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Falls are the leading cause of accidental deaths in older adults and are a growing public health concern. The American Geriatrics Society (AGS) and British Geriatrics Society (BGS) published guidelines for falls screening and risk reduction, yet few primary care providers report following any guidelines for falls prevention. This article describes a project that engaged an interprofessional teaching team to support interprofessional clinical teams to reduce fall risk in older adults by implementing the AGS/BGS guidelines. Twenty-five interprofessional clinical teams with representatives from medicine, nursing, pharmacy, and social work were recruited from ambulatory, long-term care, hospital, and home health settings for a structured intervention: a 4-hour training workshop plus coaching for implementation for 1 year. The workshop focused on evidence-based strategies to decrease the risk of falls, including screening for falls; assessing gait, balance, orthostatic blood pressure, and other medical conditions; exercise including tai chi; vitamin D supplementation; medication review and reduction; and environmental assessment. Quantitative and qualitative data were collected using chart reviews, coaching plans and field notes, and postintervention structured interviews of participants. Site visits and coaching field notes confirmed uptake of the strategies. Chart reviews showed significant improvement in adoption of all falls prevention strategies except vitamin D supplementation. Long-term care facilities were more likely to address environmental concerns and add tai chi classes, and ambulatory settings were more likely to initiate falls screening. The intervention demonstrated that interprofessional practice change to target falls prevention can be incorporated into primary care and long-term care settings.
Older adults have a greater risk of experiencing functional decline and iatrogenic complications during hospitalization than younger individuals. Geriatric day hospitals (GDHs) have been implemented mainly for rehabilitation. The goal of the current study was to expand the GDH spectrum of care to prevent hospital admissions in this population. This study details an innovative model of GDH care that offers short-term, nonrehabilitative treatment to older adults who have experienced an acute event, those with a decompensated chronic disease, or those in need of a minor procedure that would be unattainable in a regular outpatient setting. During the 6-hour visits made weekly for up to 2 months, participants receive integrated evaluations of their various health domains, education, and rapid access to examinations and procedures based on a multidisciplinary approach. In the first 6 years, 2,322 individuals attended the GDH. The analysis of a representative sample (n = 645) revealed that 81% were treated in the GDH without the need for another type of hospital care. This percentage was high for the different reasons for referral (infection, 71%; delirium, 73%; decompensated chronic disease, 81%). Between baseline and discharge, participants maintained their functional status, and their self-reported health improved. This study represents the first step in describing the role of the GDH as a possible alternative to emergency department use or hospitalization for older adults. Future studies are needed to determine the optimal individual for this model of care and to ensure its cost-effectiveness.
To compare the aggressiveness of end-of-life care in hospitalized individuals with cancer with and without dementia in France.
Nationwide register-based matched-cohort study.
Hospital facilities in France.
All individuals with cancer aged 65 and older with a diagnosis of dementia who died between January 1, 2010 and December 31, 2013, matched one-to-one with individuals with cancer without dementia (n = 26,782 matched pairs).
Older individuals with cancer with dementia were less likely to receive aggressive treatment in their last month of life than those who were not diagnosed with dementia. Dementia was associated with significantly greater likelihood of receiving chemotherapy (2.8% vs 8.5%, P < .001, adjusted odds ratio (aOR) = 0.33, 95% confidence interval (CI) = 0.31–0.36) in the month before death. Individuals with dementia were also less likely to receive radiation therapy (aOR = 0.49, 95% CI = 0.43–0.56), blood transfusions (aOR = 0.67, 95% CI = 0.64–0.70), artificial nutrition (aOR = 0.79, 95% CI = 0.73–0.85), and invasive ventilation (aOR = 0.62, 95% CI = 0.57–0.68), although they were more likely to remain hospitalized over their entire last month of life (aOR = 1.42, 95% CI = 1.37–1.48) and to have more than one emergency department visit (aOR = 1.22, 95% CI = 1.12–1.34).
Older hospitalized adults with cancer with dementia are less likely to receive aggressive cancer treatment near the end of life than those without dementia. This discrepancy raises important ethical questions for clinicians and healthcare policy-makers.
To determine the effectiveness of a proactive primary care program on the daily functioning of older people in primary care.
Single-blind, three-arm, cluster-randomized controlled trial with 1-year follow-up.
Primary care setting, 39 general practices in the Netherlands.
Community-dwelling people aged 60 and older (N = 3,092).
A frailty screening intervention using routine electronic medical record data to identify older people at risk of adverse events followed by usual care from a general practitioner; after the screening intervention, a nurse-led care program consisting of a comprehensive geriatric assessment, evidence-based care planning, care coordination, and follow-up; usual care.
Primary outcome was daily functioning measured using the Katz-15 (6 activities of daily living (ADLs), 8 instrumental activities of daily living (IADLs), one mobility item (range 0–15)); higher scores indicate greater dependence. Secondary outcomes included quality of life, primary care consultations, hospital admissions, emergency department visits, nursing home admissions, and mortality.
The participants in both intervention arms had less decline in daily functioning than those in the usual care arm at 12 months (mean Katz-15 score: screening arm, 1.87, 95% confidence interval (CI) = 1.77–1.97; screening and nurse-led care arm, 1.88, 95% CI = 1.80–1.96; control group, 2.03, 95% CI = 1.92–2.13; P = .03). No differences in quality of life were observed.
Participants in both intervention groups had less decline than those in the control group at 1-year follow-up. Despite the statistically significant effect, the clinical relevance is uncertain at this point because of the small differences. Greater customizing of the intervention combined with prolonged follow-up may lead to more-robust results.
To determine how often hospitalized older adults principally diagnosed with pneumonia, chronic obstructive pulmonary disease (COPD), or heart failure (HF) are concurrently treated for two or more of these acute cardiopulmonary conditions.
Retrospective cohort study.
368 U.S. hospitals in the Premier research database.
Individuals aged 65 and older principally hospitalized with pneumonia, COPD, or HF in 2009 or 2010.
Proportion of diagnosed episodes of pneumonia, COPD, or HF concurrently treated for two or more of these acute cardiopulmonary conditions during the first 2 hospital days.
Of 91,709 diagnosed pneumonia hospitalizations, 32% received treatment for two or more acute cardiopulmonary conditions (18% for HF, 18% for COPD, 4% for both). Of 41,052 diagnosed COPD hospitalizations, 19% received treatment for two or more acute cardiopulmonary conditions (all of which involved additional HF treatment). Of 118,061 diagnosed HF hospitalizations, 38% received treatment for two or more acute cardiopulmonary conditions (34% for pneumonia, 9% for COPD, 5% for both).
Hospitalized older adults diagnosed with pneumonia, COPD, or HF are frequently treated for two or more acute cardiopulmonary conditions, suggesting that clinical syndromes often fall between traditional diagnostic categories. Research is needed to evaluate the risks and benefits of real-world treatment for the many older adults whose presentations elicit diagnostic uncertainty or concern about coexisting acute conditions.
To examine the relationship between individual characteristics and potential correlates of elder abuse in older adults who present with fractures.
Cross-sectional analysis of deidentified data extracted from medical records.
Academic medical center.
Individuals aged 65 and with a primary diagnosis of any fracture admitted to an outpatient department or emergency department (ED) in a single southern California medical center over a 36-month period (N = 652).
Participant characteristics included demographic characteristics, number of medical visits, and point of service. Corresponding International Classification of Diseases, Ninth Revision (ICD-9) codes, E-codes, and V-codes were extracted to identify cause, location, and type of fracture. The presence of 13 potential correlates of abuse as captured by ICD-9 codes were extracted and summed. Descriptive statistics and regression models were used for analyses.
Mean age of participants was 77.2, 58% were female (58%), 60% were white (60%), and 46% had one or more potential correlates of abuse. In bivariate analyses, older age (≥80), dementia, seeking care in the ED (vs inpatient or outpatient clinics), only one visit to a medical facility (vs multiple visits) in the 36-month study period, cause of fracture as something other than a fall, and fractures of the head or face were more likely to have at least one correlate of abuse. In logistic regression, dementia (B = 0.794, standard error (SE) = 0.280); seeking care in the ED (vs outpatient or outpatient clinics) (B = 1.86, SE = 0.302); at least two visits to a medical facility (vs multiple visits) (B = −0.585, SE = 0.343); and fracture of the back (B = 0.730, SE = 0.289), head (B = 1.22, SE = 0.333), and face (B = 1.28, SE = 0.474) were associated with the presence of at least one correlate of abuse.
Certain characteristics in older adults with fracture are associated with potential correlates of abuse. Medical practitioners should have a heightened awareness when these signs are present.
As the overall incidence of Alzheimer's disease rises, the burden on caregivers and law enforcement institutions will increase to find individuals who wander. As such, technological innovations that could reduce this burden will become increasingly important. One such innovation is the GPS Shoe. As with any innovation involving the transfer of personal data to third parties, potential pitfalls with respect to loss of privacy and inadequate consent counterbalance the substantial promise of GPS shoes. To some extent, advance planning can mitigate these concerns, wherein individuals willingly elect to be monitored before their impairments progress to a stage that makes such authorization impractical. Nonetheless, tension may arise between the peace of mind of caregivers and family members and other important considerations at the intersection of autonomy, privacy, dignity, and consent. Ultimately, confronting ethical, legal, and policy considerations at the front end of product development and deployment will help ensure that new technologies are used wisely and that their lifesaving potential is realized.]]>
To assess patient and caregiver perceptions of what constitutes quality care in home-based primary care (HBPC).
Cross-sectional qualitative design; semistructured interview study.
Academic home-based primary care program.
