BACKGROUND: People with executive function problems may respond differently to physical therapy (PT) treatment than those without executive function problems. We examined the treatment response of a novel PT treatment kn...BACKGROUND: People with executive function problems may respond differently to physical therapy (PT) treatment than those without executive function problems. We examined the treatment response of a novel PT treatment known as Live Long Walk Strong (LLWS). METHODS: This study was a preplanned secondary analysis of a randomized controlled trial among middle- and older-aged Veterans (≥ 50 years) with slow walking speed. Veterans with and without executive function deficits (EFD+/EFD-) received 8 weeks of LLWS care. Changes after treatment in mobility (Short Physical Performance Battery (SPPB), walking speed, Activity Measure for Post-Acute Care) and executive function (Delis-Kaplan Executive Function System Verbal Fluency (letter fluency, category fluency, category switching)) were evaluated according to baseline EFD status using mixed linear regression models. RESULTS: Veterans who completed the 8 week LLWS treatment (N = 103) were included in this study (mean age 71), and 15% (n = 15) were EFD+. Both mobility and executive function measures were significantly lower among participants with EFD+ at all timepoints (p < 0.05). Participants showed statistically and clinically significant improvements across all mobility outcomes over time (p < 0.05), with no significant interaction by time and EFD status (p > 0.40). Statistically significant improvement was observed only in letter fluency (p = 0.02) among the executive function measures. However, we observed statistically significant time by EFD status interactions for category switching fluency (p < 0.05), favoring the EFD+ groups. Overall, participants with EFD had greater improvement in executive function compared to participants without EFD (mean composite z-score increase of 0.38 SD units vs. 0.003 SD units, respectively). CONCLUSION: LLWS treatment appears efficacious for improving mobility in individuals with and without EFD. LLWS treatment may also benefit aspects of executive function, particularly for Veterans with deficits in these cognitive domains. Future investigation of these questions within larger and more diverse cohorts is warranted.
Wiederholt SG, Edwards ST, Kinosian B
… +1 more, Zhu JM
J Am Geriatr Soc
· 2026 Jun · PMID 42050918
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BACKGROUND: Home-based medical care (HBMC) is an important care model for older adults with complex health conditions and functional limitations that can potentially prevent institutionalization. Historically, HBMC has c...BACKGROUND: Home-based medical care (HBMC) is an important care model for older adults with complex health conditions and functional limitations that can potentially prevent institutionalization. Historically, HBMC has comprised small, independent provider organizations. It is unknown whether consolidation observed in other health care sectors has similarly affected HBMC. METHODS: We used the American Academy of Home Care Medicine's national provider directory to identify a cohort of practices billing traditional, fee-for-service Medicare for HMBC in 2022. Using Pitchbook Inc., we identified whether an acquisition occurred for each of these practices and categorized acquisition types as private equity (PE) firm buyouts, health system acquisitions, and other corporate acquisitions. We described most recent acquisition timing from 2012 to 2024 for this cohort of practices and compared 2022 practice characteristics by most recent acquisition status and type as of 2022, using this as a proxy to describe current practice ownership. RESULTS: The majority of HBMC practices in our cohort with any acquisition were acquired in 2022, with the greatest number of recent private equity firm buyouts in 2021. Among 2308 HBMC practices serving 476,088 Medicare fee-for-service patients in 2022, 12.6% of patients received care from PE-acquired practices, 2.4% from health system-acquired practices, and 5.0% from other corporate-acquired practices. Acquired practices were generally larger and cared for patients with slightly higher hierarchical condition category (HCC) scores who were less often high-needs qualified. Performance measures did not differ meaningfully between acquired and non-acquired practices. CONCLUSIONS: A significant share of HBMC patients is cared for by practices that have been acquired, with further investigation warranted to understand potential effects on patient selection and care quality.
