A molecular index for biological age identified from the metabolome and senescence-associated secretome in humans

Unlike chronological age, biological age is a strong indicator of health of an individual. However, the molecular fingerprint associated with biological age is ill-defined. To define a high-resolution signature of biological age, we analyzed metabolome, circulating senescence-associated secretome (SASP)/inflammation markers and the interaction between them, from a cohort of healthy and rapid agers. The balance between two fatty acid oxidation mechanisms, β-oxidation and ω-oxidation, associated with the extent of functional aging. Furthermore, a panel of 25 metabolites, Healthy Aging Metabolic (HAM) index, predicted healthy agers regardless of gender and race. HAM index was also validated in an independent cohort. Causal inference with machine learning implied three metabolites, β-cryptoxanthin, prolylhydroxyproline, and eicosenoylcarnitine as putative drivers of biological aging. Multiple SASP markers were also elevated in rapid agers. Together, our findings reveal that a network of metabolic pathways underlie biological aging, and the HAM index could serve as a predictor of phenotypic aging in humans.

Association of inflammatory markers with muscle and cognitive function in early and late-aging older adults

OBJECTIVES

Age-related loss in muscle and cognitive function is common in older adults. Numerous studies have suggested that inflammation contributes to the decline in physical performance and increased frailty in older adults. We sought to investigate the relationship of inflammatory markers, including CRP, IL-6, IL-10, TNF-α, TNFR1, and TNFR2, with muscle and cognitive function in frail early-aging and non-frail late-aging older adults.

DESIGN

Secondary analysis of a cross-sectional study.

SETTINGS AND PARTICIPANTS

Two hundred community-dwelling older men and women were included. They had been recruited in two groups based on age and functional status: 100 early-agers (age 65-75, who had poor functional status, and more co-morbidities) and 100 late-agers (older than 75 years, who were healthier and had better functional status).

MEASUREMENTS

We assessed CRP, IL-6, IL-10, TNF-α, TNFR1, TNFR2, grip strength, Short Physical Performance Battery (SPPB) score, and cognitive function. We used correlation coefficients, partial correlations, and regression modeling adjusted for age, BMI, gender, and exercise frequency.

RESULTS

The mean age in the two groups were 70.4 and 83.2, respectively. In regression models adjusting for age, BMI, gender and exercise frequency, early-agers demonstrated significant associations between inflammatory markers and outcomes. Each mg/dl of CRP was associated with (regression coefficient ± standard error) -0.6 ± 0.2 kg in grip strength (p = 0.0023). Similarly, each pg/mL of TNF-α was associated with -1.4 ± 0.7 (p = 0.0454), each 500 pg/mL of TNFR1 was associated with -1.9 ± 0.6 (p = 0.0008), and each 500 pg/mL of TNFR2 was associated with -0.5 ± 0.2 (p = 0.0098) in grip strength. Each 500 pg/mL of TNFR1 was associated with -0.4 ± 0.2 point in SPPB (p = 0.0207) and each pg/mL in IL-10 with 0.2 ± 0.1 point in MoCA (p = 0.0475). In late-agers, no significant correlation was found between any of the inflammatory markers and functional outcomes.

CONCLUSION

In early-agers with frailty and more co-morbidities, the inflammatory markers CRP, TNF-α, TNFR1, and TNFR2 were associated with grip strength, TNFR1 was correlated with physical performance, and IL-10 was correlated with cognitive function. However, in healthier late-agers, no relationship was found between inflammatory markers and muscle or cognitive function. Our findings suggest presence of a relationship between inflammation and loss of muscle performance and cognitive function in frailer and sicker individuals, regardless of their chronological age.

Prefrontal cortex activation while walking did not change but gait speed improved after a randomized physical therapy intervention

BACKGROUND

Higher prefrontal cortex (PFC) activation while walking may indicate reduced gait automaticity.

AIM

We examine whether PFC activation during walking improves after training in older adults at risk for mobility disability.

METHODS

Forty-two adults aged ≥ 65 participated in a randomized clinical trial (NCT026637780) of a 12-week timing and coordination physical therapy intervention to improve walking (n = 20 intervention, n = 22 active control). PFC activation was measured by functional near-infrared spectroscopy (fNIRS) during four walking tasks over 15 m, each repeated 4 times: even surface walking, uneven surface walking, even dual-task, uneven dual-task; dual-task was reciting every other letter of the alphabet while walking. Gait speed and rate of correct letter generation were recorded. Linear mixed models tested between arm differences in change of fNIRS, gait speed, and letter generation from baseline to follow-up (12-week, 24-week, and 36-week).

RESULTS

Intervention arms were similar in mean age (74.3 vs. 77.0) and baseline gait speed (0.96 vs. 0.93 m/s). Of 24 comparisons of between arm differences in the fNIRS signals, only two were significant which were not supported by differences at other follow-up times or on other tasks. Gait speed, particularly during dual-task conditions, and correct letter generation did improve post-intervention but improvements did not differ by arm.

DISCUSSION AND CONCLUSIONS

After training, PFC activation during walking generally did not improve and did not differ by intervention arm. Improvements in gait speed without increased PFC activation may point toward more efficient neural control of walking.

Dissemination and implementation of evidence-based programs for people with chronic disease: the impact of the COVID-19 pandemic

Background

Using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework, we describe the implementation of evidence-based chronic disease self-management education (CDSME) programs by the Administration for Community Living CDSME Grantees during 2016-2022 and we also explore the impact of the COVID-19 pandemic on implementation.

Methods

Grantees collected data before and after the implementation of the CDSME programs and contributed to the national data repository. Data components included workshop information, participant information, and organizational data.

Results

The cohort consisted of 175,973 individuals who participated in 34 CDSME programs across 45 states. Participants had a mean ± SD age of 66.1 ± 14.8 years, were primarily female (65.9%) and had a mean ± SD of 2.6 ± 2.3 chronic conditions. Compared to the pre-COVID-19 strata, those who participated during COVID-19 were on average 1.5 years younger and had slightly less comorbidities. For individuals who had pre and post program self-reported health, 65.3% stayed the same, 24.4% improved, and 10.3% worsened (p < 0.001) after participating in CDSME programs.

Conclusion

CDSME offers a variety of programs across a broad geographic area to a diverse set of older adults in the US, underscoring the expansive reach of this public health initiative. COVID-19 appears to have shifted participant reach toward a slightly younger and healthier population. Finally, these programs appear to be effective in improving participants' self-rated health. However, these results should be interpreted with caution, given limitations due to missing data and the observational nature of this study design.

Global Positioning System Indicators of Community Mobility and Future Health Outcomes Among Older Adults

BACKGROUND

We examined the relationship between global positioning system (GPS) indicators of community mobility and incident hospitalizations, emergency department (ED) visits, and falls over 1-year in community-dwelling older adults.

METHODS

We performed a secondary analysis of a randomized trial investigating a physical therapy intervention to improve mobility in older adults. One hundred and forty-eight participants (mean age: 76.9 ± 6.2 years; 65% female) carried a GPS device following the postintervention visit. Over 1-year, new hospitalizations, falls, and ED visits were reported. GPS indicators of community mobility included the median area and compactness of the standard deviation ellipse (SDE), the median percentage of time spent outside of home (TOH), and median maximum distance from home. Generalized linear models assessed the association between 1-year risk of outcomes and GPS measures adjusted for age, race, gender, body mass index, comorbidity burden, and fall history.

RESULTS

The mean ± standard deviation of the median SDE area was 4.4 ± 8.5 km2, median SDE compactness 0.7 ± 0.2, median percentage TOH 14.4 ± 12.0%, and median maximum distance from home was 38 ± 253 km. Each 5% increase in median percentage TOH was associated with a 24% lower risk of hospitalization (incident rate ratio = IRR = 0.76, 95%CI: 0.61-0.95; p = .01). The association persisted after covariate adjustment (IRR = 0.78, 95%CI: 0.63-0.98; p = .03). No significant associations appeared for any GPS indicators with incident falls or ED visits.

CONCLUSIONS

Increased TOH was associated with a lower risk of incident hospitalization over 1 year among community-dwelling older adults. Restricted community mobility may be an indicator of activity limitations related to future health outcomes, but further study is warranted.

Caregiver strain among patients of palliative care in Sri Lanka: validation of modified caregiver strain index - Sinhala version

BACKGROUND

Care givers of Palliated patients are at risk of adverse physical, psychosocial and emotional sequelae in varied nature. Efficient and valid assessment tools facilitate early detection to take corrective measures. The Modified Caregiver Strain Index (MCSI), composed of domains associated with caregiver strain is a simple and brief tool that can be used in both clinical and field settings. This study aimed to adapt and validate this in order to cater effective palliative care services in Sri Lanka.

METHODS

After cross-cultural adaptation, 200 primary caregivers in 3 teaching hospitals were recruited. The internal consistency, item-total correlations, of the 13-item S-MCSI were performed. The criterion validity was assessed by Pearson correlation between the total scores of S-MCSI, the Karnofky Performance Scale and the Barthel index. Construct validity was determined by the principal component analysis keeping the Varimax with Keiser normalization as the rotation method. The Kaiser-Meyer-Olkin test (KMO) and Bartlett's test of sphericity statistics were also performed to determine the adequacy of the sample and correlations between items, respectively. The number of factors was determined by the Scree plot, percentage of variance explained by each component and number of Eigen values over 01 (Kaiser-Guttman rule).

