Journal of the American Medical Directors Association

Introduction - Worldwide, nursing home residents have experienced disproportionately high COVID-19 mortality due to the intersection of congregate living, multimorbidity, and advanced age. Among 12 OECD countries, Canada has had the highest proportion of COVID-19 deaths in nursing home residents (78%), raising concerns about a skewed pandemic response that averted much transmission and mortality in community-dwelling residents, but did not adequately protect those in nursing homes. To investigate this, we measured temporal variations in hospitalizations among community and nursing home-dwelling decedents with COVID-19 during the first and second waves of the pandemic. Methods - We conducted a population-based cohort study of residents of Ontario, Canada with COVID-19 who died between March 11, 2020 (first COVID-19 death in Ontario) and October 28, 2020. We examined hospitalization prior to death as a function of 4 factors: community (defined as all non-nursing home residents) vs. nursing home residence, age in years (<70, 70-79, 80-89, [&ge;]90), gender, and month of death (1st wave: March-April [peak], May, June-July 2020 [nadir], 2nd wave: August-October 2020). Results - A total of 3,114 people with confirmed COVID-19 died in Ontario from March to October, 2020 (Table 1), of whom 1,354 (43.5%) were hospitalized prior to death (median: 9 days before death, interquartile range: 4-19). Among nursing home decedents (N=2000), 22.4% were admitted to hospital prior to death, but this varied substantially from a low of 15.5% in March-April (peak of wave 1) to a high of 41.2% in June-July (nadir of wave 1). Among community-dwelling decedents (N=1,114), admission to acute care was higher (81.4%) and remained relatively stable throughout the first and second waves. Similar temporal trends for nursing home versus community decedents were apparent in age-stratified analyses (Figure 1). Women who died were less likely to have been hospitalized compared to men in both community (80% women vs 84% men) and nursing home (21% women vs 24% men) settings. Discussion - Only a minority of Ontario nursing home residents who died of COVID-19 were hospitalized prior to death, and that there were substantial temporal variations, with hospitalizations reaching their lowest point when overall COVID-19 incidence peaked in mid-April, 2020. While many nursing home residents had pre-pandemic advance directives precluding hospitalization, the low admission rate observed in March-April 2020 (15.5%) was inconsistent with both higher admission rates in subsequent months (>30%), and comparatively stable rates among community-dwelling adults. Our findings substantiate reports suggesting that hospitalizations for nursing home residents with COVID-19 were low during the peak of the pandemics first wave in Canada, which may have contributed to the particularly high concentration of COVID-19 mortality in Ontarios nursing homes.

ObjectiveSystematically review and critically appraise evidence for the association between delirium and falls in community-dwelling adults aged 60 years and above MethodsWe searched EMBASE, MEDLINE, PsycINFO, Cochrane Database of Systematic Reviews, CINAHL and Evidence-Based Medicine Reviews (EBMR) databases in April 2023. Standard methods were used to screen, extract data, assess risk of bias (using Newcastle Ottawa scale), provide a narrative synthesis and where appropriate conduct meta-analysis. ResultsWe included eight studies, with at least 3505 unique participants. Five found limited evidence for an association between delirium and subsequent falls: one adjusted study showed an increase in falls (RR 6.66;95% CI 2.16-20.53) but the evidence was low certainty. Four non-adjusted studies found no clear effect. Three studies (one with two subgroups treated separately) found some evidence for an association between falls and subsequent delirium: meta-analysis of three adjusted studies showed an increase in delirium (pooled OR 2.01; 95%CI 1.52-2.66), one subgroup of non-adjusted data found no clear effect. Number of falls and fallers were reported in the studies. Four studies and one subgroup were at high risk of bias and one study had some concerns. ConclusionsWe found limited evidence for the association between delirium and falls. More methodologically rigorous research is needed to understand the complex relationship, establish how and why this operates bi-directionally and identify potential modifying factors involved. We recommend the use of standardised assessment measures for delirium and falls. Clinicians should be aware of the potential relationship between these common presentations. Key pointsO_LIThis is the first systematic review of the association between delirium and falls in the wider community population. C_LIO_LIThere is relatively limited but consistent evidence on the direction of effect for both delirium preceding falls and falls preceding delirium. C_LIO_LIMore high-quality longitudinal work is needed to explore the nature of this potentially complex and bidirectional relationship. C_LIO_LIHistory of falls and delirium should be considered when assessing patients with incidence/suspected incidence of falls or delirium. C_LI

