Middle age is increasingly recognized as a critical period for the emergence of functional and mobility limitations. However, no prior systematic review has synthesized prevalence or incidence data specifically for this age group. This review aimed to summarize epidemiological evidence on self-reported functional and mobility limitations among middle-aged adults and to examine their associations with chronic conditions. This systematic review was registered in PROSPERO (CRD420251038883) and conducted in accordance with PRISMA 2020 guidelines. A search of PubMed, Scopus, Embase, and Web of Science was performed for studies published between 2000 and 2025. Eligible studies included population-based samples of midlife-related adults reporting prevalence or incidence of functional and/or mobility limitations. When data were available, associations between these limitations and chronic conditions were also examined. Methodological quality was assessed using the Joanna Briggs Institute checklist, and risk of bias was evaluated using the tool developed by Hoy et al. Evidence certainty was assessed using GRADE. Due to conceptual and methodological heterogeneity, a meta-analysis was not performed and findings were synthesized narratively. Twenty-six population-based studies comprising over 500,000 participants from over 30 countries worldwide met the inclusion criteria. Reported prevalence of functional and mobility limitations varied widely by domain, instrument, and task. Across many studies, estimates fell within the range of 15

RATIONALE & OBJECTIVE:Physical function is essential for independent living and good health. The trajectory of physical function and its association with important clinical outcomes is understudied in chronic kidney disease (CKD). We describe the associations of baseline and longitudinal self-reported physical function with cardiorenal outcomes among individuals with CKD. STUDY DESIGN:Prospective cohort study. SETTING & PARTICIPANTS:Participants of the multicenter Chronic Renal Insufficiency Cohort (CRIC) Study. EXPOSURE:Physical Component Summary (PCS) score and PCS slope. OUTCOME:Incident heart failure (HF), incident end-stage kidney disease (ESKD), and all-cause mortality. ANALYTICAL APPROACH:Multivariable adjusted Cox regression models examined associations of baseline PCS score with outcomes and in separate models assessed associations of PCS slope with outcomes. Effect modification was assessed by age, sex, race, and estimated glomerular fitration rate groups. RESULTS:Lower baseline PCS scores (per 10 points) were independently associated with higher risks of incident HF (HR, 1.21 [95% CI, 1.11-1.32]) and all-cause mortality (HR 1.21 [95% CI, 1.16-1.26]) but not with incident ESKD (HR, 0.98 [95% CI, 0.93-1.04]). PCS change (per 4 points annually) was also independently associated with higher risks for all 3 outcomes: incident HF (HR, 1.22 [95% CI, 1.05-1.42]), all-cause mortality (HR, 1.22 [95% CI, 1.13-1.32]), and incident ESKD (HR, 1.11 [95% CI, 1.01-1.22]). LIMITATIONS:Residual confounding, selection bias, and linearity assumption. CONCLUSIONS:Among individuals with CKD, baseline self-reported physical function was significantly associated with increased risk of incident HF and mortality after full adjustment. In addition, longitudinal changes in self-reported physical function were associated with incident HF, incident ESKD, and mortality, even after accounting for baseline self-reported physical function. These findings support monitoring for and testing of early interventions to preserve physical function and potentially prevent or delay adverse outcomes. PLAIN-LANGUAGE SUMMARY:People with chronic kidney disease (CKD) often experience a decline in physical function, but it is unclear how the decline impacts important outcomes in CKD. This study explored how both initial physical function and changes over time relate to important outcomes in CKD, including heart failure, kidney failure, and death. We found that people who rated their physical function lower or whose physical function declined over time were more likely to experience heart failure, kidney failure, and death. These patterns held true even after accounting for other heatlh conditions. These findings suggest that early interventions to preserve physical function could potentially prevent or delay these outcomes in patients but should be tested.

Aging in place-the ability to live comfortably and safely in one's own home and community as one ages-is a priority for many older adults and a growing focus of research and policy efforts. Little is known about perspectives on aging in place among the growing population of older Veterans with experiences of homelessness. Data from qualitative interviews with 21 formerly homeless Veterans ages 50 and older engaged in U.S. Department of Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) Program were analyzed using rapid qualitative analysis. Analysis revealed six interconnected themes: independence and self-sufficiency; functional status and mobility; physical and mental health; housing, food, and financial security; transportation and accessible services; and external support systems. These findings provide insight into perspectives on aging in place among older Veterans with experiences of homelessness and evidence to guide housing-based interventions for this growing population.

