Functional Disability Among Older Versus Younger Adults With Advanced Non-Small-Cell Lung Cancer

PURPOSE

To determine patient and disease characteristics associated with functional disability among adults with advanced non-small-cell lung cancer (NSCLC).

METHODS

In a prospective cohort of participants newly diagnosed with advanced NSCLC and beginning systemic treatment, functional disability in usual activities, mobility, and self-care was measured using the EuroQol-5D-5L at baseline. Demographics, comorbidities, brain metastases, Eastern Cooperative Oncology Group performance status (ECOG PS), and psychologic variables (depression [Patient Health Questionnaire-9] and anxiety [Generalized Anxiety Disorder 7-item scale]) were captured. Patients were classified into two disability groups (none-slight or moderate-severe) on the basis of total functional status scores. Differences between disability groups were determined (chi-square and t tests). Associations between patient characteristics and baseline disability were assessed using logistic regression.

RESULTS

Among 173 participants, mean age was 63.3 years, 56% were male, 83% had ECOG PS 0-1, and 41% had brain metastases. Baseline disability was present in 39% of participants, with patients having moderate to severe disability in usual activities (37.6%), mobility (26.6%), and self-care (5.2%). Depressive and/or anxiety symptoms ranged from none to severe (Patient Health Questionnaire 9-item scale M = 6.5, SD = 5.3). Depressive symptoms were the only characteristic associated with a higher odds of baseline disability (adjusted odds ratio [aOR]: 1.26; 95% CI, 1.15 to 1.38; P < .001). Participants with poorer ECOG PS (aOR: 4.64; 95% CI, 1.84 to 11.68; P = .001) and depressive symptoms (aOR: 1.15; 95% CI, 1.07 to 1.24; P < .001) had higher odds of moderate-severe mobility disability compared with the none-slight disability group.

CONCLUSION

More than one third of all adults with advanced NSCLC have moderate-severe functional disability at baseline. Psychologic symptoms were significantly associated with moderate-severe baseline disability.

Racial and Ethnic Differences in Multimorbidity Changes Over Time

BACKGROUND

Our understanding of how multimorbidity progresses and changes is nascent.

OBJECTIVES

Assess multimorbidity changes among racially/ethnically diverse middle-aged and older adults.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study using latent class analysis to identify multimorbidity combinations over 16 years, and multinomial logistic models to assess change relative to baseline class membership. Health and Retirement Study respondents (age 51 y and above) in 1998 and followed through 2014 (N=17,297).

MEASURES

Multimorbidity latent classes of: hypertension, heart disease, lung disease, diabetes, cancer, arthritis, stroke, high depressive symptoms.

RESULTS

Three latent classes were identified in 1998: minimal disease (45.8% of participants), cardiovascular-musculoskeletal (34.6%), cardiovascular-musculoskeletal-mental (19.6%); and 3 in 2014: cardiovascular-musculoskeletal (13%), cardiovascular-musculoskeletal-metabolic (12%), multisystem multimorbidity (15%). Remaining participants were deceased (48%) or lost to follow-up (12%) by 2014. Compared with minimal disease, individuals in cardiovascular-musculoskeletal in 1998 were more likely to be in multisystem multimorbidity in 2014 [odds ratio (OR)=1.78, P<0.001], and individuals in cardiovascular-musculoskeletal-mental in 1998 were more likely to be deceased (OR=2.45, P<0.001) or lost to follow-up (OR=3.08, P<0.001). Hispanic and Black Americans were more likely than White Americans to be in multisystem multimorbidity in 2014 (OR=1.67, P=0.042; OR=2.60, P<0.001, respectively). Black compared with White Americans were more likely to be deceased (OR=1.62, P=0.01) or lost to follow-up (OR=2.11, P<0.001) by 2014.

CONCLUSIONS AND RELEVANCE

Racial/ethnic older adults are more likely to accumulate morbidity and die compared with White peers, and should be the focus of targeted and enhanced efforts to prevent and/or delay progression to more complex multimorbidity patterns.

Metabolic syndrome and the benefit of a physical activity intervention on lower-extremity function: Results from a randomized clinical trial

BACKGROUND

In older adults, increases in physical activity may prevent decline in lower-extremity function, but whether the benefit differs according to metabolic syndrome (MetS) status is uncertain. We aim to investigate whether structured physical activity is associated with less decline in lower-extremity function among older adults with versus without MetS.

