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Callahan KE, Boustani M, Ferrante L, Forman DE, Gurwitz J, High KP, McFarland F, Robinson T, Studenski S, Yang M, Schmader KE. Embedding and Sustaining a Focus on Function in Specialty Research and Care. J Am Geriatr Soc 2020; 69:225-233. [PMID: 33064303 DOI: 10.1111/jgs.16860] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 07/21/2020] [Accepted: 07/25/2020] [Indexed: 12/12/2022]
Abstract
Function and the independent performance of daily activities are of critical importance to older adults. Although function was once a domain of interest primarily limited to geriatricians, transdisciplinary research has demonstrated its value across the spectrum of medical and surgical care. Nonetheless, integrating a functional perspective into medical and surgical therapeutics has yet to be implemented consistently into clinical practice. This article summarizes the presentations and discussions from a workshop, "Embedding/Sustaining a Focus on Function in Specialty Research and Care," held on January 31 to February 1, 2019. The third in a series supported by the National Institute on Aging and the John A. Hartford Foundation, the workshop aimed to identify scientific gaps and recommend research strategies to advance the implementation of function in care of older adults. Transdisciplinary leaders discussed implementation of mobility programs and functional assessments, including comprehensive geriatric assessment; integrating cognitive and sensory functional assessments; the role of culture, environment, and community in incorporating function into research; innovative methods to better identify functional limitations, techniques, and interventions to facilitate functional gains; and the role of the health system in fostering integration of function. Workshop participants emphasized the importance of aligning goals and assessments and adopting a team science approach that includes clinicians and frontline staff in the planning, development, testing, and implementation of tools and initiatives. This article summarizes those discussions.
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Pepin MJ, Valencia WM, Bettger JP, Pearson M, Manning KM, Sloane R, Schmader KE, Morey MC. Impact of Supervised Exercise on One-Year Medication Use in Older Veterans with Multiple Morbidities. Gerontol Geriatr Med 2020; 6:2333721420956751. [PMID: 32995368 PMCID: PMC7503003 DOI: 10.1177/2333721420956751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/14/2020] [Indexed: 11/16/2022] Open
Abstract
Exercise is touted as the ideal prescription to treat and prevent many chronic diseases. We examined changes in utilization and cost of medication classes commonly prescribed in the management of chronic conditions following participation in 12-months of supervised exercise within the Veterans Affairs Gerofit program. Gerofit enrolled 480 veterans between 1999 and 2017 with 12-months participation, with 453 having one or more active prescriptions on enrollment. Active prescriptions overall and for five classes of medications were examined. Changes from enrollment to 12 months were calculated, and cost associated with prescriptions filled were used to estimate net cost changes. Active prescriptions were reduced for opioids (77 of 164, 47%), mental health (93 of 221, 42%), cardiac (175 of 391, 45%), diabetes (41 of 166, 25%), and lipid lowering (56 of 253, 22%) agents. Cost estimates resulted in a net savings of $38,400. These findings support the role of supervised exercise as a favorable therapeutic intervention that has impact across chronic conditions.
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Messina JA, Moehring RW, Schmader KE, Anderson DJ. Impact of Location of Acquisition of Gram-Positive Bloodstream Infections on Clinical Outcomes Among Patients Admitted to Community Hospitals. Infect Drug Resist 2020; 13:3023-3031. [PMID: 32922048 PMCID: PMC7457735 DOI: 10.2147/idr.s259185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/07/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose We investigated the association between location of acquisition (LOA) of gram-positive (GP) bloodstream infections (BSI) in community hospitals and clinical outcomes. Methods We performed a multicenter cohort study of adult inpatients with GP BSI in nine community hospitals from 2003 to 2006. LOA was defined by CDC criteria: 1) community-acquired (CA), 2) healthcare-associated (HCA) such as BSI <48 hours after admission plus hospitalization, surgery, dialysis, invasive device, or residence in a long-term care facility in the prior 12 months, and 3) hospital-acquired (HA) as BSI ≥48 hours after hospital admission. Results A total of 750 patients were included. Patients with HCA or HA GP BSI were significantly more likely to require assistance with ≥1 activity of daily living, have higher Charlson scores, and die during the hospitalization. Patients with HCA or HA GP BSI were more likely to have BSI due to a multidrug-resistant GP organism, but less likely to receive appropriate antibiotics within 24 hours of BSI presentation. Those with CA BSI were more likely to have a streptococcal BSI and to be discharged home following hospitalization. HA BSI was a risk factor for requiring a procedure for BSI and receiving inappropriate antibiotics within 24 hours of BSI. Both HA and HCA GP BSI were risk factors for in-hospital mortality. Conclusion LOA for patients with GP BSI in community hospitals was significantly associated with differences in clinical outcomes including receiving inappropriate antibiotics and in-hospital mortality. Distinguishing LOA in a patient presenting with suspected GP BSI is a critical assessment that should influence empiric treatment patterns.
