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Journal of the American Geriatrics Society Research Summary

Insomnia means having difficulty falling or staying asleep at night. It tends to worsen as we age, and insomnia is a common problem among older adults. As many as 50 percent of people report having trouble sleeping. However, when researchers study insomnia, they may not include older adults in their studies. This means we don’t fully understand insomnia among older people.

A team of researchers from the Yale School of Medicine and the Yale School of Nursing decided to fill the knowledge gap by studying insomnia and its severity in older adults. The researchers’ theory was that insomnia would be more common and severe as people aged and would be linked to other health problems. Their study was published in the Journal of the American Geriatrics Society.

The researchers reviewed information from the Yale Precipitating Events Project (PEP), an ongoing study that began around 20 years ago. The study population consists of 754 non-disabled older adults between the ages of 78 and 102 (with an average age of about 84). Over the years, the study’s participants have regularly completed tests at home and interviews to determine their health.

The participants answered questions about sleep disorders, such as restless leg syndrome, daytime sleepiness, and sleep apnea (the medical term for when your breathing pauses during sleep). They also answered questions to determine whether they had insomnia, and if so, how severe it was.

The researchers reported that 43 percent of the older adults in the study had insomnia, and that restless leg syndrome and symptoms of depression were linked to insomnia. However, the researchers were surprised to discover that the participants’ insomnia was mild.

They also reported another surprising finding. The researchers looked at risk factors for insomnia in younger adults. These risk factors included chronic heart and breathing problems, sleep apnea, taking multiple medications, and cognitive impairment (trouble with thinking abilities). These risk factors were not linked with insomnia in the older study participants.

The researchers concluded that the high rate but mild severity of insomnia highlights the need for healthcare providers to use appropriate tests to confirm sleep problems among older adults. They also suggested that healthcare providers should take depression and restless leg syndrome into account when they treat older adults who have insomnia.

This summary is from “Insomnia in Community-Living Persons with Advanced Age.” It appears online ahead of print in the Journal of the American Geriatrics Society. The study authors are Brienne Miner, MD, MHS; Thomas M. Gill, MD; H. Klar Yaggi, MD, MPH; Nancy S. Redeker, PhD, RN; Peter H. Van Ness, PhD, MPH; Ling Han, MD, PhD; and Carlos A. Vaz Fragoso, MD.

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Journal of the American Geriatrics Society Research Summary

As we age, we may become weaker as our muscles tend to lose their mass and strength. This condition of losing muscle mass is called sarcopenia. Sarcopenia can lead to problems performing your daily activities, such as shopping, socializing, and taking care of yourself and your home. Having sarcopenia can lessen your quality of life—and your independence.

A simple, fast way to test your overall muscle strength is by measuring the strength of your handgrip. In the test, you grip a small device as hard as you can, and it measures the strength of your grip. Studies have shown that handgrip strength is closely linked to muscle mass and other signs of your general health, including nutrition and walking ability. What’s more, handgrip strength is considered an important test for diagnosing sarcopenia. Weak handgrip strength can predict low muscle mass and poor physical performance.

Research has linked handgrip strength to other health problems in older adults. Losing muscle strength as you age also means losing muscle strength in your respiratory system. (The respiratory system is the part of your body responsible for breathing.) This can lead to poor lung function. When your lungs don’t function properly, you are at higher risk for respiratory issues like bronchitis and pneumonia, as well as heart disease and even death.

However, little is known about the link between handgrip strength and lung function in older adults. A team of researchers recently decided to learn whether testing handgrip strength could help identify lung function in older Korean women. Their study was published in the Journal of the American Geriatrics Society.

The researchers used information from the 2014-2015 Korean National Health and Nutrition Examination Survey (KNHANES), which was conducted by the Korea Centers for Disease Control and Prevention (KCDC). KNHANES is a nationwide survey that looks at health and nutrition for Koreans.

The survey consists of three sections: a health interview, a nutrition survey, and a health examination. The health examination consisted of blood pressure measurements, eye and mouth exams, laboratory tests, and several other tests (including ones for strength). The researchers looked at a smaller group of survey participants: 1,773 healthy women between the ages of 65 to 79.

The researchers learned that among the 1,773 women they studied, handgrip strength was linked to lung capacity—a measure of how well your respiratory system functions. The researchers concluded that testing older adults’ handgrip strength could be a good way to test their potential for impaired lung health.