RESULTS

The total MCSI score ranged 0 to 26. The overall Cronbach's alpha of the 13-item questionnaire was 0.80 while item-total corrections ranged 0.34 to 0.62, exception of one item (0.11). Inverse correlations were demonstrated in total scores of MCSI and Karnofky Performance Scale (r =- 0.32, p < 0.001) and Barthel index (r =-0.34, P < 0.001). A Kaiser-Meyer-Olkin value of 0.79 (p < 0.001) for Bartlett's test indicated adequate sampling and nonlinearity of factors. The Scree plot showed a three-factor structure explaining 57% of the variation. Items regarding personal wellbeing of caregiver loaded together while the effects on the family loaded separately. Adjustment of personal concerns and family issues along with time alteration grouped as the third factor.

CONCLUSIONS

The study showed that the Sinhala version of MCSI has adequate psychometric properties and reliability to be used as a validated tool to estimate the caregiver burden within a short time period for any health care workers.

The association of vitamin D with bone microarchitecture, muscle strength, and mobility performance in older women in long-term care

BACKGROUND

Osteoporosis and sarcopenia are prevalent in older adults. Trabecular bone score (TBS) is a novel method to evaluate bone microarchitecture, whereas grip strength and gait speed are simple methods to assess muscle strength and function. Few studies have linked the relationship between vitamin D levels (25OHD) with TBS, grip strength, and gait speed in healthy community dwelling adults. We sought to investigate this relationship in older women with osteoporosis and multiple comorbid conditions residing in long-term care (LTC) facilities.

METHODS

We analyzed baseline 25OHD, spine TBS, grip strength, and gait speed in 246 women with osteoporosis who were residents of LTC and enrolled in a randomized controlled clinical trial.

RESULTS

On average, participants were 81.6 years old and had a BMI of 26.8 kg/m2. The correlation (r) of 25OHD with spine TBS, grip strength, and gait speed were (r = 0.15; p = 0.0208), (r = - 0.05; p = 0.4686), and (r = 0.19; p = 0.0041), respectively. Each 5 ng/dl increase in 25OHD was associated with an increase of 0.006 in spine TBS and 0.014 m/s in gait speed. After adjusting for covariates, each 5 ng/dl increase in 25OHD was associated with an increase of 0.004 in spine TBS (p = 0.0599) and 0.012 m/s in gait speed (p = 0.0144).

CONCLUSION

In older women residing in LTC facilities, 25OHD was associated with spine TBS and gait speed. The strengths of the associations suggest there may be other factors with a more prominent role in bone microarchitecture, muscle strength, and physical function in this population.

MINI ABSTRACT

Our study found in older women who are residents of long-term care facilities, vitamin D level is associated with bone microarchitecture and mobility performance.

Systematic Review and Meta-analysis of Interventions to Reduce Adverse Drug Reactions in Older Adults: An Update

BACKGROUND

We previously reported that interventions to optimize medication use reduced adverse drug reactions (ADRs) by 21% and serious ADRs by 36% in older adults. With new evidence, we sought to update the systematic review and meta-analysis.

METHOD

We searched OVID, Cochrane Library, ClinicalTrials.gov and Google Scholar from 30 April 2017-30 April 2023. Included studies had to be randomized controlled trials of older adults (mean age ≥65 years) taking medications that examined the outcome of ADRs. Two authors independently reviewed all citations, extracted relevant data, and assessed studies for potential bias. The outcomes were any and serious ADRs. We performed subgroup analyses by intervention type and setting. Random-effects models were used to combine the results from multiple studies and create summary estimates.

RESULTS

Six studies are new to the update, resulting in 19 total studies (15,675 participants). Interventions were pharmacist-led (10 studies), other healthcare professional-led (5 studies), technology based (3 studies), and educational (1 study). The interventions were implemented in various clinical settings, including hospitals, outpatient clinics, long-term care facilities/rehabilitation wards, and community pharmacies. In the pooled analysis, the intervention group participants were 19% less likely to experience an ADR (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.68-0.96) and 32% less likely to experience a serious ADR (OR 0.68, 95% CI 0.48-0.96). We also found that pharmacist-led interventions reduced the risk of any ADR by 35%, compared with 8% for other types of interventions.

CONCLUSION

Interventions significantly and substantially reduced the risk of ADRs and serious ADRs in older adults. Future research should examine whether effectiveness of interventions vary across health care settings to identify those most likely to benefit. Implementation of successful interventions in health care systems may improve medication safety in older patients.

Knowledge and Use of Evidence-Based Programs for Older Adults in the Community: A Survey of Physical Therapy Professionals

BACKGROUND AND PURPOSE

The Agency for Healthcare Research and Quality highlights the need for sustainable linkages between clinical and community settings to enhance prevention and improve care of people with chronic conditions. The first step in promoting linkages is understanding the knowledge and use of evidence-based programs by physical therapy (PT) professionals. Therefore, the objective of this study was to describe the knowledge of and referral to evidence-based programs in the community by a convenience sample of PT professionals and to examine the characteristics of those who refer to evidence-based programs.

METHODS

A cross-sectional web-based survey containing 36 questions regarding respondents' demographics and evidence-based program knowledge and referral practices was disseminated to a convenience sample of PT professionals via email, news-blasts, social media, and word of mouth.

RESULTS AND DISCUSSION

A total of 459 PT professionals completed the survey. Approximately half reported practicing for more than 20 years and 75% are members of the American Physical Therapy Association (APTA). The majority (74%) are aware of evidence-based programs; however, fewer (56%) refer to these programs. Compared with individuals who do not refer to evidence-based programs, individuals who refer are more likely to be involved in PT organizations and be an APTA Geriatrics member. Of the individuals who do not refer to evidence-based programs, 21.5% reported not knowing they existed and 33% reported not knowing where the programs are located.

CONCLUSIONS

Most survey respondents reported knowing about evidence-based programs and more than half reported being aware of the evidence-based programs available in their communities. These results indicate many PT professionals already have a knowledge of evidence-based programs to support clinic-community linkages. As survey respondents were a sample of convenience and likely do not represent all PT professionals in the United States, the results should be interpreted with caution. Additional research on a more representative sample is needed to fully understand the current utilization of evidence-based programs, which will enable us to design efforts to improve the clinic to community transition. Improving linkages between PT professionals and community resources has the potential to benefit both patients and clinicians and lessen the burden on the health care system.

Impact of sleep on chronobiology of micturition among healthy older adults

Nocturia (waking to void) is prevalent among older adults. Disruption of the well-described circadian rhythm in urine production with higher nighttime urine output is its most common cause. In young adults, their circadian rhythm is modulated by the 24-h secretory pattern of hormones that regulate salt and water excretion, including antidiuretic hormone (ADH), renin, angiotensin, aldosterone, and atrial natriuretic peptide (ANP). The pattern of hormone secretion is less clear in older adults. We investigated the effect of sleep on the 24-h secretion of these hormones in healthy older adults. Thirteen participants aged ≥65 yr old underwent two 24-h protocols at a clinical research center 6 wk apart. The first used a habitual wake-sleep protocol, and the second used a constant routine protocol that removed the influence of sleep, posture, and diet. To assess hormonal rhythms, plasma was collected at 8:00 am, 12:00 pm, 4:00 pm, and every 30 min from 7:00 pm to 7:00 am. A mixed-effects regression model was used to compare subject-specific and mean trajectories of hormone secretion under the two conditions. ADH, aldosterone, and ANP showed a diurnal rhythm that peaked during sleep in the wake-sleep protocol. These nighttime elevations were significantly attenuated within subjects during the constant routine. We conclude that sleep has a masking effect on circadian rhythm amplitude of ADH, aldosterone, and ANP: the amplitude of each is increased in the presence of sleep and reduced in the absence of sleep. Disrupted sleep could potentially alter nighttime urine output in healthy older adults via this mechanism.NEW & NOTEWORTHY Nocturia (waking to void) is the most common cause of sleep interruption among older adults, and increased nighttime urine production is its primary etiology. We showed that in healthy older adults sleep affects the 24-h secretory rhythm of hormones that regulate salt-water balance, which potentially alters nighttime urine output. Further studies are needed to elucidate the impact of chronic insomnia on the secretory rhythms of these hormones.

Exercise interventions, postural control, and prefrontal cortex activation in older adults

Improving postural control in older adults is necessary for reducing fall risk, and prefrontal cortex activation may also play a role. We sought to examine the impact of exercise interventions on postural control and prefrontal cortex activation during standing balance tasks. We hypothesized that balance would improve and prefrontal control would be reduced. We assessed a subset of participants enrolled in a randomized trial of two exercise interventions. Both groups completed strength and endurance training and the experimental treatment arm included training on timing and coordination of stepping. Postural control and prefrontal cortex activation were measured during dual-task standing balance tasks before and after the intervention. Eighteen participants in the standard strengthening and mobility training arm and 16 in the timing and coordination training arm were included. We examined pre- to post-intervention changes within each study arm, and compared them between interventions. Results did not show any pre- to post-intervention changes on standing postural control nor prefrontal cortex activation in either arm. In addition, there were no differences between the two intervention arms in either balance or prefrontal activation. While exercise interventions can improve mobility, we do not demonstrate evidence of improved standing balance or prefrontal control in standing.

Atomistic simulations of calcium aluminosilicate interfaced with liquid water

The dissolution behavior of calcium aluminosilicate based glass fibers, such as stone wool fibers, is an important consideration in mineral wool applications for both the longevity of the mineral wool products in humid environments and limiting the health impacts of released and inhaled fibers from the mineral wool product. Balancing these factors requires a molecular-level understanding of calcium aluminosilicate glass dissolution mechanisms, details that are challenging to resolve with experiment alone. Molecular dynamics simulations are a powerful tool capable of providing complementary atomistic insights regarding dissolution; however, they require force fields capable of describing not-only the calcium aluminosilicate surface structure but also the interactions relevant to dissolution phenomena. Here, a new force field capable of describing amorphous calcium aluminosilicate surfaces interfaced with liquid water is developed by fitting parameters to experimental and first principles simulation data of the relevant oxide-water interfaces, including ab initio molecular dynamics simulations performed for this work for the wüstite and periclase interfaces. Simulations of a calcium aluminosilicate surface interfaced with liquid water were used to test this new force field, suggesting moderate ingress of water into the porous glass interface. This design of the force field opens a new avenue for the further study of calcium and network-modifier dissolution phenomena in calcium aluminosilicate glasses and stone wool fibers at liquid water interfaces.