Homebound patients (n = 13) and 10 caregivers (n = 10) receiving HBPC.
Semistructured interviews explored experiences with a HBPC program and perceptions of quality care. Interviews were audio-recorded and transcribed. Qualitative content analysis was performed to identify major themes.
Five major themes emerged related to participant perceptions of quality care: access, affordability, competency, care coordination, goal attainment. Participants felt that reliable, consistent access provided "peace of mind" and reduced hospital and emergency department use. Insurance coverage of program costs and coordinated care provided by an interdisciplinary team were positively regarded. Interpersonal skills and technical abilities of providers influenced patient perception of provider competency. Assessing and helping patients attain care goals contributed to a perception of quality care.
Patients and caregivers associate high-quality HBPC with around-the-clock access to affordable interdisciplinary providers with strong interpersonal skills and technical competency. These results expand on prior research and are concordant with HBPC goals of around-the-clock access to multidisciplinary teams with the goals of reduced emergency department and hospital use. HBPC programs should be structured to optimize access, affordability, coordinated care, and goal ascertainment and alignment. Quality indicators should be created and validated with these patient and caregiver views of care quality in mind.
To inform the development of a data-driven measure of quality care for individuals with multiple chronic conditions (MCCs) derived from an electronic health record (EHR).
Qualitative study using focus groups, interactive webinars, and a modified Delphi process.
Research department within an integrated delivery system.
The webinars and Delphi process included 17 experts in clinical geriatrics and primary care, health policy, quality assessment, health technology, and health system operations. The focus group included 10 individuals aged 70–87 with three to six chronic conditions selected from a random sample of individuals aged 65 and older with three or more chronic medical conditions.
Through webinars and the focus group, input was solicited on constructs representing high-quality care for individuals with MCCs. A working list was created of potential measures representing these constructs. Using a modified Delphi process, experts rated the importance of each possible measure and the feasibility of implementing each measure using EHR data.
High-priority constructs reflected processes rather than outcomes of care. High-priority constructs that were potentially feasible to measure included assessing physical function, depression screening, medication reconciliation, annual influenza vaccination, outreach after hospital admission, and documented advance directives. High-priority constructs that were less feasible to measure included goal setting and shared decision-making, identifying drug–drug interactions, assessing social support, timely communication with patients, and other aspects of good customer service. Lower-priority domains included pain assessment, continuity of care, and overuse of screening or laboratory testing.
High-quality MCC care should be measured using meaningful process measures rather than outcomes. Although some care processes are currently extractable from electronic data, capturing others will require adapting and applying technology to encourage holistic, person-centered care.
An interprofessional collaborative practice model was established at Hennepin County Medical Center to improve discharge management from the transitional care unit of the skilled nursing facility (SNF) to home. The practice model involves a geriatrician, nurse practitioner, and pharmacist who care for individuals at a community-based SNF. Before SNF discharge, the pharmacist conducts a chart and in-person medication review and collaborates with the nurse practitioner to determine the discharge medication regimen. The pharmacist's review focuses on assessing the indication, safety, effectiveness, and convenience of medications. The pharmacist provides follow-up in-home or over the telephone 1 week after SNF discharge, focusing on reviewing medications and assessing adherence. Hospitalizations and emergency department (ED) visits 30 days after SNF discharge of individuals who received care from this model was compared with those of individuals who received usual care from a nurse practitioner and geriatrician. From October 2012 through December 2013, the intervention was delivered to 87 individuals, with 189 individuals serving as the control group. After adjusting for age, sex, race, and payor, those receiving the intervention had a lower risk of ED visits (odds ratio (OR) = 0.46, 95% confidence interval (CI) = 0.22–0.97), although there was no significant difference in hospitalizations (OR = 0.47, 95% CI = 0.21–1.08). The study suggests that an interprofessional approach involving a pharmacist may be beneficial in reducing ED visits 30 days after SNF discharge.]]>
To describe the differences observed in risk factors for delirium and outcomes between men and women undergoing hip fracture repair surgery.
Prospective cohort study.
Academic medical center.
Individuals with acute hip fracture admitted to an academic medical center (N = 431).
Information on preoperative demographic characteristics, medical history, laboratory results, and postoperative outcomes was obtained according to history and chart review. Delirium was assessed using the Confusion Assessment Method.
The overall incidence of postoperative delirium was 34%, with men more likely to experience postoperative delirium (44.8%) than women (30.2%) (P = .004). Male sex was associated with postoperative delirium in individuals with hip fracture, even after adjusting for other preoperative risk factors. Other significant preoperative risk factors included age, dementia, Parkinson's disease, and American Society of Anesthesiologists classification. Men were also more likely to experience other postoperative complications and have longer hospital length of stay.
Men are at higher risk of postoperative delirium after hip fracture repair than women and have more postoperative surgical complications. Their higher risk of postoperative delirium may be due to their underlying preoperative disease severity.
Older adults with advanced chronic kidney disease (CKD) experience functional impairment that can complicate CKD management. Failure to recognize functional impairment may put these individuals at risk of further functional decline, nursing home placement, and missed opportunities for timely goals-of-care conversations. Routine geriatric assessment could be a useful tool for identifying older adults with CKD who are at risk of functional decline and provide contextual information to guide clinical decision-making. Two innovative programs were implemented in the Veterans Health Administration that incorporate geriatric assessment into a nephrology visit. In one program, a geriatrician embedded in a nephrology clinic used standardized geriatric assessment tools with individuals with CKD aged 70 and older (Comprehensive Geriatric Assessment for CKD) (CGA-4-CKD). In the second program, a nephrology clinic used comprehensive appointments for individuals aged 75 and older to conduct geriatric assessments and CKD care (Renal Silver). Data on 68 veterans who had geriatric assessments through these programs between November 2013 and May 2015 are reported. In CGA-4-CKD, difficulty with one or more activities of daily living (ADLs), history of falls, and cognitive impairment were each found in 27.3% of participants. ADL difficulty was found in 65.7%, falls in 28.6%, and cognitive impairment in 51.6% of participants in Renal Silver. Geriatric assessment guided care processes in 45.4% (n = 15) of veterans in the CGA-4-CKD program and 37.1% (n = 13) of those in Renal Silver. Findings suggest there is a significant burden of functional impairment in older adults with CKD. Knowledge of this impairment is applicable to CKD management.]]>
To determine, in a sample of Ashkenazi Jewish aged 95 and older, whether there is a compression of morbidity similar to what has been reported in other cohorts with exceptional longevity.
Case–control study.
Longevity Genes Project (LGP) and New England Centenarian Study (NECS).
LGP (n = 439, mean age 97.8 ± 2.8) and NECS (n = 1,498, mean age 101.4 ± 4.0) participants with exceptional longevity and their respective younger referent cohorts (LGP, n = 696; NECS, n = 302).
Self- and proxy reports of age of onset of cancer, cardiovascular disease, diabetes mellitus, hypertension, osteoporosis, and stroke.
Long-lived individuals from LGP and NECS had later age of onset of cancer, cardiovascular disease, diabetes mellitus, hypertension, and osteoporosis than their respective younger reference groups. The risk of overall morbidity was lower in participants with exceptional longevity than in younger participants (NECS men: relative risk (RR) = 0.12, women: RR = 0.20; LGP men: RR = 0.18, women: RR = 0.24). The age at which 20% of each of the groups with exceptional longevity experienced specific diseases was between 18 and 24 years later than in the reference groups, stratified according to sex.
The similar extension of health span and compression of morbidity seen in NECS and LGP participants with exceptional longevity further validates the utility of these rare individuals for the study of factors that delay or prevent a broad spectrum of diseases otherwise associated with mortality and disability.
To derive and validate a method for scoring delirium severity using a recently validated, brief, structured diagnostic interview for Confusion Assessment Method (CAM)-defined delirium (3D-CAM) and to demonstrate its agreement with the CAM Severity short form (CAM-S SF) as the reference standard.
Derivation and validation analysis in a prospective cohort study.
Two academic medical centers.
Individuals aged 70 and older enrolled in the Successful Aging after Elective Surgery Study undergoing major elective noncardiac surgery (N = 566).
The sample was randomly divided into a derivation dataset (n = 377) and an independent validation dataset (n = 189). These datasets were used to develop a severity scoring method using the 3D-CAM based on the four-item CAM-S SF (3D-CAM-S) and evaluate agreement between the 3D-CAM-S and the traditional CAM-S SF using weighted kappa statistics.
A method for scoring severity using 3D-CAM items was developed that achieved good agreement with the CAM-S SF in the derivation dataset (κ = 0.94, 95% confidence interval (CI) = 0.93–0.95). The 3D-CAM-S achieved nearly identical agreement in the independent validation dataset (κ = 0.93, 95% CI = 0.92–0.95), and 100% of 3D-CAM-S scores were within 1 point of the CAM-S SF score in both datasets. The 3D-CAM-S also strongly predicts clinical outcomes.
A newly developed method for scoring delirium severity using the 3D-CAM (the 3D-CAM-S) has excellent agreement with the CAM-S SF. This new methodology enables clinicians and researchers using the 3D-CAM for surveillance to measure delirium severity and monitor its course simultaneously by tracking changes over time. The 3D-CAM-S expands the utility of the 3D-CAM as an important tool for delirium recognition and management.
To determine whether use of the Screening Tool of Older Persons' Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START) criteria reduces incident hospital-acquired adverse drug reactions (ADRs), 28-day medication costs, and median length of hospital stay in older adults admitted with acute illness.
Single-blind cluster randomized controlled trial (RCT) of unselected older adults hospitalized over a 13-month period.