METHODS

We used data from the multicenter Lifestyle Interventions and Independence for Elders (LIFE) study to analyze 1535 sedentary functionally-vulnerable women and men, aged 70 to 89 years old, assessed every 6 months (February 2010-December 2013) for an average of 2.7 years. Participants were randomized to a structured, moderate-intensity physical activity intervention (PA; n = 766) or health education program (HE; n = 769). MetS was defined according to the 2009 multi-agency harmonized criteria. Lower-extremity function was assessed by 400-m walking speed and the Short Physical Performance Battery (SPPB) score.

RESULTS

763 (49.7%) participants met criteria for MetS at baseline. Relative to HE, PA was associated with faster 400-m walking speed among participants with MetS (P < 0.001) but not among those without MetS (P = 0.91), although the test for statistical interaction was marginally non-significant (P = 0.07). In contrast, no benefit of PA versus HE was observed on the SPPB score in either MetS subgroup.

CONCLUSIONS

Among older adults at high risk for mobility disability, moderate-intensity physical activity conveys significant benefits in 400-m walking speed but not SPPB in those with, but not without, MetS. The LIFE physical activity program may be an effective strategy for maintaining or improving walking speed among vulnerable older adults with MetS.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01072500.

Pain, Complex Chronic Conditions and Potential Inappropriate Medication in People with Dementia. Lessons Learnt for Pain Treatment Plans Utilizing Data from the Veteran Health Administration

Alzheimer's disease and related dementias (ADRD), pain and chronic complex conditions (CCC) often co-occur leading to polypharmacy and with potential inappropriate medications (PIMs) use, are important risk factors for adverse drug reactions and hospitalizations in older adults. Many US veterans are at high risk for persistent pain due to age, injury or medical illness. Concerns about inadequate treatment of pain-accompanied by evidence about the analgesic efficacy of opioids-has led to an increase in the use of opioid medications to treat chronic pain in the Veterans Health Administration (VHA) and other healthcare systems. This study aims to investigate the relationship between receipt of pain medications and centrally (CNS) acting PIMs among veterans diagnosed with dementia, pain intensity, and CCC 90-days prior to hospitalization. The final analytic sample included 96,224 (81.7%) eligible older veterans from outpatient visits between October 2012-30 September 2013. We hypothesized that veterans with ADRD, and severe pain intensity may receive inappropriate pain management and CNS-acting PIMs. Seventy percent of the veterans, and especially people with ADRD, reported severe pain intensity. One in three veterans with ADRD and severe pain intensity have an increased likelihood for CNS-acting PIMs, and/or opioids. Regular assessment and re-assessment of pain among older persons with CCC, patient-centered tapering or discontinuation of opioids, alternatives to CNS-acting PIMs, and use of non-pharmacological approaches should be considered.

Risk Factors for Disability After Emergency Department Discharge in Older Adults

OBJECTIVES

We have previously shown that older adults discharged from the emergency department (ED) experience an increased disability burden within a 6-month time period after ED discharge. The objective of this study was to identify risk factors associated with increased disability burden among older adults discharged from the ED.

METHODS

This study is part of an ongoing longitudinal study of 754 community-living persons aged ≥70 years. The analytic sample included 813 ED visits without hospitalization from 430 participants who had at least one visit to an ED during a 14-year follow-up period (1998-2012). Information on ED visits and disability burden in 13 functional activities was collected during monthly interviews. Twenty-nine candidate risk factors were evaluated for their independent associations with increased disability burden using a longitudinal multivariable model.

RESULTS

In the multivariable analyses, age ≥85 (adjusted risk ratio [aRR] = 1.14, 95% confidence interval [CI] = 1.05 to 1.24), being unmarried (aRR = 1.15, 95% CI = 1.05 to 1.27), lower-extremity weakness (aRR = 1.20, 95% CI = 1.07 to 1.34), and physical frailty (aRR = 1.25, 95% CI = 1.13 to 1.37) were associated with increased disability burden. As the number of risk factors increased, the predicted mean disability burden (on a scale of 0 to 13) also increased, ranging from a value of 1.80 (95% CI = 1.43 to 2.27) for 0 risk factors to a value of 8.59 (95% CI = 7.93 to 9.29) for four risk factors.