This summary is from “Relationship between Handgrip Strength and pulmonary function in apparently healthy older women.” It appears online ahead of print in the Journal of the American Geriatrics Society. The study authors are Da-Hye Son, MD; Ji-Won Yoo, MD; Mi-Ra Cho, MD; and Yong-Jae Lee, MD, MPH, PhD.

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National Women’s Health Week (May 13-19, 2018) is a perfect reminder to female healthcare providers to practice what we preach. As caregivers and as women who serve our communities’ health, we all too often focus on the health needs of others before our own. In the immortal words of every flight attendant, “Put on your oxygen mask before assisting others.” Meaning, of course, that if you’re neglecting your own well-being, it will be difficult for you to help your clients and loved ones.

And as we age, it becomes increasingly important to monitor our health. That’s because older women are more likely than men to have chronic health conditions, including arthritis, high blood pressure, and osteoporosis.

Happily, a great deal of what it takes to boost your chances for staying physically and mentally healthy is within your power. Below is what the experts with the American Geriatrics Society’s Health in Aging Foundation recommend.

See your healthcare provider regularly. Even if you feel perfectly healthy, get a check-up at least once a year, or as often as your provider recommends.

Take medications, vitamins, and supplements only as directed. When you visit your provider, bring all the pills and other supplements you take—even those you buy over the counter without a prescription. Your provider should check all of your pills to make sure they’re safe for you, and you should check with her before taking any new medication or supplement.

Let your provider know right away if a medication or supplement seems to be causing a problem or a side effect.

Get screened. Certain screening tests can help diagnose health problems early. Ask your healthcare provider which tests are right for you.

Get vaccinated. Check with your healthcare provider to make sure you’re getting:

  • flu shot every year in late summer or early fall before the flu season begins.
  • Pneumonia vaccine: there are two types available now, called pneumococcal conjugate vaccine (PCV) 13 and pneumococcal polysaccharide vaccine (PPSV) 23. Talk to your healthcare provider.
  • tetanus shot every 10 years.
  • The shingles (herpes zoster) vaccine: once after age 50 or older.

Reduce falls and fracture risks. Take 1,200 to 1,500 mg of calcium and 800 to 1,000 IU of vitamin D daily. Do weight-bearing exercises such as walking, jogging, and aerobic dancing. If you’ve fallen in the past, ask your healthcare provider about exercise programs in your area that include strength training, balance and stretching exercises.

Use sunscreen daily. As skin ages, it becomes more susceptible to sun damage—and that boosts risks for skin cancer. Use sunscreen all year round on exposed skin, and wear a wide-brimmed hat for added protection.

Quit smoking. Tell your healthcare provider about your smoking habits and enlist his/her aid to help you stop. For additional help, call 1-800-QUITNOW. It’s never too late to stop smoking.

Eat a rainbow. Later in life you need healthy foods but fewer calories. Visit the USDA’s updated Choose My Plate for older adults to learn what a healthy diet looks like. Suggestions include:

  • Eat at least five servings of fruits and vegetables daily (less than 1/3 of older adults do this). Select a variety and choose the deepest colors—dark green leafy vegetables, orange fruits and vegetables, and blue and purple vegetables, too. Choose fiber-rich whole grain breads, pasta and rice instead of the white stuff. Pick lean meats and avoid processed meats and cold cuts.
  • To keep your bones strong, enjoy two daily servings of low-fat milk, cheese and yogurt.
  • Try to eat twice-weekly servings of heart-healthy fish, like tuna, salmon, sardines or mackerel.
  • Use healthier fats, such as extra virgin olive oil or canola oil instead of butter or lard.
  • Drink responsibly. Some—but not all—women may benefit from one alcoholic drink a day. Check with your healthcare provider to make sure this is right for you. Remember, one drink equals 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of hard liquor.

Exercise your mind and body. Regular exercise is essential for good health at any age. It improves heart health and circulation, strengthens bones, helps keep the pounds off, lifts your mood and can help ease depression. Talk to your doctor about an exercise program that’s right for you.

Get involved. Social involvement is a key to staying healthy and happy as we age. Sign up for a class, do puzzles, find an interesting hobby or club. Challenge your brain by trying new things.

