The Influence of Latent Viral Infection on Rate of Cognitive Decline over 4 Years
Allison E. Aiello, PhD, Mary N. Haan, MPH, DrPH, Lynn Blythe, BS, Kari Moore, MS, Jeffrey M. Gonzalez, MS, and William Jagust, MD

OBJECTIVES: To examine whether cytomegalovirus (CMV) and herpes simplex virus type-1 (HSV-1) are associated with cognitive decline over a 4-year period and to assess whether C-reactive protein (CRP) modifies these relationships.
DESIGN: Prospective cohort study over a 4-year period.
SETTING: Community-dwelling elderly population.
PARTICIPANTS: The sample was a subset (1,204/1,789) of participants in the Sacramento Area Latino Study on Aging (SALSA) aged 60 to 100.
MEASUREMENTS: Participants were screened annually over a 4-year period for cognitive function and episodic memory. Cognitive function was assessed using the modified Mini-Mental State Examination, and episodic memory was assessed using a word list-learning test of delayed recall. Baseline serum samples were assayed for levels of immunoglobulin G antibodies to CMV and HSV-1 and for levels of CRP.
RESULTS: There was a significantly higher rate of cognitive decline over the 4-year period in subjects with the highest CMV antibody levels at baseline than in individuals with the lowest levels (β=−0.053, standard error =0.018; P=.003), after controlling for age, sex, education, income, and chronic health conditions. There was no association between HSV-1 antibody levels and cognitive decline. CRP did not modify the relationship between viral antibody levels and cognitive decline.
CONCLUSION: This is the first study to show that individuals with higher levels of antibody to CMV experience a more-rapid rate of cognitive decline than those with lower levels. Understanding the mechanisms by which CMV influences cognition may aid development of intervention strategies targeting infection, viral reactivation, and immune response over the life course. J Am Geriatr Soc 2006;54(7):1046-1054.

Assessment of Pneumonia in Older Adults: Effect of Functional Status
Lona Mody, MD, MSc, Rongjun Sun, PhD, and Suzanne F. Bradley, MD

OBJECTIVES: Evaluate the effect of preadmission functional status on severity of pneumonia, length of hospital stay (LOS), and all-cause 30-day and 1-year mortality of adults aged 60 and older and to understand the effect of pneumonia on short-term functional impairment.
DESIGN: Prospective cohort study.
SETTING: University hospital.
PARTICIPANTS: One hundred twelve patients with radiograph-proven pneumonia (mean age 74.6) were enrolled.
MEASUREMENTS: Functional status and comorbidities were assessed using the Functional Autonomy Measurement System (SMAF) and Charlson Comorbidity Index. Clinical information was used to calculate the Pneumonia Prognostic Index (PPI).
RESULTS: Eighty-four (75%) patients were functionally independent (FI) before admission, with a SMAF score of 40 or lower. Dementia and aspiration history were higher in the group that was functionally dependent (FD) before admission (P<.001). The FI group had less-severe pneumonia per the PPI and shorter mean LOS±standard deviation (5.62±0.51 days) than the FD group (11.42±2.58, P<.004). The FI group had lower 1-year mortality (19/65, 23%) than the FD group (14/28, 50%), and the difference remained significant after adjusting for Charlson Index and severity of illness (P=.009). All patients lost function after admission, with loss being more pronounced in the FI group (mean change 19.24±12.9 vs 4.72±6.55, P<.001).
CONCLUSION: Older adults who were FI before admission were more likely to present with less-severe pneumonia and have a shorter LOS. In addition, further loss of function was common in these patients. Assessment of function before and during hospitalization should be an integral part of clinical evaluation in all older adults with pneumonia. J Am Geriatr Soc 2006;54(7):1062-1067.

Burden of Clostridium Difficile-Associated Diarrhea in a Long-Term Care Facility
Alison M. Laffan, MHS, Michelle F. Bellantoni, MD, William B. Greenough III MD, and Jonathan M. Zenilman, MD

OBJECTIVES: To describe the incidence and prevalence of Clostridium difficile–associated diarrhea (CDAD) in a long-term care facility (LTCF).
DESIGN: Retrospective review of CDAD cases between July 2001 and December 2003.
SETTING: Two hundred two–bed LTCF affiliated with an academic medical center in Baltimore, Maryland.
PARTICIPANTS: All residents of the facility during July 2001 to December 2003.
MEASUREMENTS: Clinical and laboratory-confirmed cases of CDAD.
RESULTS: Incidence of CDAD ranged from 0 to 2.62 cases per 1,000 resident days. The highest rates were observed in residents of subacute units, whereas incidence was much lower on traditional nursing home units. Prevalence of CDAD at admission was greater on units (subacute and rehabilitative) where the majority of patients were admitted from hospital settings than on those where the majority of patients were admitted from the community (nursing home units). Recurrent disease occurred in 21.7% of patients with CDAD.
CONCLUSION: CDAD remains a problem in the long-term care setting, and importation from the acute care setting accounts for a large proportion of the C. difficile seen LTCFs. As the population continues to age, issues of disease and infection in long-term care are expected to increase. New prevention and control strategies are needed to control the spread of CDAD in LTCFs. J Am Geriatr Soc 2006;54(7):1068-1073.

