, and triglycerides (all p < 0.05). The associations between sleep duration and C-reactive protein, waist circumference, and body mass index (BMI) were U-shaped (both p < 0.05). For shorter sleepers, reallocating 33 minutes of MVPA to sleep was associated with higher values of insulin, HOMA-IR, glucose, triglycerides, waist circumference, and BMI (0.7%-11.5%). Replacing 91 minutes of SB time with sleep was associated with lower waist circumference and BMI (-1.3%, -1.8%). For long sleepers, shifting 91 minutes of sleep to SB was associated with higher waist circumference and BMI (1.3%, 1.4%).

CONCLUSIONS

This is one of the first isotemporal analyses to include objectively measured sleep duration. Results illuminate possible cardiometabolic risks and benefits of reallocating time to or from sleep.

A MICROLONGITUDINAL ASSESSMENT OF SUBJECTIVE AGE AND MENTAL HEALTH DURING REHABILITATION

Recent ecological momentary assessments focused on the concomitants of daily views on aging among community-dwelling participants, yet clinical samples are underexplored. Hence, this study examined the relationships between views on aging and daily mental health during rehabilitation following osteoporotic fractures and cerebrovascular events. Measures of daily subjective age, psychological distress, and mental health were assessed among 132 older adult patients (mean age=77.9, SD=7.5, 65.9% women). Multilevel models showed that on days patients felt younger, they reported lower psychological distress and higher mental health. Time lagged analyses further showed reciprocal effects between subjective age and mental health. Finally, the subjective age-mental health covariance was stronger among patients high on age awareness. The suddenness and brutality of acute medical events highlight subjective age as an important factor in patients’ wellbeing, especially among those more attentive to their age. These findings suggest that practitioners should consider interventions focused on patients’ age identity.

USABILITY OF AN ONLINE DISCUSSION PLATFORM: DEVELOPMENT OF A CODING SCHEME

Online discussion platforms have the potential to support or even improve older adults’ well-being. Nonetheless, potential health benefits are often shaped by the usability of such platforms. Improving usability is imperative to maximize these potential benefits. As a part of a qualitative analysis of a study of an online community for older adults with frailty symptoms, we developed and refined a coding scheme targeting usability. The scheme was derived by reviewing contemporary literature on user experience, usability, and health information technology in older adults. Our review revealed challenges to apply commonly used terms to summarize our qualitative data. For example, the concept of perceived usability has different meanings and definitions in existing frameworks as they pertain to user engagement and technology adoption (specifically, the Technology Acceptance Model) than usability in an online discussion context for older adults. Because none of the meanings of usability fully encompassed the breadth of this concept for older users, we developed a coding scheme that is practical and captures a broad range of older adults’ perceptions of usability. Through qualitative analysis of the online discussion content using the newly developed coding scheme, new themes emerged such as confusing layout (e.g., difficulty in locating discussion boxes), insufficient instruction or training (trouble posting discussions), unwanted results (e.g., pressed a wrong key), and memory issues and cognitive burden. This presentation describes the process of developing a coding scheme, illustrates nuances of meanings in concepts related to usability, and presents preliminary results of our qualitative analysis.

VIRTUAL ONLINE COMMUNITIES FOR AGING LIFE EXPERIENCE (VOCALE) APPROACH: PILOT STUDIES

Emerging evidence suggests behavioral strategies focusing on symptom management can reduce frailty symptoms and improve quality of life. Unfortunately, these interventions are rarely scalable for implementation in geriatric care. Contemporary online technologies have tremendous potential for addressing this need. We developed and pilot tested an approach entitled Virtual Online Community for Aging Life Experience (VOCALE). The approach had two stages. In the first stage, we piloted the use of a Facebook platform to engage older adults with frailty symptoms in ten-week moderated discussions on health-related topics. In the second study, we used data from stage one to develop a prototypical persona of a person with frailty symptoms. The persona was then incorporated into an eight-week Facebook intervention informed by problem solving therapy to facilitate self-management in another group of older adults with frailty symptoms. The results from both rounds showed that it was feasible to recruit, engage, and retain persons ages 69-92 into virtual online community interventions. Attrition ranged from 25% to 33% in rounds one and two. In both rounds, we observed positive trends of change in health measures such as general health self-efficacy, disease self-efficacy, and health literacy. Throughout the studies, older adults shared multiple posts concerning their experience with age-related symptoms and described their self-management practices. These projects, which leveraged a common social media platform, demonstrated preliminary efficacy of an online intervention for frailty management. If confirmed, this approach might provide a viable model for other medically complex geriatric conditions where self-management is essential.

Diet Quality and Cardiovascular Disease Risk in Postmenopausal Women With Type 2 Diabetes Mellitus: The Women's Health Initiative

Background

Dietary patterns are associated with cardiovascular disease (CVD) risk in the general population, but diet–CVD association in populations with diabetes mellitus is limited. Our objective was to examine the association between diet quality and CVD risk in a population with type 2 diabetes mellitus.