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Journal of the American Geriatrics Society Research Summary

Researchers at the University of Exeter have found a statistical link between pneumonia in older people and a group of medicines commonly used to neutralize stomach acid in people with heartburn or stomach ulcers. Although proton-pump inhibitors (PPIs) are still a valuable group of medicines, research is indicating that PPIs are not as completely safe for older people as previously thought.

PPIs are medicines commonly prescribed to reduce gastric (stomach) acid production and to protect the stomach. Approximately 40 percent of older adults receive PPIs, although according to some experts, up to 85 percent of people who receive PPI prescriptions may not need them.

Researchers say people should not stop using their PPI medication, but should discuss with their prescribing healthcare professional whether the PPIs are still needed. Just stopping PPIs could be dangerous as PPIs may be useful, for example, to prevent stomach bleeds in some people.

Once thought to be relatively harmless, PPIs have more recently been linked to increased rates for certain health concerns like fractures, cardiovascular disease, and some bacterial infections. The association between PPI use and pneumonia was studied because stomach acid helps to prevent infections spreading from the gut in some individuals. Since pneumonia is a major cause of death for older adults, it is important for healthcare providers to understand the links between PPIs and pneumonia.

The Exeter team designed a study to look at statistical links in medical records between long-term PPI use and pneumonia in older adults. Their study was published in the Journal of the American Geriatrics Society.

David Melzer, Professor of Epidemiology and Public Health at the University of Exeter Medical School, said: “This study shows that there was a higher rate of pneumonia in older people who received PPIs over a two year period. Caution is needed in interpreting the findings as our study is based on analyzing data from medical records, so other factors may be involved. However, our study adds to growing evidence that PPIs are not quite as safe as previously thought, although they are still a very useful class of medication for certain groups of patients.”

The researchers used information from Clinical Practice Research Datalink (CPRD) for England, a large database containing records from many primary care practices in the U.K. They selected patients 60-years-old and older who had taken prescribed PPIs regularly and who also had previous regular medical records. The researchers identified more than 75,000 older adults who were treated with PPIs.

 As with all prescription medications, regularly review your use of medicines like PPIs with your healthcare providers to make sure each prescription is still needed.

This summary is from “Proton‐Pump Inhibitors and Long‐Term Risk of Community‐Acquired Pneumonia in Older Adults.” It appears online ahead of print in the Journal of the American Geriatrics Society. The study authors are Jan Zirk-Sadowski, PhD; Jane A. Masoli, MBChB; Joao Delgado, PhD; Willie Hamilton, MD; W. David Strain, MD; William Henley, PhD; David Melzer MBBCh, PhD; and Alessandro Ble, MD.

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Journal of the American Geriatrics Society Research Summary

For older adults, driving can mean living a more independent, satisfying life. Therefore, it’s no surprise that about 86 percent of adults age 65 and older hold active driver’s licenses, and many of us expect to drive for longer as we age.

Car crashes can be devastating or even deadly for anyone, including older adults and other road users. However, the fatal crash rate based on the distance someone travels in a vehicle begins to rise at age 65. At the same time, when older adults stop driving due to health issues or other concerns, they may experience isolation and depression. They also may be more likely to enter long-term care facilities earlier than they otherwise would.

Researchers have a history of studying driver safety in older adults after they’ve been diagnosed with dementia, a decline in memory and other mental abilities that make daily living difficult. However, we have limited knowledge about the effects on older drivers whose problems with mental abilities are less severe than those associated with dementia.

Recently, a team of researchers designed a study to learn more about cognitive health and older drivers’ crash risks. The study was published in the Journal of the American Geriatrics Society. In this study, the researchers focused on links between levels of cognitive function and crash risk among older drivers without dementia over a 14-year study period. They also assessed the link between changes in cognitive function over time and later risks of crashes.

The researchers used information from the Adult Changes in Thought (ACT) study, an ongoing study of adults aged 65 and older. The researchers linked ACT data from 2002 to 2015 to the Washington State crash database and to information from the Washington State Department of Licensing.

ACT participants were tested for their ability to think and make decisions. Researchers followed 2,615 participants for an average of 6.7 years or until they dropped out of ACT, died, were diagnosed with dementia, or failed to renew their license. The researchers then looked at motor vehicle crashes involving ACT participants. They included all crashes resulting in injury, death, or property damage totaling at least $1,000.

For older licensed drivers without dementia, lower levels of cognitive function were linked to a higher risk of motor vehicle crashes. Depression also was linked to a higher risk for crashes in older licensed drivers without dementia.