CONCLUSIONS

Among older adults discharged from the ED, several risk factors were associated with increased disability burden over the following 6 months, including age ≥85, being unmarried, lower-extremity weakness, and physical frailty. Further research is needed to evaluate whether risk stratification based on nonmodifiable factors or interventions targeting modifiable risk factors improve functional outcomes for older adults discharged from the ED.

Reform influences location of death: Interrupted time-series analysis on older adults and persons with dementia

Background

Norway instituted a Coordination Reform in 2012 aimed at maximizing time at home by providing in-home care through community services. Dying in a hospital can be highly stressful for patients and families. Persons with dementia are particularly vulnerable to negative outcomes in hospital. This study aims to describe changes in the proportion of older adults with and without dementia dying in nursing homes, home, hospital and other locations over an 11-year period covering the reform.

Methods and findings

This is a repeated cross-sectional, population-level study using mortality data from the Norwegian Cause of Death Registry hosted by the Norwegian Institute of Public Health. Participants were Norwegian older adults 65 years or older with and without dementia who died from 2006 to 2017. The policy intervention was the 2012 Coordination Reform that increased care infrastructure into communities. The primary outcome was location of death listed as a nursing home, home, hospital or other location. The trend in the proportion of location of death, before and after the reform was estimated using an interrupted time-series analysis. All analyses were adjusted for sex and seasonality. Of the 417,862 older adult decedents, 61,940 (14.8%) had dementia identified on their death certificate. Nursing home deaths increased over time while hospital deaths decreased for the total population (adjusted Relative Risk Ratio (aRRR) 0.87, 95% CI 0.82–0.92) and persons with dementia (aRRR: 0.93, 95%CI 0.91–0.96) after reform implementation.

Conclusion

This study provides evidence that the 2012 Coordination Reform was associated with decreased older adults dying in hospital and increased nursing home death; however, the number of people dying at home did not change.

Effect of a Multifactorial Fall Injury Prevention Intervention on Patient Well-Being: The STRIDE Study

BACKGROUND/OBJECTIVES

In the Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) study, a multifactorial intervention was associated with a nonsignificant 8% reduction in time to first serious fall injury but a significant 10% reduction in time to first self-reported fall injury relative to enhanced usual care. The effect of the intervention on other outcomes important to patients has not yet been reported. We aimed to evaluate the effect of the intervention on patient well-being including concern about falling, anxiety, depression, physical function, and disability.

DESIGN

Pragmatic cluster-randomized trial of 5,451 community-living persons at high risk for serious fall injuries.

SETTING

A total of 86 primary care practices within 10 U.S. healthcare systems.

PARTICIPANTS

A random subsample of 743 persons aged 75 and older.

MEASUREMENTS

The well-being measures, assessed at baseline, 12 months, and 24 months, included a modified version of the Fall Efficacy Scale, Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and depression scales, and Late-Life Function and Disability Instrument.

RESULTS

Participants in the intervention (n = 384) and control groups (n = 359) were comparable in age: mean (standard deviation) of 81.9 (4.7) versus 81.8 (5.0) years. Mean scores were similar between groups at 12 and 24 months for concern about falling, physical function, and disability, whereas the intervention group's mean scores on anxiety and depression were .7 points lower (i.e., better) at 12 months and .6 to .8 points lower at 24 months. For each of these outcomes, differences between the groups' adjusted least square mean changes from baseline to 12 and 24 months, respectively, were quantitatively small. The overall difference in means between groups over 2 years was statistically significant only for depression, favoring the intervention: -1.19 (99% confidence interval, -2.36 to -.02), with 3.5 points representing a minimally important difference.

CONCLUSIONS

STRIDE's multifactorial intervention to reduce fall injuries was not associated with clinically meaningful improvements in patient well-being.

Tracking Multimorbidity Changes in Diverse Racial/Ethnic Populations Over Time: Issues and Considerations

Multimorbidity is widely recognized as having adverse effects on health and wellbeing and may threaten the ability of older adults to live independently. Much of what is known about multimorbidity rests on research that has largely focused on one point in time, or from a static perspective. Given that there remains a lack of agreement in the field on how to standardize multimorbidity definitions and measurement, it is not surprising that analyzing and predicting multimorbidity development, progression over time, and its impact are still largely unaddressed. As a result, there are important gaps and challenges to measuring and studying multimorbidity in a longitudinal context. This Research Practice perspective summarizes pressing challenges and offers practical steps to move the field forward.