Methods and Results

We analyzed prospective data from 5809 women with prevalent type 2 diabetes mellitus at baseline from the Women's Health Initiative. Diet quality was defined using alternate Mediterranean, Dietary Approach to Stop Hypertension, Paleolithic, and American Diabetes Association dietary pattern scores calculated from a validated food frequency questionnaire. Multivariable Cox's proportional hazard regression was used to analyze the risk of incident CVD. During mean 12.4 years of follow‐up, 1454 (25%) incident CVD cases were documented. Women with higher alternate Mediterranean, Dietary Approach to Stop Hypertension, and American Diabetes Association dietary pattern scores had a lower risk of CVD compared with women with lower scores (Q5 v Q1) (hazard ratio [HR]_aMed 0.77, 95% CI 0.65–0.93; HR_DASH 0.69, 95% CI 0.58–0.83; HR_ADA 0.71, 95% CI 0.59–0.86). No association was observed between the Paleolithic score and CVD risk.

Conclusions

Dietary patterns that emphasize higher intake of fruits, vegetables, whole grains, nuts/seeds, legumes, a high unsaturated:saturated fat ratio, and lower intake of red and processed meats, added sugars, and sodium are associated with lower CVD risk in postmenopausal women with type 2 diabetes mellitus.

Use of a Wearable Technology and Motivational Interviews to Improve Sleep in Older Adults With Osteoarthritis and Sleep Disturbance: A Pilot Study

The feasibility and preliminary efficacy of a mobile health self-management intervention aimed at improving sleep among older adults with osteoarthritis and disturbed sleep were evaluated. This was a one-group pre-/posttest pilot study. Feasibility was measured by the number of participants eligible, enrolled, and retained. Primary efficacy outcomes were Insomnia Severity Index (ISI) score and two sleep actigraphy variables: total sleep time (TST) and sleep efficiency (SE). Overall step count, self-efficacy (SEff), and acceptance of sleep difficulties (ASD) were mechanisms of action variables. Assessments were at baseline, Week 14 (postintervention), and Week 19 (follow up). Mixed effect models were used to measure change over time. Twenty-four participants (mean age = 71 years) were enrolled and 22 completed the study. Improvements of 1.2 (95% confidence interval [CI] [-2.43, -0.05]; p = 0.04) and 2.5 (95% CI [0.9, 4.9]; p = 0.02) points in the ISI and ASD scores, respectively, were found over the 19-week period. These findings add to a growing literature that suggests older adults might reap benefits from mobile health interventions.

TARGETS

Older adults with osteoarthritis and insomnia symptoms.

INTERVENTION DESCRIPTION

Activity trackers synced to a dashboard that triggered personalized weekly step goals and motivational messages augmented by telephone motivational interviews.

MECHANISM OF ACTION

Physical activity, SEff, and ASD.

OUTCOMES

Sleep measures. [Res Gerontol Nurs. 2019; 12(4):167-173.].

Characteristics of Self-Reported Sleep and the Risk of Falls and Fractures: The Women's Health Initiative (WHI)

Sleep disturbances are common and may influence falls and fracture directly by influencing bone turnover and muscle strength or indirectly through high comorbidity or poor physical function. To investigate the association between self-reported sleep and falls and fractures, we prospectively studied 157,306 women in the Women's Health Initiative (WHI) using information on sleep quality, sleep duration, and insomnia from questionnaires. Annual self-report of falling two or more times (ie, "recurrent falling") during each year of follow-up was modeled with repeated measures logistic regression models fit by generalized estimating equations. Cox proportional hazards models were used to investigate sleep disturbance and time to first fracture. We examined the risks of recurrent falls and fracture by sleep duration with 7 hours as referent. We examined the risks across categories of sleep disturbance, insomnia status, and sleep quality. The average follow-up time was 7.6 years for falls and 12.0 years for fractures. In multivariable adjusted models, including adjustment for comorbidity, medications, and physical function, women who were short (≤5 hours) and long (≥10 hours) sleepers had increased odds of recurrent falls (odds ratio [OR] 1.28; 95% confidence interval [CI], 1.23 to 1.34 and OR 1.25; 95% CI, 1.09 to 1.43, respectively). Poor sleep quality, insomnia, and more sleep disturbances were also associated with an increased odds of recurrent falls. Short sleep was associated with an increased risk of all fractures, and upper limb, lower limb, and central body fractures, but not hip fractures, with hazard ratios ranging from 1.10 to 1.13 (p < 0.05). There was little association between other sleep characteristics and fracture. In conclusion, short and long sleep duration and poor sleep quality were independently associated with increased odds of recurrent falls. Short sleep was associated with modest increase in fractures. Future long-term trials of sleep interventions should include falls and fractures as endpoints. © 2018 American Society for Bone and Mineral Research.