Tertiary referral hospital in southern Ireland.
Consecutively admitted individuals aged 65 and older (N = 732).
Single time point presentation to attending physicians of potentially inappropriate medications according to the STOPP/START criteria.
The primary outcome was the proportion of participants experiencing one or more ADRs during the index hospitalization. Secondary outcomes were median length of stay (LOS) and 28-day total medication cost.
One or more ADRs occurred in 78 of the 372 control participants (21.0%; median age 78, interquartile range (IQR) 72–84) and in 42 of the 360 intervention participants (11.7%; median age 80, IQR 73–85) (absolute risk reduction = 9.3%, number needed to treat = 11). The median LOS in the hospital was 8 days (IQR 4–14 days) in both groups. At discharge, median medication cost was significantly lower in the intervention group (€73.16, IQR €38.68–121.72) than in the control group (€90.62, IQR €49.38–162.53) (Wilcoxon rank test Z statistic = −3.274, P < .001).
Application of STOPP/START criteria resulted in significant reductions in ADR incidence and medication costs in acutely ill older adults but did not affect median LOS.
To assess the effect of continuous positive airway pressure (CPAP) on napping behavior in adults aged 60 and older with obstructive sleep apnea–hypopnea syndrome (OSAHS).
Retrospective cohort study using questionnaires.
Sleep center.
Individuals starting CPAP treatment between April 2010 and March 2012 (mean age 65.2 ± 4.7; M:F = 3.9:1; N = 107).
All subjects underwent sleep studies, clinical reviews, and CPAP adherence checks and completed a questionnaire regarding CPAP adherence, current employment status, sleep patterns before and after CPAP, and factors affecting their current sleep patterns.
CPAP treatment duration was 82.7 ± 30.0 weeks, and objective adherence was 5.4 ± 2.0 hours per night overall. Daytime nap frequency before CPAP treatment was higher in those with a history of stroke or cardiovascular disease. Both sexes had a significant reduction in daytime napping (men, P < .001; women, P = .008), evening napping (men, P < .001; women, P = .02), and daily nap duration (men, P < .001; women, P = .02). Logistic regression analysis showed that the reduction in self-reported daily nap duration was associated with younger age (odds ratio (OR) = 0.86, P = .04), a decrease in ESS score (OR = 1.20, P = .03), and longer self-reported daily nap duration at baseline (OR = 31.52, P < .001).
Long-term CPAP treatment in older adults with OSAHS can play a significant role in reducing nap frequency and daily nap duration. Aging or shorter baseline daily nap duration may attenuate this effect.
Multiple studies have shown that quality of care for dementia in primary care is poor, with physician adherence to dementia quality indicators (QIs) ranging from 18% to 42%. In response, the University of California at Los Angeles (UCLA) Health System created the UCLA Alzheimer's and Dementia Care (ADC) Program, a quality improvement program that uses a comanagement model with nurse practitioner dementia care managers (DCM) working with primary care physicians and community-based organizations to provide comprehensive dementia care. The objective was to measure the quality of dementia care that nurse practitioner DCMs provide using the Assessing Care of Vulnerable Elders (ACOVE-3) and Physician Consortium for Performance Improvement QIs. Participants included 797 community-dwelling adults with dementia referred to the UCLA ADC program over a 2-year period. UCLA is an urban academic medical center with primarily fee-for-service reimbursement. The percentage of recommended care received for 17 dementia QIs was measured. The primary outcome was aggregate quality of care for the UCLA ADC cohort, calculated as the total number of recommended care processes received divided by the total number of eligible quality indicators. Secondary outcomes included aggregate quality of care in three domains of dementia care: assessment and screening (7 QIs), treatment (6 QIs), and counseling (4 QIs). QIs were abstracted from DCM notes over a 3-month period from date of initial assessment. Individuals were eligible for 9,895 QIs, of which 92% were passed. Overall pass rates of DCMs were similar (90–96%). All counseling and assessment QIs had pass rates greater than 80%, with most exceeding 90%. Wider variation in adherence was found among QIs addressing treatments for dementia, which patient-specific criteria triggered, ranging from 27% for discontinuation of medications associated with mental status changes to 86% for discussion about acetylcholinesterase inhibitors. Comprehensive dementia care comanagement with a nurse practitioner can result in high quality of care for dementia, especially for assessment, screening, and counseling. The effect on treatment QIs is more variable but higher than previous reports of physician-provided dementia care.
To determine hospital-level predictors of readmission after hip fracture or potentially related inpatient care processes.
Retrospective cohort study.
U.S. acute care hospitals.
Fee-for-service Medicare beneficiaries who underwent hip fracture surgery between 2007 and 2009 (N = 458,526).
Information was obtained on hospital case volumes, teaching status, bed count, nurse staffing, and technological capabilities from Medicare files, and multivariable logistic regression was used to measure the association between these factors and an endpoint of readmission or death at 30 days and between these factors and the timing of surgery.
Participants treated in the highest-volume hospitals (>175 cases for the study period) had lower odds of readmission or death at 30 days than those treated in low-volume hospitals (≤12; adjusted odds ratio (aOR) = 0.87, 95% confidence interval (CI) = 0.83–0.92, P < .001). Higher nurse skill mix (aOR = 0.88, 95% CI = 0.8–0.96; P = .007) and higher ratio of nurses to beds (aOR = 0.98; 95% CI = 0.97–0.99; P < .001) were also associated with better 30-day outcomes. Greater hospital case volume was associated with lower odds of surgical delay beyond 48 hours.
Better nurse staffing and higher case volumes are associated with lower rates of readmission and mortality after hip fracture surgery; individuals treated at high-volume centers experienced fewer delays in treatment, potentially indicating better inpatient care processes.
To determine the contribution of cognitive impairment, prefracture functional impairment, and treatment as predictors of functional status and mobility 6 months after discharge from rehabilitation for older adults with hip fracture.
Inpatient rehabilitation units of two community hospitals.
Adults with hip fractures aged 65 and older who were discharged from a rehabilitation unit and had been living in the community before the fracture (N = 133).
Mini-Mental State Examination (MMSE) score at discharge from rehabilitation was used to identify the presence and severity of cognitive impairment. Outcomes were measured using questions from two subscales of the Functional Independence Measure (Self-Care Function and Functional Mobility) and the New Mobility Scale (NMS). Measurements were made at discharge from a rehabilitation setting and 3 and 6 months after discharge.
Prefracture functional impairment was associated with worse outcomes throughout the 6 months after discharge and with lower rates of improvement, or in some cases decline, after discharge. Cognitive impairment was associated with worse outcomes throughout the 6 months after discharge but was only weakly associated with lower rates of improvement or decline. The Patient Centered Rehabilitation Model of care targeting persons with cognitive impairment (PCRM-CI) intervention group had higher NMS scores after discharge than a usual care group.
Although cognitive impairment and prefracture functional impairment contribute to poor outcomes, prefracture functional impairment was more strongly associated with poor outcomes than cognitive impairment. There is evidence to show that individuals with cognitive impairment are able to regain their mobility, which suggests a need for postdischarge targeted interventions that include a focus on activities of daily living for older adults with cognitive impairment and functional impairment to stabilize gains from inpatient rehabilitation.
To examine the associations between self-reported nighttime sleep duration and daytime sleep and incident heart failure (HF) in men with and without preexisting cardiovascular disease (CVD).
Population-based prospective study.
General practices in 24 British towns.
Men aged 60–79 without prevalent HF followed for 9 years (N = 3,723).
Information on incident HF cases was obtained from primary care records. Assessment of sleep was based on self-reported sleep duration at night and daytime napping.
Self-reported short nighttime sleep duration and daytime sleep of longer than 1 hour were associated with preexisting CVD, breathlessness, depression, poor health, physical inactivity, and manual social class. In all men, self-reported daytime sleep of longer than 1 hour duration was associated with significantly greater risk of HF after adjustment for potential confounders (adjusted hazard ratio (aHR) = 1.69, 95% CI = 1.06–2.71) than in those who reported no daytime napping. Self-reported nighttime sleep duration was not associated with HF risk except in men with preexisting CVD (<6 hours: aHR = 2.91, 95% CI = 1.31–6.45; 6 hours: aHR = 1.89, 95% CI = 0.89–4.03; 8 hours: aHR = 1.29, 95% CI = 0.61–2.71; ≥9 hours: aHR = 1.80, 905% CI = 0.71–4.61 vs nighttime sleep of 7 hours). Snoring was not associated with HF risk.
Self-reported daytime napping of longer than 1 hour is associated with greater risk of HF in older men. Self-reported short sleep (<6 hours) in men with CVD is associated with particularly high risk of developing HF.
To compare the effectiveness and cardiovascular safety of long-acting beta-agonists (LABAs) with those of leukotriene receptor antagonists (LTRAs) as add-on treatments in older adults with asthma already taking inhaled corticosteroids (ICSs).
Retrospective cohort study.
Medicare fee-for-service (FFS) claims (2009–10) for a 10% random sample of beneficiaries continuously enrolled in Parts A, B, and D in 2009.
Medicare beneficiaries aged 66 and older continuously enrolled in FFS Medicare with Part D coverage with a diagnosis of asthma before 2009 treated exclusively with ICSs plus LABAs or ICSs plus LTRAs (N = 14,702).
The augmented inverse propensity-weighted estimator was used to compare the effect of LABA add-on therapy with that of LTRA add-on therapy on asthma exacerbations requiring inpatient, emergency, or outpatient care and on cardiovascular (CV) events, adjusting for demographic characteristics, comorbidities, and county-level healthcare-access variables.
