rural nurse organization

Just as orthopedic nurses are skilled at caring for the musculoskeletal system, and cardiac nurses specialize in caring for the heart, rural nurses are skilled at knowing a little bit about everything and balancing the needs of their patients with the often limited resources in small and sometimes isolated parts of the country.

With this realization, NRHA is excited to launch its Rural Health Nursing Certification Program! Join us for a webinar about this brand new, multifaceted course designed to equip rural nurses with the information they need and a network of colleagues to help them provide quality care in rural settings while recognizing and celebrating their vast skill sets.

For more information, see below:

Nursing Certification Program Webinar on February 21st at 1 pm EST – register here

Enrollment is open for all Certification Programs for 2023 Cohorts - visit our website for details and application information at www.crhleadership.com

The Call for Nominations is open for the 2023 RNO Election. Please consider nominating a member colleague or yourself. A nominee must be a current RNO member. 

Offices to be filled in 2023:

President Elect: 1-year, then 2 as President, then 1 year as Past President
Treasurer: 2-year term
Member at Large: 3-year term

Please send the nominee’s name, the office, the nominee’s qualifications, and contact information to Adrianne Lane at lanea6@nku.edu by February 28. If you have questions, please email Adrianne and set up a time to discuss any questions you may have. Do consider this leadership opportunity.  Thank you. 

Blog by Audrey Snyder, PhD, RN, FNP-BC, FAANP, FAEN, FAAN, President Rural Nurse Organization and Associate Dean of Experiential Learning and Innovation at the University of North Carolina Greensboro and Jessi (Seonglim) Hong, BSN, recent University of North Carolina Greensboro graduate.

As the FDA grants approval for Coronavirus vaccines for younger age groups, public health nurses must consider targeted messaging. We know that congregate settings show a higher risk of transmission of COVID-19. Some concerns expressed by college age students include missing classes if they had side effects and feeling they could not risk missing classes or an assignment.

Involve school systems. Schools could be involved and provide notes for students' instructors after getting vaccinated that would excuse the students from their school assignments, quizzes, or exams for a couple of days if they need it to recover but ONLY after getting vaccinated that day. This could be posted on the school's websites, their student health center's websites, their school's social media pages, signs displayed on their campus and dorms, and school emails / text messages. Sometimes, students would need that extra couple of days to complete assignments that they might be behind on or even take a break for their mental health.

Capitalize on peer pressure. Everyone has to wait for at least 15 minutes after being vaccinated. A small slip with a QR code to the registration webpage could be provided to each vaccinated person. While people are waiting in the post-vaccine area and/or making their second appointments (if Pfizer or Moderna), the person can message this site to their friends and friends to encourage them to get vaccinated. Since young people tend to have their own group of friends (high school and college) that influence them, it would be easier to reach those people through their own friends or families.

Survey young people to develop programing. Young people / adults are still in the stage of finding themselves, so their focus is generally more on themselves versus considering others. We need to survey and find out what they miss the most during this pandemic. Then use the data to build a foundation on what factors we need to focus on to plan how to target the population. Regardless of age, people hate feeling like they're being told what to do. People automatically draw back when they feel that they're being forced to do something. It's natural. On some campuses there have been lotteries for vaccinated students to win tuition, food, or housing vouchers.  It might be successful if the school surveys students on what STUDENTS would like to win. The school will provide the options of the prizes that the young people would be interested in (of course, more data would need to be collected about the topic prior to posting surveys), and students will have their voices counted towards the prizes they picked. This is a great option to consider because people's participation and cooperation increase when they're active participants in the planning process. Then the school can decide which prizes will be given in which week for students who received vaccines for that week. And students who would like to receive those prizes will be more likely to show up during the week to receive their vaccines.

The surveys can be posted on the school's social media such as Facebook, Instagram, or by using school emails or even better by using all of them to reach the maximum number of students possible. Following the vaccine clinics, the school will send out the information to the winner(s) and the prize they won. The school can ask the student who won to share their story on their social media so that their other classmates or colleagues can see them too. Social media is the fastest way to disseminate information for young people.

