Rebecca T. Brown

Delayed versus Immediate Cord Clamping in Preterm Infants

Background The preferred timing of umbilical‐cord clamping in preterm infants is unclear. Methods We randomly assigned fetuses from women who were expected to deliver before 30 weeks of gestation to either immediate clamping of the umbilical cord (≤10 seconds after delivery) or delayed clamping (≥60 seconds after delivery). The primary composite outcome was death or major morbidity (defined as severe brain injury on postnatal ultrasonography, severe retinopathy of prematurity, necrotizing enterocolitis, or late‐onset sepsis) by 36 weeks of postmenstrual age. Analyses were performed on an intention‐to‐treat basis, accounting for multiple births. Results Of 1634 fetuses that underwent randomization, 1566 were born alive before 30 weeks of gestation; of these, 782 were assigned to immediate cord clamping and 784 to delayed cord clamping. The median time between delivery and cord clamping was 5 seconds and 60 seconds in the respective groups. Complete data on the primary outcome were available for 1497 infants (95.6%). There was no significant difference in the incidence of the primary outcome between infants assigned to delayed clamping (37.0%) and those assigned to immediate clamping (37.2%) (relative risk, 1.00; 95% confidence interval, 0.88 to 1.13; P=0.96). The mortality was 6.4% in the delayed‐clamping group and 9.0% in the immediate‐clamping group (P=0.03 in unadjusted analyses; P=0.39 after post hoc adjustment for multiple secondary outcomes). There were no significant differences between the two groups in the incidences of chronic lung disease or other major morbidities. Conclusions Among preterm infants, delayed cord clamping did not result in a lower incidence of the combined outcome of death or major morbidity at 36 weeks of gestation than immediate cord clamping. (Funded by the Australian National Health and Medical Research Council [NHMRC] and the NHMRC Clinical Trials Centre; APTS Australian and New Zealand Clinical Trials Registry number, ACTRN12610000633088.)

Factors Associated with Geriatric Syndromes in Older Homeless Adults

Although older homeless adults have high rates of geriatric syndromes, risk factors for these syndromes are not known. We used multivariable regression models to estimate the association of subject characteristics with the total number of geriatric syndromes in 250 homeless adults aged 50 years and older. Geriatric syndromes included falls, cognitive impairment, frailty, major depression, sensory impairment, and urinary incontinence. A higher total number of geriatric syndromes was associated with having less than a high school education, medical comorbidities (diabetes and arthritis), alcohol and drug use problems, and difficulty performing one or more activities of daily living. Clinicians who care for older homeless patients with these characteristics should consider screening them for geriatric syndromes. Moreover, this study identifies potentially modifiable risk factors associated with the total number of geriatric syndromes in older homeless adults. This knowledge may provide targets for clinical interventions to improve the health of older homeless patients.

Pathways to Homelessness among Older Homeless Adults: Results from the HOPE HOME Study

Little is known about pathways to homelessness among older adults. We identified life course experiences associated with earlier versus later onset of homelessness in older homeless adults and examined current health and functional status by age at first homelessness. We interviewed 350 homeless adults, aged 50 and older, recruited via population-based sampling. Participants reported age at first episode of adult homelessness and their life experiences during 3 time periods: childhood (<18 years), young adulthood (ages 18–25), and middle adulthood (ages 26–49). We used a structured modeling approach to identify experiences associated with first adult homelessness before age 50 versus at age 50 or older. Participants reported current health and functional status, including recent mental health and substance use problems. Older homeless adults who first became homeless before 50 had more adverse life experiences (i.e., mental health and substance use problems, imprisonment) and lower attainment of adult milestones (i.e., marriage, full-time employment) compared to individuals with later onset. After multivariable adjustment, adverse experiences were independently associated with experiencing a first episode of homelessness before age 50. Individuals who first became homeless before age 50 had higher prevalence of recent mental health and substance use problems and more difficulty performing instrumental activities of daily living. Life course experiences and current vulnerabilities of older homeless adults with first homelessness before age 50 differed from those with later onset of homelessness. Prevention and service interventions should be adapted to meet different needs.

Health Outcomes of Obtaining Housing Among Older Homeless Adults

OBJECTIVES We determined the impact of obtaining housing on geriatric conditions and acute care utilization among older homeless adults. METHODS We conducted a 12-month prospective cohort study of 250 older homeless adults recruited from shelters in Boston, Massachusetts, between January and June 2010. We determined housing status at follow-up, determined number of emergency department visits and hospitalizations over 12 months, and examined 4 measures of geriatric conditions at baseline and 12 months. Using multivariable regression models, we evaluated the association between obtaining housing and our outcomes of interest. RESULTS At 12-month follow-up, 41% of participants had obtained housing. Compared with participants who remained homeless, those with housing had fewer depressive symptoms. Other measures of health status did not differ by housing status. Participants who obtained housing had a lower rate of acute care use, with an adjusted annualized rate of acute care visits of 2.5 per year among participants who obtained housing and 5.3 per year among participants who remained homeless. CONCLUSIONS Older homeless adults who obtained housing experienced improved depressive symptoms and reduced acute care utilization compared with those who remained homeless.