Influence of Recent Standing, Moving, or Sitting on Daytime Ambulatory Blood Pressure

Background There are no recommendations for being seated versus nonseated during ambulatory blood pressure (BP) monitoring (ABPM). The authors examined how recent standing or moving versus sitting affect average daytime BP on ABPM. Methods and Results This analysis used baseline assessments from a clinical trial in desk workers with office systolic BP (SBP) 120 to 159 mm Hg or diastolic BP (DBP) 80 to 99 mm Hg. ABPM was measured every 30 minutes with a SunTech Medical Oscar 2 monitor. Concurrent posture (standing or seated) and moving (steps) were measured via a thigh-worn accelerometer. Linear regression determined within-person BP variability explained (R2) by standing and steps before ABPM readings. Mean daytime BP and the prevalence of mean daytime BP >135/85 mm Hg from readings after sitting (seated) or after recent standing or moving (nonseated) were compared with all readings. Participants (n=266, 59% women; age, 45.2±11.6 years) provided 32.5±3.9 daytime BP readings. Time standing and steps before readings explained variability up to 17% for daytime SBP and 14% for daytime DBP. Using the 5-minute prior interval, seated SBP/DBP was lower (130.8/79.7 mm Hg, P<0.001) and nonseated SBP/DBP was higher (137.8/84.3 mm Hg, P<0.001) than mean daytime SBP/DBP from all readings (133.9/81.6 mm Hg). The prevalence of mean daytime SBP/DBP ≥135/85 mm Hg also differed: 38.7% from seated readings, 70.3% from nonseated readings, and 52.6% from all readings (P<0.05). Conclusions Daytime BP was systematically higher after standing and moving compared with being seated. Individual variation in activity patterns could influence the diagnosis of high BP using daytime BP readings on ABPM.

Effects of a Physical Therapist Intervention on GPS Indicators of Community Mobility in Older Adults: A Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

The authors compared the effects of a standard strength and endurance intervention with a standard plus timing and coordination training intervention on community mobility measured using global positioning systems (GPS) among community-dwelling older adults in this secondary analysis of a randomized controlled trial.

METHODS

Participants were randomized to a standard or a standard plus timing and coordination training program. Community mobility was measured using the Life Space Assessment (LSA) and GPS indicators of community mobility at baseline, as well as at 12 (immediately after the intervention), 24, and 36 weeks. Linear mixed models were used for analysis.

RESULTS

There were 166 participants with GPS data at baseline, including 81 in the standard plus group and 85 in the standard group. The groups did not differ in participant characteristics or GPS measures at baseline. There were no significant within-group changes in GPS indicators of community mobility or LSA score over time, nor between-group differences of the same.

CONCLUSION

There were no significant changes in community mobility with either intervention or between-intervention differences. These findings suggest that interventions targeting physical function alone may not be sufficient to improve community mobility or participation in older adults. Future research should focus on the development of multifaceted interventions targeted to improve real-world participation.

IMPACT

The studied interventions did not significantly change community mobility measured using GPS-derived community mobility measures or self-report measures in older adults, suggesting that more comprehensive interventions may be needed to target improvements in community mobility.

Temporal Sequence of Laryngeal Vestibule Closure and Reopening is Associated With Airway Protection

BACKGROUND

Upper esophageal sphincter opening (UESO), and laryngeal vestibule closure (LVC) are two essential kinematic events whose timings are crucial for adequate bolus clearance and airway protection during swallowing. Their temporal characteristics can be quantified through time-consuming analysis of videofluoroscopic swallow studies (VFSS).

OBJECTIVES

We sought to establish a model to predict the odds of penetration or aspiration during swallowing based on 15 temporal factors of UES and laryngeal vestibule kinematics.

METHODS

Manual temporal measurements and ratings of penetration and aspiration were conducted on a videofluoroscopic dataset of 408 swallows from 99 patients. A generalized estimating equation model was deployed to analyze association between individual factors and the risk of penetration or aspiration.

RESULTS

The results indicated that the latencies of laryngeal vestibular events and the time lapse between UESO onset and LVC were highly related to penetration or aspiration. The predictive model incorporating patient demographics and bolus presentation showed that delayed LVC by 0.1 s or delayed LVO by 1% of the swallow duration (average 0.018 s) was associated with a 17.19% and 2.68% increase in odds of airway invasion, respectively.

CONCLUSION

This predictive model provides insight into kinematic factors that underscore the interaction between the intricate timing of laryngeal kinematics and airway protection. Recent investigation in automatic noninvasive or videofluoroscopic detection of laryngeal kinematics would provide clinicians access to objective measurements not commonly quantified in VFSS. Consequently, the temporal and sequential understanding of these kinematics may interpret such measurements to an estimation of the risk of aspiration or penetration which would give rise to rapid computer-assisted dysphagia diagnosis.

LEVEL OF EVIDENCE

2 Laryngoscope, 133:521-527, 2023.

Insomnia symptoms and postoperative healthcare utilization in veterans undergoing decompressive laminectomy for lumbar spinal stenosis

Study Objectives

Lumbar spinal stenosis is an age-related spine condition that contributes to pain and disability. Decompressive laminectomy (DL) is regularly performed to alleviate symptoms. Insomnia symptoms are common among people living with chronic pain and may affect key DL outcomes, such as healthcare utilization. We examined associations of insomnia symptom severity with post-DL healthcare utilization in veterans with lumbar spinal stenosis.

Methods

Veterans (N = 200) with lumbar spinal stenosis undergoing DL were recruited into a prospective cohort study and self-reported insomnia symptom severity on the Insomnia Severity Index prior to DL. Post-DL, veterans reported on pain and non-pain-related monthly healthcare office visits, emergency room visits, hospitalizations, and mental health visits for 1 year. Incident rate ratios (IRRs) obtained via negative binomial regression evaluated associations of insomnia symptom severity with healthcare utilization rates.

Results

Approximately 51% of participants endorsed insomnia symptoms of at least mild severity. Participants who reported at least mild insomnia symptoms had more healthcare office visits (IRR = 1.23, p = .04), general mental health visits (IRR = 3.98, p < .0001), and pain-related mental health visits (IRR = 9.55, p = .01) than those without insomnia symptoms. Adjusting for covariates, rates of mental health visits, overall (IRR = 3.13, p = .001) and pain-related (IRR = 6.93, p = .02), remained statistically significantly higher.

Conclusions

Insomnia symptoms are associated with postoperative healthcare utilization lending support for future work to examine the value of assessing and intervening on insomnia symptoms prelaminectomy.

The Association of Bone Turnover Markers with Muscle Function, Falls, and Frailty in Older Women in Long-Term Care

BACKGROUND

Osteoporosis and sarcopenia commonly coexist in older adults. There is strong evidence that bone and muscle impact each other through mechanical and biochemical cross-talk.

OBJECTIVES

We sought to investigate the relationship between the markers of bone remodeling including the C-terminal telopeptide of type 1 collagen (CTX) and procollagen type 1 N propeptide (P1NP) with muscle function, falls, and frailty in older women residing in long-term care (LTC) facilities.

DESIGN

A secondary analysis of a randomized controlled trial.

SETTING

Residents of LTC.

PARTICIPANTS

One hundred seventy-eight older women with osteoporosis.

MEASUREMENTS

We measured and analyzed baseline CTX, P1NP, gait speed, sit to stand time, history of falls, and frailty index.

RESULTS

Participants had a mean age of 86.7 years and BMI of 27.6 kg/m2. The correlation (r) of CTX with gait speed and sit to stand test, as indices for muscle function, were -0.193 (p=0.0163) and 0.152 (p=0.0507), respectively. Additionally, CTX level was significantly associated with history of falls (p=0.0068), recurrent falls (p=0.0260), and frail phenotype (p=0.0126). P1NP did not have a significant association with gait speed, sit to stand test, and history of falls; however, it was associated with frail phenotype (p=0.0137). Most findings persisted after adjusting for age.

CONCLUSIONS

In older women residing in LTC facilities, CTX was associated with gait speed, falls history, and frail phenotype, whereas P1NP was only associated with frail phenotype. These findings suggest a relationship between bone remodeling and muscle function.

An evaluation of remote algorithm-assisted consultations for the safe prescribing of progesterone-only pills in a digital setting

Introduction

This study aimed assessed the prescribing quality of progesterone-only pills (POP) to determine whether online asynchronous algorithmic assisted consultations alone could help women or whether enhanced remote consultations still need to be performed. Our digital service follows Faculty of Sexual and Reproductive Healthcare FSRH clinical guidance, patients who have conditions that fall in category of UKMEC 3 and 4 would be signposted to other methods.1,2 The service works by patients completing an online consultation which is supported by algorithm-assisted consultations. The algorithm is written by doctors and pulls out the relevant information for the clinician to suggest whether it safe to prescribe. Asynchronized consultations using algorithms can identify patients for whom POP is not suitable to prescribe. As this is safe and scalable, it has the potential to improve access to contraception for women. For those women where technology identifies that POP is not suitable, there is still an important place for remote interaction to ensure that women are able to make an informed and safe contraceptive choice.

Aim

To review patients who met a Faculty of Sexual and Reproductive Healthcare (FSRH) exclusion for POP to determine adherence to FSRH clinical guidance on signposting these patients to in-person services where appropriate,1.2 and to review patients’ medical records, who were initially declined POP after completing an online consultation to identify the outcome and potential pathway improvement.