Caughey GE, Schwabe J, Pulling BW
… +15 more, Crotty M, Williams H, Kellie A, Harvey G, Wesselingh SL, Roder D, Nixon KL, Sluggett JK, Cations M, Gill TK, Khadka J, Corlis M, Dawkins C, von Thien M, Inacio MC
BACKGROUND: Older people's preference is to age in place. Optimizing the delivery of high-quality home-based primary care for this growing population is a priority for healthcare systems worldwide. Provision of primary c...BACKGROUND: Older people's preference is to age in place. Optimizing the delivery of high-quality home-based primary care for this growing population is a priority for healthcare systems worldwide. Provision of primary care is essential to support the health and wellbeing of the older population, yet there is a lack of high-quality evidence quantifying the effects of primary care services for the older population. This study aimed to examine the association of continuity of primary care and primary health care patterns on the risk of mortality and hospitalization in the older population. METHODS: A retrospective cohort study was conducted between 1 July 2016 and 31 December 2019 of 120,522 older people (≥ 65 years) living in the community receiving long-term care. Continuity of primary care and patterns of primary care service utilization on the risk of mortality and nine hospitalization-related outcomes were examined. Propensity score methods for confounding adjustment and survival analyses were employed. RESULTS: Compared with seeing a new primary care physician (n = 25,213, 30%), seeing a known primary care physician (n = 41,309, 49.1%) was associated with lower risks of hospitalizations ranging from 18% reduction for medication-related hospitalization (sHR = 0.82, 95% CI 0.74-0.91) to 28% reduction for fractures (sHR = 0.72, 95% CI 0.66-0.78). The care pattern of high preventive primary care service use (n = 34,021, 62.4%) was associated with lower risks of hospitalization ranging from 15% for ED presentations (sHR = 0.85, 95% CI 0.80-0.92) to 36% for pressure injury-related hospitalization (sHR = 0.64, 95% CI 0.52-0.80) compared to high overall primary care use (n = 5293, 9.7%). CONCLUSIONS: Care patterns focusing on prevention and disease management, and continuity of primary care were associated with more favorable health outcomes among older people aiming to age in place.
Chow SW, Javier NM, Brown K
… +4 more, Goldhirsch S, Perez S, Cunningham T, Sanon M
J Am Geriatr Soc
· 2026 Jun · PMID 42037169
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BACKGROUND: Academic medicine programs face compounded challenges from public health crises, health inequities, and evolving federal policies pertaining to Diversity, Equity, and Inclusion (DEI). Older adults and individ...BACKGROUND: Academic medicine programs face compounded challenges from public health crises, health inequities, and evolving federal policies pertaining to Diversity, Equity, and Inclusion (DEI). Older adults and individuals living with serious illness-particularly those from marginalized communities-experienced greater morbidity and mortality during the COVID-19 pandemic and may continue to see disproportionately negative outcomes amid 2025 federal regulatory changes. METHODS: Within a Department of Geriatrics and Palliative Medicine, a DEI initiative evolved into the MOSAIC Council (Mission Oriented Strategies Advancing Inclusive Communities)-reframing its scope, governance, and program activities to preserve psychological safety, engagement, and institutional relevance. MOSAIC and departmental leadership defined the program's mission to: (1) foster a supportive and inclusive learning and work environment, (2) develop responsive approaches to discrimination and bias, and (3) provide accessible resources to support all department members. Activities consisted of lectures, facilitated forums, workshops, and community-building experiences, with ongoing feedback used to guide program refinement. RESULTS: From 2021 to 2025, MOSAIC demonstrated sustained engagement, delivering more than 140 sessions, consistent attendance, and positive participant feedback. Structural and resilient adaptations included expansion of the champion team, iterative feedback and needs assessments, and prioritization of flexible, community-informed programming. Focus on internal community building and psychological safety supported program growth and resilience and facilitated integration of MOSAIC principles into departmental culture and practices. CONCLUSIONS: MOSAIC demonstrates that internal DEI development in a geriatric and palliative department can be sustained through intentional resilience and adaptive design, despite restrictive policy environments. This model offers a pragmatic framework for academic health programs seeking to improve workforce environment and advance equitable care for older adults and seriously ill populations while navigating evolving regulatory landscapes. Future directions include extending this framework to patient and caregiver communities.