OBJECTIVE As the number of older adults undergoing spine surgery grows, it is important to better understand the risks of this procedure, including associated costs. The authors recently reported that undergoing more complex spine surgeries is strongly associated with postoperative delirium (POD). The goal of this study was to examine the costs associated with POD among patients undergoing spine surgeries of varying complexity. METHODS Data from a prospective observational cohort study of 256 adults aged ≥ 65 years who underwent spine surgery were analyzed. Preoperative, intraoperative, and postoperative variables were collected. The primary outcome of POD was defined as a positive score on any of three measures (Confusion Assessment Method for the Intensive Care Unit, Nursing Delirium Screening Scale, and chart review). The authors conducted univariable and multivariable analyses to examine factors associated with POD and estimated costs of POD stratified by tier of surgery. RESULTS Risk factors associated with POD included age, lower education level, baseline cognitive impairment, American Society of Anesthesiologists class ≥ III, tier 4 surgery, high estimated blood loss, intensive care unit admission, postoperative complications, and hospital length of stay. In multivariable analyses, age, baseline cognitive impairment, postoperative complications, and length of hospitalization remained significantly associated with POD. The mean total costs were significantly higher in the group with delirium versus without delirium ($99,543 vs $67,892). Additionally, more patients who developed delirium required discharge to an acute rehabilitation facility (47.0% vs 21.5%, p < 0.001). In analyses stratified by tier of surgery, the greatest difference in mean costs between those with delirium versus without delirium was observed in tier 4 ($164,902 vs $116,579, p < 0.001). CONCLUSIONS Spine surgeries with greater complexity are associated with an increased risk of POD, with higher costs and rates of intensive care unit admissions, more postoperative complications, and discharge to acute rehabilitation facilities. Delirium prevention interventions targeted to older adults at high risk for POD have the potential to optimize outcomes and decrease healthcare costs.

There are many approaches in implementation science research and practice to prospectively and pragmatically measure the amount of effort required to implement a particular evidence-based practice (EBP). We sought to 1) demonstrate how to prospectively and pragmatically document implementation activities in a real-world implementation trial; 2) quantify implementation dose (frequency and time spent) across the implementation of four EBPs; and 3) explore potential drivers of variation in implementation dose across EBP, sites, implementation progress, and wave. We built on the existing literature to develop a prospective and pragmatic way to track implementation activities during a type III hybrid effectiveness-implementation stepped wedge trial. We then quantified both total implementation dose (defined as total time spent by the implementer team) and how much of this dose was synchronous (defined as time spent working directly with local implementers at the sites receiving the intervention). We used multiple linear regression to understand what factors may influence differences in total implementation dose delivered (such as which evidence-based practice was being implemented, in which wave of the stepped wedge, at which medical centers), as well as how dose was related to implementation progress, categorized by 1) decision to participate, 2) training, 3) implementation with support, and 4) independent implementation. From 2022 to 2023, we prospectively captured implementation dose across 25 implementation instances related to four EBPs that were implemented at seven VA medical centers. We implemented Surgical Pause seven times, TAP six times, CAPABLE six times, and EMPOWER six times. We captured and categorized 1,271 h of implementation activities. Asynchronous administrative activities were most common across implementation phases. Other common synchronous activities include engaging collaborators, problem solving, providing updates, and ongoing action/implementation planning. The EBP was the largest driver of variation in implementation dose overall. Site, implementation progress, and wave did not independently explain variations in implementation dose. The EBP being implemented was a much stronger predictor of the implementation dose required than were other factors, such as experience implementing the EBP or characteristics of the medical center where the intervention was being implemented.