Methods

A retrospective case-note review of 362 patients, who met a FSRH exclusion criteria for POP, using a large digital sexual health service for POP (Cerelle, Cerazette, Norgeston, Noriday) between 1.3.21-25.5.22. Those patients who were not prescribed POP were then identified, to see how they were managed; how many were signposted to the clinic and how many were managed remotely and subsequently prescribed POP. The data underwent descriptive statistical analysis. Ethical approval was not required as this was a service evaluation.

Results

Of the 362 patients who met the FSRH exclusion criteria (100% female, aged 18-51), 288 (80%) patients were declined from POP treatment and signposted to in-persons services, 74 (20%) were prescribed POP after clinician review. Of the 288 who were initially declined POP, 110 (38%) patients sought further advice with a clinician remotely, resulting in 83 being prescribed POP and 27 being declined. Overall clinicians correctly followed guidance for 99% (284/288) of POP consultations who met the FSRH exclusion criteria.2 Of these 4 patients reported potential exclusion criteria for POP and were prescribed. Upon reflection, clinicians felt the potential exclusion criteria could have been explored further before prescribing.

Discussion/Conclusion

Asynchronous consultations bring lots of efficiencies, assists clinicians in triaging and managing the majority of patients. We’ve developed a pathway where patients can undertake a further discussion with a clinician remotely, which resulted in provision of remote contraception. This is convenient for patients and has the potential or may ease pressure off in-person services.

References

1. Faculty of Sexual & Reproductive Healthcare (FSRH). Clinical Effectiveness Unit. FSRH Guidance – Progesterone-only pills. March 2015. Amended April 2019. Royal College of Obstetricians & Gynaecologists Website www.fsrh.org/standards-and-guidance/documents/cec-ceu-guidance-pop-mar-2015 Accessed May 2022

2. Faculty of Sexual & Reproductive Healthcare (FSRH). UK Medical Eligibility Criteria (UKMEC) Summery sheets for contraceptive use. April 2016. Amended September 2019. Website www.fsrh.org/standards-and-guidance/documents/ukmec-2016-summary-sheets Accessed May 2022

Falls prediction using the nursing home minimum dataset

OBJECTIVE

The purpose of the study was to develop and validate a model to predict the risk of experiencing a fall for nursing home residents utilizing data that are electronically available at the more than 15 000 facilities in the United States.

MATERIALS AND METHODS

The fall prediction model was built and tested using 2 extracts of data (2011 through 2013 and 2016 through 2018) from the Long-term Care Minimum Dataset (MDS) combined with drug data from 5 skilled nursing facilities. The model was created using a hybrid Classification and Regression Tree (CART)-logistic approach.

RESULTS

The combined dataset consisted of 3985 residents with mean age of 77 years and 64% female. The model's area under the ROC curve was 0.668 (95% confidence interval: 0.643-0.693) on the validation subsample of the merged data.

DISCUSSION

Inspection of the model showed that antidepressant medications have a significant protective association where the resident has a fall history prior to admission, requires assistance to balance while walking, and some functional range of motion impairment in the lower body; even if the patient exhibits behavioral issues, unstable behaviors, and/or are exposed to multiple psychotropic drugs.

CONCLUSION

The novel hybrid CART-logit algorithm is an advance over the 22 fall risk assessment tools previously evaluated in the nursing home setting because it has a better performance characteristic for the fall prediction window of ≤90 days and it is the only model designed to use features that are easily obtainable at nearly every facility in the United States.

0310 Sleep Health Characteristics in Sedentary Desk-Based Workers

Introduction

Many occupations consist of predominantly desk-based work, which leads to prolonged periods of sitting during the workday. Excessive periods of sedentary behavior could have a negative impact on health outcomes, including sleep. The purpose of this study was to characterize sleep health in a sample of sedentary desk-based workers.

Methods

This secondary analysis of baseline data from an ongoing clinical trial included 125 inactive adults with elevated, nonmedicated blood pressure and desk-based occupations (49.6% female, age=43.9±10.6 y, 85.6% White race, body mass index [BMI]=30.9±6.4 kg/m²). Sleep was assessed using validated questionnaires (e.g., Pittsburgh Sleep Quality Index [PSQI], Insomnia Severity Index [ISI]) and 7 nights of actigraphy. Six dimensions of sleep health (regularity, satisfaction, alertness, timing, efficiency, and duration) were categorized as “good” or “poor”; a composite score summed good sleep health dimensions on a scale of 0-6.

Results

The mean sleep health score was 4.7±1.1; 24.8% of participants met “good” criteria for all 6 sleep health dimensions. The most common “good” sleep health dimensions were efficiency (89.0%) and alertness (87.2%); the least common was regularity (60%). The mean PSQI score was 5.5±3.0, and 41.6% had poor sleep quality (PSQI &gt;5); a trend was observed in adults with poor sleep quality to have lower sleep health (p=0.055). The mean ISI score was 7.1±4.7, and 40% had at least mild-severity insomnia symptoms (ISI ≥8); those with insomnia symptoms had significantly lower sleep health compared to those without insomnia symptoms (p=0.04). Sleep health was not significantly correlated with age, BMI, systolic blood pressure, diastolic blood pressure, mean arterial pressure, or mean daily sedentary behavior (each r≤ .08, p≥0.38) and did not differ between males and females (p=0.26). However, White adults had significantly better sleep health compared to their non-White counterparts (6.4% Black, 5.6% Asian, 2.4% other) (p&lt;0.001).

Conclusion

This sample of sedentary desk-based workers presented generally good sleep health. This warrants future investigations comparing adults with different levels of occupational activity and non-desk-based occupations to understand why highly sedentary behavior is associated with negative health outcomes.

Support (If Any)

This study was funded by National Institutes of Health (NIH) grants R01HL134809 and R01HL147610.

0048 The Association Between Sleep Health and Work- and Health-Related Quality of Life in Desk Workers and Differences in Associations Pre- and Post-COVID-19 Emergence

Introduction

COVID-19 resulted in many office workers switching to remote work. Emerging studies report working from home has negatively affected sleep health (SH) and psychological well-being. Our aim was to evaluate the relationship between SH and health- and work-related quality of life and explore whether these associations differed pre- and post-COVID-19 emergence.

Methods

Baseline data from 125 adults enrolled pre- (n=59) and post-COVID-19 emergence (n=66) in a clinical trial with desk jobs were included in this analysis (86.4% White; 49.6% female; 43.9±10.7 y). Health-related quality of life (HRQoL) was assessed using the SF-36 questionnaire, which addresses eight health concepts (physical, social, and role functioning; mental health; health perceptions; energy or fatigue; pain; general health) and yields 2 summary scales (mental component summary, physical component summary). Workplace productivity and worker health was measured using the Health and Work Questionnaire (HWQ). Six SH dimensions were assessed using questionnaires (satisfaction, alertness) and 7 nights of actigraphy (regularity, timing, efficiency, duration). Each dimension was categorized as “good” or “poor”; a composite score was created based on the sum of good SH dimensions. Multiple linear regression models were adjusted for gender and age and stratified by enrollment pre- or post-COVID-19 emergence. Data are presented as standardized coefficients (β) and p-values (p).

Results

Compared to participants enrolled prior to COVID-19, those enrolled post-COVID-19 had worse SF-36 emotional, social, and general health and greater HWQ-assessed impatience (all p&lt;0.05); however, SH did not differ between those enrolled pre- and post-COVID. Prior to COVID-19, greater SH was associated with higher SF-36 physical component scores (β=.389, p=.003); however, no association was observed post-COVID (β=.137, p=.271). In contrast, no association was observed pre-COVID between SH and SF-36 mental component scores (β=.181, p=.160), but greater SH was associated with greater mental component scores post-COVID (β =.308, p=.004). Furthermore, better SH was associated with lower stress post-COVID (β =-.423, p&lt;.001).

Conclusion

SH was associated with HRQoL and workplace and worker health, though these associations sometimes differed between pre- and post-COVID emergence. Research should explore whether promoting SH in employees impacts their personal and workplace-related quality of life.

Support (If Any)

This study was funded by National Institutes of Health (NIH) grants R01HL134809 and R01HL147610.

0562 Associations of Insomnia Symptoms and Unhealthy Alcohol Use with Post-Operative Healthcare Utilization in Veterans Undergoing Decompressive Laminectomy for Lumbar Spinal Stenosis

Introduction

Lumbar spinal stenosis (LSS) affects 11-39% of adults and contributes to significant pain and disability. Decompressive laminectomy (DL) is a common surgical intervention for LSS but many with medical and psychosocial comorbidities may not improve. Insomnia and unhealthy alcohol use, for example, are common among people living with chronic pain and may affect key laminectomy outcomes, such as healthcare utilization rates. We examined associations of self-reported rates of post-DL healthcare utilization in Veterans with insomnia symptoms and alcohol use.

Methods

We analyzed data from a multi-site prospective cohort study of Veterans with LSS undergoing DL. Participants (N=200) self-reported prior 12-month alcohol use behavior (Short Michigan Alcohol Screening Test; SMAST) and prior two-week insomnia symptoms (Insomnia Severity Index; ISI) prior to surgery; 12-months of post DL healthcare office visits, ER visits, hospitalizations, and mental health visits were reported over the telephone monthly. Negative binomial regression models via incident rate ratios (IRR) compared healthcare utilization rates between individuals reporting alcohol-related problems only (SMAST &gt;2), insomnia symptoms only (ISI ≥ 8), and both to those reporting neither.