BACKGROUND: Evidence guiding first-line antihypertensive drug choice in adults aged 75 years or older is limited, despite widespread use of angiotensin receptor blockers (ARBs) and calcium channel blockers (CCBs) in late...BACKGROUND: Evidence guiding first-line antihypertensive drug choice in adults aged 75 years or older is limited, despite widespread use of angiotensin receptor blockers (ARBs) and calcium channel blockers (CCBs) in late older age. METHODS: We conducted a target trial emulation using a new-user design in a nationwide linked healthcare claims database in Japan. Adults aged ≥ 75 years who had no prescription of either drug class in the preceding 12 months and initiated an ARB (n = 10,037) or a CCB (n = 19,785) were followed from treatment initiation. The primary outcome was all-cause mortality; secondary outcomes included hospitalization for heart failure, myocardial infarction, stroke, and major adverse cardiovascular events (MACE). Intention-to-treat effects were estimated using inverse probability of treatment and censoring weighting with pooled logistic regression models. RESULTS: Among 29,822 patients, median follow-up was 4.0 years. During follow-up, 3487 deaths occurred. ARB therapy was associated with lower all-cause mortality than CCB therapy (hazard ratio [HR], 0.885; 95% CI, 0.823-0.951). The estimated 5-year risk of death was 12.7% for ARB users and 14.8% for CCB users (absolute risk difference, -2.1 percentage points; 95% CI, -3.1 to -1.0). ARB therapy was also associated with lower risks of heart failure hospitalization (HR, 0.843; 95% CI, 0.774-0.918), myocardial infarction (HR, 0.867; 95% CI, 0.795-0.945), stroke (HR, 0.931; 95% CI, 0.869-0.998), and MACE (HR, 0.889; 95% CI, 0.848-0.931). Associations were consistent across age subgroups, including adults aged ≥ 85 years. CONCLUSION: In adults aged 75 years or older, ARB-based antihypertensive therapy was associated with lower risks of mortality and cardiovascular events compared with CCB-based therapy. These findings suggest that first-line antihypertensive drug choice may have prognostic implications in late older age.
Lachs J, Barghout R, Haussner W
… +7 more, Hancock D, Benton E, Dorsett M, Peters G, Cash R, Holley J, Rosen T
J Am Geriatr Soc
· 2026 Apr · PMID 42033788
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BACKGROUND: Agitation in older adults presents unique challenges for emergency medical services (EMS) clinicians. To safely assess, treat, and transport these patients, EMS providers must manage this agitation, which is...BACKGROUND: Agitation in older adults presents unique challenges for emergency medical services (EMS) clinicians. To safely assess, treat, and transport these patients, EMS providers must manage this agitation, which is often caused by delirium or behavioral symptoms of dementia. Strategies routinely used in younger patients, such as physical restraints and chemical sedatives, have a much higher risk of causing harm in older adults. EMS provider practices in this area are understudied. Our objective was to examine U.S. state protocols for guidance on agitation management in older adults. METHODS: We reviewed publicly available statewide EMS protocols and the National EMS Model Guidelines to identify agitation management guidance and whether modifications for older adults were included. We assessed each protocol for the presence of 26 elements using a standardized approach. RESULTS: We analyzed 34 state protocols and the National Model Guidelines. While 33 protocols (97%) included guidance for managing agitation and 19 protocols (58%) included pediatric-specific considerations, only 11 (33%) addressed older adults. Among these, the most common modification was sedative medication dose reduction (9 protocols, 27%). No protocols included modifications to guidance/criteria for physical restraint use, prioritization/escalation between physical restraint and chemical sedation, or sedative medication selection for older adults. Guidance on medication selection varied: 29 protocols (88%) included standing orders for sedative medications, most commonly midazolam (27 protocols, 82%), ketamine (23 protocols, 70%), haloperidol (17 protocols, 52%). Only 7 protocols (21%) included specific dose adjustments for older adults, typically a 50% reduction. Benzodiazepines were most commonly recommended, while antipsychotics were less common. CONCLUSIONS: Most state EMS protocols provide guidance on management of agitated patients, including use of physical restraints and chemical sedatives, yet modifications or specific guidance for older adults are uncommon. Recognizing and addressing this gap represents an important opportunity to improve quality of prehospital care for older adults.