Introduction: End of life decision making poses unique challenges for individuals with dementia and their family caregivers as cognitive decline shifts decision making responsibility to surrogates. Methods: Using 2010 to 2022 Health and Retirement Study (HRS) exit interview data, we compared advance directive completion, decision making needs near death, involvement of others in decision making, and concordance between expressed preferences and care received among decedents with and without dementia. Analyses incorporated HRS exit interview sampling weights, primary sampling units, and strata to account for the complex multistage probability design of HRS and produce nationally representative estimates of U.S. older adult decedents (50 years or older). Weighted descriptive statistics and design adjusted Wald tests were used to compare groups. Results: Among 5,389 decedents, 1,010 (weighted 17.7%) had dementia prior to death. Decedents with dementia were more likely to have completed advance directives than those without dementia (81.3% vs. 69.1%, p<.001). However, they also had significantly higher decision making needs in the final days of life (54.3% vs. 47.2%, p<.001). Children or grandchildren were more frequently involved in care decisions for decedents with dementia (63.9% vs. 45.6%, p<.001). Despite differences in decision making processes, most decedents in both groups expressed preferences for comfort focused care, and preference care concordance exceeded 90% in both groups. Conclusions: Findings suggested that dementia reshaped the structure and intensity of the shared decision making process by increasing surrogate engagement and decisional demands, underscoring the importance of early advance care planning and structured support for family caregivers to sustain goal concordant care.

BackgroundMore than one in four older adults experience a fall each year. While exercise programs are effective in reducing fall-related injuries (FRI), participation remains low due to access barriers. The primary aim of this study was to evaluate whether older adults who registered for Nymbl, a self-guided, asynchronous, balance application, experienced fewer FRIs as compared to age-similar individuals who did not register. MethodsThis retrospective cohort study used data from Kaiser Permanente Colorado, linked to Nymbl registration and usage records based on patient name and demographic information between February 2018 and September 2024. The cohort included individuals aged 60 and older with continuous health plan enrollment for 12 months before and after Nymbl registration (or a randomly assigned index date). Logistic regression models estimated the association between Nymbl registration and FRIs during the 12-month follow-up, stratified by history of FRIs. Marginal effects reported the absolute risk difference associated with Nymbl registration. Secondary analyses examined dose-response effects of Nymbl usage and whether the effect of Nymbl was additive to participation in other exercise programs. ResultsWe identified 3,735 individuals who registered for Nymbl and 114,219 age-eligible non-registrants. Among individuals with a prior FRI, Nymbl registration was associated with a 4.24 percentage point reduction in acute FRIs, however no significant effect was estimated for individuals without a baseline FRI. Secondary analysis indicated that at least five sessions were required to achieve a meaningful reduction in FRIs, and effects were limited to those not already participating in other exercise programs. ConclusionFindings from this study suggest that asynchronous, self-guided balance applications may reduce FRIs among older adults with a history of falls who are not otherwise engaged in structured exercise programs. Remotely delivered fall prevention programs may help overcome access barriers and can be used to supplement in-person and guided exercise programs.

BackgroundA SARS-CoV-2 vaccine booster dose has been recommended for all nursing home residents. However, we lack effectiveness data on boosters preventing infection, death and hospitalization in this frail population. MethodsWe emulated nested target trials in two large nursing home systems in parallel to evaluate the effectiveness of a SARS-CoV-2 mRNA vaccine booster at preventing infection, hospitalization, or death. Residents who completed a 2-dose series of the mRNA vaccine and were eligible for a booster were included in from September 22, 2021 to November 5, 2021. Outcomes were measured through December 18, 2021, including test-confirmed SARS-CoV-2 infection, hospitalization, or death. The vaccine effectiveness at day 42 was estimated with a Kaplan-Meier estimator, both unadjusted and weighted with the inverse probability of treatment. ResultsThe two NH systems were large and multi-state, System 1 included 200 NH (8,538 control and 5,721 boosted residents) and System 2 included 127 NHs (4,100 control and 2,291 boosted residents). Booster vaccination reduced infections by 50.4% (95% Confidence Interval [CI]: 29.4%, 64.7%) SARS-CoV-2 infections in System 1 and 58.2% (32.3%, 77.8%) in System 2. Boosted residents in System 1 also had a 97.3% (86.9%, 100.0%) reduction in SARS-CoV-2 associated death, but too few events for comparison in System 2. ConclusionsDuring a Delta predominant period, SARS-CoV-2 booster vaccination significantly reduced infection in two U.S. nursing home systems. In the larger System 1 a 97% reduction in SARS-CoV-2 related death was also observed. These findings strongly support administration of vaccine boosters to nursing home residents.