Use of Acute Care Services Among Older Homeless Adults

the study cohort was highly educated, numerate, and well insured, with a higher than average income level, thus differing from a population-based cohort of patients with DCIS. Second, we administered hypothetical scenarios to individuals personally not diagnosed as having DCIS. While it is possible that patients with DCIS may react differently to the survey, the use of hypothetical scenarios allowed us to explore women’s preferences toward systemic therapy and active surveillance, unbiased by previous knowledge regarding DCIS and standard modes of treatment options. Finally, the projected outcomes in the scenarios were generalized and static, whereas true outcomes vary depending on patient age, tumor grade, and other case-specific factors. We conclude that the terminology used to describe DCIS has a significant and important impact on patients’ perceptions of treatment alternatives. Health care providers who use “cancer” to describe DCIS must be particularly assiduous in ensuring that patients understand the important distinctions between DCIS and invasive cancer.

The Course of Functional Impairment in Older Homeless Adults: Disabled on the Street.

Over the past 25 years, the proportion of the homeless population 50 years of age and older has increased rapidly, from 11% in 19901 to nearly 50% today.2 Older homeless adults experience early onset of age-related conditions relative to the general population, including difficulty performing basic self-care activities that are considered essential for independence, such as bathing and dressing.3 Such difficulty, or “functional impairment,” occurs in 30% of homeless adults in their fifties and early sixties, a prevalence exceeding that of housed adults 20 years older.3 However, it is unknown if functional impairment among older homeless adults is transient or persistent, and thus what types of interventions are needed to address these deficits. If functional impairment persists or worsens in a substantial number of older homeless adults, more units of accessible permanent supportive housing and personal care attendants may be needed. In contrast, if most functional impairment is transient in this population, different types of interventions may be appropriate. We examined the characteristics and persistence of functional impairment in a cohort of homeless adults age 50 and older and identified risk factors for persistent or worsened functional impairment.

Functional disability in late-middle-aged and older adults admitted to a safety-net hospital

To determine the prevalence of preadmission functional disability in late‐middle‐aged and older safety‐net inpatients and to identify characteristics associated with functional disability by age.

Frailty as an Outcome in Geriatrics Research: Not Ready for Prime Time?