Ali A, Senthinathan A, Rashidian L
… +7 more, Bai YQ, Wodchis WP, Bronskill SE, Backman C, Thavorn K, Kuluski K, Guilcher SJT
J Am Geriatr Soc
· 2026 Jun · PMID 42026973
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BACKGROUND: Hip fractures are a significant public health concern, associated with substantial morbidity and mortality. Mortality is the most serious consequence of hip fractures, with a 1-year rate ranging from 14% to 3...BACKGROUND: Hip fractures are a significant public health concern, associated with substantial morbidity and mortality. Mortality is the most serious consequence of hip fractures, with a 1-year rate ranging from 14% to 36%. Hospital harms are also more prevalent among older adults with hip fractures, further increasing their risk of mortality. This study aimed to assess the incremental risk of all-cause mortality up to one-year post-discharge among hip fracture patients who experienced hospital harm. METHODS: A population-based retrospective cohort study using linked health administrative data in Ontario, Canada, was conducted. The cohort included individuals aged 50 years and older hospitalized for hip fractures between April 2008 and March 2022 and discharged alive. All-cause mortality within one-year post-discharge was the primary outcome, and hospital harm was the main exposure. We used Cox proportional hazards models to assess the association between hospital harm and mortality, adjusting for covariates (e.g., age, sex, comorbidities, frailty, and surgery status). RESULTS: A total of 131,472 patients admitted for acute hip fractures and discharged alive were included in the study, with a mean age of 80.67 ± 10.56 years. Of these patients, 17.5% experienced hospital harm during their admission for an acute hip fracture. The overall mortality rate was 18.4% within 1-year post-discharge. After adjusting for covariates, patients who experienced overall harm had a 42% higher risk of all-cause mortality during the 1-year period post-discharge (adjusted hazard ratio, aHR = 1.42, 95% confidence interval, CI: 1.38-1.46) compared to those without harm. CONCLUSION: Experiencing hospital harm significantly increased the risk of 1-year mortality after discharge among hip fracture patients. These findings underscore the importance of improving patient safety and minimizing preventable harm in hospital settings. Mitigation strategies, such as enhanced monitoring and safety protocols, could reduce hospital harm and improve long-term survival. Future research should focus on evaluating such interventions.
Akman Z, Park DY, Sohal S
… +12 more, Li DK, Hu JR, Romero LM, Rossi R, Nouri A, Nezhad SA, Al Mouslmani M, Campbell G, Kochar A, Frampton J, Damluji AA, Nanna MG
BACKGROUND: While PCI is widely used for chronic coronary disease (CCD), older adults (≥ 75 years) face distinct procedural risks, and their outcomes compared with younger patients remain incompletely understood. METHODS...BACKGROUND: While PCI is widely used for chronic coronary disease (CCD), older adults (≥ 75 years) face distinct procedural risks, and their outcomes compared with younger patients remain incompletely understood. METHODS: We investigated age-related differences in health outcomes following PCI for CCD using Vizient Clinical Data Base that includes both inpatient and outpatient PCI. Vizient aggregates clinical and outcome data from over 97% of U.S. academic medical centers and 1000+ community hospitals. We included all patients that underwent PCI for CCD between January 2016 and June 2022. The primary outcome was the occurrence of major adverse cardiovascular events (MACE). After propensity-score matching older (≥ 75 years) and younger (< 75 years) adults, we analyzed major adverse cardiovascular events (MACE) in the year following index PCI using Kaplan-Meier curves. Relative risks (RR) were calculated using Zou's modified Poisson approach. Secondary outcomes included all-cause mortality, repeat PCI, major bleeding, and cardiovascular-related hospitalizations. RESULTS: A total of 176,492 patients were included. 70.5% of patients were < 75 years old, while 29.5% were ≥ 75 years old. Most PCIs for CCD occurred in the outpatient setting (51.0%), followed by inpatient (28.6%), observation (17.1%), and other (3.3%) settings. Older adults experienced lower adjusted risk of MACE (relative risk [RR] 0.93, 95% confidence interval [CI] 0.89-0.96), as well as MI or repeat PCI, compared with younger adults. They experienced higher risk of hospitalization for a cardiovascular cause (RR 1.40, 95% CI 1.36-1.44). No significant difference was observed in the risk of all-cause mortality or major bleeding. CONCLUSION: After adjusting for baseline differences, older adults who undergo PCI for CCD have a risk of MACE and major bleeding that is comparable to younger patients. However, older adults do experience higher rates of subsequent cardiovascular hospitalizations following PCI for CCD.