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Colón-Emeric C, Pieper CF, Schmader KE, Sloane R, Bloom A, McClain M, Magaziner J, Huffman KM, Orwig D, Crabtree DM, Whitson HE. Two Approaches to Classifying and Quantifying Physical Resilience in Longitudinal Data. J Gerontol A Biol Sci Med Sci 2020; 75:731-738. [PMID: 30993327 PMCID: PMC7328208 DOI: 10.1093/gerona/glz097] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Approaches for quantifying physical resilience in older adults have not been described. METHODS We apply two conceptual approaches to defining physical resilience to existing longitudinal data sets in which outcomes are measured after an acute physical stressor. A "recovery phenotype" approach uses statistical methods to describe how quickly and completely a patient recovers. Statistical methods using a recovery phenotype approach can consider multiple outcomes simultaneously in a composite score (eg, factor analysis and principal components analysis) or identify groups of patients with similar recovery trajectories across multiple outcomes (eg, latent class profile analysis). An "expected recovery differential" approach quantifies how patients' actual outcomes are compared to their predicted outcome based on a population-derived model and their individual clinical characteristics at the time of the stressor. RESULTS Application of the approaches identified different participants as being the most or least physically resilient. In the viral respiratory cohort (n = 186) weighted kappa for agreement across resilience quartiles was 0.37 (0.27-0.47). The expected recovery differential approach identified a group with more comorbidities and lower baseline function as highly resilient. In the hip fracture cohort (n = 541), comparison of the expected recovery differentials across 10 outcome measures within individuals provided preliminary support for the hypothesis that there is a latent resilience trait at the whole-person level. CONCLUSIONS We posit that recovery phenotypes may be useful in clinical applications such as prediction models because they summarize the observed outcomes across multiple measures. Expected recovery differentials offer insight into mechanisms behind physical resilience not captured by age and other comorbidities.
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Hastings SN, Stechuchak KM, Coffman CJ, Mahanna EP, Weinberger M, Van Houtven CH, Schmader KE, Hendrix CC, Kessler C, Hughes JM, Ramos K, Wieland GD, Weiner M, Robinson K, Oddone E. Discharge Information and Support for Patients Discharged from the Emergency Department: Results from a Randomized Controlled Trial. J Gen Intern Med 2020; 35:79-86. [PMID: 31489559 PMCID: PMC6957582 DOI: 10.1007/s11606-019-05319-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 06/10/2019] [Accepted: 08/08/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Little research has been done on primary care-based models to improve health care use after an emergency department (ED) visit. OBJECTIVE To examine the effectiveness of a primary care-based, nurse telephone support intervention for Veterans treated and released from the ED. DESIGN Randomized controlled trial with 1:1 assignment to telephone support intervention or usual care arms (ClinicalTrials.gov: NCT01717976). SETTING Department of Veterans Affairs Health Care System (VAHCS) in Durham, NC. PARTICIPANTS Five hundred thirteen Veterans who were at high risk for repeat ED visits. INTERVENTION The telephone support intervention consisted of two core calls in the week following an ED visit. Call content focused on improving the ED to primary care transition, enhancing chronic disease management, and educating Veterans and family members about VHA and community services. MAIN MEASURES The primary outcome was repeat ED use within 30 days. KEY RESULTS Observed rates of repeat ED use at 30 days in usual care and intervention groups were 23.1% and 24.9%, respectively (OR = 1.1; 95% CI = 0.7, 1.7; P = 0.6). The intervention group had a higher rate of having at least 1 primary care visit at 30 days (OR = 1.6, 95% CI = 1.1-2.3). At 180 days, the intervention group had a higher rate of usage of a weight management program (OR = 3.5, 95% CI = 1.6-7.5), diabetes/nutrition (OR = 1.8, 95% CI = 1.0-3.0), and home telehealth services (OR = 1.7, 95% CI = 1.0-2.9) compared with usual care. CONCLUSIONS A brief primary care-based nurse telephone support program after an ED visit did not reduce repeat ED visits within 30 days, despite intervention participants' increased engagement with primary care and some chronic disease management services. TRIALS REGISTRATION ClinicalTrials.gov NCT01717976.
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Ailabouni NJ, Marcum ZA, Schmader KE, Gray SL. Medication Use Quality and Safety in Older Adults: 2018 Update. J Am Geriatr Soc 2019; 67:2458-2462. [PMID: 31765004 DOI: 10.1111/jgs.16243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/20/2019] [Accepted: 10/04/2019] [Indexed: 01/04/2023]
Abstract
Improving the quality of medication use and medication safety is an important priority for prescribers who care for older adults. The objective of this article was to identify key articles from 2018 that address these issues. In addition, we selected four of these articles to annotate, critique, and discuss their broader implications for clinical practice. The first study highlights a cluster-randomized trial that utilized a pharmacist-led education-based intervention delivered to both patients and physicians to deprescribe four types of inappropriate medications (sedative-hypnotics, first-generation antihistamines, selective nonsteroidal anti-inflammatory drugs, and glyburide). The second study, a nested case-control study using data from within the UK Clinical Practice Research Datalink, examined the association between anticholinergic exposure, overall and by anticholinergic medication class, and dementia risk in 40 770 older adults. The third study, a longitudinal cohort study of 1028 Swedish older adults, examined the association between antihypertensive medications and incident dementia. The last study was a randomized, double-blind, placebo-controlled trial that investigated the effect of daily low-dose aspirin (100 mg) for primary prevention on cardiovascular events and major hemorrhage in 19 144 community-dwelling older adults. Collectively, this current article provides insight into the pertinent topics of medication use quality and safety in older adults and helps raise awareness about optimal prescribing in older adults. J Am Geriatr Soc 67:2458-2462, 2019.