Advance care planning is essential for aligning future care with the values and preferences of people living with dementia and their families. Challenges from people with dementias fluctuating mental capacity, gradual decline and healthcare professionals limited advance care planning knowledge and skills remain to enable people with dementia to fully engage with the process; tailored interventions are needed. This rapid review synthesised evidence on advance care planning interventions, communication strategies and health-related outcomes in dementia care. Following Cochranes guidance for rapid reviews, we searched CINAHL, Cochrane Central, PubMed, and Web of Science through May 2025. After duplicate removal, title-abstract and full-text screening were conducted in Covidence with dual independent reviewers. Data extraction and quality assessment, using Joanna Briggs Institute tools, employed a single-reviewer approach with verification by second reviewer. Twenty-five studies from 2015-2025 across 12 countries met inclusion criteria. Included articles were of quantitative designs (n=15), qualitative (n=5) and mixed methods (n=4). Interventions fell into three categories: video as decision aids; web-based tools; and multicomponent programmes combining education, structured discussions, and documentation support for people with dementia, families and healthcare professionals. Primary outcomes consistently showed increased advance care planning uptake. Certain secondary outcomes--carer burden, cost of care, carers sense of competence, hospitalisation rates, quality-adjusted life year, quality of life of people with dementia, rate of burdensome treatments--demonstrated mixed results. Communication strategies identified included embedding relevant theories such as relational autonomy and shared decision-making frameworks for advance care planning process. Study quality ranged from poor (n=8) to high (n=6). Common limitations include small sample sizes, unclear randomisation and allocation processes and limited reflexivity in qualitative research. These findings suggest that contextually tailored advance care planning interventions improve uptake but require standardised outcomes and broader cultural adaptation to comprehensively assess impacts on health outcomes.

BackgroundSocial homecare workers (personal aides/assistants) are crucial for people wishing to receive end-of-life care at home. AimTo determine current UK social care policy priorities and gaps regarding end-of-life care provision by homecare workers, including support and training for this workforce. DesignPolicy document review and content analysis; eligible documents were current UK policy documents informing homecare worker practice/service delivery, identified by team expertise, networks, study partners and bibliography review of included documents. We quantified (existence, frequency) predetermined codes of interest in relation to end-of-life/palliative/care of the dying/bereavement, homecare workforce, and support and training. Where homecare worker codes were contextually situated, we extracted and tabulated the surrounding text and examined for reference to training and support. We subjected extracted text content to framework analysis through the lens of Bronfenbrenners Adapted Ecological Systems Theory. Results1,464 homecare worker codes were identified in the 36 included documents, but only 72 times/17 documents in the context of end-of-life care. In the context of end-of-life care and homecare workers, education and training codes were present 3 and 35 times respectively. The need for end-of-life education and training was recognised, but in general, little detail about delivery and implementation was given (e.g., whose responsibility; funding; minimum standard and content). ConclusionsThe homecare worker role in end-of-life care is poorly recognised in national policy. Little guidance is provided regarding minimum training standards or delivery. Given an ageing population globally and expected increased demand for end-of-life homecare, national and international policy guidance should include this workforce. KEY MESSAGE BOXO_ST_ABSWhat was already known?C_ST_ABSO_LISocial homecare workers (variously known as personal assistants/aides or helps) play a significant role in providing end-of-life care for individuals in their own homes. C_LIO_LIThe demand for homecare is increasing due to an ageing population globally and access to good quality provision of end-of-life care is a priority to support community-based care. C_LI What are the new findings?O_LIThere is a policy gap regarding homecare workers in the context of end-of-life care, with little progress since 2010. C_LIO_LIFew policy documents recognise the role of homecare workers in providing end-of- C_LIO_LIlife homecare and there is little evidence that previous highly relevant policy recommendations (2010) have been incorporated in more recent current policy or enacted in practice. C_LIO_LIThe need for homecare workers education and training in the context of end-of-life care is recognised, but few details about minimum content and standards, or delivery are given. C_LI What is their significance?O_LIAlthough this is a UK-based study, given the ageing population internationally with likely increased need for care at the end-of-life, training, role definitions, and support to enable the homecare worker workforce to provide end-of-life care has relevance as a clinical and social care practice priority around the world. C_LIO_LIPolicy guidance around end-of-life care should i) include the social homecare workforce; stipulate minimum training requirements in relation to end-of-life care, and ii) integrate this support and training into routine job descriptions, and as part of the working day. C_LIO_LIImproved training and support is an important step to increase the quality of end-of-life care provision. C_LI