Apply the Health Belief Model. Sundstrom and colleagues (2015) explored the Health Belief Model (HBM) with factors influencing college-age women’s decision to receive HPV vaccine. The HBM explains how an individual’s behavior might change if they perceive that they’re susceptible to a serious health disease. In other words, if pros outweigh cons, the individual’s behavior will change. Some of the factors include safety and concerns about the vaccine, cost, consent from parents, and perception of individual’s susceptibility to disease. Four factors that the researcher collected data on were perceived threat, benefits, barriers, and cues to action. Perceived threats were concerns about getting the disease and complications from it. Benefits included physician’s recommendation, support from parents, and individual’s desire to prevent disease or complications which affected the individual’s decision to receive the vaccine. Barriers were mainly concerns about the safety of the vaccine. Cues to action included TV, internet, magazine, paper, news, mass media campaigns, and so on. Students’ concern regarding the safety of getting vaccinated was the only factor that was a negative impact.

Some of the important information that needs to be considered are racial disparities and involvement of parents and students’ primary physicians. Based on the study results, race/ethnicity was the major predictor of college-age women receiving the HPV vaccine. First year black students were least likely to receive the vaccine compared to white students who were more likely to receive the vaccine compare to other students in different races. Parents and primary physicians were identified as the most trusted sources to obtain information about the vaccine and TV and internet were least likely sources to obtain the same information. The main reason that the participants avoided TV and internet was due to misleading or incomprehensive information. The researcher also pointed out that it’s crucial to provide multimodal information and target both internal and external cues to action. And the reason was that the information they obtain from their parents or primary physicians were more trustworthy than the information they’d obtain from TV and internet. For media, new media such as YouTube videos, Twitters, and text messages were identified as the most effective communication to promote successful message delivery. Another important factor was that college-age women were strongly influenced by their peer’s intention to vaccinate or vaccination. They were more likely to get vaccinated if their peers were, as well.

If we consider the results of this vaccine study (Sundstrom et al., 2015), it’s crucial to collect data from parents, healthcare providers, people that are college-age, and people with different races/backgrounds regarding COVID-19 hesitancy. We need to collect data on parents’ and health care providers’ intentions of getting vaccinated (their family and friends) and their barriers, then come up with interventions that will target them. Since parents and physicians are the most influential in deciding to get vaccinated or not, we need to market to them the most. College students will most likely listen to their parents and physicians rather than TV and internet when they’re weighing the pros and cons of getting the COVID-19 vaccines. People, especially college students, will be less likely to trust information from TV and internet because it can be ambiguous and misleading.

We need comprehensive data from people in all age groups, but specifically from college students. We need to collect data on their opinions of media coverage on the vaccines, perceived accuracy of vaccine information, and preferred communication media. We need to identify what kind of messages each individual received from watching commercials or news on the vaccines to decide if they had negative impact on getting vaccinated. Their perceived accuracy of vaccine information is needed to evaluate if any additional information is needed to clarify misinformation. Finding out their preferred communication media is important because that’s how they will be in contact with vaccine information. Technology is developing fast, so we need to be more sensitive of which social media is on trend now. For example, current trending media for college students is Tik-Tok, Snapchat, and Instagram.

Lastly, collecting information on individual barriers is crucial. For many, safety concern is a major barrier. Each individual would like to know the accurate and comprehensive information on each COVID-19 vaccine brand that addresses safety concerns that they might have. Along with that, we need to target the same audience with consequences of COVID-19, such as multi-organ failure or huge hospital bills, so that they can weigh pros and cons of getting vaccinated. Having a vaccine question hotline staffed with a knowledgeable person and a designated person to answer concerns at vaccine sites before the person makes it to the vaccine station can help ensure people have accurate information to make decisions on vaccination.

A couple of interventions we can implement are involving peers and creating narrated videos. College students are most likely influenced by their peers. Instead of reaching out to each individual, contacting a group of students could be more successful. A group of students can be a sports team or a student organization whose members can easily catch the virus from each other. By reminding them of this fact, students might feel more motivated to get vaccinated to protect their friends or teammates from catching COVID. Narrated videos that have their colleagues, friends, or family plus a healthcare or CDC expert will more likely influence college students to get vaccinated than lengthy emails or the school’s public messages.

One last thing to think about is different cultures and languages. It could be difficult for students that are on international studies or are immigrants to understand the vaccine information fully. They might not feel safe enough to get vaccinated because they might not understand the severity or consequences of the disease either because of a language barrier or a lack of knowledge. Also, they might not be aware of the types of different COVID vaccines or their potential side effects. It’s essential to see the statistical data of different races and cultures of each college’s students and to determine how many different languages the informational videos should be narrated in.