Results

Approximately 52% of participants reported insomnia symptoms, 75% unhealthy alcohol use, and 39% both. Rates of office, ER, and hospital visits were descriptively highest in those reporting insomnia only; mental health visits were highest in those with both insomnia and unhealthy alcohol use. Those with insomnia only had more ER (IRR=2.39, p=.04) and mental health visits (IRR=4.32, p=.03) than those with neither insomnia nor unhealthy alcohol use; individuals with both insomnia and unhealthy alcohol use also had more mental health visits (IRR=4.22, p=.01). Adjusting for covariates rendered IRRs attenuated and statistically nonsignificant, but magnitudes remained high.

Conclusion

Most Veterans with LSS reported insomnia symptoms and/or unhealthy alcohol use. Those with insomnia symptoms reported the highest rates of healthcare utilization, including higher rates of ER and mental health visits. Insomnia symptoms may contribute to post-operative healthcare utilization, lending support for assessment and intervention of sleep-related problems pre-laminectomy.

Support (If Any)

This material is based on work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, grant # RX000798. Dr. Tighe is supported by Career Development/Capacity Building Award Number IK2 RX003393 from the United States (U.S.) Department of Veterans Affairs Rehabilitation R&D (Rehab RD) Service. Dr. Bachrach is supported by a U.S. Department of Veterans Affairs Health Services Research and Development Service (HSR&D) Career Development Award (CDA 20-057).

0253 The Association Between Sleep Health and Mood in Sedentary Desk Workers

Introduction

Poor sleep, most commonly insufficient sleep duration or low sleep quality, has been linked with disruptions of mood. However, it is unclear how sleep health—more broadly, other multiple dimensions of sleep—is associated with mood. The purpose of this study was to investigate the associations between sleep health and mood in a sample of desk-working sedentary adults.

Methods

This cross-sectional study used baseline data from inactive adults with desk-based jobs (N=125, 49.6% female, 43.9±10.6 years) who enrolled in an ongoing clinical trial. Sleep was assessed using validated questionnaires and 7 nights of actigraphy. Collectively, these measures were utilized to assess six different sleep dimensions: regularity, satisfaction, alertness, timing, efficiency, duration. Each dimension was categorized as “good” or “poor”. A sleep health score was calculated by summing the number of good dimensions (range: 0-6; higher is better). Mood was assessed using Profile of Mood States (POMS); its 7 subscales (tension, anger, fatigue, depression, esteem-affect, vigor, confusion) were summed (with a constant of 100) to create a Total Mood Disturbance (TMD) score. Multiple linear regression models examined associations between sleep health and mood adjusting for age, gender, and whether pre- or post-COVID-19.

Results

The mean sleep health score was 4.7±1.1; the mean TMD score was 96.6±18.5. Better sleep health was associated with lesser TMD (β=-0.32, p<0.001) and better mood on each of the POMS subscales (β≥0.18, p<0.05), aside from esteem-related affect (p=0.31). Of the individual sleep dimensions, only satisfaction, alertness, and efficiency were associated with TMD (β≥0.18, p<0.05). Satisfaction was the only individual sleep dimension that was consistently associated with better mood on each subscale (β≥0.17). Alertness, efficiency, and duration were inconsistently associated with individual mood subscales. Regularity and timing were not associated with any mood subscales (p≥0.267 and p≥0.073, respectively).

Conclusion

Better sleep health was associated with less TMD. Satisfaction was the sleep dimension that consistently associated with each subscale of mood. The cross-sectional, observational design limits casual inference between sleep health and mood disturbance due to a lack of temporality and the potential for residual confounding.

Support (If Any)

This study was funded by National Institutes of Health (NIH) grants R01HL134809 and R01HL147610.

Effect of Timing and Coordination Training on Mobility and Physical Activity Among Community-Dwelling Older Adults: A Randomized Clinical Trial

Importance

Standard exercise interventions targeting underlying physiologic system impairments have limited success in improving walking. Augmenting standard interventions with timing and coordination training, which incorporates the principles of motor learning and integrates multiple systems, may be more successful.

Objective

To determine whether a standard strength and endurance program incorporating timing and coordination training (standard-plus) improves gait speed more than strength and endurance training alone.

Design, Setting, and Participants

The Program to Improve Mobility in Aging (PRIMA) study was an assessor-blinded, randomized, 2-group intervention trial that included a 12-week intervention and 24-week follow-up period. The trial was conducted at a university research clinic from 2016 to 2020. Participants included 249 community-dwelling older adults (aged ≥65 years) with gait speed between 0.60 and 1.20 m/s. Statistical analysis was performed from December 2020 to March 2021.

Interventions

Participants were randomized to standard strength and endurance (n = 125) or standard-plus, including timing and coordination training (n = 124), 50 to 60 minutes, twice a week for 12 weeks.

Main Outcomes and Measures

Primary outcome of gait speed and secondary outcomes representing components of the intervention (leg strength and power, 6-minute walk test, chair sit-and-reach test, and figure of 8 walk test) and activity and participation (Late Life Function and Disability Instrument and daily physical activity measured by accelerometry) were measured at 12, 24, and 36 weeks.

Results

Among 249 randomized participants, 163 (65.5%) were female, 22 (8.8%) were Black, 219 (88.0%) were White; mean (SD) age was 77.4 (6.6) years; mean (SD) gait speed was 1.07 (0.16) m/s; and 244 (98.0%) completed the intervention. The 2 groups did not have significantly different improvements in gait speed or secondary outcomes representing the components of the intervention at any time point. For gait speed, individuals in the standard-plus group had a mean (SD) improvement of 0.079 (0.135) m/s over 12 weeks, 0.065 m/s (0.141) over 24 weeks, and 0.059 (0.150) m/s over 36 weeks; individuals in the standard group improved gait speed by 0.081 (0.124) m/s over 12 weeks, 0.051 (0.129) m/s over 24 weeks, and 0.065 (0.148) m/s over 36 weeks.

Conclusions and Relevance

This randomized clinical trial found no difference in gait speed change between the standard and standard-plus intervention groups, and both groups showed sustained improvements in mobility 24 weeks after the intervention.

Trial Registration

ClinicalTrials.gov Identifier: NCT02663778.

Benign prostatic hyperplasia/obstruction ameliorated using a soluble guanylate cyclase activator

Benign prostatic hyperplasia (BPH) is a feature of ageing males. Up to half demonstrate bladder outlet obstruction (BOO) with associated lower urinary tract symptoms (LUTS) including bladder overactivity. Current therapies to reduce obstruction, such as α1-adrenoceptor antagonists and 5α-reductase inhibitors, are not effective in all patients. The phosphodiesterase-5 inhibitor (PDE5I) tadalafil is also approved to treat BPH and LUTS, suggesting a role for nitric oxide (NO• ), soluble guanylate cyclase (sGC), and cGMP signalling pathways. However, PDE5I refractoriness can develop for reasons including nitrergic nerve damage and decreased NO• production, or inflammation-related oxidation of the sGC haem group, normally maintained in a reduced state by the cofactor cytochrome-b5-reductase 3 (CYB5R3). sGC activators, such as cinaciguat (BAY 58-2667), have been developed to enhance sGC activity in the absence of NO• or when sGC is oxidised. Accordingly, their effects on the prostate and LUT function of aged mice were evaluated. Aged mice (≥24 months) demonstrated a functional BPH/BOO phenotype, compared with adult animals (2-12 months), with low, delayed voiding responses and elevated intravesical pressures as measured by telemetric cystometry. This was consistent with outflow tract histological and molecular data that showed urethral constriction, increased prostate weight, greater collagen deposition, and cellular hyperplasia. All changes in aged animals were attenuated by daily oral treatment with cinaciguat for 2 weeks, without effect on serum testosterone levels. Cinaciguat had only transient (1 h) cardiovascular effects with oral gavage, suggesting a positive safety profile. The benefit of cinaciguat was suggested by its reversal of an overactive cystometric profile in CYB5R3 smooth muscle knockout mice that mirrors a profile of oxidative dysfunction where PDE5I may not be effective. Thus, the aged male mouse is a suitable model for BPH-induced BOO and cinaciguat has a demonstrated ability to reduce prostate-induced obstruction and consequent effects on bladder function. © 2021 The Pathological Society of Great Britain and Ireland.

Dissemination and Implementation of Evidence-Based Falls Prevention Programs: Reach and Effectiveness

BACKGROUND

Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, we describe the implementation of evidence-based fall prevention programs (EBFPPs) by Administration for Community Living grantees during 2014-2019.

METHOD

Forty-four grantees contributed to the national data repository. Data components include workshop information, participant information, attendance records, and organizational data. Data were collected before and after implementation of the EBFPPs.

RESULTS

Ten different programs were offered in 35 states with the most common settings being senior centers (25.3%), residential facilities (16.8%), health care organizations (12.5%), and faith-based organizations (11.1%). Individuals who participated in the programs (N = 85 848) had an age of 75.5 ± 9.7 years and were primarily female (79.7%), and the majority (86.2%) reported at least some fear of falling. At the postprogram assessment, 31.8% reported less fear of falling, 21.6% reported fewer falls, and 10.1% reported fewer injurious falls (all p < .0001).

CONCLUSIONS

EBFPPs implemented by Administration for Community Living grantees reached over 85 000 older adults. Participation in the EBFPPs resulted in improved confidence, decreased fear of falling, and fewer falls and injurious falls. Future efforts should focus on reaching specific underserved minorities and examining the effectiveness of individual programs.

Zoledronic acid and bone health in older adults with cognitive impairment

Fracture prevention in cognitively impaired individuals is lacking. This work highlights the benefits of zoledronic acid on bone health in cognitively impaired older adults. Demonstrating benefits of therapy may increase treatment uptake and reduce fracture risk in this group.

INTRODUCTION

Osteoporosis has detrimental consequences for frail older adults. The effects on those with both osteoporosis and cognitive impairment are compounded due to increased risk of falls and changes in mobility, both of which can lead to fracture. However, there are limited data on treatment benefits for osteoporotic individuals with cognitive impairment.