BackgroundFalls are a major cause of morbidity in older adults. Low-cost wearable devices track potential falls risk factors, but adoption in older adults remains uncertain. MethodsWe conducted a 6-month prospective observational study in community-dwelling adults who self-reported a recent fall or were deemed at increased risk. Participants were given a wrist-worn wearable device (Fitbit, Garmin or Polar), synced with a smartphone application (Smplicare app) to collect additional information by questionnaires, including self-reported falls. We analysed adherence wearing the devices, and studied step count and sleep data in relation to falls. ResultsOf 284 people (74.2{+/-}9.0 years, 68% women) in the study, 266 (94%) provided at least 7 days of data, with 196 (76%) engaged on at least half of study days. Engagement did not differ by self-reported technology confidence. There were 81 (30%) people who reported a fall during follow-up, but only 5 (6%) resulted in hospital attendance. Each additional hour of average sleep was associated with a 24% reduction in falls risk (HR 0.76, 95% CI 0.63 to 0.92), but in multivariable models only carer support (aHR 3.47, 95% CI 1.46 to 8.26) and incontinence (aHR 2.26, 95% CI 1.34 to 3.82) remained independently associated with falls. No changes in step or sleep patterns were noted after falls, but there was high individual heterogeneity. ConclusionWearable adoption, risk factor identification and digital self-reporting of falls is feasible in older adults using low-cost commercial technology. The importance of simple wearable measures like sleep for fall risk were outweighed by markers of frailty. Future research should understand how these granular wearable data could add to proactive falls risk assessment.

BackgroundFear of falling (FoF) is common amongst community-dwelling older adults and is associated with higher falls risk. FoF is common amongst those with gait and balance abnormalities (GABAb), yet the ability of FoF measures to predict GABAb has not been assessed. MethodsData were reviewed from attendees of the North Tyneside Community Falls Prevention Service. The Falls Efficacy Scale International (FES-I) was used to measure falls efficacy, with a score larger than 23.5 indicating a concern for falling. Gait and balance measures were assessed, with cut-offs used to indicate poor and non-poor results for timed up and go (TUG) (>14s), five times sit to stand (FTSS) (>15s) and gait speed (GS) (<1 m/s). Receiver operating characteristic curves were generated for sensitivity and specificity analysis. ResultsFES-I score had good to excellent sensitivity when predicting TUG (87.1%), FTSS (82.9%) and GS results (73.0%) indicative of significant GABAb. Moderate specificity was also observed when predicting GS (62%) and FTSS (62.3%); a low to moderate specificity was observed when predicting TUG (50.0%). ConclusionA FES-I score of 23.5 or more showed high specificity in identifying those with prolonged TUG and FTSS and slower GS, with moderate specificity.

BackgroundLimitations in activities of daily living have widespread implications for the well-being of older adults. However, the relation between performance-based physical function and self-reported functional impairment is inconsistent. MethodsThe cohort included 6,282 White women and 310 Black women aged 65 and older participating in the Study of Osteoporotic Fractures (SOF) from 1986 to 2010 who reported no limitations in any Instrumental Activities of Daily Living (IADL) at baseline. Approximately every two to six years, participants self-reported their physical limitations and trained interviewers assessed common measures of physical performance (i.e., usual gait speed, grip strength, and chair stand time). We used Cox proportional hazards models using age as the time scale to calculate hazard ratios between individual and summary measures of physical performance and incident IADL limitations. ResultsOver follow-up, 4,193 White women and 118 Black women developed IADL impairment (IR = 451.34 and 361.52 per 10,000 person-years, respectfully). Usual gait speed was associated with IADL limitations in both race cohorts (slowest gait vs. fastest gait HR: 3.83, 95% CI: 3.41 - 4.31; HR: 2.59, 95% CI: 1.42 - 4.73). For every one-point increase in summary performance score, rate of IADL limitations was lower for both White women and Black women (HR: 0.79, 95% CI: 0.78-0.80; HR: 0.87, 95% CI: 0.81 - 0.94). ConclusionIn this longitudinal study, women with poorer performance in individual and summary measures of physical function had an increased rate of incident IADL limitations over follow-up compared to women with the best performance. These findings confirm previous research using cross-sectional data.