What we should not forget is the fact that safety is the most importance concern against getting vaccinated, especially for COVID. Therefore, it is crucial to provide up-to-date research information on each COVID vaccine for each individual to decide which vaccine they would like to receive (if they have the option). Because of possible complications that happened with a few people who received the vaccines, some students and their parents will be worried and hesitant towards getting vaccinated. Mass media constantly showing news and raising fear in people has not helped, either. As nurses, it is our job to educate them on how rarely complications happen (provide accurate numbers), how they will be monitored post-vaccine for these potential complications, what signs or symptoms to watch out for, and when to see a doctor or seek emergency care. Personally, when we had people who were concerned about the potential side effects, we asked them to weigh the pros and cons of getting vaccinated, “Would you rather have small potential side effects from getting these vaccines or have multi-organ failure due to COVID complications?” I think that sometimes people need to be redirected. They do not realize that the fear or thoughts they have are not originally theirs. It is what their subconscious mind picked up from listening to all the news and people talking about the vaccines.

Identifying barriers and concerns can help tailor marketing of the CoVID-19 vaccine. Public health nurses can then target messaging to increase COVID-19 vaccine uptake in the younger population. Now is the time to act as high school students prepare to go to college and before the fall semester is back in session for college and high school students. 

References

Sundstrom, B., Carr, L. A., DeMaria, A. L., Korte, J. E., Modesitt, S. C., & Pierce, J. Y. (2015). Protecting the next generation: elaborating the health belief model to increase HPV vaccination among college-age women. Social Marketing Quarterly, 21(3), 173–188.

Author: Angeline Bushy, PhD, RN, FAAN, U.S. Army, Col. (Retired)

Since the founding of our country, rural Americans have always responded when our Nation has gone to war. In the American Revolution, rural Americans left their homes and their families to fight the threat of loss to their families and their lands. During the American Civil War, rural Americans again responded to fight the threat of loss to their way of life and to protect their families. However, during the Civil War, the United States government instituted the first-ever military draft. Again, motivated by tradition and values, rural Americans responded.

According to an Issue Paper published by the National Rural Health Association Rural (2007) people respond to such needs because they maintain value structures that are reflective of service to others and service to their country, volunteerism, care of home, and a sense of place. They also respond to economic concerns and certainly through patriotism. Whether motivated by their values, patriotism, and/or economic concerns, the picture has not changed much in 200 years. More than 44 percent of U.S. military recruits come from rural areas, Pentagon figures show. In contrast, 14 percent come from major cities. Youths living in the most sparsely populated Zip Codes are 22 percent more likely to join the Army, with an opposite trend in cities. Regionally, most enlistees come from the South (40 percent) and West (24 percent) (NRHA, 2007).

In the last two decades, the United States has been involved with a number of military conflicts predominately in the Mideast (US Department of Veterans Affairs (VA), 2013), resulting in the deployment of numerous military personnel. Moreover, it is not unusual for a soldier to be deployed multiple times within a 3 year period. Since the U.S. has an all-volunteer military (army, air force, navy, marines) the majority are in the reserve component or the National Guard. Again, a disproportionate number of returning veterans have rural origins and are returning to their home communities having physical and emotional healthcare needs.

Compared to urban veterans, rural veterans have higher prevalence of physical illness, lower health-related quality of life, and greater health care needs. Despite their greater need, rural veterans are less likely than urban veterans to use VA or private sector health care services. The disparity in use of health care may be due in part to longer driving distances to VA medical facilities experienced by many rural veterans, relative to their urban counterparts. VA primary care is available within a 30-minute drive for 91% of urban veterans, 38% of rural veterans, and 22% of highly rural veterans. Fewer than half (49%) of highly rural veterans live within 60 minutes of VA primary care.

The Department of Veterans Affairs (VA) is statutorily required to provide the VA-enrolled veteran with access to timely and quality medical care. It does so through the nation’s largest integrated healthcare delivery system, with more than 150 VA medical centers (VAMCs), 800 community-based outpatient clinics (CBOCs), and a range of other types of facilities (e.g., nursing homes) that provide care to more than 5.5 million patients. Despite this, Congress remains concerned that veterans, in particular, rural veterans, may not be able to access VA health services. Among veterans enrolled in VA health care, 41% reside in rural or highly rural areas. Rural-enrolled veterans share certain characteristics that influence access to and the need for care.