METHODS

This post hoc, secondary analysis of data from a randomized, double-blind, placebo-controlled clinical trial of single-dose zoledronic acid included 179 women age ≥ 65 years residing in assisted living facilities or nursing homes, 43 of whom had mild to severe cognitive impairment. We assessed bone mineral density (BMD) of the total hip, femoral neck, and lumbar spine by dual-energy x-ray absorptiometry and serum bone turnover markers (C-terminal telopeptide of type I collagen and procollagen type I N propeptide) at 6 and 12 months.

RESULTS

In participants with cognitive impairment, those who received zoledronic acid had 4.3% greater BMD at the total hip (p=.005) and 5.3% greater BMD at the femoral neck (p<.001) after 12 months compared to those in the placebo group. Bone turnover markers demonstrated significant decreases at 6 months in those with cognitive impairment who received active treatment compared to the placebo group. Improvements in bone health measures with zoledronic acid were similar to those seen in participants without cognitive impairment.

CONCLUSION

Zoledronic acid improves bone health in frail older women with cognitive impairment similar to those without impairment. Further studies are warranted to assess the benefit for fracture reduction in this undertreated population.

A Preliminary Investigation of Similarities of High Resolution Cervical Auscultation Signals Between Thin Liquid Barium and Water Swallows

Dysphagia, commonly referred to as abnormal swallowing, affects millions of people annually. If not diagnosed expeditiously, dysphagia can lead to more severe complications, such as pneumonia, nutritional deficiency, and dehydration. Bedside screening is the first step of dysphagia characterization and is usually based on pass/fail tests in which a nurse observes the patient performing water swallows to look for dysphagia overt signs such as coughing. Though quick and convenient, bedside screening only provides low-level judgment of impairment, lacks standardization, and suffers from subjectivity. Recently, high resolution cervical auscultation (HRCA) has been investigated as a less expensive and non-invasive method to diagnose dysphagia. It has shown strong preliminary evidence of its effectiveness in penetration-aspiration detection as well as multiple swallow kinematics. HRCA signals have traditionally been collected and investigated in conjunction with videofluoroscopy exams which are performed using barium boluses including thin liquid. An HRCA-based bedside screening is highly desirable to expedite the initial dysphagia diagnosis and overcome all the drawbacks of the current pass/fail screening tests. However, all research conducted for using HRCA in dysphagia is based on thin liquid barium boluses and thus not guaranteed to provide valid results for water boluses used in bedside screening. If HRCA signals show no significant differences between water and thin liquid barium boluses, then the same algorithms developed on thin liquid barium boluses used in diagnostic imaging studies, it can be then directly used with water boluses. This study investigates the similarities and differences between HRCA signals from thin liquid barium swallows compared to those signals from water swallows. Multiple features from the time, frequency, time-frequency, and information-theoretic domain were extracted from each type of swallow and a group of linear mixed models was tested to determine the significance of differences. Machine learning classifiers were fit to the data as well to determine if the swallowed material (thin liquid barium or water) can be correctly predicted from an unlabeled set of HRCA signals. The results demonstrated that there is no systematic difference between the HRCA signals of thin liquid barium swallows and water swallows. While no systematic difference was discovered, the evidence of complete conformity between HRCA signals of both materials was inconclusive. These results must be validated further to confirm conformity between the HRCA signals of thin liquid barium swallows and water swallows.

Does Zoledronic Acid Improve Appendicular Lean Mass in Older Women with Osteoporosis? A Sub-Analysis of a Randomized Clinical Trial

BACKGROUND

Coexistence of osteoporosis and sarcopenia (osteosarcopenia), is associated with increased risk for fractures, falls, and mortality. Although there are multiple medications for management of osteoporosis, there are no approved pharmacotherapy for sarcopenia.

OBJECTIVES

We examined the effect of zoledronic acid on muscle mass indices including ALM (Appendicular Lean Mass) and ALM/Height2 in a cohort of older women with osteoporosis who were residents of Long-Term Care Communities (LTCCs).

DESIGN

A secondary analysis of a 2-year double-blind, randomized, placebo-controlled clinical trial.

SETTING

Residents of LTCCs.

PARTICIPANTS

Sixty-two postmenopausal women with osteoporosis.

INTERVENTION

Participants either received 5 mg infusion of zoledronic acid or placebo, once at the start of the study.

MEASUREMENTS

Participant's ALM/Height2, ALM, total hip BMD (Bone Mineral Density) and spine BMD were measured in 6, 12 and 24 months.

RESULTS

On average, participants were 86.7 years old and had a BMI of 27.4 kg/m2. There was no significant difference in change from baseline (mean ± SE) between the treatment group and the placebo group in ALM/Height2: (-0.15 vs -0.02, p = 0.541) and (-0.17 vs 0.001, p = 0.315) and (-0.29 vs -0.19, p = 0.646) or ALM: (-0.38 vs -0.09, p = 0.455) and (-0.45 vs -0.005, p = 0.216) and (-0.70 vs -0.48, p = 0.553) at 6, 12, and 24 months respectively. In addition, after adjusting for a possible confounding, the ALM/Height2 or ALM did not have significant improvements from baseline at 6 months, 12 months, and 24 months either in the treatment group or in the placebo group. However, there were significant improvements in the BMD at the total hip and the spine in the treatment group compared with the placebo group at all three time points.

CONCLUSIONS

Among older women residing in LTCCs, a single dose of zoledronic acid did not increase ALM/Height2 and ALM, despite improving the BMD at the total hip and the spine at the 2-year follow-up.

Changes in GPS-Derived Community Mobility After Motor Skill Training in Older Adults

The study purpose was to identify the effects of a motor skill training intervention to improve gait speed on community mobility among community-dwelling older adults. The study included 249 participants randomized to standard physical therapy or a standard plus motor skill training program. Community mobility was measured using the Life Space Assessment (LSA) and GPS at baseline, 12 (post-intervention), 24 and 36 weeks. There were 124 participants (M age=77.4±6.7; 68.6% female; LSA: 76.2±17.6) randomized to the standard plus and 125 (M age=77.4±6.4; 62.4% female; LSA: 74.3±18.2) to the standard group. There was no significant between-group difference in pre- or post-intervention LSA scores and no significant pre- to post-intervention change over time in either group. GPS results are pending. While there were no differences in self-reported LSA, we anticipate objective GPS measurement of community mobility will better capture post-intervention changes and differences between groups.

Motor Skill Training Effect on Real-Time Prefrontal Cortex Activation During Walking

We aimed to test the effects of motor skill training (MST) on gait automaticity measured by changes in prefrontal cortex (PFC) activation during actual walking. We used data from a 12-week trial of older adults (mean age=75.5, 60.5% women) randomized to standard physical therapy and standard+MST in a 1:1 ratio. Functional near infrared spectroscopy (fNIRS) measured PFC activation during simple and dual task walking. We will apply linear mixed models to assess effects of task, time, and MST on PFC activation. We will compare the PFC activation 1) during dual task walking compared to simple walking; 2) across visits after intervention; and 3) between participants receiving MST compared to standard physical therapy. These results will demonstrate whether gait automaticity, as evidenced by PFC activation during walking, is affected by MST.

Modified Application of Cardiac Rehabilitation in Older Adults (MACRO) Trial: Protocol changes in a pragmatic multi-site randomized controlled trial in response to the COVID-19 pandemic

BACKGROUND

Older adults are at higher risk for cardiovascular disease and functional decline, often leading to deterioration and dependency. Cardiac rehabilitation (CR) provides opportunity to improve clinical and functional recovery, yet participation in CR decreases with age. Modified Application of CR in Older Adults (MACRO) is a National Institute on Aging (NIA)-funded pragmatic trial that responds to this gap by aiming to increase enrollment of older adults into CR and improving functional outcomes. This article describes the methodology and novel features of the MACRO trial.

METHODS

Randomized, controlled trial of a coaching intervention (MACRO-I) vs. usual care for older adults (age ≥ 70 years) eligible for CR after an incident cardiac hospitalization. MACRO-I incorporates innovations including holistic risk assessments, flexible CR format (i.e., helping patients to select a CR design that aligns with their personal risks and preferences), motivational prompts, nutritional emphasis, facilitated deprescription, enhanced education, and home visits. Key modifications were necessitated by the COVID-19 pandemic, including switching from a performance-based primary endpoint (Short Physical Performance Battery) to a patient-reported measure (Activity Measure for Post-Acute Care Computerized Adaptive Testing). Changes prompted by COVID-19 maintain the original intent of the trial and provide key methodologic advantages.

CONCLUSIONS

MACRO is exploring a novel individualized coaching intervention to better enable older patients to participate in CR. Due to COVID-19 many aspects of the MACRO protocol required modification, but the primary objective of the trial is maintained and the updated protocol will more effectively achieve the original goals of the study.