ObjectiveTo determine the frequency of falls and their serious complications in palliative care units (PCUs), as well as explore the complex interplay between falls, independence, and quality of dying. MethodsA secondary analysis of a large prospective cohort study of 23 PCUs in Japan was conducted from January 2017 to June 2018. Palliative care specialist physicians recorded whether patients experienced falls, serious complications from falls, activities that led to falls, independence (workability in the last days and use of indwelling urinary catheter), and Good Death Scale. ResultsOf the 1,633 patients evaluated, 9.2% (95% Confidence interval [95% CI 7.8 to 11]) experienced falls within 30 days prior to death. The patients who fell were mostly men, had eastern cooperative oncology group performance status 3 on admission, a longer estimated prognosis on admission, and delirium during hospitalization. Serious falls causing fractures or intracranial hemorrhages were rare (0.3% [95% CI 0.038 to 0.57]). The most common reason for falls was the need to use the toilet. The Good Death Scale and indwelling urinary catheter use were not significantly associated with falls. ConclusionFalls occur in approximately 10% of patients in PCUs, but serious complications are rare. The relationship between falls, independence, and quality of dying is complex; that is, a fall may not be necessarily bad, if it is the result of respect for the patients independence. Healthcare providers need to consider fall prevention while supporting patients desire to move on their own to maintain independence. WHAT IS ALREADY KNOWN ON THIS TOPICO_LIFalls are a major healthcare concern because of their potential to cause physical harm, emotional distress, and increased healthcare costs. C_LIO_LIAlthough many studies have investigated falls in acute care settings and the elderly population, there is a lack of literature specifically focusing on falls in the unique context of palliative care units. C_LI WHAT THIS STUDY ADDSO_LIFalls occur in only approximately 10% of patients, and only five cases (0.3%) of serious events were due to falls in palliative care units (PCUs). C_LIO_LIIndependence and quality of dying are not significantly compromised by falls. C_LI HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICYO_LIAlthough fall prevention is considered a priority, healthcare providers should support patients desires to move on their own to maintain independence. C_LIO_LIIt may be possible to maintain independence and quality of dying even for patients who have fallen. C_LI

BackgroundThe COVID-19 pandemic has greatly affected nursing home residents (NHRs), a vulnerable group with high rates of illness and death. While vaccination is essential for reducing infections and severe outcomes in the short term, it is important to understand how long antibody levels and neutralizing activity last. This understanding will help us create effective public health strategies for the long term. According to current CDC guidelines, individuals over the age of 65 should receive a booster dose six months after their previous vaccination. MethodsThis observational retrospective cohort study analyzed post-vaccination serum from samples with up to 400 days of follow-up from 697 NHRs and 127 healthcare workers (HCWs) across Northeast Ohio and Rhode Island. Analyses were conducted to model decay rates of both neutralizing and binding antibody titers and the impact of previous exposures to SARS-CoV-2 on these decay rates. ResultsResults indicate that NHRs show Wuhan and Omicron BA.4/5 neutralizing and binding antibody titers diminish significantly from 2 weeks to 12 months post-vaccination. NHRs with prior infection show higher peak antibody titers and slower decay than those naive to infection. Antibody levels after vaccination for infection-naive NHR residents lagged HCW and NHR with prior infection, but then decayed at a similar rate. ConclusionThe immunologic findings in this cohort of NHR are in line with the existing real-world clinical effectiveness data in older individuals and support the CDC recommendation of a bi-annual vaccination to reduce severe COVID-19 outcomes in persons age 65 and older.

The relationship between poor mental health and cognitive impairments in older age is well- established. Social engagement also influences cognitive ability; however much of the research on this relationship has not accounted for the impact of mental health and demographic factors. This study examined the associations between cognitive ability and mental health in older adults, controlling for social interaction and socio-demographic factors. In total, 7,685 individuals aged 65 or older were drawn from the UK Household Longitudinal Study Understanding Society (1). Cognitive abilities were assessed using self-reports and performance on five tasks (immediate and delayed word recall, subtraction, number series and numerical ability). Mental health scores were derived from the General Health Questionnaire (GHQ-12). We controlled for social interaction, gender, ethnicity, educational background, marital status, number of children, and geographic location. We found positive relationships between mental health and all measures of cognitive ability except performance on subtraction and number series tasks. These relationships remained after controlling for social interaction. Demographic factors that contributed to the relationship between mental health and cognitive ability included being White, having higher education, being male for numerical tasks only, and being female, married or divorced for verbal memory tasks only. Overall, our results suggest that the relationship between mental health and cognitive abilities persists when controlling for social interaction alongside socio- demographic factors in older adults, underscoring the importance of addressing these factors in policies and interventions for healthy ageing.