Health-care use and cost for multimorbid persons with dementia in the National Health and Aging Trends Study

BACKGROUND

Most persons with dementia have multiple chronic conditions; however, it is unclear whether co-existing chronic conditions contribute to health-care use and cost.

METHODS

Persons with dementia and ≥2 chronic conditions using the National Health and Aging Trends Study and Medicare claims data, 2011 to 2014.

RESULTS

Chronic kidney disease and ischemic heart disease were significantly associated with increased adjusted risk ratios of annual hospitalizations, hospitalization costs, and direct medical costs. Depression, hypertension, and stroke or transient ischemic attack were associated with direct medical and societal costs, while atrial fibrillation was associated with increased hospital and direct medical costs. No chronic condition was associated with informal care costs.

CONCLUSIONS

Among older adults with dementia, proactive and ambulatory care that includes informal caregivers along with primary and specialty providers, may offer promise to decrease use and costs for chronic kidney disease, ischemic heart disease, atrial fibrillation, depression, and hypertension.

Statistical Considerations for Embedded Pragmatic Clinical Trials in People Living with Dementia

There is overwhelming need for nonpharmacological interventions to improve the health and well-being of people living with dementia (PLWD). The National Institute on Aging Imbedded Pragmatic Alzheimer's Disease (AD) and AD-Related Dementias Clinical Trials (IMPACT) Collaboratory supports clinical trials of such interventions embedded in healthcare systems. The embedded pragmatic clinical trial (ePCT) is ideally suited to testing the effectiveness of complex interventions in vulnerable populations at the point of care. These trials, however, are complex to conduct and interpret, and face challenges in efficiency (i.e., statistical power) and reproducibility. In addition, trials conducted among PLWD present specific statistical challenges, including difficulty in outcomes ascertainment from PLWD, necessitating reliance on reports by caregivers, and heterogeneity in measurements across different settings or populations. These and other challenges undercut the reliability of measurement, the feasibility of capturing outcomes using pragmatic designs, and the ability to validly estimate interventions' effectiveness in real-world settings. To address these challenges, the IMPACT Collaboratory has convened a Design and Statistics Core, the goals of which are: to support the design and conduct of ePCTs directed toward PLWD and their caregivers; to develop guidance for conducting embedded trials in this population; and to educate quantitative and clinical scientists in the design, conduct, and analysis of these trials. In this article, we discuss some of the contemporary methodological challenges in this area and develop a set of research priorities the Design and Statistics Core will undertake to meet these goals. J Am Geriatr Soc 68:S68-S73, 2020.

Impact of Aging and HIV Infection on the Function of the C-Type Lectin Receptor MINCLE in Monocytes

Both aging and HIV infection are associated with an enhanced pro-inflammatory environment that contributes to impaired immune responses and is mediated in part by innate immune pattern-recognition receptors. MINCLE is a C-type lectin receptor that recognizes trehalose-6,6'-dimycolate or "cord factor," the most abundant glycolipid in Mycobacterium tuberculosis. Here, we evaluated MINCLE function in monocytes in a cohort of HIV-infected and uninfected young (21-35 years) and older adults (≥60 years) via stimulation of peripheral blood mononuclear cells with trehalose-6,6-dibehenate, a synthetic analog of trehalose-6,6'-dimycolate and measurement of cytokine production (interleukin [IL]-10, IL-12, IL-6, tumor necrosis factor-α) by multicolor flow cytometry. Our studies show an age- and HIV-associated increase in cytokine multifunctionality of monocytes both at the population and single cell level that was dominated by IL-12, IL-10, and IL-6. These findings provide insight into the host response to M. tuberculosis and possible sources for the pro-inflammatory environment seen in aging and HIV infection.