Congress has demonstrated continuing interest in modifying VA delivery of care to expand access for rural veterans. Such interest has been demonstrated through report language, statutory mandates, appropriation of funds, and authorization of demonstration projects. In particular, Congress has encouraged the VA to collaborate with federally qualified health centers (FQHCs)—facilities that receive federal grants and are required to be located in areas where there are few providers, particularly rural areas. The VA is generally a provider—rather than a financer—of health care services; however, the VA has statutory authority to reimburse non-VA providers for services that are not readily available within the VA’s integrated health care delivery system. VA facilities may consider contracting with outside providers to provide services to rural veterans.

One type of facility that the VA has contracted with in the past are FQHCs. Although FQHCs are one type of facility that the VA can collaborate with, FQHCs may be candidates for VA collaboration because, as a condition of receiving a federal grant, they must meet certain requirements that include providing specific types of services, maintaining certain records, and meeting certain quality standards. These requirements, and the leverage that the federal government may have as a funding source may facilitate VA-FQHC collaboration to provide care to veterans in rural areas. Some considerations that may arise during attempts to increase VA-FQHC collaboration include the costs of care to an FQHC, the VA, and veterans; the capacity of an FQHC to serve veterans in addition to its existing patients; and the compatibility of the VA and an FQHC in terms of the services available, quality initiatives, accreditation, and use of electronic health records. To address these considerations and encourage VA-FQHC collaboration, there are a number of policy levers that Congress might use. These include oversight, an incentive fund, directed spending, statutory mandates, and watchful waiting. Congress may also consider a combination of these levers.

Table I: VA-Enrolled Veterans *

Not all veterans are eligible to enroll in the VA. In general, eligibility for enrollment in VA health care operates through a system of eight priority groups, based on veteran status, the presence of service-connected disabilities or exposures, income, and/or other factors, such as status as a former prisoner of war or receipt of a Purple Heart. Once enrolled in the VA health care system, a veteran remains enrolled and does not have to reapply, even if the veteran’s priority group changes (due, for example, to a change in income).Veteran status is established by active-duty status in the U.S. Armed Forces and an honorable discharge or release from active military service. Generally, persons enlisting in one of the armed forces after September 7, 1980, and officers commissioned after October 16, 1981, must have completed two years of active duty or the full period of their initial service obligation to be eligible for VA health care benefits. Service members discharged at any time because of service-connected disabilities are not held to this requirement. Veterans returning from combat operations are eligible to enroll for five years from the date of discharge without having to satisfy a means test or demonstrate a service-connected disability. A service-connected disability is a disability that was incurred or aggravated in the line of duty in the U.S. Armed Forces (38 U.S.C. §101 (16)). The VA determines whether veterans have service-connected disabilities and, for those with such disabilities, assigns ratings from 0% to 100% based on the severity of the disability (38 C.F.R. §§4.1-4.31). Veterans who are eligible on the basis of exposure include those veterans who may have been exposed to Agent Orange during the Vietnam War or veterans who may have diseases potentially related to service in the Gulf War.

*Source: CRS Report R42747, Health Care for Veterans: Answers to Frequently Asked Questions, by Sidath Viranga Panangala and Erin Bagalman.

References:

Congressional Research Service. (2013, April 3). Health Care for Rural Veterans: The Example of Federally Qualified Health Centers. Accessed on May 21, 2013 from http://www.himss.org/files/HIMSSorg/Content/files/20130418-CRS-RptHealthCareRuralVeterans.pdf

National Rural Health Association Issue Paper. (2007). Rural Veterans: A special Concern for Rural Health Advocates. Accessed May 21, 2013 from: http://www.ruralhealthweb.org/go/rural-health-topics/veterans-health

US Department of Veterans Affairs Website, Accessed on May 21, 2013 from: http://www.va.gov

US Department of Veterans Affairs (2013). Rural Health Exchange Information. Accessed on May 21, 2013, from http://www.va.gov/health/NewsFeatures/20110421a.asp

Author: Margaret (Meega) Wells, PhD, RN, NP

Nurse practitioners in the primary care setting in both rural and urban areas are in ideal positions to provide quality care to older adult patients to help them maintain independence and function. According to the U.S. Census Bureau (2010), it is estimated that 13% of the U.S. population is 65 years and older. Most of these older adults reside in the community and receive health care in outpatient settings. Older adult patients are often complicated to manage and nurse practitioners must be systematic and thorough in providing care to this group. A comprehensive geriatric assessment (CGA) should be performed once a year along with periodic focused assessments for the management of chronic illnesses. Ideally, performing a CGA on a regular basis will allow the nurse practitioner to detect subtle changes in older adults and intervene before major problems occur. Components of the comprehensive geriatric assessment should include medical, psychosocial, cognitive, and functional assessments. Assessing functional assessment of older adults using physical performance measures will be the focus of this article. 