Elderly Patients with Hip Fracture with Positive Affect Have Better Functional Recovery over 2 Years
Lisa Fredman, PhD, William G. Hawkes, PhD, Sandra Black, PhD, Rosanna M. Bertrand, PhD, and Jay Magaziner, PhD, MSHyg

OBJECTIVES: To evaluate whether patients with hip fracture with high positive affect had better functioning than those with low positive affect or depressive symptoms in three performance-based measures over 2 years after the fracture.
DESIGN: Longitudinal study with assessments at baseline and 2, 6, 12, 18, and 24 months posthospitalization.
SETTING: Community.
PARTICIPANTS: Four hundred thirty-two patients, aged 65 and older, hospitalized for hip fracture in Baltimore, Maryland, between 1990 and 1991.
MEASUREMENTS: High and low positive affect and depressive symptoms were based on baseline Center for Epidemiologic Studies Depression Scale score, usual and rapid walking speed, one chair stand, demographic factors, comorbidities, and history of cognitive impairment.
RESULTS: At each follow-up point, respondents with high positive affect at baseline (36% of sample) had faster walking and chair stand speeds than those with low positive affect (13%) and depressive symptoms (51%). For example, at 6 months, the mean usual walking pace was 0.4 m/s (standard error (SE)=0.02) for respondents with high positive affect, versus 0.4 m/s (SE=0.03) and 0.35 m/s (SE=0.02) for patients with low positive affect and depressive symptoms, respectively; adjusted differences were 0.02 (95% confidence interval (CI)=−0.06–0.09) and 0.06 (95% CI=0.01–0.11). Respondents with high positive affect appeared to achieve their maximum improvement in usual pace approximately 6 months before other respondents, but this interaction was not statistically significant. Respondents with consistently high positive affect had the best functioning over the follow-up period.
CONCLUSION: High positive affect seems to have a beneficial influence on performance-based functioning after hip fracture. J Am Geriatr Soc 2006;54(7):1074-1081.

MODELS AND SYSTEMS OF GERIATRIC CARE
Geriatric Resources for Assessment and Care of Elders (GRACE): A New Model of Primary Care for Low-Income Seniors
Steven R. Counsell, MD, Christopher M. Callahan, MD, Amna B. Buttar, MD, MS, Daniel O. Clark, PhD, and Kathryn I. Frank, RN, DNS

The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care for low-income seniors and their primary care physicians (PCPs) was developed to improve the quality of geriatric care so as to optimize health and functional status, decrease excess healthcare use, and prevent long-term nursing home placement. The catalyst for the GRACE intervention is the GRACE support team, consisting of a nurse practitioner and a social worker. Upon enrollment, the GRACE support team meets with the patient in the home to conduct an initial comprehensive geriatric assessment. The support team then meets with the larger GRACE interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison) to develop an individualized care plan including activation of GRACE protocols for evaluating and managing common geriatric conditions. The GRACE support team then meets with the patient's PCP to discuss and modify the plan. Collaborating with the PCP, and consistent with the patient's goals, the support team then implements the plan. With the support of an electronic medical record and longitudinal tracking system, the GRACE support team provides ongoing care management and coordination of care across multiple geriatric syndromes, providers, and sites of care. The effectiveness of the GRACE intervention is being evaluated in a randomized, controlled trial. J Am Geriatr Soc 2006;54(7):1136–1141.

Effect of Cataract Surgery on Falls and Mobility in Independently Living Older Adults
Gerald McGwin, Jr, MS, PhD, Hilary D. Gewant, MA, Kayvon Modjarrad, Tyler Andrew Hall, MD, and Cynthia Owsley, MSPH, PhD

OBJECTIVES: To determine the effect of cataract surgery on the occurrence of falls and mobility and balance problems in older adults with cataract.
DESIGN: Longitudinal follow-up study.
SETTING: Clinical Research Unit, University of Alabama at Birmingham.
PARTICIPANTS: Persons aged 55 and older with a cataract were recruited from 12 eye clinics in Alabama from October 1994 through March 1996. Participants were classified into two groups: those who had cataract surgery (surgery group, n=122) and those who had not (no-surgery group, n=92).
MEASUREMENTS: At baseline and 1-year follow-up visits, information on the occurrence of falls and mobility and balance problems was collected based on subjects' recall of events during the prior 12 months.
RESULTS: After adjusting for demographic, behavioral, medical, and visual characteristics, there was no difference between the two groups in the likelihood of falling (risk ratio (RR)=0.96, 95% confidence interval (CI)=0.64–1.42) or in having mobility (RR=0.81, 95% CI=0.55–1.18) or balance difficulties (RR=0.71, 95% CI=0.37–1.39).
CONCLUSION: Cataract surgery had no association with the occurrence of falls or mobility or balance problems in independently living older adults with a cataract. J Am Geriatr Soc 2006;54(7):1089-1094.