Characterizing Swallows From People With Neurodegenerative Diseases Using High-Resolution Cervical Auscultation Signals and Temporal and Spatial Swallow Kinematic Measurements

Purpose The prevalence of dysphagia in patients with neurodegenerative diseases (ND) is alarmingly high and frequently results in morbidity and accelerated mortality due to subsequent adverse events (e.g., aspiration pneumonia). Swallowing in patients with ND should be continuously monitored due to the progressive disease nature. Access to instrumental swallow evaluations can be challenging, and limited studies have quantified changes in temporal/spatial swallow kinematic measures in patients with ND. High-resolution cervical auscultation (HRCA), a dysphagia screening method, has accurately differentiated between safe and unsafe swallows, identified swallow kinematic events (e.g., laryngeal vestibule closure [LVC]), and classified swallows between healthy adults and patients with ND. This study aimed to (a) compare temporal/spatial swallow kinematic measures between patients with ND and healthy adults and (b) investigate HRCA's ability to annotate swallow kinematic events in patients with ND. We hypothesized there would be significant differences in temporal/spatial swallow measurements between groups and that HRCA would accurately annotate swallow kinematic events in patients with ND. Method Participants underwent videofluoroscopic swallowing studies with concurrent HRCA. We used linear mixed models to compare temporal/spatial swallow measurements (n = 170 ND patient swallows, n = 171 healthy adult swallows) and deep learning machine-learning algorithms to annotate specific temporal and spatial kinematic events in swallows from patients with ND. Results Differences (p < .05) were found between groups for several temporal and spatial swallow kinematic measures. HRCA signal features were used as input to machine-learning algorithms and annotated upper esophageal sphincter (UES) opening, UES closure, LVC, laryngeal vestibule reopening, and hyoid bone displacement with 66.25%, 85%, 68.18%, 70.45%, and 44.6% accuracy, respectively, compared to human judges' measurements. Conclusion This study demonstrates HRCA's potential in characterizing swallow function in patients with ND and other patient populations.

Effect of Reducing Sedentary Behavior on Blood Pressure (RESET BP): Rationale, design, and methods

Sedentary behavior (SB) has recently been recognized as a strong risk factor for cardiovascular disease, with new guidelines encouraging adults to 'sit less, move more.' Yet, there are few randomized trials demonstrating that reducing SB improves cardiovascular health. The Effect of Reducing Sedentary Behavior on Blood Pressure (RESET BP) randomized clinical trial addresses this gap by testing the effect of a 3-month SB reduction intervention on resting systolic BP. Secondary outcomes include other BP measures, pulse wave velocity, plasma renin activity and aldosterone, and objectively-measured SB (via thigh-mounted activPAL) and physical activity (via waist-worn GT3X accelerometer). RESET BP has a targeted recruitment of 300 adults with desk jobs, along with elevated, non-medicated BP (systolic BP 120-159 mmHg or diastolic BP 80-99 mmHg) and physical inactivity (self-reported aerobic physical activity below recommended levels). The multi-component intervention promotes 2-4 fewer hours of SB per day by replacing sitting with standing and light-intensity movement breaks. Participants assigned to the intervention condition receive a sit-stand desk attachment, a wrist-worn activity prompter, behavioral counseling every two weeks (alternating in-person and phone), and twice-weekly automated text messages. Herein, we review the study rationale, describe and evaluate recruitment strategies based on enrollment to date, and detail the intervention and assessment protocols. We also document our mid-trial adaptations to participant recruitment, intervention deployment, and outcome assessments due to the intervening COVID-19 pandemic. Our research methods, experiences to date, and COVID-specific accommodations could inform other research studying BP and hypertension or targeting working populations, including those seeking remote methods.

Physical Therapists as Partners for Community Fall Risk Screenings and Referrals to Community Programs

Objectives: Physical therapists (PTs) are integral team members in fall prevention in clinical settings; however, few studies have investigated PTs' engagement in pro-bono community-based falls prevention. Therefore, we aimed to describe the characteristics of PTs and physical therapist assistants (PTAs) in the United States who conduct community-based fall screenings, the reach of screenings, their knowledge and utilization of the Centers for Disease Control and Prevention's fall-risk screening toolkit (STEADI, Stopping Elderly Accidents, Deaths, and Injuries), and therapists' knowledge and referrals to evidence-based programs (EBPs) and community resources. Methods: A cross-sectional survey distributed to a convenience sample of PTs/PTAs in the United States through news-blasts, and social media. Results: Four hundred and forty-four therapists who worked with older adults completed the survey. Approximately 40% of the respondents (n = 180) conduct screenings, most frequently annually. People who screen tend to be PTs with >20 years of experience, work in outpatient/wellness or academia, and be involved in the least amount of direct patient care. The majority (n = 344, 77.5%) of survey respondents were somewhat to very familiar with the STEADI, and ~84% (n = 114) of respondents who were very familiar with the STEADI (n = 136) use the toolkit to conduct community-based, pro-bono fall risk screenings. Twenty-six percent (n = 14) out of the 53 PTAs who responded to the survey conduct falls screenings in the community. Of the PTs/PTAs who conduct community-based fall screenings (n = 180), ~ 75% (n = 136) are aware of and refer older adults to EBPs. Over half also refer to Silver Sneakers and/or senior centers. Discussion: PTs and PTAs are key partners in evidence-based multifactorial fall prevention in the community. Data helps inform community organizations that most PTs who engage in community-based fall risk screening utilize the STEADI toolkit and refer to community-based programs. Community organizations seeking PT partners to engage in fall risk screenings and promote referrals to local resources or EBPs will likely have the most success collaborating with local physical therapy education programs or physical therapy clinic managers.

Establishing Reference Values for Temporal Kinematic Swallow Events Across the Lifespan in Healthy Community Dwelling Adults Using High-Resolution Cervical Auscultation

Few research studies have investigated temporal kinematic swallow events in healthy adults to establish normative reference values. Determining cutoffs for normal and disordered swallowing is vital for differentially diagnosing presbyphagia, variants of normal swallowing, and dysphagia; and for ensuring that different swallowing research laboratories produce consistent results in common measurements from different samples within the same population. High-resolution cervical auscultation (HRCA), a sensor-based dysphagia screening method, has accurately annotated temporal kinematic swallow events in patients with dysphagia, but hasn't been used to annotate temporal kinematic swallow events in healthy adults to establish dysphagia screening cutoffs. This study aimed to determine: (1) Reference values for temporal kinematic swallow events, (2) Whether HRCA can annotate temporal kinematic swallow events in healthy adults. We hypothesized (1) Our reference values would align with a prior study; (2) HRCA would detect temporal kinematic swallow events as accurately as human judges. Trained judges completed temporal kinematic measurements on 659 swallows (N = 70 adults). Swallow reaction time and LVC duration weren't different (p > 0.05) from a previously published historical cohort (114 swallows, N = 38 adults), while other temporal kinematic measurements were different (p < 0.05), suggesting a need for further standardization to feasibly pool data analyses across laboratories. HRCA signal features were used as input to machine learning algorithms and annotated UES opening (69.96% accuracy), UES closure (64.52% accuracy), LVC (52.56% accuracy), and LV re-opening (69.97% accuracy); providing preliminary evidence that HRCA can noninvasively and accurately annotate temporal kinematic measurements in healthy adults to determine dysphagia screening cutoffs.

Validating Goal Attainment in Veterans Undergoing Decompressive Laminectomy: A Preliminary Study

OBJECTIVE

Although decompressive laminectomy (DL) for lumbar spinal stenosis (LSS) is a common procedure among older adults, it is unclear whether surgical definitions of success translate into patient-defined success. Using goal attainment scaling (GAS) to compare goal achievement between individuals, we investigated the relationship between surgical-defined functional recovery and achievement of personalized goals in patients who underwent DL for LSS.

PARTICIPANTS

Twenty-eight community-dwelling veterans scheduled to undergo DL.

METHODS

Participants were interviewed over the phone to set 1-year post-DL goals within 30 days before undergoing DL. Brigham Spinal Stenosis (BSS) score, comorbidities, cognitive function, and psychological factors also were assessed. GAS and BSS were repeated 1 year after DL. GAS scores were transformed into GAS-T scores (T-score transformation) to standardize achievement between patients and GAS-T change scores to compare study variables.

RESULTS

Seventeen of 28 participants had successful DL outcomes by BSS standards, though none of the participants achieved all of their GAS goals, with follow-up GAS-T scores averaging 44.5 ± 16.8. All three BSS scales positively correlated with GAS-T change scores: severity change r = 0.52, P = 0.005; physical function change r = 0.51, P = 0.006; and satisfaction r = 0.70, P < 0.001. Covariate analysis revealed a negative correlation between GAS-T change score and fear-avoidance beliefs: r = -0.41, P = -0.029.

CONCLUSION

There was congruent validity between GAS and the BSS in older veterans undergoing DL for LSS. Given the need for patient-centered care in older adults, future investigations exploring GAS in larger studies that target additional pain conditions and include participants with greater demographic diversity are warranted.

297 The Relationship Between Sleep and Objectively Measured Sedentary Behavior in Adults with Desk Jobs

Introduction

Both poor sleep and sedentary behavior lead to negative health outcomes. While some previous studies have observed an association between poor sleep and greater sedentary behavior, few studies have assessed this relationship using an objective measure of sedentary behavior. We examined the association of both self-reported and objectively-measured sleep with objectively-measured sedentary behavior.

Methods

In a secondary analysis of baseline data from an ongoing clinical trial, the present analysis included 157 physically inactive adults with elevated blood pressure (120–159 mmHg systolic or 90–99 diastolic) and desk jobs (82.8% white, 65.6% female, age 45.5±12.0). To assess sedentary behavior, participants wore an accelerometer/inclinometer (activPAL3 micro) on the upper thigh continuously for 7 days. Variables included total sedentary time, prolonged sedentary time (≥30 minute bouts), and sit-to-stand transitions; these were averaged across all waking hours as well as the workday. To assess sleep, participants completed the Pittsburgh Sleep Quality Index (PSQI) and a subsample (n=57) wore an Actiwatch Spectrum for 7 nights. Variables examined included the PSQI global score, actigraphy-based total sleep time (TST) and sleep efficiency (SE). Linear regression examined associations between sleep and sedentary behavior, with adjustments for age, gender, race, body mass index, and activPAL3 wear time.