Rethinking rehabilitation after percutaneous coronary intervention: a protocol of a multicentre cohort study on continuity of care, health literacy, adherence and costs at all care levels (the CONCARDPCI)

INTRODUCTION

Percutaneous coronary intervention (PCI) aims to provide instant relief of symptoms, and improve functional capacity and prognosis in patients with coronary artery disease. Although patients may experience a quick recovery, continuity of care from hospital to home can be challenging. Within a short time span, patients must adjust their lifestyle, incorporate medications and acquire new support. Thus, CONCARD^PCI will identify bottlenecks in the patient journey from a patient perspective to lay the groundwork for integrated, coherent pathways with innovative modes of healthcare delivery. The main objective of the CONCARD^PCI is to investigate (1) continuity of care, (2) health literacy and self-management, (3) adherence to treatment, and (4) healthcare utilisation and costs, and to determine associations with future short and long-term health outcomes in patients after PCI.

METHODS AND ANALYSIS

This prospective multicentre cohort study organised in four thematic projects plans to include 3000 patients. All patients undergoing PCI at seven large PCI centres based in two Nordic countries are prospectively screened for eligibility and included in a cohort with a 1-year follow-up period including data collection of patient-reported outcomes (PRO) and a further 10-year follow-up for adverse events. In addition to PROs, data are collected from patient medical records and national compulsory registries.

ETHICS AND DISSEMINATION

Approval has been granted by the Norwegian Regional Committee for Ethics in Medical Research in Western Norway (REK 2015/57), and the Data Protection Agency in the Zealand region (REG-145-2017). Findings will be disseminated widely through peer-reviewed publications and to patients through patient organisations.

TRIAL REGISTRATION NUMBER

NCT03810612.

Comorbid conditions and emergency department treat and release utilization in multimorbid persons with cognitive impairment

BACKGROUND

There is an increasing focus in the emergency department (ED) on addressing the needs of persons with cognitive impairment, most of whom have multiple chronic conditions. We investigated which common comorbidities among multimorbid persons with cognitive impairment conferred increased risk for ED treat and release utilization.

METHODS

We examined the association of 16 chronic conditions on use of ED treat and release visit utilization among 1006 adults with cognitive impairment and ≥ 2 comorbidities using the nationally-representative National Health and Aging Trends Study merged with Fee-For-Service Medicare claims data, 2011-2015.

RESULTS

At baseline, 28.5% had ≥6 conditions and 35.4% were ≥ 85 years old. After controlling for sex, age, race, education, urban-living, number of disabled activities of daily living, and sampling strata, we found significantly increased adjusted risk ratios (aRR) of ED treat and release visits for persons with depression (aRR 1.38 95% CI 1.15-1.65) representing 78/100 person-years, and osteoarthritis or rheumatoid arthritis (aRR 1.32 95% CI 1.12-1.57) representing 71/100 person-years. At baseline 93.9% had ≥1 informal caregiver and 69.7% had a caregiver that helped with medications or attended physician visits.

CONCLUSION

These results show that multimorbid cognitively impaired older adults with depression or osteoarthritis or rheumatoid arthritis are at higher risk of ED treat and release visits. Future ED research with multimorbid cognitively impaired persons may explore behavioral aspects of depression and/or pain and flairs associated with osteoarthritis or rheumatoid arthritis, as well as the role of informal caregivers in the care of these conditions.

An Agenda for Addressing Multimorbidity and Racial and Ethnic Disparities in Alzheimer's Disease and Related Dementia

Advancements in Alzheimer's disease and related dementias (ADRD) research on the U.S. population acknowledge the importance of the high burden of ADRD on segments of the population and yet-to-be characterized risks attributable to the burden of multiple chronic diseases (multimorbidity). These realizations suggest successful strategies in caring for people with ADRD and their caregivers will rely not only on clinical treatments but also on more refined and comprehensive models of ADRD that take its broad effects on the whole-person and the whole of society into consideration. To this end, it is critical to characterize and address the relationship between ADRD and multimorbidity combinations that complicate care and lead to poor outcomes, particularly with regard to racial and ethnic disparities in the occurrence, course, and effects of ADRD. Several research and policy recommendations are presented to address the intersection of ADRD, multimorbidity, and underrepresented populations most at risk for adverse outcomes.