The researchers noted that, unfortunately, there is not yet a widely accepted specific clinical exam, procedure, or lab test that can evaluate driving and crash risk related to cognitive function. The researchers concluded that older drivers with lower levels of cognitive function were somewhat more likely to be involved in a crash. These older drivers, their family members, and their healthcare providers must balance the benefits of independence, mobility, and social engagement with the potential for car crashes as they make decisions about whether an older person should continue to drive.

With support from the National Highway Traffic Safety Administration, the AGS Health in Aging Foundation offers a host of tools—including overviews, tip sheets, and check-lists—to help older adults and caregivers better understand driving safety and driving alternatives. For more information on assessing driving abilities or finding different transportation options when independent driving is no longer safe, click here.

This summary is from “Cognitive decline and older driver crash risk.” It appears online ahead of print in the Journal of the American Geriatrics Society. The study authors are Laura A. Fraade-Blanar, PhD; Beth E. Ebel, MD, MSc; MPH; Eric B. Larson, MD MPH; Jeanne M. Sears, PhD; Hilaire J. Thompson, PhD, RN, ACNP-BC; Kwun Chuen G. Chan, PhD; and Paul K. Crane, MD, MPH.

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Journal of the American Geriatrics Society Research Summary

Delirium is a sudden change in mental status that often occurs when older adults are in the hospital or after they have surgery. More than 20 percent of older adults may experience delirium.  The condition can lead to longer hospital stays, the need to be placed on a respirator (a machine that helps you breathe), long-term changes in your cognitive (mental) health, physical disability, and even death.

Acute illness (illnesses that happen suddenly, as opposed to chronic conditions that you live with over a longer period of time), surgery, and medications can contribute to delirium. In addition, disrupting regular routines may trigger sudden confusion or changes in behavior for certain people.

When healthcare professionals don’t recognize or diagnose delirium, it can delay an older person’s recovery.  Prolonged delirium can have a lasting impact on health and well-being. What’s more, delirium is distressing for caregivers—the family or friends involved in caring for an older adult. In hospitals, healthcare professionals screen (“test”) for delirium. However, despite routine screening, more than 60 percent of older adults with delirium are not diagnosed in hospitals.

In a new study, published in the Journal of the American Geriatrics Society, researchers set out to learn whether caregivers could use existing questionnaires and other tools to detect delirium on their own. The researchers reviewed 6,056 scientific papers about delirium screening. They specifically were looking for proven methods that caregivers could use in home settings.

The researchers identified six tools that caregivers could use. Each one took just several minutes or less to use and had 11 items or fewer to complete. Three tools could be completed by the caregiver alone.

According to the researchers, using these caregiver-centered delirium detection tools, caregivers are generally able to identify delirium symptoms more easily than healthcare professionals who may be less familiar with the person being evaluated. Having caregivers test a person for delirium also makes it easier for the caregiver to be alert for delirium throughout a person’s hospital stay. As a result, caregivers may be able to notify healthcare professionals of changes in mental status sooner, potentially leading to earlier and more frequent diagnoses for older people under their care. Engaging caregivers in delirium detection may also decrease caregiver distress. Many studies have shown that caregiver involvement in health care helps improve patient and caregiver outcomes.

Overall, caregiver-centered delirium detection tools enable caregivers to improve delirium detection. The tools can help to reduce the challenges that can accompany undiagnosed delirium. No risks associated with these tools have been reported. The researchers suggest that future studies should monitor caregiver use of delirium detection tools.

 This summary is from “Caregiver-Centered Delirium Detection Tools.” It appears online ahead of print in the Journal of the American Geriatrics Society. The study authors are Brianna Rosgen; Karla Krewulak, PhD; Danielle Demiantschuk MA; E. Wesley Ely, MD, MPH; Judy E. Davidson, DNP; Henry T. Stelfox, MD, PhD; and Kirsten Fiest, PhD.

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Journal of the American Geriatrics Society Research Summary

After being discharged from the hospital, an older person often is admitted directly to a skilled nursing facility (SNF). SNFs specialize in the skilled care we need to recover properly.  These facilities also provide the additional rehabilitation we may need before returning home. However, experts have raised concerns about the uneven quality of SNF services, the substantial differences among them, and how they are used in different parts of the country. A transfer from an SNF to a long-term care facility, for example, is considered a failure to achieve the goals of SNF care.  Most older people view a move to a long-term care facility as a step in the wrong direction.