The primary analysis showed that LTRA add-on treatment was associated with greater odds of asthma-related hospitalizations or emergency department visits (odds ratio (OR) = 1.4, P < .001), as well as outpatient exacerbations requiring oral corticosteroids or antibiotics (OR = 1.41, P < .001) than LABA treatment. LTRA add-on therapy was also less effective in controlling acute symptoms, as indicated by greater use of short-acting beta agonists (rate ratio = 1.58, P < .001). LTRA add-on treatment was associated with lower odds of experiencing a CV event than LABA treatment (OR = 0.86, P = .006).
This study provides new evidence specific to older adults to help healthcare providers weigh the risks and benefits of these add-on treatments. Further subgroup analysis is needed to personalize asthma treatments in this high-risk population.
To investigate the relationship between urinary incontinence (UI) and subsequent development of social dysfunction, using longitudinal data collected over 15 years from women aged 70 and older.
Longitudinal data from the Australian Longitudinal Study on Women's Health.
Women born between 1921 and 1926 (aged 70–75 in 1996, 85–90 in 2011) (N = 12,432).
UI, social dysfunction, other health and demographic factors.
Generalized estimating equations were used to examine the association between social dysfunction and UI over time, adjusted for time, health, and social covariates. Social dysfunction and UI increased over time in older women. UI was associated with 30% greater odds of social dysfunction (P < .001), adjusted for time, health, and social covariates in the model with no time lag. UI was also associated with social dysfunction measured one survey period later (forward time lag) (odds ratio (OR) = 1.23, 95% confidence interval (CI) = 1.13–1.34) and one survey period earlier (reverse time lag) (OR = 1.30, 95% CI = 1.19–1.43), indicating an absence of causality. Social dysfunction was associated with living in urban areas, more health conditions, poor mental health, providing care for other people, and poor physical function.
UI was associated with social dysfunction in older women, although the association did not appear to be causal but reflective of the women's overall level of function and general health. UI is not necessarily socially debilitating, unless a woman has other health problems.
To investigate the etiology of transient loss of consciousness (T-LOC) suspected to be syncope and unexplained falls in elderly adults with dementia.
Prospective, observational, multicenter study.
Acute care wards, syncope units or centers for the diagnosis of dementia.
Individuals aged 65 and older with a diagnosis of dementia and one or more episodes of T-LOC of a suspected syncopal nature or unexplained falls during the previous 3 months were enrolled.
The causes of T-LOC suspected to be syncope and unexplained falls were evaluated using a simplified protocol based on European Society of Cardiology guidelines.
Of 357 individuals enrolled, 181 (50.7%) had been referred for T-LOC suspected to be syncope, 166 (46.5%) for unexplained falls, and 10 (2.8%) for both. An initially suspected diagnosis of syncope was confirmed in 158 (87.3%), and syncope was identified as the cause of the event in 75 (45.2%) of those referred for unexplained falls. Orthostatic hypotension was the cause of the event in 117 of 242 (48.3%) participants with a final diagnosis of syncope.
The simplified syncope diagnostic protocol can be used in elderly people with dementia referred for suspected syncope or unexplained falls. Unexplained falls may mask a diagnosis of syncope or pseudosyncope in almost 50% of cases. Given the high prevalence of orthostatic syncope in participants (~50%), a systematic reappraisal of drugs potentially responsible for orthostatic hypotension is warranted.
To evaluate frequency of use of two anti-dementia drug classes approved for treatment of symptoms, whether populations most likely to benefit are treated, and correlates of treatment initiation.
Nationally representative cohort study.
Fee-for-service Medicare.
Elderly adults with dementia enrolled in Medicare Parts A, B, and D in 2009 (N = 433,559) and a subset with incident dementia (n = 185,449).
Main outcome was any prescription fill for antidementia drugs (cholinesterase inhibitors (ChEIs) or memantine) within 1 year.
Treatment with antidementia drugs occurred in 55.8% of all participants with dementia and 49.3% of those with incident dementia. There was no difference between ChEIs and memantine use according to dementia severity (measured as death within first year or living in residential care vs in a community setting) even though memantine is not indicated in mild disease. In incident cases, initiation of treatment was lower in residential care (relative risk (RR) = 0.82, 95% confidence interval (CI) = 0.81–0.83) and with more comorbidities (RR = 0.96, 95% CI = 0.96–0.96). Sixty percent of participants were managed in primary care alone. Seeing a neurologist (RR = 1.07, 95% CI = 1.06–1.09) or psychiatrist (RR = 1.17, 95% CI = 1.16–1.19) was associated with higher likelihood of treatment than seeing a primary care provider alone, and seeing geriatrician was associated with with lower likelihood (RR = 0.96, 95% CI = 0.93–0.99). Across the United States, the proportion of newly diagnosed individuals started on antidementia treatment varied from 32% to 66% across hospital referral regions.
Antidementia drugs are used less often in people with late disease, but there is no differentiation in medication choice. Although primary care providers most often prescribe antidementia medication without specialty support, differences in practice between specialties are evident.
To examine health literacy as a mediator of racial disparities in cognitive decline as measured by executive function in elderly adults.
Prospective cohort study.
Secondary analysis of ElderWalk trial in Boston, Massachusetts.
English-speaking African-American and Caucasian individuals in a walking intervention for community-dwelling adults aged 65 and older without dementia at baseline who completed baseline and 12-month evaluations (N = 198).
Health literacy was measured using the Short Test of Functional Health Literacy in Adults. Fluid and crystallized cognitive functions were measured at baseline and 12 months using the Trail-Making Test Part B minus Part B (TMT B–A) and the Controlled Oral Word Association Test (COWAT). Associations between health literacy and 12-month cognitive decline were modeled using multivariate linear regression.
Participants with higher health literacy and education experienced less cognitive decline than those with limited health literacy according to the TMT B–A (P = .01). After adjusting for covariates, Caucasian participants (n = 63) experienced less decline than African-American participants (n = 135) on TMT B–A (P = .001) and COWAT (P = .001). Adjusting for health literacy led to a 25.3% decrease in the point estimate for racial difference in TMT B–A and a 19.5% decrease in COWAT. Although independently related to cognitive decline, educational attainment did not mediate racial differences.
Health literacy is a partial mediator of racial disparities in cognitive decline. These results indicate the need to develop interventions to mitigate cognitive decline that individuals with low heath literacy can use and to modify the healthcare environment to better accommodate this population.
To define multimorbidity "classes" empirically based on patterns of disease co-occurrence in older Americans and to examine how class membership predicts healthcare use.
Retrospective cohort study.
Nationally representative sample of Medicare beneficiaries in file years 1999–2007.
Individuals aged 65 and older in the Medicare Beneficiary Survey who had data available for at least 1 year after index interview (N = 14,052).
Surveys (self-report) were used to assess chronic conditions, and latent class analysis (LCA) was used to define multimorbidity classes based on the presence or absence of 13 conditions. All participants were assigned to a best-fit class. Primary outcomes were hospitalizations and emergency department visits over 1 year.
The primary LCA identified six classes. The largest portion of participants (32.7%) was assigned to the minimal disease class, in which most persons had fewer than two of the conditions. The other five classes represented various degrees and patterns of multimorbidity. Usage rates were higher in classes with greater morbidity, but many individuals could not be assigned to a particular class with confidence (sample misclassification error estimate = 0.36). Number of conditions predicted outcomes at least as well as class membership.
Although recognition of general patterns of disease co-occurrence is useful for policy planning, the heterogeneity of persons with significant multimorbidity (≥3 conditions) defies neat classification. A simple count of conditions may be preferable for predicting usage.
To compare the ability of the commonly used Women's Health Initiative (WHI) and Cardiovascular Health Study (CHS) frailty phenotypes to predict falls, hip fracture, and death in WHI Clinical Trial participants aged 65 and older.
Longitudinal cohort study.
WHI Clinical Trial.
Participants with data for WHI and CHS frailty phenotypes (N = 3,558).
Frailty was operationally defined in the CHS as the presence of three or more of weight loss, poor energy, weakness, slowness, and low physical activity. WHI operationalized frailty similarly but with the RAND-36 physical function scale substituted for slowness and weakness (RAND-36 physical function scale score <13 = 2 points, 13–78 = 1 point, >78 = 0 points). Frailty was defined as a summary score of 3 or greater, prefrailty as a score of 2 or 1, and nonfrailty as a score of 0. Outcomes were modeled using Cox regression. Harrell C-statistics were compared for models containing alternative instruments.
Approximately 5% of participants were frail based on the CHS or WHI phenotype. The WHI frailty phenotype was associated with higher rates of falls (hazard ratio (HR) = 1.48, P = .003), hip fracture (HR = 1.87, P = .04), and death (HR = 2.32, P < .001). Comparable HRs in CHS-phenotype frail women were 1.32 (P = .04), 1.08 (P = .83), and 1.91 (P < .001), respectively. Harrell C-statistics revealed marked but insignificant differences in predicting abilities between CHS and WHI phenotype models (P > .50 for all).
The WHI phenotype, which does not require direct measurements of physical performance, might offer a practical advantage for epidemiological and clinical needs.
To examine whether life expectancy influences treatment pattern of nonmelanoma skin cancer, or keratinocyte carcinoma (KC), the most common malignancy and the fifth most costly cancer to Medicare.
Nationally representative cross-sectional study.
Nationally representative Health and Retirement Study linked to Medicare claims.
Treatments (N = 9,653) from individuals aged 65 and older treated for basal or squamous cell carcinoma between 1992 and 2012 (N = 2,702) were included.