Han JH, Jackson JC, Vasilevskis EE
… +13 more, Wang G, Jenkins CA, Duggan MC, Kubilay NZ, Thompson J, Moser KM, Bryant PT, Miller KF, Wrenn JO, Schnelle JF, Dittus RS, Ely EW, Simmons S
J Am Geriatr Soc
· 2026 May · PMID 41992853
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BACKGROUND: Delirium afflicts 17% of older emergency department (ED) patients and 25% of older hospitalized patients. This form of acute brain failure is associated with accelerated cognitive decline. We conducted a rand...BACKGROUND: Delirium afflicts 17% of older emergency department (ED) patients and 25% of older hospitalized patients. This form of acute brain failure is associated with accelerated cognitive decline. We conducted a randomized controlled trial to determine whether early cognitive intervention improved 4-month global cognition in older ED patients hospitalized with delirium. METHODS: A two-site randomized controlled trial was conducted with English-speaking patients aged 65 years or older who were delirious at enrollment. Patients were excluded if they had end-stage dementia, resided in a nursing home, or were in hospice. Patients were randomized to receive a cognitive intervention within 24 h of ED presentation or usual care in a 1:2 ratio. Patients randomized to cognitive intervention received twice-daily cognitive training sessions during hospitalization and weekly cognitive rehabilitation for up to 12 weeks after hospital discharge. The primary outcome was global cognition at 4 months using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), with higher scores indicating better cognition. To determine the effect of the cognitive intervention on 4-month global cognition, proportional odds logistic regression was performed, adjusted for pre-illness dementia and function, and other confounders. Adjusted odds ratios (aORs) and their 95% confidence intervals (95% CIs) are reported. RESULTS: A total of 283 patients were randomized; 97 were randomized into the cognitive intervention arm, and 186 were randomized into the usual care arm. A total of 152 patients had 4-month RBANS data. The median interquartile range (IQR) RBANS score at 4 months was 67 (49, 80) and 67 (52, 83) in the intervention and usual care groups, respectively. In the adjusted analysis, the cognitive intervention was not significantly associated with 4-month RBANS (aOR = 0.86; 95% CI: 0.45, 1.65). CONCLUSIONS: Early cognitive intervention was not associated with improved 4-month global cognition in older ED patients hospitalized with delirium.
Zhang W, Sun C, Kaufman BG
… +5 more, Coles T, Pan W, Smith VA, Coe NB, Van Houtven CH
J Am Geriatr Soc
· 2026 Apr · PMID 41992599
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BACKGROUND: Monitoring trends in key quality of life (QoL) indicators is crucial for effective surveillance and guiding targeted interventions to improve well-being. Few studies have examined population-level trends amon...BACKGROUND: Monitoring trends in key quality of life (QoL) indicators is crucial for effective surveillance and guiding targeted interventions to improve well-being. Few studies have examined population-level trends among older adults with cognitive impairment, particularly across different living and care arrangements. METHODS: We used repeated cross-sectional data from the 2008-2022 Health and Retirement Study (HRS) to examine trends in five key QoL indicators among a nationally representative sample of older adults with cognitive impairment, overall and by living and care arrangements. Logistic regression was applied to estimate prevalence rates of binary outcomes, and linear regression was used to estimate mean values of continuous outcomes, adjusting for covariates. RESULTS: The analytic sample included 7469 older adults with persistent cognitive impairment. Overall trends in poorer self-rated health, elevated depressive symptoms, and loneliness remained relatively stable over time. Among community-dwelling individuals, the prevalence of high life satisfaction increased (2008: 49.7%, 95% CI: 48.9%-50.6%; 2022: 55.8%, 95% CI: 54.3%-57.4%), whereas the prevalence of high purpose in life declined (2008: 55.5%, 95% CI: 54.5%-56.4%; 2022: 49.1%, 95% CI: 47%-51.2%). QoL varied across living and care arrangements. Community-dwelling individuals without Activities of Daily Living or Instrumental Activities of Daily Living (ADL/IADL) limitations consistently reported better QoL. Among those with ADL/IADL limitations, individuals without reported caregiving support had a higher prevalence of loneliness (2022: 33.2% vs. 22.6%) and a lower prevalence of high life satisfaction (2022: 41% vs. 54.2%) compared to those with caregiving support. CONCLUSIONS: Low QoL indicators were more prevalent among community-dwelling individuals with ADL/IADL limitations. These findings emphasize the importance of increasing access to home-based care and tailored interventions to enhance psychosocial well-being in community settings.