In a new study, researchers decided to examine the role that SNFs play with regard to older adults’ placements in long-term care facilities. Their study was published in the Journal of the American Geriatric Society.

The researchers studied the role of SNF quality and how it affected older adults’ risks of transitioning to long-term care facilities. They also looked at whether any aspects of skilled nursing were linked with an older adult’s risk of entering long-term care facilities. The research team focused specifically on whether the quality ratings of SNFs (available to the public, free of charge, here) helped predict long-term care placements.

The researchers used information from a variety of Medicare and other qualified sources that included data on more than 500,000 people aged 65 and older.

The researchers learned that a person’s risk of eventual placement in long-term care nursing homes varied a great deal based on the SNF where they received care. Older adults in SNFs with higher quality ratings had significantly lower risks for placement in long-term care facilities.

The researchers concluded that learning more about the processes in place at specific SNFs might help explain variations in care and could help guide future efforts. Eventually, these efforts may help older adults successfully return to the community following hospitalization.

This summary is from “Clinical Investigation: Variation among skilled nursing facilities in patients’ risk of subsequent long-term care residence.” It appears online ahead of print in the Journal of the American Geriatrics Society. The study authors are James S. Goodwin, MD; Shuang Li, PhD; Addie Middleton, PhD, PT; Kenneth Ottenbacher, PhD, OTR; and Yong-Fang Kuo, PhD.

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Journal of the American Geriatrics Society Research Summary

More than 25 percent of adults aged 65 or older have diabetes. Diabetes develops when the amount of sugar (or glucose) in your blood becomes too high. This happens either because your body doesn’t make enough insulin (type 1 diabetes), or because your body doesn’t respond to the insulin it makes (type 2 diabetes).

Older adults are especially likely to develop type 2 diabetes, because as we age, our bodies are less able to process sugars. What’s more, being overweight can increase our chances of developing the condition.

If you’re an older adult with type 2 diabetes, it’s likely that your healthcare provider has recommended that you carefully maintain your blood sugar levels with diet, exercise, and perhaps even medication. Blood sugar levels are typically monitored with a simple blood test that gives you a result called your “A1c level.” This is the percentage measurement of glucose levels in your blood over about three months.

But what should your target blood sugar level (A1c) be? If it’s too low, you could be at risk for hypoglycemia, or low blood sugar. When this occurs, you can fall or lose consciousness.

In a new study published in the Journal of the American Geriatrics Society, researchers say the evidence against “tightly” controlling blood sugar levels for older adults—the practice of targeting a more specific A1c level, often through the use of medications—hasn’t filtered down to clinics and primary care practices, where there may be value in pursuing looser target levels for blood sugar.

In their study, researchers examined records from the Diabetes Collaborative Registry for more than 30,000 adults aged 75 or older. In the study, 26 percent of older adults with diabetes had A1c levels less than 7 percent. They were treated with medications that have a high risk for lowering blood sugar to the point that someone could be at increased risk for a fall or losing consciousness.

Contrary to what researchers thought, these factors were each linked to having tight blood sugar control using a “high-risk” medication: older age, being male, or having heart failure, chronic kidney disease, and coronary artery disease. According to the researchers, people with these characteristics or conditions have the most potential to be harmed if they experience hypoglycemia and their A1c goals should be more relaxed.

The researchers concluded that we need more specific guidance about how to safely treat older adults with diabetes, and that we need to translate that guidance to help busy clinicians and their patients.

 This summary is from “Use of Intensive Glycemic Management in Older Adults with Diabetes.” It appears online ahead of print in the Journal of the American Geriatrics Society. The study authors are Suzanne V. Arnold, MD, MHA; Kasia J. Lipska MD; Jingyan Wang MS; Leo Seman, MD PhD; Sanjeev N. Mehta MD, MPH; and Mikhail Kosiborod MD.

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Journal of the American Geriatrics Society Research Summary

According to a new study published in the Journal of the American Geriatrics Society, living in socially and economically disadvantaged neighborhoods can have a negative influence on older adults’ health and well-being.

Older adults who live in disadvantaged neighborhoods report having poorer health and have more difficulty getting around and performing daily tasks. What’s more, older adults living in disadvantaged neighborhoods tend to have more chronic illnesses and higher rates of death than do older adults who live in less disadvantaged neighborhoods.