Midlife is a key life-course period for understanding risk factors of cognitive decline. Despite growing evidence demonstrating polygenic contributions to age-related disease risk, less is understood about how polygenic scores (PGS) may relate to cognitive traits in middle age. In a cross-sectional analysis, we investigated how PGS for Alzheimer’s disease (AD), longevity, subjective-wellbeing (based on life satisfaction and positive affect), and cognitive-function may relate to cognition in a cohort of middle-aged adults with normal cognition. The Health and Retirement Study (HRS) is an ongoing survey in Americans aged 50 years or older. We studied a cohort of 6615 individuals from the HRS (5359 European-ancestry, 1256 African-ancestry) aged 50-56 years with normal cognition at baseline, as determined by the HRS cognitive test battery. PGS derived from genetic variants associated with traits through genome-wide association studies in independent cohorts were available for all individuals. Linear regressions adjusted for baseline age, gender, and years of education were performed separately by genetically-defined ancestral group. Higher baseline cognition was observed in females (European-ancestry β=0.72±0.08, p <0.001; African-ancestry β=0.46±0.18, p =0.009) and individuals with more years of education (European-ancestry β=0.39±0.02, p <0.001; African-ancestry β=0.29±0.04, p <0.001). Higher cognitive-function PGS related to higher cognition (European-ancestry β=0.19±0.04, p <0.001; African-ancestry β=0.20±0.09, p =0.024). In the European-ancestry group, the cognitive-function PGS partially mediated the relationship between education and cognition (proportion mediated in European-ancestry=0.019, CI=0.010–0.030, p <0.001; proportion mediated in African-ancestry=0.016, CI=-0.002–0.050, p =0.072). The cognitive-function PGS still partially mediated the relationship between education and cognition in a subset of the European-ancestry group matched to the African-ancestry group based on age, gender, education, and cognition ( n =1256 European-ancestry, proportion mediated=0.016, CI=0.002–0.040, p =0.016). Therefore, the lack of mediation in the African-ancestry group is likely not due to smaller sample size. We did not observe associations between cognition and PGS for AD, longevity, and subjective-wellbeing in either midlife ancestral group. In this HRS cohort, more years of education were related to higher baseline cognition, and in individuals with European-ancestry, this relationship was partially mediated by a PGS for cognitive-function. Future directions include assessing the contribution of PGS to cognition over time, and investigating how environmental and life-course factors may moderate the association between PGS and cognition.

The Tailored Activity Program (TAP), an intervention for people living with dementia (PLWD) and their caregivers, has been shown to reduce behavioral symptoms for PLWD and caregiver burden. While TAP is proven as an evidence-based practice (EBP), it has yet to be implemented at scale. The Department of Veterans Affairs (VA) has prioritized the Age-Friendly Health System (AFHS) initiative, providing an opportunity to test implementation of TAP in a complex healthcare system. We conducted semi-structured pre-implementation interviews with leaders and clinicians at 6 VA Medical Centers (VAMCs) to engage key implementation partners and understand their unique implementation contexts. We utilized team-based rapid qualitative analysis to identify themes related to implementation determinants. We interviewed 65 unique informants in 58 interviews (5 VAMC leaders, 36 department leaders, and 17 frontline clinical staff). Informants identified 4 key factors critical to consider prior to implementing TAP: (1) alignment with organizational priorities; (2) perceived value and fit with existing clinical workflows; (3) competition with existing organizational and clinical priorities; and (4) considerations about the effect of caregiver burden on participation. We identified key factors to consider for successful implementation of a multicomponent intervention for PLWD and their caregivers within a complex healthcare system. As the AFHS initiative expands, there is a growing need for EBPs focused on the care of PLWD and their caregivers. These factors can guide clinicians, leaders, and implementation scientists in planning for implementation and sustainment of EBPs to bolster AFHS initiatives. Trial Registration Registered 05 May 2021, at ISRCTN #60,657,985. Reporting Guidelines The COnsolidated criteria for REporting Qualitative research (COREQ) checklist was used to ensure proper standards for reporting qualitative studies (see attached).