TRACKING CHANGES IN MULTIMORBIDITY AMONG RACIALLY AND ETHNICALLY DIVERSE POPULATIONS

Multimorbidity is widely recognized as having adverse effects on health and wellbeing above and beyond the risk attributable to individual chronic disease. Much of what is known about multimorbidity rests on research that has largely focused on one point-in-time, or from a static perspective, with little consideration to issues involved in assessing longitudinal changes in multimorbidity. In addition, less focus has been placed on assessing racial and ethnic variations in longitudinal changes of multimorbidity. Addressing this knowledge gap, we highlight important issues and considerations in addressing multimorbidity research from a longitudinal perspective and present findings from longitudinal models that examine differences in the rate of chronic disease accumulation and multimorbidity onset between non-Hispanic white (white), non-Hispanic black (black), and Hispanic study participants in the Health and Retirement Study starting in middle-age and followed for up to 16 years.

Personalized and typical concurrent risk of limitations in social activity and mobility in older persons with multiple chronic conditions and polypharmacy

PURPOSE

We define personalized concurrent risk (PCR) as the subject-specific probability of an index outcome within a defined interval of time, while currently at risk for a separate outcome, where the outcomes are not mutually exclusive and can be jointly modeled with a shared random intercept. We further define typical concurrent risk as the risk obtained by setting the random intercept to null.

METHODS

Drawing data from the Medical Expenditure Panel Survey (cohorts 2008-2013), we jointly model limitations in social activity and mobility over two years among older community-dwelling persons with both hypertension and chronic obstructive pulmonary disease. The joint model uses inverse probability of treatment weighting based on each participant's baseline propensity of polypharmacy (≥5 classes of medication).

RESULTS

Even among participants with the same covariates, older persons with multiple chronic conditions exhibit wide-ranging heterogeneity of the treatment effect from polypharmacy, a risk factor for negative health outcomes among older persons. The magnitude of the PCRs is dominated by the value of the subject-specific random effect.

CONCLUSIONS

Estimates of PCR and typical concurrent risk can be calculated from national or institutional data sets and may facilitate the practice of personalized care for older patients with multiple chronic conditions.

Racial/ethnic differences in multimorbidity development and chronic disease accumulation for middle-aged adults

Background

Multimorbidity–having two or more coexisting chronic conditions–is highly prevalent, costly, and disabling to older adults. Questions remain regarding chronic diseases accumulation over time and whether this differs by racial and ethnic background. Answering this knowledge gap, this study identifies differences in rates of chronic disease accumulation and multimorbidity development among non-Hispanic white, non-Hispanic black, and Hispanic study participants starting in middle-age and followed up to 16 years.

Methods and findings

We analyzed data from the Health and Retirement Study (HRS), a biennial, ongoing, publicly-available, longitudinal nationally-representative study of middle-aged and older adults in the United States. We assessed the change in chronic disease burden among 8,872 non-Hispanic black, non-Hispanic white, and Hispanic participants who were 51–55 years of age at their first interview any time during the study period (1998–2014) and all subsequent follow-up observations until 2014. Multimorbidity was defined as having two or more of seven somatic chronic diseases: arthritis, cancer, heart disease (myocardial infarction, coronary heart disease, angina, congestive heart failure, or other heart problems), diabetes, hypertension, lung disease, and stroke. We used negative binomial generalized estimating equation models to assess the trajectories of multimorbidity burden over time for non-Hispanic black, non-Hispanic white, and Hispanic participants. In covariate-adjusted models non-Hispanic black respondents had initial chronic disease counts that were 28% higher than non-Hispanic white respondents (IRR 1.279, 95% CI 1.201, 1.361), while Hispanic respondents had initial chronic disease counts that were 15% lower than non-Hispanic white respondents (IRR 0.852, 95% CI 0.775, 0.938). Non-Hispanic black respondents had rates of chronic disease accumulation that were 1.1% slower than non-Hispanic whites (IRR 0.989, 95% CI 0.981, 0.998) and Hispanic respondents had rates of chronic disease accumulation that were 1.5% faster than non-Hispanic white respondents (IRR 1.015, 95% CI 1.002, 1.028). Using marginal effects commands, this translates to predicted values of chronic disease for white respondents who begin the study period with 0.98 chronic diseases and end with 2.8 chronic diseases; black respondents who begin the study period with 1.3 chronic diseases and end with 3.3 chronic diseases; and Hispanic respondents who begin the study period with 0.84 chronic diseases and end with 2.7 chronic diseases.