Many issues affect the relationship between neighborhoods and health. One may be that disadvantaged neighborhoods have lower levels of social support for older adults and their caregivers. These neighborhoods also tend to have fewer physical resources, such as access to health care, retail stores, and recreational facilities.

Social and other resources are important for older adults. Therefore, older adults living in disadvantaged neighborhoods may find it harder to maintain well-being while aging. This can make it challenging for our society as a whole to benefit from our increased longevity.

The research team who conducted the study used the 2013 Medicare Health Outcome Survey (HOS) survey. This is a telephone and mail survey that was given to older adults enrolled in Medicare Advantage (MA) health plans (MA plans are insurance plans offered by private companies approved by Medicare). Around 17.6 million people are enrolled in MA plans. This is 31 percent of the population eligible for Medicare (the government program that provides health insurance to people 65-years-old and older). Information about 187,434 older adults was included in the study.

The researchers concluded that disadvantaged neighborhoods are an important predictor of mobility and other limitations among MA beneficiaries, particularly for those with multiple chronic conditions. Compared to those living in less disadvantaged neighborhoods, MA beneficiaries who have multiple chronic conditions and who live in the most disadvantaged neighborhoods are 12 percent more likely to report difficulty performing at least one daily task, such as bathing, dressing, or keeping house.

The researchers suggested that increasing resources in disadvantaged neighborhoods to support health programs for older adults could improve their health outcomes.

This summary is from “Linking Neighborhood Context and Health in Community-Dwelling Older Adults in the Medicare Advantage Program.” It appears online ahead of print in the Journal of the American Geriatrics Society. The study authors are Daniel Jung, BS; Amy Kind, MD, PhD; Stephanie Robert, MSW, PhD; William Buckingham, PhD; and Eva DuGoff, PhD, MPP.

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Journal of the American Geriatrics Society Research Summary

Heart failure affects more than 6 million people in the U.S.—most of whom are older adults. Roughly half the older adults who have heart failure also live with five or more other chronic health conditions. This group of people may have difficulty performing daily activities, such as walking, bathing, and eating. And older adults who have multiple chronic illnesses plus heart failure generally require more frequent health care, including more visits to healthcare providers and hospitalizations.

Recently, researchers examined the impact of having multiple chronic conditions and having difficulty with daily activities on the health of older adults with heart failure. Until now, there’s been no research on the combined effects of having all three problems for older adults. The researchers published their findings in the Journal of the American Geriatrics Society.

The researchers sent questionnaires to 6,346 older adults who had been diagnosed with heart failure; 2,692 participants returned the questionnaires and were included in the study.

Of the people with heart failure included in the study:

  • 25 percent had no other chronic illnesses or trouble performing daily activities.
  • 35 percent had other chronic illnesses.
  • 9 percent had trouble performing daily activities.
  • 31 percent had other chronic illnesses and trouble performing daily activities.

The most common non-heart-disease-related chronic conditions the participants reported were diabetes (45 percent), arthritis (40 percent), and cancer (31 percent).

The daily activities that the participants reported having the most difficulty performing/completing were using transportation (37 percent), preparing meals (28 percent), and bathing (23 percent).

The researchers discovered that the participants who had other chronic conditions plus trouble performing their daily activities had the highest risk for death, hospitalizations, and visits to healthcare providers and emergency rooms. They also learned that participants who had either other chronic conditions or problems performing their daily activities had a similar risk for hospitalization or emergency room visits.

The researchers concluded that, when healthcare providers care for people with heart failure, they should also consider the person’s chronic illnesses and problems with daily activities. The researchers also said that having difficulty performing daily activities could lead to serious consequences for heart failure patients.

This summary is from “Multimorbidity and Functional Limitation in Patients with Heart Failure: A Prospective Community Study.” It appears online ahead of print in the February 2018 issue of the Journal of the American Geriatrics Society. The study authors are Sheila M. Manemann, MPH; Alanna M. Chamberlain, PhD; Véronique L. Roger, MD, MPH; Cynthia Boyd, MD; Andrea Cheville, MD; Shannon M. Dunlay, MD, MS; Susan A. Weston, MS; Ruoxiang Jiang, BS; and Lila J. Finney Rutten, PhD.

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