Neupane I, Mikolasko B, Adams CA
… +9 more, Monteiro JFG, Mujahid N, Girouard L, Arabi J, Rajan A, Bose A, Lueckel S, McNicoll L, Gravenstein S
J Am Geriatr Soc
· 2026 Jun · PMID 41992533
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BACKGROUND: Older trauma patients with rib fractures experience significantly higher morbidity and mortality compared to younger individuals. As effective pain control is a foundation of management, older adults present...BACKGROUND: Older trauma patients with rib fractures experience significantly higher morbidity and mortality compared to younger individuals. As effective pain control is a foundation of management, older adults present a challenge for clinicians aiming to balance pain control with adverse event risk. Despite the growing utilization of transdermal buprenorphine for acute pain, its effectiveness specifically in older patients with rib fractures remains under explored. METHODS: This retrospective cohort study at a trauma intensive care unit within a Level I trauma center, examined 779 patients aged ≥ 65 years admitted with multiple rib fractures from December 1, 2022 to November 30, 2024. Outcomes were compared between those who received transdermal buprenorphine and those who did not. Primary outcome was oral morphine equivalent consumption. Secondary outcomes included non-opioid analgesic use, naloxone administration, hospital length of stay (LOS), intensive care unit (ICU) LOS, complications, discharge disposition, in-hospital mortality, and 30-day readmission rates. RESULTS: Seven hundred and eighteen admissions met inclusion criteria, with 16.4% (118) receiving transdermal buprenorphine. They were significantly older (82.0 ± 8.2 vs. 79.5 ± 8.9 years, p = 0.0054) and presented with higher comorbidities (CCI 7.3 ± 4.1 vs. 6.3 ± 3.7; p = 0.0064). Total hospital opioid use did not differ significantly. However, second day post administration opioid requirements were significantly lower in the transdermal buprenorphine group (6.5 ± 17.6 mg vs. 14.8 ± 24.9 mg, adjusted p = 0.0359), as well as overall opioid consumption after patch application (18.1 ± 46.5 mg vs. 73.8 ± 138.5 mg; adjusted p < 0.0001). No differences were observed on days three or four. We report no naloxone use in the transdermal buprenorphine group versus 1.1% in the non-transdermal buprenorphine group. There were no significant differences in other secondary outcomes. CONCLUSION: Older trauma patients with multiple rib fractures treated with transdermal buprenorphine used less opioids and less naloxone during acute pain management without other benefits including LOS and mortality, suggesting a favorable safety and analgesic profile. However, a formal evaluation through a randomized controlled trial is warranted.
BACKGROUND: Virtual reality (VR) has the potential to improve the quality of life for older adults. Most studies use proprietary VR programs, specifically designed for one goal, which vastly limits the generalizability a...BACKGROUND: Virtual reality (VR) has the potential to improve the quality of life for older adults. Most studies use proprietary VR programs, specifically designed for one goal, which vastly limits the generalizability and use by the older adult population. We sought to identify out of the box (OOTB) VR applications-available to the general population-that have applicability to geriatric care and potential value in improving quality of life. METHODS: We convened and provided VR headsets to an interdisciplinary group of geriatricians, geriatric advanced practice nurses, health services researchers, older adults, and VR advanced users. Panelists were explained the goal of the study and tasked with independently searching and compiling applications that had applicability to geriatrics care or older adults, preferencing those that were cost-free or low-cost (< $20). Panel members regularly met to perform constant comparative qualitative analysis in discussions of the identified VR programs. Between meetings, panelists tested the apps that were identified and re-convened with further information. RESULTS: Of the over 200 OOTB VR applications examined, panel members identified 44 VR applications that had potential geriatric applicability and value. Potential applications were organized based on price, category, ease of use, and usefulness/applicability to older adults. Panel members reviewed potential negative attributes and applications were ranked/eliminated on perceived usability and utility for older adults. Applications were then thematically analyzed and included (1.) Cognitive support, (2.) Functional Loss/Exercise, (3.) Anti-anxiety/agitation-relaxation, (4.) Depression alleviating entertainment, and (5.) Isolation-relieving entertainment. CONCLUSION: Out of the box VR experiences can have geriatric applicability and potential value for older adults. Identifying OOTB VR through a consensus panel is the first step to generalizing use in this population. Future research will include testing with older adults, across various settings and levels of physical and cognitive function.