Conclusions

Middle-aged non-Hispanic black adults start at a higher level of chronic disease burden and develop multimorbidity at an earlier age, on average, than their non-Hispanic white counterparts. Hispanics, on the other hand, accumulate chronic disease at a faster rate relative to non-Hispanic white adults. Our findings have important implications for improving primary and secondary chronic disease prevention efforts among non-Hispanic black and Hispanic Americans to stave off greater multimorbidity-related health impacts.

Joint modeling of concurrent binary outcomes in a longitudinal observational study using inverse probability of treatment weighting for treatment effect estimation

PURPOSE

Correlated healthcare utilization outcomes may be encoded as binary outcomes in epidemiologic studies. We demonstrate how to account for correlation between concurrent binary outcomes and confounding by person characteristics when estimating a treatment effect in observational studies.

METHODS

We present a joint shared-parameter model, weighted by inverse probability of treatment weights (IPTW) to account for confounding. The model is evaluated in a simulation study that emulates the Medical Expenditure Panel Survey data and compared with a covariate-adjusted joint model and with separate outcome models (IPTW weighted and covariate adjusted).

RESULTS

For the IPTW-weighted joint model, relative bias in the estimated treatment effect on outcome 1 ranged from -0.057 to -0.033 and outcome 2 from -0.077 to -0.043. For the covariate-adjusted joint model, relative bias ranged from -0.010 to -0.083 for outcome 1 and from -0.087 to -0.110 for outcome 2. The covariate-adjusted joint model estimated the effect more closely than the covariate-adjusted separate model. The IPTW-weighted joint model estimated the effect more closely for outcome 1.

CONCLUSIONS

The IPTW-weighted joint model handles correlation between binary outcomes, adjusts for confounding, and estimates the treatment effect accurately in observational studies. We illustrate the contribution of person-specific effects in estimating personalized risk.

Chronic Conditions, Medically Supportive Care Partners, And Functional Disability Among Cognitively Impaired Adults

BACKGROUND AND OBJECTIVES

To assess whether medically supportive care partners modify the associations of symptomatic chronic conditions with the number of functional disabilities in a cohort of multimorbid older adults with cognitive impairment.

RESEARCH DESIGN AND METHODS

The research design is a prospective study of a nationally representative cohort of Medicare beneficiaries. National Health and Aging Trends Study (NHATS) data were linked with Medicare claims for years 2011-2015. Participants were aged 65 or older and had cognitive impairment with at least 2 chronic conditions (N = 1,003). Annual in-person interviews obtained sociodemographic information at baseline and time-varying variables for caregiving, hospitalization, and 6 activities of daily living (ADL); these variables were merged with Center for Medicare and Medicaid Services data to ascertain 16 time-varying chronic conditions. A care partner was defined as a person who sat with their care recipient during doctor visits in the past year and/or who helped them with prescribed medications in the last month. Chronic condition associations and their potential effect modifications by care partner status were assessed using weighted generalized estimating equations accounting for the complex survey design of the longitudinal analytical sample.

RESULTS

Chronic kidney disease, depression, and heart failure were associated with an increased number of functional disabilities. Among these, only the association of chronic kidney disease with the number of functional disabilities (interaction p value = .001) was weakened by the presence of a care partner.

DISCUSSION AND IMPLICATIONS

The presence of care partners showed limited modification of the associations of symptomatic chronic conditions with functional disability.

Bayesian Model Averaging for Selection of a Risk Prediction Model for Death within Thirty Days of Discharge: The SILVER-AMI Study

We describe a selection process for a multivariable risk prediction model of death within 30 days of hospital discharge in the SILVER-AMI study. This large, multi-site observational study included observational data from 2000 persons 75 years and older hospitalized for acute myocardial infarction (AMI) from 94 community and academic hospitals across the United States and featured a large number of candidate variables from demographic, cardiac, and geriatric domains, whose missing values were multiply imputed prior to model selection. Our objective was to demonstrate that Bayesian Model Averaging (BMA) represents a viable model selection approach in this context. BMA was compared to three other backward-selection approaches: Akaike information criterion, Bayesian information criterion, and traditional p-value. Traditional backward-selection was used to choose 20 candidate variables from the initial, larger pool of five imputations. Models were subsequently chosen from those candidates using the four approaches on each of 10 imputations. With average posterior effect probability ≥ 50% as the selection criterion, BMA chose the most parsimonious model with four variables, with average C statistic of 78%, good calibration, optimism of 1.3%, and heuristic shrinkage of 0.93. These findings illustrate the utility and flexibility of using BMA for selecting a multivariable risk prediction model from many candidates over multiply imputed datasets.