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Hemmersbach-Miller M, Alexander BD, Pieper CF, Schmader KE. Age matters: older age as a risk factor for CMV reactivation in the CMV serostatus-positive kidney transplant recipient. Eur J Clin Microbiol Infect Dis 2019; 39:455-463. [PMID: 31758441 DOI: 10.1007/s10096-019-03744-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 10/17/2019] [Indexed: 12/29/2022]
Abstract
Evaluate risk factors for cytomegalovirus (CMV) reactivation during the first year after kidney transplantation in the CMV-seropositive older recipient. Retrospective single-center study. Between 2011 and 2015, 91 patients ≥ 65 years received a kidney transplant; these were matched with 91 controls, aged 40-60. Risk of CMV reactivation in the CMV-seropositive recipients was analyzed. Sixty-three older and 54 younger recipients were included; 50% had received CMV-directed prophylaxis. CMV reactivation was significantly more frequent in the older group (71.4% vs 44.4%, p = 0.003) and occurred earlier (p = 0.003). A multivariate model showed that only age was associated with CMV reactivation (OR 2.48, p = 0.03). After excluding patients that received thymoglobulin, older age group remained the only risk factor of CMV reactivation (OR 3.81, p = 0.014). Recurrent event analysis showed that the older cohort had an HR of 1.94 (p = 0.01) of CMV viremia; there was significant episode-cohort interaction (p < 0.01). While the older group had a higher risk of infection (HR = 2.43), after the initial episode the relative hazards were approximately equal (HR = 1.08, at period 2). This suggests that it is key to specifically avoid the first episode of reactivation. Universal prophylaxis or a hybrid prophylaxis model should be considered in the CMV-seropositive kidney transplant recipient aged ≥ 65 years.
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Weinberg A, Popmihajlov Z, Schmader KE, Johnson MJ, Caldas Y, Salazar AT, Canniff J, McCarson BJ, Martin J, Pang L, Levin MJ. Persistence of Varicella-Zoster Virus Cell-Mediated Immunity After the Administration of a Second Dose of Live Herpes Zoster Vaccine. J Infect Dis 2019; 219:335-338. [PMID: 30165651 DOI: 10.1093/infdis/jiy514] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 08/23/2018] [Indexed: 11/13/2022] Open
Abstract
Protection against zoster conferred by zoster vaccine live (ZVL; Zostavax) wanes over time. We compared varicella-zoster virus cell-mediated immunity (VZV-CMI) of adults ≥70 years who received a second dose of ZVL ≥10 years after the initial dose with de novo-immunized age-matched controls. Before and during the first year after vaccination, VZV-CMI was significantly higher in reimmunized compared with de novo vaccinees. At 3 years, VZV-CMI differences between groups decreased and only memory responses remained marginally higher in reimmunized participants. In conclusion, the increase in VZV-CMI generated by reimmunization with ZVL is at least equally persistent compared with de novo immunization.
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Cobey S, Gouma S, Parkhouse K, Chambers BS, Ertl HC, Schmader KE, Halpin RA, Lin X, Stockwell TB, Das SR, Landon E, Tesic V, Youngster I, Pinsky BA, Wentworth DE, Hensley SE, Grad YH. Poor Immunogenicity, Not Vaccine Strain Egg Adaptation, May Explain the Low H3N2 Influenza Vaccine Effectiveness in 2012-2013. Clin Infect Dis 2019; 67:327-333. [PMID: 29471464 PMCID: PMC6051447 DOI: 10.1093/cid/ciy097] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 02/03/2018] [Indexed: 12/28/2022] Open
Abstract
Background Influenza vaccination aims to prevent infection by influenza virus and reduce associated morbidity and mortality; however, vaccine effectiveness (VE) can be modest, especially for subtype A(H3N2). Low VE has been attributed to mismatches between the vaccine and circulating influenza strains and to the vaccine’s elicitation of protective immunity in only a subset of the population. The low H3N2 VE in the 2012–2013 season was attributed to egg-adaptive mutations that created antigenic mismatch between the actual vaccine strain (IVR-165) and both the intended vaccine strain (A/Victoria/361/2011) and the predominant circulating strains (clades 3C.2 and 3C.3). Methods We investigated the basis of low VE in 2012–2013 by determining whether vaccinated and unvaccinated individuals were infected by different viral strains and by assessing the serologic responses to IVR-165, A/Victoria/361/2011, and 3C.2 and 3C.3 strains in an adult cohort before and after vaccination. Results We found no significant genetic differences between the strains that infected vaccinated and unvaccinated individuals. Vaccination increased titers to A/Victoria/361/2011 and 3C.2 and 3C.3 representative strains as much as to IVR-165. These results are consistent with the hypothesis that vaccination boosted cross-reactive immune responses instead of specific responses against unique vaccine epitopes. Only approximately one-third of the cohort achieved a ≥4-fold increase in titer. Conclusions In contrast to analyses based on ferret studies, low H3N2 VE in 2012–2013 in adults does not appear to be due to egg adaptation of the vaccine strain. Instead, low VE might have been caused by low vaccine immunogenicity in a subset of the population.