Limited life expectancy defined according to aged 85 and older, medical comorbidities, Charlson Comorbidity Index score of 3 or greater, difficulty in at least one activity of daily living (ADL), and a Lee index of 13 or greater. Treatment type (Mohs micrographic surgery (MMS) (most intensive, highest cost), excision, or electrodesiccation and curettage (ED&C) (least intensive, lowest cost)), according to procedure code.
Most KCs (61%) were treated surgically. Rates of MMS (19%), excision (42%), and ED&C (39%) were no different in participants with limited life expectancy and those with normal life expectancy. For example, 19% of participants with difficulty or dependence in ADLs, 20% of those with a Charlson comorbidity score greater than 3, and 15% of those in their last year of life underwent MMS; participants who died within 1 year of diagnosis were treated in the same way as those who lived longer.
A one-size-fits-all approach in which advanced age, health status, functional status, and prognosis are not associated with intensiveness of treatment appears to guide treatment for KC, a generally nonfatal condition. Although intensive treatment of skin cancer when it causes symptoms may be indicated regardless of life expectancy, persons with limited life expectancy should be given choices to ensure that the treatment matches their goals and preferences.
To assess the feasibility and validity of the International Dementia Alliance (IDEAL) instrument for Informal Caregivers (IDEAL-IC), which is based on the IDEAL instrument for professionals (IDEAL-P), for staging individuals with dementia.
Memory clinic of a university hospital.
Informal caregivers of 73 community-dwelling elderly adults referred to a memory clinic and six geriatric registrars.
Caregivers completed the IDEAL-IC; physicians completed the original IDEAL-P and the Clinical Dementia Rating sum of boxes (CDR-SB). Missing items and floor and ceiling effects were reviewed to assess feasibility. To test construct validity, a priori hypotheses were defined for expected correlations between IDEAL-IC, IDEAL-P, and CDR-SB scores.
Seventy-three IDEAL-IC instruments were completed, 86% of which had no missing items. Three percent of all 730 individual items were missing. No floor or ceiling effects were detected. CDR scores were 0 7%, 0.5 in 33%, 1 in 27%, 2 in 10%, and unknown in 23%. IDEAL-IC scores correlated highly with IDEAL-P scores (correlation coefficient (r) = 0.70) and with CDR-SB scores (r = 0.65) as expected; the difference between these two correlations was smaller than expected. Agreement between IDEAL-IC and IDEAL-P scores was 34% within a range of 1 point difference on 36-point scales, 57% within a range of two points, and 81% within a range of five points. Correlation between IDEAL-P and CDR-SB was very high (r = 0.85).
Results of this study indicate good feasibility and high validity of staging dementia by informal caregivers using the IDEAL-IC.
To determine whether older people with advance directive for euthanasia (ADEs) are stable in their advance desire for euthanasia in the last years of life, how frequently older people with an ADE eventually request euthanasia, and what factors determine this.
Mortality follow-back study nested in a cohort study.
The Netherlands.
Proxies of deceased members of a cohort representative of Dutch older people (n = 168) and a cohort of people with advance directives (n = 154).
Data from cohort members (possession of ADE) combined with after-death proxy information on cohort members' last 3 months of life. Multiple logistic regression analysis was performed on determinants of a euthanasia request in individuals with an ADE.
Response rate was 65%. One hundred forty-two cohort members had an ADE at baseline. Three months before death, 87% remained stable in their desire for euthanasia; 47% eventually requested euthanasia (vs 6% without an ADE), and 16% died after euthanasia. People with an ADE were more likely to request euthanasia if they worried about loss of dignity.
The majority of older adults who complete an ADE will have a stable preference over time, but an advance desire for euthanasia does not necessarily result in a euthanasia request. Writing an ADE may reflect a person's need for reassurance that they can request euthanasia in the future.
To investigate the association between mortality and heritability of a rescaled Fried frailty index, the Scale of Aging Vigor in Epidemiology (SAVE), to determine its value for genetic analyses.
Longitudinal, community-based cohort study.
The Long Life Family Study (LLFS) in the United States and Denmark.
Long-lived individuals (N = 4,875, including 4,075 genetically related individuals) and their families (N = 551).
The SAVE was administered to 3,599 participants and included weight change, weakness (grip strength), fatigue (questionnaire), physical activity (days walked in prior 2 weeks), and slowness (gait speed); each component was scored 0, 1, or 2 using approximate tertiles, and summed (range 0 (vigorous) to 10 (frail)). Heritability was determined using a variance component–based family analysis using a polygenic model. Association with mortality in the proband generation (N = 1,421) was calculated using Cox proportional hazards mixed-effect models.
Heritability of the SAVE was 0.23 (P < .001) overall (n = 3,599), 0.31 (P < .001) in probands (n = 1,479), and 0.26 (P < .001) in offspring (n = 2,120). In adjusted models, higher SAVE scores were associated with higher mortality (score 5–6: hazard ratio (HR) = 2.83, 95% confidence interval (CI) = 1.46–5.51; score 7–10: HR = 3.40, 95% CI = 1.72–6.71) than lower scores (0–2).
The SAVE was associated with mortality and was moderately heritable in the LLFS, suggesting a genetic component to age-related vigor and frailty and supporting its use for further genetic analyses.
To determine whether there are racial and ethnicity group differences in Resources for Enhancing Alzheimer's Caregiver Health (REACH II) intervention delivery.
Randomized controlled trial.
Community-based intervention delivered at five sites across the United States.
Family caregivers of persons with dementia who were randomized to the active intervention condition (N = 323).
Nine in-home sessions (90 minutes each) and three telephone sessions (30 minutes each) were intended to be delivered and designed to reduce caregiver burden and depression, improve caregiver self-care and social support, and help caregivers manage behavior problems in persons with dementia.
Interventionists recorded the type of intervention (home or telephone), start and stop times, and whether specific intervention content modules (e.g., stress management, social support) were administered in each session.
Overall, REACH II intervention delivery was high, with more than 80% of randomized caregivers completing at least five in-home sessions and receiving eight or more hours of intervention contact, but black caregivers completed fewer in-home sessions (mean 6.98) than Hispanics (mean 7.84) or whites (mean 8.25) and received less total intervention contact time (mean 683 minutes) than Hispanics (mean 842 minutes) or whites (mean 798 minutes). No significant differences in exposure to content according to race or ethnicity were found after controlling for demographic covariates.
Blacks in REACH II received significantly less intervention contact. Similar multicomponent interventions should examine whether there are systematic differences in intervention delivery across specific demographic subgroups and explore implications for treatment outcomes.
To characterize Medicare expenditure and usage trends in individuals with a coded diagnosis of Alzheimer's disease and related dementia (ADRD) or mild cognitive impairment (MCI) during the periods leading up to and after diagnosis.
Retrospective observational cohort study.
Five percent sample of the 2009 to 2013 Medicare claims files.
Individuals newly diagnosed with ADRD (n = 25,916) or MCI (n = 2,784), each with a propensity-score matched control subject.
Medicare expenditures and usage during the 24 months before and after a new diagnosis of ADRD or MCI.
Medicare expenditures were 42% higher in participants with ADRD ($10,622 vs $15,091, P < .001) and 41% higher in those with MCI ($9,728 vs $13,691, P < .001) during the year before diagnosis than in matched controls. Medicare expenditures of participants with ADRD increased to $27,126 for the first 12 months immediately after diagnosis and decreased to $17,257 during the 12 months after that. For participants with MCI, average Medicare expenditures were $20,386 for the 12 months after diagnosis and $14,286 for the 12 months after that. Use of inpatient care, postacute skilled nursing facility care, and home health care increased substantially after diagnosis of ADRD or MCI.
Participants with ADRD and MCI incurred significantly higher Medicare expenditures than matched controls, even before they received a formal diagnosis. Medicare expenditures of individuals with ADRD and MCI may start to increase at least 12 months before their diagnosis, peak during the first few months immediately after diagnosis, and decrease afterward but remain at a higher level than before diagnosis. These findings highlight the importance of early diagnosis and indicate the need for complex case management to coordinate care transitions for individuals with ADRD and MCI.
To examine the longitudinal association between physical performance and risk of dementia in individuals aged 90 and older without dementia.
Population-based longitudinal study.
The 90+ Study, Laguna Woods, California.
Men n = 176 and women n = 402 without dementia from The 90+ Study (n = 578, mean age 93.3). At baseline, 54% of participants were cognitively normal, and 46% had cognitive impairment, no dementia.
Physical performance measures (4-m walk, 5 chair stands, handgrip, standing balance) were scored from 0 (unable to perform) to 4 (best performance). The outcome was dementia, diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Hazard ratios (HRs) for dementia in relation to baseline physical performance were estimated using Cox regression after adjustment for potential confounders. HRs and P-values for the overall Wald chi-square are reported to show the magnitude of each physical performance measure and the strength of the association between each measure and incident dementia.
Poor physical performance in most measures was associated with greater risk of incident dementia over a mean follow-up of 2.6 years (range 0.6–9.0 years). After controlling for potential confounders, standing balance had the strongest association with incident dementia (HRs = 1.9–2.5, overall P = .02), followed by 4-m walk (HRs = 1.1–1.8, overall P = .04) and handgrip (HRs = 1.0–2.0, overall P = .03). The association with five chair stands was not significant. In a subanalysis limited to cognitively normal participants, HRs were attenuated, but most remained in the same direction.
Poor physical performance is associated with risk of developing dementia over an average 2.6-year follow-up in the oldest-old, indicating that poor physical performance may be an early sign of late-age dementia.