BACKGROUND:Mobility decline often begins in midlife, and early identification of individuals at risk of accelerated deterioration can enable timely prevention. However, there is no validated self-report instrument that specifically assesses mobility in the middle-aged population. METHODS:The Mobility in Middle-Age Questionnaire (MMQ) was developed through a 7-step Delphi process, consisting of 10 experts, involving item selection and content validation in both English and Hebrew, comprising 2 factors: (1) Current Mobility Ability and (2) 1-Year Mobility Change. Psychometric properties were assessed in 610 US and 594 Israeli middle-aged adults. Analyses included internal consistency, test-retest reliability, structural and construct validity (using the 10-item Physical Functioning scale [PF-10] from SF-36), and floor/ceiling effect assessments. A "Potential Mobility Risk Zone" was defined as the lowest 20% of MMQ scores. RESULTS:The MMQ showed excellent internal consistency (Cronbach's α = .94 English; .92 Hebrew) and strong test-retest reliability (intraclass correlation coefficient = 0.89-0.90). Exploratory factor analysis explained 66% of variance; confirmatory factor analysis showed good fit (Comparative Fit Index = 0.99, Tucker-Lewis Index = 0.99, Standardized Root Mean Square Residual = 0.05). Construct validity was supported, with all pre-defined hypotheses confirmed. MMQ showed significantly lower ceiling effects than PF-10 (3.9% vs. 34.5% in United States; 0.17% vs 25.25% in Israel, p < .001, large effect sizes). A score of 50 (20th percentile) was proposed as a preliminary "Potential Mobility Risk" Threshold. CONCLUSIONS:The MMQ is a reliable and valid tool for detecting early mobility decline in midlife. Longitudinal studies are needed to confirm its predictive value and responsiveness to change.

Middle age is a key life course period for targeting modifiable risk factors for late-life cognitive decline. Although the prevalence of chronic conditions that are risk factors for cognitive impairment has increased in middle-aged adults since the 1990s, little is known about corresponding trends in cognitive trajectories and incidence of cognitive impairment. We conducted a cohort study of 7,852 participants ages 50-56 enrolled from 1998-2010 in the Health and Retirement Study (HRS) without cognitive impairment at baseline. Participants were followed biennially to examine cognitive trajectories and new-onset cognitive impairment by age 65, based on the HRS cognitive test battery. We used mixed effects models to examine change in cognitive scores and Cox regression models to compare incidence of cognitive impairment no dementia (CIND) across three birth cohorts (1942-1947, "War Babies"; 1948-1953, "Early Baby Boomers"; 1954-1959, "Mid Baby Boomers"). Mid Boomers had lower baseline cognitive scores compared to earlier cohorts but a slower rate of cognitive decline. Hazards of CIND were higher among White Early and Mid Boomers compared to War Babies in the first half of follow-up, but lower in the second half. In both trajectory and incidence analyses, those with lower educational attainment and racial/ethnic minorities were at higher risk for worse cognitive outcomes. Findings show mixed trends in cognitive outcomes among middle-aged Americans. Overall, Mid Boomers had lower baseline cognitive scores but slower decline compared to earlier cohorts. However, disparities in cognitive outcomes persisted among those with lower educational attainment and racial/ethnic minorities.

Measuring functional status allows clinicians to deliver evidence-based interventions to prevent or delay associated adverse outcomes. Functional status is seldom routinely measured in primary care settings where most older adults receive care. Interprofessional team-based care is increasingly regarded as an important feature of high quality and efficient health care systems. Yet despite growing evidence of the benefits of team-based care, in primary care there are not yet standards for how to operationalize interprofessional practice. In this study we explored interprofessional perspectives on assessing functional status among older adults in team-based VA primary care clinics. We conducted qualitative interviews with 57 primary care team members (nursing staff, primary care providers, and social workers) from six geographically diverse VA medical centers. We drew from implementation science frameworks and sociotechnical theories to ground our thematic analysis in dynamic, real-world contexts. Interviews revealed the view that all primary care team members play a role in measuring and addressing functional status. Participants also described a perceived hierarchy of accuracy of assessment based on role and outlined strategies for validating the accuracy of functional status assessments. These results can inform guidelines for functional status measurement in primary care that improve interprofessional assessment and team-based communication.