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Elias AM, Ogunwale AN, Pepin MJ, Bailey JC, Adams AD, Colón-Emeric CS, Vognsen JD, Schmader KE, Pavon JM. High Prevalence of Fall-Related Medication Use in Older Veterans at Risk for Falls. J Am Geriatr Soc 2019; 68:438-439. [PMID: 31657005 DOI: 10.1111/jgs.16233] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 09/28/2019] [Indexed: 11/29/2022]
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Schmader KE, Levin MJ, Chen M, Matthews S, Riley M, Woo W, Hervé C, Grupping K, Schuind A, Oostvogels L, Curran D. 2778. Impact of Reactogenicity on Quality of Life and Physical Functioning in Adults ≥50 Years Receiving Both Doses of the Adjuvanted Recombinant Zoster Vaccine. Open Forum Infect Dis 2019. [PMCID: PMC6810498 DOI: 10.1093/ofid/ofz360.2455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background The adjuvanted recombinant zoster vaccine (RZV) is efficacious in preventing herpes zoster in adults ≥ 50 years. The current study investigates whether the vaccinees’ quality of life (QoL) and physical functioning (PF) are impacted by local and systemic reactions due to RZV. In a previous report of this phase III, open-label, multicenter study (NCT02979639), overall PF and QoL were not significantly affected by a first RZV dose. [1] Here we report the results from the same study after a second RZV dose and safety results from dose 1 up to study end. Methods Adults aged ≥ 50 years were to receive 2 doses of RZV 2 months apart. Changes in mean Short Form health survey (SF-36) PF score between pre- and post-each RZV dose for 7 days, QoL, reactogenicity and safety were assessed. Results 401 adults received dose 1 and 391 received dose 2 of RZV. Post-second RZV dose, the reported solicited local symptoms were pain (75.1%), erythema (22.4%) and swelling (13.9%), and the most frequent solicited systemic symptoms were fatigue (46.3%), headache (37.5%) and myalgia (32.9%). Grade 3 solicited symptoms were reported by 7.2% (local) and 11.1% (general) of participants, and 5 (1.2%) participants reported reactogenicity triggering medical attention post-second RZV dose. From first dose up to study end, 14 (3.5%) participants reported 21 serious adverse events, none related to RZV. In days 1–2, post-second RZV dose, a transient, clinically-important decrease in SF-36 PF score (table) was seen in those reporting grade 3 solicited symptoms, which impacted activities such as walking and climbing stairs. Overall, during the 7 days post-second RZV dose, a mean change of −0.4 points was observed from the mean baseline score, indicating the PF was not clinically meaningfully impacted. No overall quality-adjusted-life-year loss was recorded. Conclusion Overall, the QoL and PF of adults ≥ 50 years were not affected post-second RZV dose; a transient impact was observed in adults with grade 3 reactogenicity. These results and the observed reactogenicity and safety profile are consistent with first RZV dose results, as well as that of previous studies with the RZV vaccine in adults of similar age. Funding: GlaxoSmithKline Biologicals SA. 1. Schmader et al., Abstract 2488, IDWeek 2018 ![]()
Disclosures All authors: No reported disclosures.