To investigate the relationship between warfarin treatment and different strata of all-cause mortality risk assessed using the Multidimensional Prognostic Index (MPI) based on information collected using the Standardized Multidimensional Assessment Schedule for Adults and Aged Persons (SVaMA) in community-dwelling older adults with atrial fibrillation (AF).
Retrospective observational study.
Older community-dwelling adults who underwent a SVaMA evaluation establishing accessibility to homecare services and nursing home admission from 2005 to 2013 in the Padova Health District, Italy.
Community-dwelling individuals with AF aged 65 and older (N = 1,827).
Participants were classified as being at mild (MPI-SVaMA-1), moderate (MPI-SVaMA-2), or severe (MPI-SVaMA-3) risk of mortality using the MPI-SVaMA, a validated prognostic tool based on age, sex, comorbidity, cognitive status, mobility and functional disability, pressure sore risk, and social support. The association between warfarin treatment and mortality was tested using multivariate- and propensity score–adjusted Cox regression models, controlling for age, sex, all SVaMA domains, concomitant diseases, and drug treatments.
Higher MPI-SVaMA scores were associated with lower rates of warfarin treatment and higher 3-year mortality. After adjustment for propensity score quintiles, warfarin treatment was significantly associated with lower 2-year mortality in individuals with MPI-SVaMA-1 (hazard ratio (HR) = 0.64, 95% confidence interval (CI) = 0.50–0.82), MPI-SVaMA-2 (HR = 0.68, 95% CI = 0.55–0.85), and MPI-SVaMA-3 (HR = 0.55, 95% CI = 0.44–0.67). Heterogeneity analyses confirmed that the effect of warfarin treatment was not different between MPI-SVaMA groups (P for heterogeneity = .48).
Community-dwelling older adults with AF benefitted from anticoagulation in terms of lower all-cause mortality over a mean follow-up of 2 years, regardless of poor health and functional condition. Although this benefit can be ascribed to the treatment, it may also reflect better overall care.
To evaluate whether low glycosylated hemoglobin (HbA1c), blood pressure (BP), and total cholesterol (TC) are associated with lower risk of all-cause mortality in very old individuals with type 2 diabetes mellitus.
Population-based cohort study.
Primary care database in the United Kingdom.
Individuals aged 80 and older with type 2 diabetes mellitus (N = 25,966).
Associations between baseline HbA1c, BP, and TC and all-cause mortality were evaluated in Cox proportional hazards models. Analyses were adjusted for sex, age, duration of diabetes mellitus, lifestyle variables, HbA1c, BP, TC, comorbidities, prescribing of antidiabetic and cardiovascular drugs, and participants' general practice.
There were 4,490 deaths during follow-up (median 2.0 years; mortality 104.7 per 1,000 person-years). Mortality in participants with low (<6.0% (<42 mmol/mol)) or high (≥8.5% (≥69 mmol/mol)) HbA1c was similar to that in those with the reference HbA1c (8.0–8.4% (64–68 mmol/mol)). Mortality was lowest in individuals with HbA1c of 7.0–7.4% (53–57 mmol/mol) (80.9 per 1,000 person-years, adjusted hazard ratio (aHR) = 0.80, 95% confidence interval (CI) = 0.70–0.91, P = .001). Mortality was higher in individuals with lower BP (e.g., <130/70 mmHg, 151.7 per 1,000 person-years, aHR = 1.52, 95% CI = 1.34–1.72, P < .001 vs reference BP <150/90 mmHg) and in the lowest TC category (<3.0 mmol/L, 138.7 per 1,000 person-years, aHR = 1.42, 95% CI = 1.24–1.64, P < .001 vs reference TC 4.5–4.9 mmol/L). The relationship between TC and mortality varied according to sex and prescription of lipid-lowering drugs.
Low HbA1c, BP, and TC may be associated with higher mortality in very old adults with type 2 diabetes mellitus. Further research is required to understand these associations and to identify optimal treatment targets in this population.
To investigate the association between polypharmacy and mortality in nursing home (NH) residents.
Prospective observational cohort study.
Six NHs in central Israel.
Mobile with dementia and fully dependent residents (N = 764; n = 558 (73%) fully dependent, n = 206 (27%) mobile residents with dementia requiring institutional care; mean age 82.2 ± 5.9).
Two-year mortality and its association with number of drugs that individual residents were taking at baseline, controlled for multiple confounders.
At baseline, 268 residents were taking five or fewer drugs per day, 202 were taking six or seven, and 294 were taking eight or more. In the multivariate analysis, the likelihood of dying within 2 years in the group taking six or seven drugs per day (odds ratio (OR = 0.95, 95% CI = 0.63–1.43) and in those taking eight or more (OR = 1.20, 95% CI = 0.78–1.84) was similar to that of those taking five or fewer. Variables at baseline independently associated with greater mortality were male sex (OR = 1.75, 95% CI = 1.24–2.46), older age (OR = 1.07, 95% CI = 1.04–1.10), higher Charlson Comorbidity Index (OR = 1.17, 95% CI = 1.04–1.30), and taking anticoagulant (OR = 1.78, 95% CI = 1.01–3.13) or antihyperglycemic medication (OR = 1.69, 95% CI = 1.12–2.53). Variables at baseline independently associated with lower mortality were higher body mass index (OR = 0.99, 95% CI = 0.93–0.99) and taking lipid-lowering medication (OR = 0.54, 95% CI = 0.36–0.80) and selective serotonin reuptake inhibitors or serotonin–norepinephrine reuptake inhibitors (OR = 0.52, 95% CI = 0.37–0.75).
Polypharmacy, defined quantitatively according to number of drugs, was not associated with mortality in these NH residents.
To develop three prognostic indices of varying degree of required detail for 2-year pneumonia risk in older adults.
Retrospective cohort study.
Group Health (GH), an integrated healthcare delivery system.
Community-dwelling dementia-free individuals aged 65 and older who had been GH members for at least 2 years before start of follow-up and were enrolled in the Adult Changes in Thought study (N = 3,375; development cohort, n = 2,250; validation cohort, n = 1,125.
Potential pneumonia risk factors were identified from questionnaire data and interviewer assessments of functional status, medical history, smoking and alcohol use, cognitive function, personal care, and problem solving. Risk factors were also identified based on physical measures such as grip strength and gait speed and administrative database information on comorbid illnesses, laboratory tests, and prescriptions dispensed. Incident community-acquired pneumonia was defined presumptively from administrative data and validated using medical record review.
Participants (59% female) contributed 12,998 visits at which risk factors were assessed; 642 pneumonia events were observed during follow-up. Age, sex, chronic obstructive pulmonary disease, congestive heart failure, body mass index, and use of inhaled or oral corticosteroids were critical predictors in all prognostic indices. A risk score based on these seven variables, information on which is commonly available in electronic medical records (EMRs), had equal or better performance (c-index = 0.69 in the validation cohort) than scores including more-detailed data such as functional status.
Data commonly available in EMRs can stratify older adults into groups with varying subsequent 2-year pneumonia risk.
To examine associations between inflammation and physical function and potential mediation by white matter hyperintensities (WMHs) in African Americans (AAs) and European Americans (EAs).
Cross-sectional analysis using linear and logistic models with generalized estimating equations to account for family clustering, reporting results as regression coefficients (β) and odds ratios (ORs) adjusted for education, alcohol, exercise, body mass index, hypertension, diabetes mellitus, heart disease, cognition, ankle–brachial index, race (site), and supported interactions.
Genetic Epidemiology Network of Arteriopathy-Genetics of Microangiopathic Brain Injury Study cohort.
AA and EA sibships with two or more siblings with hypertension before age 60 (N = 1,960; 65% female, 51% AA, aged 26–91, 50% obese, 72% hypertensive).
Inflammation (C-reactive protein (CRP), interleukin-6 (IL6), soluble tumor necrosis factor receptors (sTNFRs) 1 and 2, WMH volume (cm3) according to magnetic resonance imaging), walking speed (cm/s) over 25 feet, and mobility difficulty (any self-reported difficulty walking half a mile).
In separate models, inflammatory markers were associated with walking speed (sTNFR1: β = −2.74, P < .001; sTNFR2: β = −1.23, P = .03; CRP: β = −1.95, P = .001; IL6: β = −1.24, P = .03) and mobility difficulty (sTNFR1: OR = 1.36, P = .001; sTNFR2: OR = 1.25, P = .005; CRP: OR = 1.22, P = .005; IL6: OR = 1.18, P = .02); the association between WMH volume and sTNFR1 in AA (β = 0.07, P = .06) did not reach typical statistical thresholds. WMH volume was associated with walking speed in AA (β = −3.17, P = .02) but not with mobility difficulty (OR = 1.10, P = .54). Adjusting for WMH did not change associations.
In young, middle-aged, and older adults with prevalent cardiovascular risk factors, multiple inflammatory biomarkers were associated with slower walking speed independent of microvascular disease in the brain. There was little evidence of mediation by brain WMH volume. Inflammation may contribute to physical function impairments through pathways other than brain microvascular disease, particularly in AAs.
To examine whether delirium in individuals with hip fracture is associated with high C-reactive protein (CRP), interleukin-6 (IL-6), and soluble IL-6 receptor (sIL-6R) levels in the cerebrospinal fluid (CSF).
Prospective cohort study.
Two university hospitals in Oslo, Norway, and Edinburgh, United Kingdom.
Individuals admitted with acute hip fracture (N = 151).
Participants were assessed for delirium pre- and postoperatively using the Confusion Assessment Method. Prefracture cognitive impairment was detected using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Serum was collected preoperatively and CSF just before the onset of spinal anesthesia. Cytokine levels in serum and CSF samples were determined using an enzyme-linked immunosorbent assay. Student t-tests or Mann–Whitney U-tests were used for between-group comparisons. Spearman rho was used for correlations.