Functional Component

The functional assessment should include self-reported measures as well as an objective physical performance measure. First, it is necessary to ask patients if they have any difficulties with activities of daily living (ADL). ADL include eating, dressing, ambulating, and toileting. Next, patients should be asked about their ability to perform instrumental activities of daily living (IADL). IADL include shopping, managing finances, housekeeping, taking medications, using the telephone, and driving or using public transportation and this requires higher executive functioning. Inability to perform IAD is also associated with cognitive impairment. (Reppermund et al., 2011)

It is important that nurse practitioners watch their patients’ walk and this is often omitted from the geriatric assessment. Patients are usually put in the exam room and assisted to the exam table prior to the nurse practitioner’s arrival to the room. Nurse practitioners may not have the opportunity to observe patients walk unless they incorporate it into the physical exam. There are several physical performance measures that can be used to objectively measure physical function. Gait speed and Timed Up and Go (TUG) are two measures that will be discussed in this article and both of these measures include observation of gait.

In many cohort studies, gait speed, or the rate in which one walks, has been found to be associated with survival in older adults. (Cesari et al., 2005; Cesari et al., 2009; Ostir, Kuo, Berges, Markides, & Ottenbacher, 2007; Rolland et al., 2006; Rosano et al., 2008) Walking requires energy, movement control, and support, which put a demand on multiple organ systems, and this is why gait speed is thought to predict survival. (Abellan van Kan et al., 2009) Gait speed is usually calculated using time in seconds to walk 4 meters and is reported in meters per second. Gait speeds of 1 m/s or faster suggest healthier aging, while gait speeds of 0.6 m/s or slower increase the likelihood of poor health and function. (Viccaro, Perera, & Studenski, 2011)

In a systematic review of 9 cohort studies for a total of 34,485 community-dwelling older adults who had gait speed measured at baseline, and survival monitored for at least 5 years, the overall 5-year survival rate for participants was 84% and the 10-year survival rate was 59.7%. (Abellan van Kan et al., 2009) The mean gait speed of the participants was 0.92 meters per second (m/s) and it was associated with survival in all studies using hazard ratios. Survival increased as gait speed increased in 0.1 m/s increments.

Gait speed measurement has a place in the clinical setting because it may help identify older adults who have a high probability of living for 5 or 10 years and would benefit from more intensive preventative interventions. Further, gait speed may be used to help stratify risks of the patient for surgery or chemotherapy. Gait speed is relatively easy to measure and only requires a stopwatch and a 4-meter course. Patients are instructed to walk at usual pace, as if walking down the street, with no further encouragement or instructions. A gait speed less than 1 m/s or a declining gait speed over time may indicate a new health problem that requires evaluation. A physical therapy referral may be needed at this time. A recent systematic review of frail older adults found that an exercise intervention improved gait speed and performance on ADLs; however, the type of exercise was not specified nor was the effect on mortality. (Chou, Hwang, & Wu, 2012) Hardy and colleagues found that improved gait speed significantly reduced mortality in a sample of community-dwelling adults 65 years and older. (Hardy, Perera, Roumani, Chandler, & Studenski, 2007)

The TUG test can also be used to assess balance and gait. The TUG measures some aspects of balance such as rising, walking, turning, and sitting and is correlated with functional mobility. (Podsiadlo & Richardson, 1991) The TUG is quick, requires no special equipment, and can be done in about 1-2 minutes during an office visit. The TUG is the time it takes a patient to rise from a standard height chair with arms, walk 10 feet (3 meters), turn around, walk back to the chair and sit down. Patients may use their arms or an assistive device when rising from the chair; however, another person may not assist them. This screening test is timed and using assistive devices or the arms of the chair to rise may slow down the time it takes to complete the task. An independently mobile adult should be able to complete the TUG in less than 10 seconds. A TUG time of 15 seconds or greater requires further evaluation to determine the cause of the mobility impairment. If a musculoskeletal problem is found to be the problem, a referral to physical therapy may be appropriate.

Gait speed and TUG both were found to predict health decline, ADL difficulty, and falls in older adults living the community. (Viccaro et al., 2011) However, both tests were found to be more useful in predicting recurrent falls rather than first-time falls. (Viccaro et al., 2011)According to the Panel on Prevention of Falls in Older Persons, TUG is recommended to evaluate gait and balance in patients with a positive fall screen or those at risk for falling. (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011) Evidence exists that supports using gait speed or the TUG to screen for mobility impairment; however, more research is needed is support interventions that can improve or maintain physical function.