Results

Participants had (mean±standard deviation) 11.1±1.5 hours sedentary time per day, with 6.3±2.0 occurring in ≥30 minute bouts, and 51.3±13.4 sit-to-stand transitions. During the workday, participants had 6.6±1.3 hours sedentary time with 3.8±1.7 occurring in ≥30 minute bouts and 27.2±11.2 sit-to-stand transitions. PSQI global score was 4.9±2.9; 32.5% were classified as poor sleepers. Actigraphic TST was 6.7±0.8 hours, with SE of 85.4±6.3%.Greater SE was associated with less sit-to-stand transitions during the workday (β=-0.36, p=0.01) and during the full day (β=-0.37, p=0.01). Subjective sleep quality and actigraphic TST were not associated with sedentary behavior.

Conclusion

We did not find a cross-sectional association between sedentary behavior and sleep in insufficiently active adults, potentially due to restricted range of sedentary behavior and physical activity in the sample. The association between greater sleep efficiency with fewer sit-to-stand transitions is counterintuitive and warrants further exploration.

Support (if any)

This study was funded by National Institutes of Health (NIH) grants R01HL134809 and R01HL147610.

Covid-19 shelter-at-home and work, lifestyle and well-being in desk workers

Background

Emerging cross-sectional reports find that the COVID-19 pandemic and related social restrictions negatively affect lifestyle behaviours and mental health in general populations.

Aims

To study the longitudinal impact of COVID-19 on work practices, lifestyle and well-being among desk workers during shelter-at-home restrictions.

Methods

We added follow-up after completion of a clinical trial among desk workers to longitudinally measure sedentary behaviour, physical activity, sleep, diet, mood, quality of life and work-related health using validated questionnaires and surveys. We compared outcomes assessed before and during COVID-19 shelter-at-home restrictions. We assessed whether changes in outcomes differed by remote working status (always, changed to or never remote) using analysis of covariance (ANCOVA).

Results

Participants (N = 112; 69% female; mean (SD) age = 45.4 (12.3) years; follow-up = 13.5 (6.8) months) had substantial changes to work practices, including 72% changing to remote work. Deleterious changes from before to during shelter-at-home included: 1.3 (3.5)-h increase in non-workday sedentary behaviour; 0.7 (2.8)-point worsening of sleep quality; 8.5 (21.2)-point increase in mood disturbance; reductions in five of eight quality of life subscales; 0.5 (1.1)-point decrease in work-related health (P < 0.05). Other outcomes, including diet, physical activity and workday sedentary behaviour, remained stable (P ≥ 0.05). Workers who were remote before and during the pandemic had greater increases in non-workday sedentary behaviour and stress, with greater declines in physical functioning. Wake time was delayed overall by 41 (61) min, and more so in workers who changed to remote.

Conclusions

Employers should consider supporting healthy lifestyle and well-being among desk workers during pandemic-related social restrictions, regardless of remote working status.

Anterior-posterior distension of maximal upper esophageal sphincter opening is correlated with high-resolution cervical auscultation signal features

Objective. Adequate upper esophageal sphincter (UES) opening is essential during swallowing to enable clearance of material into the digestive system, and videofluoroscopy (VF) is the most commonly deployed instrumental examination for assessment of UES opening. High-resolution cervical auscultation (HRCA) has been shown to be an effective, portable and cost-efficient screening tool for dysphagia with strong capabilities in non-invasively and accurately approximating manual measurements of VF images. In this study, we aimed to examine whether the HRCA signals are correlated to the manually measured anterior-posterior (AP) distension of maximal UES opening from VF recordings, under the hypothesis that they would be strongly associated.Approach. We developed a standardized method to spatially measure the AP distension of maximal UES opening in 203 swallows VF recording from 27 patients referred for VF due to suspected dysphagia. Statistical analysis was conducted to compare the manually measured AP distension of maximal UES opening from lateral plane VF images and features extracted from two sets of HRCA signal segments: whole swallow segments and segments excluding all events other than the duration of UES is opening.Main results. HRCA signal features were significantly associated with the normalized AP distension of the maximal UES opening in the longer whole swallowing segments and the association became much stronger when analysis was performed solely during the duration of UES opening.Significance. This preliminary feasibility study demonstrated the potential value of HRCA signals features in approximating the objective measurements of maximal UES AP distension and paves the way of developing HRCA to non-invasively and accurately predict human spatial measurement of VF kinematic events.

Probable Delirium as a Risk Factor for Adverse Surgical Outcomes in Geriatric Patients With Acute Hip Fracture: Preoperative Assessment Using a Short Screening Tool

Hip fractures in geriatric patients are associated with substantial morbidity and mortality including postoperative delirium. Few data are available regarding preoperative identification of patients at risk of postoperative delirium before surgical repair of hip fracture. We used the Ultrabrief Two-Item Bedside Test, a proxy for delirium, to identify patients who are likely to have adverse outcomes postoperatively. This prospective pilot study included patients 65 years and older with an acute hip fracture. The questionnaire was administered preoperatively, and patients were followed up for 30 days postoperatively. We enrolled 30 patients, with a mean age of 78 years. The 12 patients with an abnormal test result had a significantly lower body mass index, a trend in descriptive statistics for pulmonary disease, and a higher ASA physical status. In addition, hospital stay following fracture repair was longer for patients with an abnormal test result, although not significantly (mean [SD]=8.8 [4.2] days vs 6.4 [2.0] days, median=8 vs 6 days, log-rank P=.052). A 2-item questionnaire could help identify patients who have sustained hip fracture who are likely to have a longer hospitalization. Future studies are needed to confirm these findings and determine whether interventions can reduce risk.

Association of Protein and Genetic Biomarkers With Response to Lumbar Epidural Steroid Injections in Subjects With Axial Low Back Pain

OBJECTIVE

The purpose of this observational study was to examine the association of protein and genetic biomarkers with pain and pain-related disability in individuals with axial low back pain undergoing epidural steroid injections.

DESIGN

Forty-eight adults with axial low back pain undergoing an epidural steroid injection were recruited from an academic medical center. Blood samples were assayed at baseline and follow-up for plasma proteins and functional single-nucleotide polymorphisms associated with pain. Data regarding pain and function were collected at baseline and follow-up. The characteristics of responders (defined as 50% improvement in pain score) and nonresponders were compared, and the association between response and baseline biomarkers was examined.

RESULTS

Thirty-five percent of subjects were responders to injection. Responders had lower baseline plasma levels of chondroitin sulfate 846 and higher neuropeptide Y and serotonin levels than nonresponders, and baseline neuropeptide Y level correlated with change in disability levels. In addition, subjects with the variant allele for the catechol-O-methyltransferase single-nucleotide polymorphism demonstrated increased odds of responding to the injection.

CONCLUSIONS

These data identify candidates who may have utility for patient selection for spinal procedures and provide support for exploration in prospective studies to assess and validate their predictive ability.

Non-immunotherapy options for the first-line management of hepatocellular carcinoma: exploring the evolving role of sorafenib and lenvatinib in advanced disease

The results of the sharp trial established sorafenib, a tyrosine kinase inhibitor (tki), as the sole first-line treatment option in advanced hepatocellular carcinoma (hcc) for more than a decade. In 2020, there has been a surge in new therapies for hcc, including immunotherapeutic strategies and the approval of a number of novel tkis. In addition to sorafenib, lenvatinib and combination atezolizumab-bevacizumab now represent standard first-line treatment options. As those systemic therapy options begin to be better utilized, assurance of adequate liver function and optimal timing are required to improve patient outcomes. Furthermore, sequencing of the agents will have to be carefully tailored, given the increasing armamentarium of choices. Here, we discuss the role of lenvatinib and sorafenib in the first-line management of hcc.

Transforming the Medication Regimen Review Process Using Telemedicine to Prevent Adverse Events

BACKGROUND/OBJECTIVES

Federally-mandated consultant pharmacist-conducted retrospective medication regimen reviews (MRRs) are designed to improve medication safety in nursing homes (NH). However, MRRs are potentially ineffective. A new model of care that improves access to and efficiency of consultant pharmacists is needed. The objective of this study was to determine the impact of pharmacist-led telemedicine services on reducing high-risk medication adverse drug events (ADEs) for NH residents using medication reconciliation and prospective MRR on admission plus ongoing clinical decision support alerts throughout the residents' stay.

DESIGN

Quality improvement study using a stepped-wedge design comparing the novel service to usual care in a one-year evaluation from November 2016 to October 2017.

SETTING

Four NHs (two urban, two suburban) in Southwestern Pennsylvania.

PARTICIPANTS

All residents in the four NHs were screened. There were 2,127 residents admitted having 652 alerts in the active period.

INTERVENTION

Upon admission, pharmacists conducted medication reconciliation and prospective MRR for residents and also used telemedicine for communication with cognitively-intact residents. Post-admission, pharmacists received clinical decision support alerts to conduct targeted concurrent MRRs and telemedicine.

MEASUREMENT

Main outcome was incidence of high-risk medication, alert-specific ADEs. Secondary outcomes included all-cause hospitalization, 30-day readmission rates, and consultant pharmacists' recommendations.

RESULTS

Consultant pharmacists provided 769 recommendations. The intervention group had a 92% lower incidence of alert-specific ADEs than usual care (9 vs 31; 0.14 vs 0.61/1,000-resident-days; adjusted incident rate ratio (AIRR) = 0.08 (95% confidence interval (CI) = 0.01-0.40]; P = .002). All-cause hospitalization was similar between groups (149 vs 138; 2.33 vs 2.70/1,000-resident-days; AIRR = 1.06 (95% CI = 0.72-1.58); P = .75), as were 30-day readmissions (110 vs 102; 1.72 vs 2.00/1,000-resident-days; AIRR = 1.21 (95% CI = 0.76-1.93); P = .42).

CONCLUSIONS

This is the first evaluation of the impact of pharmacist-led patient-centered telemedicine services to manage high-risk medications during transitional care and throughout the resident's NH stay, supporting a new model of patient care.