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Hanlon JT, Schmader KE. Measuring Underuse and Overuse of Medications. J Am Geriatr Soc 2019; 67:2428. [PMID: 31390044 DOI: 10.1111/jgs.16111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 07/09/2019] [Indexed: 11/26/2022]
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Carpenter CR, Mody L, Lundebjerg NE, Walter LC, Schmader KE, High K. Do what you love. Love what you do. Dr. Arti Hurria's trailblazing transdisciplinary legacy. J Geriatr Oncol 2019; 11:158-159. [PMID: 31378641 DOI: 10.1016/j.jgo.2019.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 07/25/2019] [Indexed: 11/16/2022]
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Schmader KE, Levin MJ, Grupping K, Matthews S, Butuk D, Chen M, Idrissi ME, Fissette LA, Fogarty C, Hartley P, Klein NP, Nevarez M, Uusinarkaus K, Oostvogels L, Curran D. The Impact of Reactogenicity After the First Dose of Recombinant Zoster Vaccine on the Physical Functioning and Quality of Life of Older Adults: An Open-Label, Phase III Trial. J Gerontol A Biol Sci Med Sci 2019; 74:1217-1224. [PMID: 30256905 PMCID: PMC6625580 DOI: 10.1093/gerona/gly218] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Herpes zoster and its related complications are associated with significant medical burden, which negatively affects quality of life and daily functioning of the patients. The recently licensed recombinant zoster vaccine (RZV) offers high efficacy but is associated with local and systemic reactions. This study assessed the impact of RZV on the quality of life and daily functioning of participants and implications for caregivers. METHODS Four hundred and one adults aged 50 years or older received single RZV doses at 0 and 2 months in this open-label, single-arm, multicenter study (NCT02979639). Change in mean SF-36 Physical Functioning score following first-dose administration, quality of life, reactogenicity, safety, productivity loss, and health care resource utilization was assessed. The current analysis was performed post-vaccine dose-1; safety follow-up will continue until 1 year post-dose-2. RESULTS The most common solicited local symptoms were injection-site pain (77.5%), redness (23.0%), and swelling (13.3%); the most frequent solicited systemic reactions were fatigue (33.5%), headache (28.3%), and myalgia (26.8%). Grade 3 reactogenicity occurred in 9.5% of participants and was associated with a transient clinically important decrease in SF-36 Physical Functioning score (affecting activities such as walking, carrying groceries, climbing stairs) on Days 1 and 2 post-first vaccination. No clinically meaningful reductions in mean SF-36 Physical Functioning scale scores from pre- to post-RZV dose-1 were observed (mean +1.9 points, primary end point), and no overall quality-adjusted-life-year loss was recorded post-dose-1. Five participants reported lost workdays; caregiver workload was not increased. CONCLUSIONS Overall, the physical functioning and quality of life of older adults were not affected by a first RZV dose. The observed reactogenicity was consistent with previous studies.
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Kurupati RK, Haut LH, Schmader KE, Ertl HC. Age-related changes in B cell metabolism. Aging (Albany NY) 2019; 11:4367-4381. [PMID: 31283526 PMCID: PMC6660053 DOI: 10.18632/aging.102058] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 06/24/2019] [Indexed: 12/18/2022]
Abstract
Antibody responses to vaccinations or infections decline upon aging. In this study we tested if metabolic changes in B cells may contribute to attenuation of responses to influenza vaccination in aged humans. Our data show that aging affects mitochondrial functions in B cells leading to increases in mitochondrial reactive oxygen species (MROS) and mitochondrial mass (MM) in some aged B cell subsets and decreases in expression levels of Sirtuin 1 (SIRT1), Forkhead box protein (FOX)O1 and carnitine palmitoyltransferase 1 (CPT-1). Seahorse analyses showed minor defects in glycolysis in the aged B cells after activation but a strong reduction in oxidative phosphorylation. The analyses of the transcriptome revealed further pronounced defects in one-carbon metabolism, a pathway that is essential for amino acid and nucleotide metabolism. Overall our data support the notion that the declining ability of aged B cells to increase their metabolism following activation contributes to the weakened antibody responses of the elderly.
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Curran D, Andrew MK, Levin MJ, Turriani E, Matthews S, Fogarty C, Klein NP, Grupping K, Oostvogels L, Schmader KE. Evaluation of two frailty indices, with practical application in a vaccine clinical trial. Hum Vaccin Immunother 2019; 15:2960-2968. [PMID: 31157595 PMCID: PMC6930102 DOI: 10.1080/21645515.2019.1622974] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Frail older adults are at increased risk of poor clinical outcomes. Frailty assessment is therefore important in clinical trials to understand the benefits and harms of interventions. However, consensus is lacking on how frailty should be assessed.We developed a prospectively specified index using a battery of formal tests and instruments and a retrospectively generated index using medical comorbidities and patient reported outcomes (PROs) within an adjuvanted recombinant zoster vaccine (RZV) trial (NCT02979639). For both frailty indices (FIs), a total deficit score was calculated as the accumulation of deficits and participants were categorized as non-frail, pre-frail and frail. We assessed (1) the feasibility and validity of both FIs; (2) the impact of RZV vaccine reactogenicity by frailty status on Short Form-36 [SF-36] physical functioning (PF) scores.Of 401 participants, aged ≥50 years, 236 (58.9%) were categorized non-frail, 143 (35.7%), pre-frail, and 22 (5.5%) frail using the prospective FI. Corresponding numbers for the retrospective FI were 192 (47.9%), 169 (42.1%) and 40 (10.0%), respectively. Strong concordance was observed between the frailty status assessments (P < .001). The proportion defined as frail increased from 1.5%, to 10.4% in participants aged 50-59, and ≥70 years, respectively, for the prospective FI. Corresponding numbers for the retrospective FI were 3.7%, and 17.2%, respectively. RZV vaccination was associated with a transient, non-clinically meaningful, decrease on the SF-36 PF score in frail participants.Both frailty indices provided similar results. The retrospectively generated FI offers the advantage of being easier to incorporate into vaccine clinical trials of older adults.