BACKGROUND AND OBJECTIVES:The Housing and Urban Development-Veterans Affairs Supported Housing (HUD-VASH) program provides rental subsidies, case management, and supportive services to Veterans who are currently or formerly homeless, 77% of whom are aged ≥50. Few interventions have been developed to address the needs of older Veterans in HUD-VASH. RESEARCH DESIGN AND METHODS:We conducted a 2-stage study to inform the development of an intervention to promote aging in place in HUD-VASH. First, we completed qualitative interviews with 21 older Veterans in HUD-VASH and focus groups with 13 staff members to identify unmet needs for supporting aging in place. Second, we used a modified Delphi process with 9 staff and 1 Veteran to prioritize 66 intervention elements based on perceived feasibility and importance. RESULTS:We identified 4 main themes: need for services to support aging in place, expanding the HUD-VASH workforce, focus on home delivery, and importance of trust. The top-rated intervention elements spanned 5 categories: (1) staffing (by social workers, primary care providers, nurses, home health aides); (2) focus (on geriatric needs, mental health needs, dementia care, medication management); (3) modality (in the home or medical center); (4) timing (delivery of the intervention when Veterans have functional impairment, memory impairment, mental health problems, trouble caring for themselves, or are new to HUD-VASH); and (5) duration (regularly scheduled or ongoing as needed). DISCUSSION AND IMPLICATIONS:Veterans and staff members identified key intervention elements which can help inform Veterans Affairs (VA) efforts to develop and implement interventions to enhance aging in place in HUD-VASH.

Aging is associated with gradual mobility decline, often undetected until it affects daily life. This study investigates the potential of smartphone-based accelerometry to detect early age-related changes in gait and stair performance in middle-aged adults. Eighty-eight healthy participants were divided into four age groups: young (20-35 years), early middle-aged (45-54 years), late middle-aged (55-65 years), and older adults (65-80 years). They completed single-task, cognitive, and physical dual-task gait assessments and stair negotiation tests. While single-task walking did not reveal early changes, cognitive dual-task cost (DTC) of stride time variability deteriorated in late middle age. A strong indicator of early mobility changes was movement similarity, measured using dynamic time warping (DTW), which declined from early middle age for both cognitive DTC and stair negotiation. These findings highlight the potential of smartphone-based assessments, particularly movement similarity, to detect subtle mobility changes in midlife, allowing for targeted interventions to promote healthy aging.

BackgroundMaintaining functional status, defined as the ability to perform daily activities such as bathing, dressing, and preparing meals, is central to older adults' quality of life, health, and ability to remain independent. Identifying functional impairments - defined as having difficulty or needing help performing these activities - is essential for clinicians to provide optimal care to older adults, and on a population level, understanding function can help anticipate service needs. Yet uptake of standardized measurement of functional status into routine patient care has been slow and inconsistent due to the burden posed by current tools. The goal of the Patient-Aligned Care Team (PACT) Functional Status Screening Initiative is to implement and evaluate a patient-centered, low-burden intervention to improve identification and management of functional impairment among older veterans in Veterans Health Administration (VHA) primary care settings.MethodsWe will conduct a hybrid type 2 implementation-effectiveness cluster-randomized adaptive trial at 8 VHA sites using the Practical, Robust Implementation and Sustainability Model (PRISM) to guide implementation and evaluation. During a Pre-Implementation phase, we will engage clinical partners and develop local adaptations to maximize intervention-setting fit. During an Implementation phase, we will launch a standard bundle of implementation strategies (coalition building, champions, technical assistance) and system-level audit and feedback, identify sites with low uptake, and randomize those sites to receive continued standard vs. enhanced strategies (standard strategies plus clinician-level audit and feedback). The primary implementation outcome is reach (proportion of eligible patients at each site who receive screening/assessment) and the primary effectiveness outcome is appropriate management of impairment (proportion of patients with identified impairments who receive related referrals).DiscussionImplementing routine measurement of functional status in primary care has the potential to improve identification and management of functional impairment for older veterans. Improved management includes increasing access to services and supports for veterans and family caregivers, reducing potentially preventable acute care utilization, and allowing veterans to live in the least restrictive setting for as long as possible. Implementation will also provide data to inform the delivery of proactive interventions to prevent and delay development of functional impairment and improve quality of life, health, and independence.Trial registrationRegistered at ClinicalTrials.gov on May 7, 2024, at NCT06404970 (https://clinicaltrials.gov/).Reporting guidelinesStandards for Reporting Implementation Studies (Additional file 1).