Summary

It is essential that nurse practitioners perform a comprehensive geriatric assessment as least once a year on all older adult patients. The four components of this evaluation include medical, psychosocial, cognitive, and functional assessments. In the primary care setting, many nurse practitioners do not always objectively evaluate the physical functional ability of patients. Either gait speed or TUG can be used to measure functional ability in older adults. Both are easy to perform and do not require special equipment other than a chair, a measured distance, and a stopwatch. Both tests require patients to follow direction to carry out the task. The nurse practitioner can obtain much information from watching the patient perform these tasks. Maintaining independence is important to older adults and detecting subtle changes in functional ability can help nurse practitioners to manage the care older adult patients more effectively. The nurse practitioner should perform a comprehensive geriatric assessment that includes either gait speed or the TUG. If either is found to be slow or declined from the previous year, careful evaluation of the patient is needed and an intervention such as physical therapy or an individualized exercise program may be an appropriate addition to the treatment plan prescribed by the nurse practitioner.

References

Abellan van Kan, G., Rolland, Y., Andrieu, S., Bauer, J., Beauchet, O., Bonnefoy, M., et al. (2009). Gait speed at usual pace as a predictor of adverse outcomes in community-dwelling older people an international academy on nutrition and aging (IANA) task force. Journal of Nutrition, Health & Aging, 13(10), 881-889.

Cesari, M., Kritchevsky, S. B., Penninx, B. W., Nicklas, B. J., Simonsick, E. M., Newman, A. B., et al. (2005). Prognostic value of usual gait speed in well-functioning older people--results from the health, aging and body composition study. Journal of the American Geriatrics Society, 53(10), 1675-1680.

Cesari, M., Pahor, M., Marzetti, E., Zamboni, V., Colloca, G., Tosato, M., et al. (2009). Self-assessed health status, walking speed and mortality in older mexican-americans. Gerontology, 55(2), 194-201.

Chou, C., Hwang, C., & Wu, Y. (2012). Effect of exercise on physical function, daily living activities, and quality of life in the frail older adults: A meta-analysis. Archives of Physical Medicine and Rehabilitation, 93(2), 237-244.

Hardy, S. E., Perera, S., Roumani, Y. F., Chandler, J. M., & Studenski, S. A. (2007). Improvement in usual gait speed predicts better survival in older adults. Journal of the American Geriatrics Society, 55(11), 1727-1734.

Ostir, G. V., Kuo, Y. F., Berges, I. M., Markides, K. S., & Ottenbacher, K. J. (2007). Measures of lower body function and risk of mortality over 7 years of follow-up. American Journal of Epidemiology, 166(5), 599-605.

Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. (2011). Summary of the updated american geriatrics society/british geriatrics society clinical practice guideline for prevention of falls in older persons. Journal of the American Geriatrics Society, 59(1), 148-157.

Podsiadlo, D., & Richardson, S. (1991). The timed "up & go": A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 39(2), 142-148.

Reppermund, S., Sachdev, P. S., Crawford, J., Kochan, N. A., Slavin, M. J., Kang, K., et al. (2011). The relationship of neuropsychological function to instrumental activities of daily living in mild cognitive impairment. International Journal of Geriatric Psychiatry, 26(8), 843-852.

Rolland, Y., Lauwers-Cances, V., Cesari, M., Vellas, B., Pahor, M., & Grandjean, H. (2006). Physical performance measures as predictors of mortality in a cohort of community-dwelling older french women. European Journal of Epidemiology, 21(2), 113-122.

Rosano, C., Aizenstein, H., Brach, J., Longenberger, A., Studenski, S., & Newman, A. B. (2008). Special article: Gait measures indicate underlying focal gray matter atrophy in the brain of older adults. Journals of Gerontology Series A-Biological Sciences & Medical Sciences, 63(12), 1380-1388.

U.S, C. B. (2010). USA QuickFacts. Retrieved December 29, 2011, from http://quickfacts.census.gov/qfd/states/00000.html

Viccaro, L. J., Perera, S., & Studenski, S. A. (2011). Is timed up and go better than gait speed in predicting health, function, and falls in older adults?. Journal of the American Geriatrics Society, 59(5), 887-892.