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Hemmersbach-Miller M, Alexander BD, Sudan DL, Pieper C, Schmader KE. Infections after kidney transplantation. Does age matter? Clin Transplant 2019; 33:e13516. [PMID: 30849194 DOI: 10.1111/ctr.13516] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/19/2019] [Indexed: 12/19/2022]
Abstract
Infections threaten successful outcomes after kidney transplantation. Our aim was to determine if the number, types of infections and the risk factors for common infections differed between older compared to younger kidney transplant (KT) recipients in the first year after surgery. We performed a single-center retrospective cohort study. Between 2011 and 2015, 91 KTs were performed in patients ≥65 years of age; these were matched 1:1 (by year of transplantation, sex and race) to controls aged 40-60 years. Over 90% of both groups had an infectious complication. Urinary tract infections (UTIs) and cytomegalovirus (CMV) viremia were significantly more frequent in older recipients. Older adults had more late onset UTIs, including after stent removal. CMV viremia was more frequent in older adults in the 1-6 months post-transplant period. Due to our center-specific protocol utilizing pre-emptive monitoring in the CMV recipient-seropositive population, the higher CMV incidence in the aged recipient was driven by this subpopulation of older adults. No difference in pneumonias or bloodstream infections were found, nor in surgical complications, rejection or graft loss. Mortality was higher at 1-year post-transplant in the older recipients (9.9% vs 1.1%; P = 0.018). Prophylactic and immunosuppressive strategies may need to be altered for older KT recipients.
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Kritchevsky SB, Forman DE, Callahan KE, Ely EW, High KP, McFarland F, Pérez-Stable EJ, Schmader KE, Studenski SA, Williams J, Zieman S, Guralnik JM. Pathways, Contributors, and Correlates of Functional Limitation Across Specialties: Workshop Summary. J Gerontol A Biol Sci Med Sci 2019; 74:534-543. [PMID: 29697758 PMCID: PMC6417483 DOI: 10.1093/gerona/gly093] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Indexed: 12/25/2022] Open
Abstract
Traditional clinical care models focus on the measurement and normalization of individual organ systems and de-emphasize aspects of health related to the integration of physiologic systems. Measures of physical, cognitive and sensory, and psychosocial or emotional function predict important health outcomes like death and disability independently from the severity of a specific disease, cumulative co-morbidity, or disease severity measures. A growing number of clinical scientists in several subspecialties are exploring the utility of functional assessment to predict complication risk, indicate stress resistance, inform disease screening approaches and risk factor interpretation, and evaluate care. Because a substantial number of older adults in the community have some form of functional limitation, integrating functional assessment into clinical medicine could have a large impact. Although interest in functional implications for health and disease management is growing, the science underlying functional capacity, functional limitation, physical frailty, and functional metrics is often siloed among different clinicians and researchers, with fragmented concepts and methods. On August 25-26, 2016, participants at a trans-disciplinary workshop, supported by the National Institute on Aging and the John A. Hartford Foundation, explored what is known about the pathways, contributors, and correlates of physical, cognitive, and sensory functional measures across conditions and disease states; considered social determinants and health disparities; identified knowledge gaps, and suggested priorities for future research. This article summarizes those discussions.
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Hemmersbach-Miller M, Wolfe CR, Schmader KE. Solid organ transplantation in older adults. Infectious and other age-related considerations. ACTA ACUST UNITED AC 2019; 3. [PMID: 34113803 PMCID: PMC8189398 DOI: 10.21926/obm.transplant.1901046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In the U.S., older adults aged 65 or above comprise nearly one quarter of the solid organ transplant (SOT) waitlists, and the number of transplants performed in this age group continues to increase. There are no specific guidelines for the assessment and follow up of the older SOT candidate or recipient. Older adults are at increased risk of infectious complications after SOT. Despite these complications and even with the use of suboptimal donors, overall outcomes are favorable. We provide an overview to specific consideration as they relate to the older SOT candidate and recipient.