Quality improvement and implementation science evaluations are often complex mixed methods approaches conducted by interdisciplinary teams. These efforts are challenging in normal circumstances; the COVID-19 pandemic and subsequent shift to remote work have posed additional challenges to this type of work. Novel approaches, tools, and processes may be needed to improve the rigor and cohesion of mixed methods evaluations, especially with a team working remotely.Quality improvement and implementation science evaluations are often complex mixed methods approaches conducted by interdisciplinary teams. These efforts are challenging in normal circumstances; the COVID-19 pandemic and subsequent shift to remote work have posed additional challenges to this type of work. Novel approaches, tools, and processes may be needed to improve the rigor and cohesion of mixed methods evaluations, especially with a team working remotely.Our aim was to create a rigorous evaluation plan for a large hybrid type III implementation-evaluation trial implementing new evidence-based processes at nine medical centers. Given the trial’s complexity and a geographically-distributed remotely-working interdisciplinary team, we found that existing tools did not meet our needs. We thus created a novel process for developing a rigorous evaluation plan that others could replicate.This process has seven steps: 1) select a template and identify point person; 2) complete initial development; 3) obtain targeted asynchronous feedback; 4) identify and analyze gaps; 5) conduct targeted virtual synchronous discussion; 6) finalize working document; and 7) apply the plan and solicit ongoing feedback.Interdisciplinary quality improvement and implementation science project teams need tools and processes to ensure clear communication, well-ordered workflow, and rigorous operationalization of evaluation aims. The seven-step evaluation plan tool not only helped to enhance the rigor and execution of a large program evaluation, but the process also served an important convening function to enhance coordination between remote team members. Our work builds on existing processes for evaluation plan development while incorporating team science approaches.

OBJECTIVE:To evaluate the effects of physician and advanced practitioner specialization in skilled nursing facility (SNF)-based practice (SNFists) on the outcomes of patients with Alzheimer's disease and related dementias (ADRD) admitted to SNF for post-acute care. STUDY SETTING AND DESIGN:Taking advantage of the natural experiment provided by the growth of SNFists, we conducted a within-SNF difference-in-differences analysis with cross-temporal matching. Our primary outcome was functional improvement at SNF discharge, measured using a validated activities of daily living (ADL) score. Secondary outcomes included unplanned rehospitalization, emergency department (ED) visits, observational stays within 30 days of SNF admission, successful discharge to the community, SNF length of stay, admission into long-term nursing home care within 6 months of SNF discharge, and 30- and 60-day Medicare payments for professional and facility services. DATA SOURCES AND ANALYTIC SAMPLE:Medicare facility and professional claims and Nursing Home Minimum Data Set (MDS) data from 2012 and 2019 were used. The study sample included 338,574 community-dwelling fee-for-service Medicare beneficiaries with ADRD, age 65 or older, discharged from an acute care hospital to one of the 5196 SNFs that experienced an increase in patients treated by SNFists. PRINCIPAL FINDINGS:We did not observe an association between SNFist care and patient post-acute care outcomes or costs. CONCLUSIONS:Specialization in SNF-based practice among physicians and advanced practitioners alone may not be an effective strategy to improve post-acute care outcomes or reduce costs to Medicare for patients with ADRD.

Urgency urinary incontinence (UUI), a risk factor for falls, affects 40

In the U.S., more than one million older adults with low incomes live in apartment buildings subsidized by the Low-Income Housing Tax Credit. Although this population experiences disproportionate rates of nursing home admission, little is known about residents' perspectives on factors that influence their ability to live independently in these settings. Fifty-eight residents aged 62 and older and eight study partners participated in qualitative interviews about their perspectives on living independently in subsidized housing, including barriers and facilitators. We analyzed transcripts using a hybrid inductive and deductive approach to qualitative thematic analysis. Barriers and facilitators for living independently in subsidized housing related to the influence of the social and physical environment on individuals' experiences of living independently, including factors unique to subsidized housing. Findings suggest how interventions to optimize functional status and promote independence among older adults living in subsidized housing can build on existing strengths of the subsidized housing environment to improve outcomes.