Sixty participants had prior cognitive impairment (IQCODE score ≥3.44). Delirium was diagnosed in 46 participants (77%) with prior cognitive impairment and 25 (29%) without. In participants without prior cognitive impairment, CSF CRP levels were higher in participants with delirium (median 0.05 μg/mL, interquartile range (IQR) 0.02–0.12 μg/mL) than in those without delirium (median 0.01 μg/mL, IQR 0.00–0.06 μg/mL) (P = .01); there were no differences in participants with prior cognitive impairment. In secondary analyses, in participants with prior cognitive impairment, the concentration of CSF sIL-6R was higher in those participants who developed delirium than in the other subgroups, but this difference was not statistically significant. Serum levels of CRP, IL-6, and sIL-6R were not different according to delirium in participants with or without prefracture cognitive impairment.
High CSF levels of CRP and sIL-6R may be associated with delirium. Different pathophysiological mechanisms may operate in different subgroups, notably in relation to the presence of prior cognitive impairment.
To determine whether cognitive dysfunction, in particular impaired executive function, may be a risk factor for early readmission in older adults independently managing their medications.
Prospective observational study.
Tertiary hospital.
Individuals aged 65 years and older discharged to home from the medicine service of a tertiary hospital (N = 452).
Participants underwent a cognitive assessment including the Short Blessed Test (SBT), the executive function component of the Montreal Cognitive Assessment, and the Trail-Making Test Part B (TMT-B). Hospital use and demographic data were obtained. A logistic regression model was used to fit the likelihood of readmission on the basis of participant characteristics, medication management, and cognitive performance. Likelihood of hospital readmission within 30 days was determined.
For participants managing medications themselves, adjusted 30-day odds of readmission increased 13% on average with each point decrease in SBT score (P = .003) and 9% on average with each 0.01 decrease in TMT-B score (P = .02). For participants who were independent in medication management with more than seven medications, the odds of 30-day readmission increased 16% on average with each point decrease in SBT score (P = .01) and 15% on average with each 0.01 decrease in TMT-B score (P = .03).
Cognitive dysfunction, particularly executive dysfunction, is a risk factor for readmission in individuals managing their own medications. This risk is greater in individuals taking more than seven medications. The interaction of cognitive function, medication management, and number of medications may enhance risk-stratification efforts to identify individuals at risk of early readmission.
To investigate the effect of the number and type of comorbid conditions on death and hospitalizations in individuals with incident heart failure (HF).
Population-based cohort study.
Olmsted County, Minnesota.
Olmsted County, Minnesota, residents with incident HF from 2000 to 2010 (mean age 76 ± 14, 56% female) (N = 1,714).
The prevalence of 16 chronic conditions obtained at HF diagnosis classified into three groups: cardiovascular (CV) related, other physical, and mental.
The mean number of conditions per participant was 2.6 ± 1.5 for CV-related conditions, 1.3 ± 1.1 for other physical conditions, and 0.30 ± 0.61 for mental conditions. After a mean follow-up of 4.2 years, 1,073 deaths and 6,306 hospitalizations had occurred. After adjustment for age, sex, ejection fraction, in- or outpatient status, and number of other conditions, an increase of one other physical condition was associated with a 14% (HR = 1.14, 95% CI = 1.08–1.20) greater risk of death and a 26% (HR = 1.26, 95% CI = 1.20–1.32) greater risk of hospitalization, and an increase of one mental condition was associated with a 31% (HR = 1.31, 95% CI = 1.19–1.44) greater risk of death and an 18% (HR = 1.18, 95% CI = 1.07–1.29) greater risk of hospitalization. In contrast, an increase of one CV-related condition was not associated with greater risk of death and was associated with a 10% (HR = 1.10, 95% CI = 1.06–1.15) greater risk of hospitalization.
CV-related conditions are the most common type of comorbid conditions in individuals with HF, but other physical and mental conditions are more strongly associated with death and hospitalizations. This underscores the effect of non-CV conditions on outcomes in HF.
To examine the effect of statins on long-term mortality in older adults hospitalized with coronary artery disease (CAD).
Retrospective analysis.
University teaching hospital.
Individuals aged 80 and older (mean aged 85.2, 56% female) hospitalized from January 2006 to December 2010 with acute myocardial infarction (AMI), unstable angina pectoris, or chronic CAD and discharged alive (N = 1,262). Participants were divided into those who did (n = 913) and did not (n = 349) receive a discharge prescription for a statin.
All-cause mortality over a median follow-up of 3.1 years.
Participants treated with statins were more likely to be male, to have a primary diagnosis of AMI, to have traditional cardiovascular risk factors, and to receive other standard cardiovascular medications in addition to statins. In unadjusted analysis, statin therapy was associated with lower mortality (hazard ratio (HR) = 0.83, 95% confidence interval (CI) = 0.71–0.96). After adjustment for baseline differences between groups and propensity for receiving statin therapy, the effect of statins on mortality was no longer significant (HR = 0.88, 95% CI = 0.74–1.05). The association between statins and mortality was similar in participants aged 80 to 84 and those aged 85 and older.
In this cohort of older adults hospitalized with CAD, statin therapy had no significant effect on long-term survival after adjustment for between-group differences. These findings, although preliminary, call into question the benefit of statin therapy for secondary prevention in a real-world population of adults aged 80 and older and underscore the need for shared decision-making when prescribing statins in this age group.
To examine the association between four markers of overall nutritional status (a serum biomarker (albumin) and three anthropometric indices (body mass index (BMI), midarm circumference (MAC), calf circumference (CC))) and incident hearing impairment in older Japanese adults.
Community-based prospective cohort study.
Kurabuchi Town, Gunma Prefecture, Japan.
Individuals aged 65 and older (143 men, 195 women) without hearing impairment at baseline examination (2005–06) who participated in repeated examinations 4 years later (2009–10) (N = 338).
The three anthropometric indices were measured at baseline, and nephelometry was used to assess serum albumin levels. Hearing impairment was defined as failure to hear a 30-dB hearing level signal at 1 kHz and a 40-dB signal at 4 kHz in the better ear on pure-tone audiometry.
Over the 4-year period, 16.3% of participants developed hearing impairment. Those with lower marker values had greater risk of hearing impairment than those with higher marker values (multivariable adjusted odds ratio (aOR) = 2.18, 95% confidence interval (CI) = 1.05–4.57 for albumin ≤4.0 g/dL; aOR = 2.72, 95% CI = 1.10–6.71 for BMI <19.0 kg/m2). The pattern of association showed a similar tendency for MAC and CC. Excluding obese participants did not changed the results substantially.
Further research is needed to determine whether interventions that improve markers of nutritional status may help prevent age-related hearing loss in older adults.
To assess the prevalence and correlates of self-reported hearing loss during the last 2 years of life.
Observational cohort study.
The Health and Retirement Study (HRS), a longitudinal nationally representative cohort of adults aged 50 and older (2000–13).
Older adults (N = 5,895, mean age at death 78, 53% female, 20% nonwhite).
The HRS interview closest to death was used (mean 12.2 months before death). Participants rated their hearing (excellent, very good, good, fair, poor) and indicated whether they used hearing aids. The prevalence and correlates of fair and poor ratings are described, adjusted for age and sex.
Thirty-two percent (95% confidence interval (CI) = 31–34%) of all participants and 60% (95% CI = 57–64%) of the 7% of participants who used hearing aids rated their hearing as fair or poor. The prevalence of fair or poor hearing was highest in participants interviewed closest to death (29% 19–24 months before death, 36% 1–6 months before death, P for trend = .01). Correlates of fair or poor hearing during the last 2 years of life included age at death (50–59, 22%; 60–69, 21%; 70–79, 26%; 80–89, 38%; ≥90, 50%), sex (men 35%, women 30%), race and ethnicity (Hispanic 42%, white 33%), wealth (lowest quartile 38%, highest quartile 27%), history of heart disease (yes 38%, no 27%), activity of daily living dependence (yes 42%, no 26%), difficulty taking medications (yes 46%, no 29%), and probable dementia (yes 44%, no 24%).
Self-reported hearing loss increases during the last 2 years of life and is associated with physical and social vulnerability.
Limited research exists regarding the effect of anticholinergics on falls and fractures in elderly nursing home residents in the United States. This study examined the risk of fractures associated with anticholinergic medication use in elderly nursing home residents with depression. A nested case-control design involving a cohort of elderly adults with depression from the 2007 to 2010 Minimum Data Set (MDS)–linked Medicare data was used to evaluate the risk of fractures. The study sample included Medicare beneficiaries aged 65 and older diagnosed with depression having at least one nursing home stay during 2007 to 2010 and no history of falls or fractures in 2007 (base period). Cases were individuals with incident fractures after the baseline period. For each case, four age- and sex-matched controls were selected using incidence density sampling. Anticholinergic exposure was defined using the Anticholinergic Drug Scale (ADS). Prescription of Level 2 or 3 anticholinergic medications within 30 days before the event date was the primary exposure. The primary outcome was an inpatient or outpatient claim for a fracture between January 1, 2008, and December 31, 2010. A conditional logistic regression model stratified on matched case-control sets was used to evaluate association between anticholinergic use and fractures, controlling for other risk factors of the outcome. The study sample consisted of 40,452 individuals with fractures and 161,808 matched controls. After adjusting for other risk factors, high-level anticholinergic use was associated with 14% greater fracture risk than nonuse (odds ratio (OR) = 1.14, 95% confidence interval (CI) = 1.11–1.17). The high risk of fractures remained consistent across levels of anticholinergic potency (Level 2, OR = 1.15, 95% CI = 1.11–1.19; Level 3, OR = 1.10, 95% CI = 1.07–1.15). The study findings remained consistent in multiple sensitivity analyses. Overall, use of high-level anticholinergic medications was associated with greater risk of fracture than no use in elderly adults with depression. Given safety concerns, there is a need to optimize anticholinergic use in elderly adults.]]>
To examine the extent to which limited English proficiency (LEP) poses a risk to physical and mental health, using older Korean Americans as a target population.