Frailty, one of the key syndromes of aging, is defined as a state of decreased physiologic reserve and increased vulnerability to stressors, such as acute illness, injury, or surgery. During the past several decades, frailty has been increasingly recognized as a strong predictor of poor outcomes, including acute care use, disability, and death, in older adults (1). For this reason, developing interventions to prevent or delay frailty and its associated adverse outcomes is an emerging area of geriatrics research. Despite this growing focus, no single, universally accepted definition of frailty exists. Rather, several definitions are commonly used, each of which takes a different approach to capturing the key feature of decreased physiologic reserve (2, 3). Although these definitions differ, each has been shown to have similar predictive power for identifying older adults at highest risk for poor outcomes (1). This tension points to a key issue in frailty research: Although the role of frailty as a predictor is well-established and increasingly used to inform clinical care, its core definitionand by extension, its role as an outcomeis still evolving. Because the defining feature of frailty is decreased physiologic reserve, physical activity is regarded as one of the most promising interventions for preventing or ameliorating frailty (4). By improving endurance and lean muscle mass, exercise is hypothesized to reduce frailty and, more important, prevent the adverse consequences of frailty, such as loss of independence in activities of daily living and loss of mobility (4). An increasing number of studies have tested this hypothesis by examining whether physical activity prevents disability among frail older adults (5, 6). Findings from these studies are mixed, possibly because they used varying definitions of frailty and did not always define frailty by using validated criteria (5, 6). A smaller number of studies have examined whether physical activity reduces the risk for frailty and also have shown inconsistent findings (7, 8). In their current Annals article, Trombetti and colleagues (9) address some of these previous inconsistencies by using data from the LIFE (Lifestyle Interventions and Independence for Elders) trial. This study was a large, multicenter, single-blind, randomized controlled trial comparing the effect of a long-term physical activity program with that of a health education program on the incidence of major mobility disability (MMD) among sedentary older adults (10). The studys main findings showed that the physical activity intervention reduced MMD during an average follow-up of more than 2.5 years (10). In this secondary analysis of the LIFE data, Trombetti and colleagues asked the following 2 questions: Is the LIFE intervention equally effective in reducing MMD in both frail and nonfrail persons, and is it associated with a lower risk for frailty, defined according to a commonly used frailty index? For the first question, the authors found that baseline frailty status did not influence the beneficial effect of physical activity on the incidence of MMD. Rather, the LIFE intervention was equally effective in reducing MMD among both frail and nonfrail people. This is an important point for clinicians to take away, because we sometimes have concerns about the safety or efficacy of prescribing exercise for our frail older patients. However, these findings suggest that we should not use frailty as a reason not to prescribe activity but should prescribe physical activity to all of our older patients, regardless of frailty status. For the second question, the authors found that the effect of the physical activity intervention on preventing or delaying frailty was inconsistent and unconvincing. Although 1 submeasure of the frailty index improved as measured by the full frailty index, the overall risk for frailty did not differ between the physical activity and health education groups. This finding seems surprising given the clear and compelling effect of the LIFE intervention on reducing the risk for MMD. Frailty generally precedes the downstream outcomes of disability and loss of independence in older persons, and frailty, as a measure of physiologic reserve, often is used to identify persons at high risk for adverse outcomes, such as MMD. For most patients, the value of preventing frailty rests on the assumption that preventing this intermediate outcome will prevent or delay disability (1). Of interest, this investigation showing that the LIFE intervention did not prevent frailty was a post hoc analysis conceived after the LIFE study was completed. However, it would have been quite logical for the LIFE team to assess the effect of LIFE on this measure of frailty before committing to the very resource-intensive full study. Yet, this very logical approach of assessing the intermediate outcome of frailty as proof of concept would have been unfortunate, because we would have never learned of the highly beneficial effects of the LIFE intervention in preventing MMD. These findings raise a key, larger question: Is frailty ready for a role as an intermediate outcome in geriatrics research? The use of frailty as an intermediate outcome has considerable appeal, because studies focused on frailty often require less time and expense than those focused on the more downstream outcome of disability. The frailty measure used in this study represents just one of several commonly used criteria. Yet, the results of smaller, previous studies examining the effect of physical activity on other frailty measures also have shown inconsistent results (7, 8). We know that current measures of frailty are highly effective in predicting the risk for poor outcomes. However, the findings from this and previous trials suggest that as defined, these frailty measures may not yet capture the core feature of decreased physiologic reserve in a way that can be used as a meaningful intermediate outcome. Our understanding of the basic mechanisms of frailty is continuing to evolve (1). As this understanding grows, frailty may play an increasingly important role as an intermediate outcome that can elucidate the basic mechanisms by which physical activity improves mobility and functioning among older adults. In the meantime, a continued focus on patient-centered outcomes that directly correspond to improved quality of life for patientssuch as mobility and functionis warranted. We thus argue that for now, frailty remains a powerful predictor of patient-centered outcomes but is not yet ready for a role as a full-fledged outcome measure in geriatrics research.

Wealth-Associated Disparities in Death and Disability in the United States and England

Importance Low income has been associated with poor health outcomes. Owing to retirement, wealth may be a better marker of financial resources among older adults. Objective To determine the association of wealth with mortality and disability among older adults in the United States and England. Design, Setting, and Participants The US Health and Retirement Study (HRS) and English Longitudinal Study of Aging (ELSA) are nationally representative cohorts of community-dwelling older adults. We examined 12 173 participants enrolled in HRS and 7599 enrolled in ELSA in 2002. Analyses were stratified by age (54-64 years vs 66-76 years) because many safety-net programs commence around age 65 years. Participants were followed until 2012 for mortality and disability. Exposures Wealth quintile, based on total net worth in 2002. Main Outcomes and Measures Mortality and disability, defined as difficulty performing an activity of daily living. Results A total of 6233 US respondents and 4325 English respondents aged 54 to 64 years (younger cohort) and 5940 US respondents and 3274 English respondents aged 66 to 76 years (older cohort) were analyzed for the mortality outcome. Slightly over half of respondents were women (HRS: 6570, 54%; ELSA: 3974, 52%). A higher proportion of respondents from HRS were nonwhite compared with ELSA in both the younger (14% vs 3%) and the older (13% vs 3%) age cohorts. We found increased risk of death and disability as wealth decreased. In the United States, participants aged 54 to 64 years in the lowest wealth quintile (Q1) (⩽

Older and incarcerated: policy implications of aging prison populations

39 000) had a 17% mortality risk and 48% disability risk over 10 years, whereas in the highest wealth quintile (Q5) (>