Design and analysis of longitudinal trials of antimicrobial use at the end of life: to give or not to give?

This perspective review considers analytic features of the design of a longitudinal trial regarding antimicrobial therapy in older terminal cancer patients receiving palliative care. We first overview antimicrobial use at the end of life; both the potential hazards and benefits. Antimicrobial prescribing should consider both initiation as well as cessation of medications when analyzing the burden of medications. Approaches to decision making regarding antimicrobial use are presented and the importance of health literacy in these decision processes. We next present aspects of both feasibility and comparative trial design with a health literacy intervention to reduce antimicrobial use in older terminal cancer patients receiving palliative care. Considerations to clustered randomization and given that infections can reoccur over a trial period, we share suggestions of longitudinal modeling of clustered randomized trial data.

Are China's oldest-old living longer with less disability? A longitudinal modeling analysis of birth cohorts born 10 years apart

BACKGROUND

China has transitioned from being one of the fastest-growing populations to among the most rapidly aging countries worldwide. In particular, the population of oldest-old individuals, those aged 80+, is projected to quadruple by 2050. The oldest-old represent a uniquely important group-they have high demand for personal assistance and the highest healthcare costs of any age group. Understanding trends in disability and longevity among the oldest-old-that is, whether successive generations are living longer and with less disability-is of great importance for policy and planning purposes.

METHODS

We utilized data from successive birth cohorts (n = 20,520) of the Chinese oldest-old born 10 years apart (the earlier cohort was interviewed in 1998 and the later cohort in 2008). Disability was defined as needing personal assistance in performing one or more of five essential activities (bathing, transferring, dressing, eating, and toileting) or being incontinent. Participants were followed for age-specific disability transitions and mortality (in 2000 and 2002 for the earlier cohort and 2011 and 2014 for the later cohort), which were then used to generate microsimulation-based multistate life tables to estimate partial life expectancy (LE) and disability-free LE (DFLE), stratified by sex and age groups (octogenarians, nonagenarians, and centenarians). We additionally explored sociodemographic heterogeneity in LE and DFLE by urban/rural residence and educational attainment.

RESULTS

More recently born Chinese octogenarians (born 1919-1928) had a longer partial LE between ages 80 and 89 than octogenarians born 1909-1918, and octogenarian women experienced an increase in partial DFLE of 0.32 years (P = 0.004) across the two birth cohorts. Although no increases in partial LE were observed among nonagenarians or centenarians, partial DFLE increased across birth cohorts, with a gain of 0.41 years (P < 0.001) among nonagenarians and 0.07 years (P = 0.050) among centenarians. Subgroup analyses revealed that gains in partial LE and DFLE primarily occurred among the urban resident population.

CONCLUSIONS

Successive generations of China's oldest-old are living with less disability as a whole, and LE is expanding among octogenarians. However, we found a widening urban-rural disparity in longevity and disability, highlighting the need to improve policies to alleviate health inequality throughout the population.

AGS Report on Engagement Related to the NIH Inclusion Across the Lifespan Policy

After passage of the 21st Century Cures Act, the National Institutes of Health held a workshop in 2017 to consider expanding its inclusion policy to encompass individuals of all ages. American Geriatrics Society (AGS) leaders and members participated in the workshop and formal feedback period. AGS advocacy clearly impacted the resulting workshop report and Inclusion Across the Lifespan policy that eliminates upper-age limits for research participation unless risk justified and changes the language used to describe older adults and other vulnerable groups. AGS recommendations that were not specifically stated in the updated policy were to encourage active recruitment of older adults, add standard measures of function and/or frailty, and change review criteria to ensure the health status of a study population mirrors typical clinical populations. The updated inclusion policy ultimately offers academic geriatrics programs the opportunities to expand knowledge about health in aging and to continue to provide leadership for research and advocacy efforts on behalf of older adults. J Am Geriatr Soc 67:211-217, 2019.