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Schwartz JB, Schmader KE, Hanlon JT, Abernethy DR, Gray S, Dunbar-Jacob J, Holmes HM, Murray MD, Roberts R, Joyner M, Peterson J, Lindeman D, Tai-Seale M, Downey L, Rich MW. Pharmacotherapy in Older Adults with Cardiovascular Disease: Report from an American College of Cardiology, American Geriatrics Society, and National Institute on Aging Workshop. J Am Geriatr Soc 2018; 67:371-380. [PMID: 30536694 DOI: 10.1111/jgs.15634] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To identify the top priority areas for research to optimize pharmacotherapy in older adults with cardiovascular disease (CVD). DESIGN Consensus meeting. SETTING Multidisciplinary workshop supported by the National Institute on Aging, the American College of Cardiology, and the American Geriatrics Society, February 6-7, 2017. PARTICIPANTS Leaders in the Cardiology and Geriatrics communities, (officers in professional societies, journal editors, clinical trialists, Division chiefs), representatives from the NIA; National Heart, Lung, and Blood Institute; Food and Drug Administration; Centers for Medicare and Medicaid Services, Alliance for Academic Internal Medicine, Patient-Centered Outcomes Research Institute, Agency for Healthcare Research and Quality, pharmaceutical industry, and trainees and early career faculty with interests in geriatric cardiology. MEASUREMENTS Summary of workshop proceedings and recommendations. RESULTS To better align older adults' healthcare preferences with their care, research is needed to improve skills in patient engagement and communication. Similarly, to coordinate and meet the needs of older adults with multiple comorbidities encountering multiple healthcare providers and systems, systems and disciplines must be integrated. The lack of data from efficacy trials of CVD medications relevant to the majority of older adults creates uncertainty in determining the risks and benefits of many CVD therapies; thus, developing evidence-based guidelines for older adults with CVD is a top research priority. Polypharmacy and medication nonadherence lead to poor outcomes in older people, making research on appropriate prescribing and deprescribing to reduce polypharmacy and methods to improve adherence to beneficial therapies a priority. CONCLUSION The needs and circumstances of older adults with CVD differ from those that the current medical system has been designed to meet. Optimizing pharmacotherapy in older adults will require new data from traditional and pragmatic research to determine optimal CVD therapy, reduce polypharmacy, increase adherence, and meet person-centered goals. Better integration of the multiple systems and disciplines involved in the care of older adults will be essential to implement and disseminate best practices. J Am Geriatr Soc 67:371-380, 2019.
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Schmader KE, Levin MJ, Grupping K, Matthews S, Butuk D, Chen M, Idrissi ME, Fissette LA, Fogarty C, Hartley P, Klein NP, Nevarez M, Uusinarkaus K, Oostvogels L, Curran D. 2488. The Impact of Reactogenicity After Administration of the Recombinant Zoster Vaccine Upon the Physical Functioning and Quality of Life of Older Adults. Open Forum Infect Dis 2018. [PMCID: PMC6255533 DOI: 10.1093/ofid/ofy210.2141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Herpes zoster (HZ) and its related complications are associated with a significant burden of illness in older adults, which negatively impacts patients’ physical functioning and quality-of-life (QoL). The recombinant zoster vaccine (RZV) shows high efficacy for the prevention of HZ in older adults but is associated with local and systemic reactions. Therefore, this study assessed the impact of RZV reactogenicity upon the physical functioning and QoL of participants. Methods 401 adults aged ≥50 years received a dose of RZV at 0 and 2 months in this open-label, single-arm, multicenter study (NCT02979639). Changes in mean SF-36 Physical Functioning score were assessed between pre-dose-1 vaccination and post-dose-1 vaccination for 7 days (primary endpoint). Decreased scores are associated with decreased physical functioning. QoL, reactogenicity and safety were also assessed. The current analysis was performed post-dose-1 vaccination of the 2-dose RZV schedule. Results No clinically meaningful reductions in overall mean SF-36 Physical Functioning scores from pre- to post-RZV dose-1 were observed (mean +1.9 points) and no overall quality-adjusted-life-year loss was recorded post-dose-1. However, grade 3 reactogenicity occurred in 9.5% of participants, and was associated with a transient, clinically-important decrease in SF-36 Physical Functioning score (impacting activities such as walking, carrying groceries, climbing stairs) on Days 1–2 post-first-vaccination (Table 1). The solicited local symptoms were pain (77.5%), redness (23.0%) and swelling (13.3%); the most frequent solicited systemic reactions were fatigue (33.5%), headache (28.3%) and myalgia (26.8%). Conclusion Overall, the physical functioning and QoL of older adults were not significantly affected by a first RZV dose. Grade 3 reactogenicity was associated with a small transient decrease in physical functioning 1–2 days post-dose-1 that resolved by Day 3 post-vaccination. Funding: GlaxoSmithKline Biologicals SA ![]()
Disclosures K. E. Schmader, GSK group of companies: Investigator, Research grant. M. J. Levin, GSK group of companies: Grant Investigator and Scientific Advisor, Consulting fee and Research grant. K. Grupping, GSK group of companies: Employee, Salary. S. Matthews, GSK group of companies: Consultant, Consulting fee. M. El Idrissi, GSK group of companies: Employee and Shareholder, Salary. L. A. Fissette, GSK group of companies: Employee, Salary. C. Fogarty, Medical Research: Investigator, Research grant. N. P. Klein, GSK group of companies: Investigator, Research support. M. Nevarez, GSK group of companies: Investigator, Investigator stipend. K. Uusinarkaus, GSK group of companies: Investigator, Research grant. L. Oostvogels, GSK group of companies: Employee, Salary. D. Curran, GSK group of companies: Employee and Shareholder, GSK shares and Salary.