Background and ObjectivesParkinsons disease is the second most common neurodegenerative disorder globally. Despite its prevalence, the provision of Palliative Care for people living with Parkinsons disease (PLwPD) is often delayed or entirely absent. To date, no study has explored what constitutes a "good death", a central goal of palliative care, from the perspective of PLwPD themselves. We aimed to give voice to PLwPD on this topic through a qualitative approach. MethodsIn this cross-sectional multicenter qualitative study, we conducted semi-structured interviews with 30 PLwPD selected through purposive sampling from four geriatric and neurology outpatient clinics between May 2021 and December 2022. An interdisciplinary team analyzed the transcripts using inductive thematic analysis. The process involved independent coding by three researchers, followed by iterative collaborative team discussions to refine and standardize the analysis, all grounded in a constructionist paradigm. To ensure methodological rigor, we employed techniques of triangulation, thick descriptions, and reflexivity. ResultsThe sample was diverse in terms of race/ethnicity, gender, age (36-84 years), religious affiliation, educational background, and disease stage. We identified two major themes: Fears and Coping. Reported fears included experiencing disability, pain and discomfort, fear of feeling shame, fear of being a burden, fear of being abandoned and left helpless. Coping was a multidimensional theme, comprising the relational experience of feeling well cared for (defined by being valued, receiving clear and honest communication, and being treated with love and kindness) alongside the active strategies of finding opportunities for joy and drawing on religiosity and spirituality. Religiosity/spirituality appeared as a key factor in emotional regulation, fostering a sense of purpose and acceptance in the face of death. DiscussionOur findings suggest that improving palliative care for PLwPD requires an approach that actively addresses specific fears and strengthens the multiple dimensions of coping, which includes fostering opportunities for joy, supporting spirituality, and enhancing the relational experience of feeling well cared for. This study illuminates often-overlooked aspects of care and provides a basis for the development of person-centered interventions aimed at preventing and alleviating suffering in this population.

BackgroundCOVID-19 pandemic has had a major impact on society, including on residents of nursing homes (NH), who have a higher risk of complications and mortality due their physical and intellectual disabilities. AimTo identify which risk factors associated with developing COVID-19 infection with symptoms in institutionalized older people. MethodsA 1-year longitudinal multicenter study was conducted in 5 NH during the period December 2019 to March 2021. The inclusion criteria used were residents aged 65 years or over, living in the NH permanently, with a diagnostic test for COVID-19 confirmed by reverse transcription polymerase chain reaction and/or serological test. The main variable was symptomatic COVID-19, with at least one of the following symptoms (fever, respiratory difficulties, cough, diarrhea, sudden urinary incontinence and disorientation or delirium). Three assessments were performed: baseline, six and twelve months follow-up. Descriptive and bivariate analysis (calculating relative risk-RR) were performed, considering a 95% confidence level and a statistically significant p <0.05. ResultsOf the total sample of 78 individuals who tested positive for COVID-19, mean age 84.6 years (SD={+/-}7.8), 62 (79.5%) were female; 40 (51.3%) participants presented with COVID-19 symptoms. Living in a private NH (RR=3.6, 95% CI [1.2-11.0], p=0.023) and having suffered a stroke (RR=4.1, 95% CI [1.1-14.7], p=0.033) were positively associated with developing COVID-19 infection with symptoms. ConclusionsHaving suffered a stroke and living permanently in a private health care facility were positively associated with symptomatic COVID-19 in this sample of institutionalized older people.