Cross-sectional survey.
Older Korean Americans (N = 1,301).
Health outcomes were indexed using binary variables covering activity limitation, self-rated health, and probable depression. Participants who reported that they spoke English less than very well were categorized as manifesting LEP.
Approximately 71% of the sample had LEP. Those with LEP scored lower on all measures of health than their English-proficient counterparts. In multivariate models, the risk of having activity limitations was 2.72 times as great (95% confidence interval (CI) = 1.72–4.29, P < .001), a fair or poor rating of health 2.59 times as great (95% CI = 1.91–3.49, P < .001), and probable depression 1.73 times as great (95% CI = 1.29–2.31, P < .001) in participants with LEP.
Limited English proficiency was identified as a critical source of health vulnerability. Systematic efforts should be made to reach out to older immigrants with LEP and include them in health-related research and prevention and intervention programs.
In a randomized clinical trial, Geriatric Resources for Assessment and Care of Elders (GRACE), a model of care that works in collaboration with primary care providers (PCPs) and patient-centered medical homes to provide home-based geriatric care management focusing on geriatric syndromes and psychosocial problems commonly found in older adults, improved care quality and reduced acute care use for high-risk, low-income older adults. To assess the effect of GRACE at a Veterans Affairs (VA) Medical Center (VAMC), veterans aged 65 and older from Marion County, Indiana, with PCPs from four of five VAMC clinics who were not on hospice or dialysis were enrolled in GRACE after discharge home from an acute hospitalization. After an initial home-based transition visit to GRACE enrollees, the GRACE team returned to conduct a geriatric assessment. Guided by 12 protocols and input from an interdisciplinary panel and the PCP, the GRACE team developed and implemented a veteran-centric care plan. Hospitalized veterans from the fifth clinic, who otherwise met enrollment criteria, served as a usual-care comparison group. Demographic, comorbidity, and usage data were drawn from VA databases. The GRACE and comparison groups were similar in age, sex, and burden of comorbidity, although predicted risk of 1-year mortality in GRACE veterans was higher. Even so, GRACE enrollment was associated with 7.1% fewer emergency department visits, 14.8% fewer 30-day readmissions, 37.9% fewer hospital admissions, and 28.5% fewer total bed days of care, saving the VAMC an estimated $200,000 per year after program costs during the study for the 179 veterans enrolled in GRACE. Having engaged, enthusiastic VA leadership and GRACE staff; aligning closely with the medical home; and accommodating patient acuity were among the important lessons learned during implementation.


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Tata Motors Q1 net loss at Rs 328.78cr
Mumbai: Auto major Tata Motors on Monday posted a consolidated loss of Rs 328.78 crore in first quarter of the
current fiscal, and said it has secured guarantees from four
banks to raise Euro 340 million that would be used to fund its
needs over the next 12 months.
A 52 per cent fall in JLR`s wholesale volume led Tata Motors to record a consolidated net loss of Rs 328.78 crore for the quarter ended June 30, 2009, against a profit of Rs
719.69 crore during the same quarter last fiscal.
The financial numbers, according to company`s Vice-Chairman Ravi Kant, are strictly not comparable since the
home-grown auto major had completed the JLR acquisition on June 2, 2008.
The Indian auto company had acquired the British marquee brands Jaguar and Land Rover for USD 2.3 billion. However, following huge losses in the company amid the global turmoil,
Tata Motors had sought assistance from the UK government, but
talks did not materialise.
He said, "Earlier, the UK government was to give the
guarantee. European Investment Bank was to give the loan. Now,
we have replaced the UK government with commercial banks. Work
is on and very soon, we would tie-up the nuances," Kant said,
adding the interest rates on the commercial bank loan rates
would be "more attractive".
The company has secured guarantees from four banks -
Burdale, Standard Chartered Bank, Bank of Baroda and GE - to
secure an Euro 340 million loan from the European Investment
Tata Motors Chief Financial Officer C Ramakrishnan said the JLR has received new funding source to meet
production forecast and funding requirement for the next 12
"Continued adverse Global automotive market conditions
have resulted in an overall reduction in JLR volumes during
the quarter," Kant said, adding, JLR has focused on aligning
production with demand, reducing costs and working capital
The company had a standalone net profit of Rs 513.76
crore, for the quarter ended June 30, 2009.
Total income from operations stood at Rs 16,397 crore for
the reported quarter against Rs 14,490.18 crore recorded in
the same quarter the previous fiscal.
Tata Motors` consolidated debt now stands at Rs 34-35,000
crore, he said.
The company said its "world truck" would be launched in
the domestic market in the current quarter and was to be
launched in South Korea as well.
Tata Motors, which launched JLR models in Mumbai last
month, said it has received good response and has sold 16
vehicles. By March, additional six showrooms would be opened
and out of them three-four showrooms will be opened by
December this year.
Bureau Report
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St Ives with my G3
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Re: St Ives with my G3
In reply to Mike Bilton2 • Nov 4, 2012
I would like to see them too. But where are they?
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Mick Jagger Pays Tribute to L'Wren Scott: 'I Will Never Forget Her'
Mick Jagger has released a heartfelt tribute following the death of his designer girlfriend L'Wren Scott. The designer was found dead by her assistant on Monday, March 17 of apparent suicide. Jagger, who was in Australia when she died, released a statement on Facebook on Tuesday.
"I am still struggling to understand how my lover and best friend could end her life in this tragic way," he wrote. "We spent many wonderful years together and had made a great life for ourselves."
"I have been touched by the tributes that people have paid to her, and also the personal messages of support that I have received," he continued. "I will never forget her."
Previously, a representative for Jagger said that the rocker was "completely shocked and devastated by the news." The Rolling Stones' seven-date tour in Australia and New Zealand has been postponed "as a result of the death of L'Wren Scott." As quoted by USA Today, the band says, "Mick Jagger, Keith Richards, Charlie Watts and Ronnie Wood wish to thank all of their fans for their support at this difficult time and hope that they will fully understand the reason for this announcement."
Jagger's model daughter Georgia May Jagger also canceled her appearance in a modeling gig in Melbourne following the sad news. She reportedly headed back to the U.S. to be with her family.
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Shading objects with Gradient Mesh
Shading objects with Gradient Mesh
In this chapter, we'll take a look at one of the most impressive features in all of illustrator, and it goes by the name Gradient Mesh. And it allows you to add shadows and highlights inside of a single path outline. So that you can make it appear contoured and volumetric and just plain real. Now, you could think of a gradient mesh as a kind of net that you cast around a path outline, and at the intersection of any two ropes in that net, is an anchor point. And you can not only move the anchor point around, but you can also assign it a color, and then Illustrator, creates a series of miniature gradients, between all the pairs of colorful points. And as a result, we can take these flat path outlines and turn them into this dramatic dimensional final piece of art.
I cannot wait to show you how gradient mesh works.
Shading objects with Gradient Mesh provides you with in-depth training on Design. Taught by Deke McClelland as part of the Illustrator CS6 One-on-One: Mastery
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Sony Mavica FD-97
Announced Feb 9, 2001 •
2 megapixels | 2.5″ screen | 39 – 390 mm (10×)
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Announced Feb 9, 2001
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|1600 x 1200
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|1/2.7" (5.312 x 3.984 mm)
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|39–390 mm
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|1/500 sec
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|Disk 3.5" (2x speed) or MemoryStick (slot)
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By Ryan Clark | October 22, 2005
In a piece of news that may surprise some, NBC is currently in talks with Jesse Ventura to star in a sitcom.
Tickets for the WWE Survivor Series PPV on November 27th go on sale this Saturday at 10 a.m.
Deep South Wrestling, the newest WWE developmental territory, will be holding open tryouts from November 11 to 13 in McDonough, GA at the Deep South Arena. Those interested in participating should call 678-432-4410.
Former WWE and WCW star Chris Kanyon was arrested at 3AM on October 16th. Kanyon was charged with disorderly conduct and obstucting/opposing an officer. He was released on a $750 cash bond later that day.
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WWE Star Frustrated?, Rusev Wants Better Competition (Video), Lilian Garcia - WWE Battleground Note
New WWE Title Announced For The RAW Brand, Big SummerSlam Main Event In The Works
Which WWE Stars Have Not Been Assigned To A Brand?


text:
Hello Frühstücker,
this time I've booked a table at a special place:
One of the oldest Cafe's in Munich is "Cafe am Beethovenplatz" also know as "Mariandl".
It is an Vienna Cafehouse Style place with live music nearly every day.
On "our" Sunday the Trio "Barcarole" (two guitarrs, one bass) is playing.
If you don't get a place this time, don't despair: If it's any good we'll go there again :-)
See you,
PS @ Jalil: As promised you are my "+1" :)
Wieder ein sehr schönen Vormittag und ein gutes Frühstück - danke, Monika!
0 · January 26, 2014
perfect Sunday morning. Thanks to Monica
2 · January 26, 2014
Sorry, I would have liked to know you all, but tomorrow I can't. :(
0 · January 25, 2014
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