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Gray SL, Marcum ZA, Schmader KE, Hanlon JT. Update on Medication Use Quality and Safety in Older Adults, 2017. J Am Geriatr Soc 2018; 66:2254-2258. [PMID: 30423194 DOI: 10.1111/jgs.15665] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 01/10/2023]
Abstract
Improving the quality of medication use and medication safety in older adults is an important public health priority and is of paramount importance for clinicians who care for them. We selected four important articles from 2017 that address these issues to annotate and critique, and we discuss the broader implications for optimizing medication use. A longer list of articles is given in an online appendix. The first study provides national data on the prevalence of central nervous system-active medication polypharmacy in older adults and how this has changed over a 9-year period (2004-2013). The second study characterizes prevalence of and factors associated with nonadherence to antiepileptic drugs in 36,912 older adults with epilepsy, with an emphasis on minorities. The third study describes the extent of antibiotic use in residents of 381 long-term care facilities (LTCF) in British Columbia, Canada, from 2007 to 2014. Finally, we discuss a meta-analysis of 42 studies that evaluated the prevalence of hospital admissions caused by adverse drug reactions in older adults. This article is intended to provide a narrative review of important publications on medication use quality and safety for clinicians and researchers committed to optimizing medication use in older adults. J Am Geriatr Soc 66:2254-2258, 2018.
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Cone EB, Hammill BG, Routh JC, Lipkin ME, Preminger GM, Schmader KE, Scales CD. Disproportionate Use of Inpatient Care by Older Adults With Kidney Stones. Urology 2018; 120:103-108. [PMID: 29940233 PMCID: PMC6689223 DOI: 10.1016/j.urology.2018.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 06/04/2018] [Accepted: 06/05/2018] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To describe variation in utilization and costs of inpatient care for patients with kidney stones, examining associations with older age. MATERIALS AND METHODS Using the Nationwide Inpatient Sample we examined inpatient discharges with stone diagnoses from 2007 to 2011. We examined length of stay, hospitalization cost, and postdischarge care utilization using multivariable regression to identify associations between patient/hospital characteristics and resource. RESULTS An estimated 1.7 million hospital discharges for stone disease occurred during the study period. Median length of stay was 2.1 days with a median cost of $6300. Hospital use was substantially higher among persons ≥65 years old (older adults) as compared to those aged 18-64 (younger adults): median length of stay was 3.1 days, with 25% staying more than 5.9 days. Older adults were significantly more likely to utilize home health (odds ratio [OR] 3.6) or skilled nursing (OR 5.0) after discharge. Older adults accounted for 1 in 3 hospital discharges, 40% of costs, and half of postdischarge care utilization. They were more likely to be septic during hospitalization (OR 1.8) which doubled costs per episode, but less likely to receive surgery (OR 0.93). CONCLUSION While historically at lower risk for kidney stones compared to younger adults, older adults utilizing inpatient care account for a disproportionate share of the economic burden of disease. Utilization is higher for older adults across multiple dimensions, including hospital costs, length of stay, and postdischarge care. These findings suggest that efforts to understand and mitigate the impact of kidney stones on this vulnerable population are required.
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Agarwal D, Schmader KE, Kossenkov AV, Doyle S, Kurupati R, Ertl HCJ. Immune response to influenza vaccination in the elderly is altered by chronic medication use. Immun Ageing 2018; 15:19. [PMID: 30186359 PMCID: PMC6119322 DOI: 10.1186/s12979-018-0124-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/21/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The elderly patient population is the most susceptible to influenza virus infection and its associated complications. Polypharmacy is common in the aged, who often have multiple co-morbidities. Previous studies have demonstrated that commonly used prescription drugs can have extensive impact on immune defenses and responses to vaccination. In this study, we examined how the dynamics of immune responses to the two influenza A virus strains of the trivalent inactivated influenza vaccine (TIV) can be affected by patient's history of using the prescription drugs Metformin, NSAIDs or Statins. RESULTS We provide evidence for differential antibody (Ab) production, B-cell phenotypic changes, alteration in immune cell proportions and transcriptome-wide perturbation in individuals with a history of long-term medication use, compared with non-users. We noted a diminished response to TIV in the elderly on Metformin, whereas those on NSAIDs or Statins had higher baseline responses but reduced relative increases in virus-neutralizing Abs (VNAs) or Abs detected by an enzyme-linked immunosorbent assay (ELISA) following vaccination. CONCLUSION Collectively, our findings suggest novel pathways that might underlie how long-term medication use impacts immune response to influenza vaccination in the elderly. They provide a strong rationale for targeting the medication-immunity interaction in the aged population to improve vaccination responses.
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Hadley EC, Kuchel GA, Newman AB, Allore HG, Bartley JM, Bergeman CS, Blinov ML, Colon-Emeric CS, Dabhar FS, Dugan LL, Dutta C, Eldadah BA, Ferrucci L, Kirkland JL, Kritchevsky SB, Lipsitz LA, Nadkarni NK, Reed MJ, Schmader KE, Sierra F, Studenski SA, Varadhan R, Walston JD, Whitson HE, Yung R. Corrigendum to: Report: NIA Workshop on Measures of Physiologic Resiliencies in Human Aging. J Gerontol A Biol Sci Med Sci 2018; 73:995. [PMID: 29788088 PMCID: PMC6001895 DOI: 10.1093/gerona/glx172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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