Background: Sleep problems are common in older people and have been associated with increased fall risk, but the mechanisms underlying this relationship remain unclear. Gait quality reflects balance control and neurological function and may provide insight into pathways linking sleep health and falls. Methods: Data from 758 community-dwelling older people ([&ge;]65 years; mean age 75.8 years, 69.3% women) were analysed. Sleep problems were assessed at baseline using a self-reported item (Patient Health Questionnaire-9, question 3). Daily-life gait quality and habitual walking speed were derived from one week of wearable sensor monitoring. Falls and injurious falls were prospectively recorded over 12 months. Associations between sleep problems, gait quality, and fall incidence were examined using regression models adjusted for demographic, pain and cognitive factors, and use of sleeping medication. Results: Sleep problems were reported by 43.9% of participants. Sleep problems were not associated with habitual walking speed, but were associated with lower gait quality in daily life (adjusted {beta} = -0.15, 95% CI -0.27 to -0.03). Participants reporting sleep problems had higher incidence rates of total falls (adjusted IRR = 1.42, 95% CI 1.07 to 1.90) and injurious falls (adjusted IRR = 1.50, 95% CI 1.07 to 2.10). Conclusions: Self-reported sleep problems were associated with impaired real-world gait quality and substantially higher rates of falls and injurious falls in older people. These findings suggest that sleep problems may increase fall risk by altering balance control rather than by reducing walking speed. Sleep should be considered when managing fall risk, and fall risk should be considered in older people with sleep complaints.

ObjectiveThe Getting Older Adults Outdoors randomized trial showed a 10-week outdoor walk group (OWG) program was not superior to 10 weekly phone reminders on increasing physical and mental health; however, OWG attendance varied. This study examined whether a dose-response relationship existed between OWG attendance and improvement in physical and mental health among older adults with mobility limitations. MethodsWe analyzed data from 98 older adults randomized to a 10-week park-based OWG program. Participants were classified as attending 0-9, 10-15, and 16-20 OWG sessions based on attendance tertiles. Outcomes included change in scores on measures of walking endurance, comfortable and fast walking speed, balance, lower extremity strength, walking self-efficacy, and emotional well-being pre- to post-intervention. ResultsSeventy-nine older adults with complete information on the seven health outcomes were included (age=74.7{+/-}6.6 years, 72% female). Compared to those who attended 0-9 OWG sessions, participants attending 16-20 sessions exhibited a 52.7-meter greater improvement in walking endurance (95% CI:12.3, 93.1); 0.15-meter/second greater improvement in comfortable walking speed (95% CI:0.00, 0.29); and 0.17-meter/second greater improvement in fast walking speed (95% CI:0.02, 0.33). Higher attendance was also associated with higher odds of experiencing an improvement in walking self-efficacy (OR=4.03; 95% CI:1.05, 16.85) and fast walking speed (OR=9.00, 95% CI:1.59, 61.73). No significant dose-response relationships for balance, lower extremity strength, and emotional well-being were observed. ConclusionsHigher attendance in outdoor walking interventions is associated with greater improvements in walking endurance, walking speed, and walking self-efficacy among older adults with mobility limitations.

Frail, older people receiving supportive care in the home are at high risk of falls and functional decline that leads to either unplanned hospital admissions or permanent residential care, making it difficult to safely remain at home. Community home care organisations are well positioned to deliver high quality falls prevention programs if staff are suitably trained. This research aims to train community home care workers to deliver a fall prevention program to home care clients and evaluate program implementation and effectiveness. A 2-phase hybrid effectiveness-implementation, pre- post design using a realist approach will be undertaken with a home care organisation. Home care workers, comprising community therapy assistants and community support workers, employed by the organisation will be trained to deliver the program by the organisations allied health professional staff using a train the trainer model. A multi-media falls prevention program (education and exercises) will be tailored to the clients falls risk profile to raise falls awareness and promote physical activity and self-management. Clients receiving home care from the organisation will be recruited. Implementation of the program will be guided by the Consolidated Framework for Implementation Research, barriers and enablers will be identified at the client, staff, and organisation levels. Program effectiveness will be determined through client engagement, program satisfaction, knowledge acquisition, attitudes and enactment of falls prevention strategies, changes in functional mobility, falls and falls injuries and a cost-consequence analysis. If successful, home care clients may enhance their functional mobility and reduce their risk of falling, allowing them to stay safely at home. Home care organisations could positively contribute to the sustainable development of a well-trained workforce delivering evidence-based programs.

Importance and ObjectiveCOVID-19 has a high mortality rate amongst nursing home populations (26.4% nationally and 28.3% in New Jersey). Identification of factors influencing mortality in COVID-19 positive nursing home populations may help direct physicians towards appropriate glycemic, blood pressure, weight, kidney function, lipid, thyroid, and hematologic management to reduce COVID-19 mortality. Design, Setting, and ParticipantsRetrospective cross-sectional study of patients in two nursing home facilities (one urban, one suburban) from 3/16/2020 to 7/13/2020 with positive COVID-19 PCR assays. Age, race, sex, lipids, hematologic parameters, body mass index, blood pressure, thyroid function, albumin, blood urea nitrogen, creatinine, and hemoglobin A1c were correlated with COVID-19 mortality by chi-squared analysis. Main Outcome and Results56 patients met the inclusion criteria for the study. Mortality was 14.3% while the New Jersey nursing home average mortality rate was 28.3% as of August 2020. Our patient cohort had a 49.5% reduction in mortality compared to the state average. In our overall cohort, none of the clinical parameters correlated with COVID-19 mortality using chi-squared analysis. In the 56 patient cohort, average clinical and laboratory findings were 74.0 years, 62.5% female, 28.5% uncontrolled hypertension, BMI 25.6, hemoglobin A1c 6.4, TSH 2.4, vitamin B12 568.3, folate 12.4, iron 47.8, total iron binding capacity 271.8, hemoglobin 11.6, albumin 3.5, triglycerides 100.3, total cholesterol 133.5, HDL 40.9, and BUN to Creatinine ratio 22.2:1. Logistic multivariate regression analyses failed to demonstrate clinically significant correlation with COVID-19 mortality. In the urban nursing home, BUN to creatinine ratio exceeding 20:1 was the only factor that showed statistical significance to COVID-19 mortality (p = 0.03). In the suburban nursing home, age over 80 was the only clinical factor demonstrating statistical significance to COVID-19 mortality (p = 0.003). Conclusions and RelevanceIn our COVID-19 positive nursing home patients, no one parameter was clinically significant in the overall 56-patient cohort; however, mortality in our population was 14.3% compared to New Jerseys 28.3%, a 49.5% reduction in mortality. Rigorous control of the aforementioned clinical parameters may have contributed to this reduction in mortality. Further research requires analysis of more nursing home patients to determine whether rigorous control of clinical parameters decreases mortality from COVID-19. Key PointsO_ST_ABSQuestionC_ST_ABSWhat clinical parameters lead to a lower mortality rate in nursing home patients with COVID-19? FindingsIn this cross-sectional analysis of 56 SARS-CoV-2 positive New Jersey nursing home residents from March to July 2020, controlling hemoglobin A1c, blood pressure, hematologic and lipid panels to recommended levels yielded a mortality rate of 14.3%, a 49.5% reduction from the 28.3% mortality rate of COVID-19 in New Jersey nursing homes. MeaningMaintaining rigorous control of clinical parameters in nursing home populations may account for a decreased mortality rate of COVID-19.

BackgroundOlder adults walking has so far been evaluated using standardised assessments of walking capacity within a clinical setting. By taking the evaluation out of the laboratory into the real world, this study provides first evidence of the ability of Digital Mobility Outcomes (DMOs) to detect changes over time and the Minimal Important Difference (MID) in patients after proximal femoral fracture (PFF). This will guide the implementation of DMOs in research and clinical care. MethodsFor this multicenter prospective cohort study, 381 community-dwelling older adults were included within one year after sustaining a PFF and assessed at two time points, separated by six months. Walking activity and gait DMOs were measured using a single wearable device worn on the lower back for up to seven days. A global impression of change question and three mobility-related outcome measures (Late-Life Function and Disability Instrument; Short Physical Performance Battery; 4m gait speed) were used as anchor variables. To assess each DMOs ability to detect changes, we calculated the standardized mean change as effect size. For estimating MIDs, both distribution-based and anchor-based methods were applied, followed by triangulation by experts if at least three anchor-based estimates were available per DMO, resulting in single-point estimates. ResultsAll three anchor variables demonstrated substantial changes. Overall, 10 out of 24 available DMOs showed large and 7 DMOs moderate positive effects in the expected direction of the respective anchors. Seven DMOs showed no or only small effects. For 12 DMOs, at least three anchor-based estimates were available, enabling MID triangulation. MIDs for walking activity DMOs per day were: a walking duration of 10 minutes, a step count of 1,000 steps, 50 walking bouts (WB), and 15 WBs in WBs over 10 seconds. For gait DMOs, depending on the walking bout length, MIDs for walking speed were between 0.04 m/s and 0.08 m/s, and MIDs for cadence between 4 and 6 steps/minute. Almost all DMOs showed a strong ability to detect improvement in mobility, but rarely in detecting decline. ConclusionsFor the first time, MIDs are presented for real-world DMOs in PFF patients. These MIDs inform sample size requirements and interpretation of intervention effects for clinical trials, thereby providing guidance and reassurance for clinicians and regulatory bodies.