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Gondi S, Berchuck SI, Brown RT, Hinderlie M, Easton L, Smith L, Berchuck JE, Burden HS, Berchuck CM. A Community Partnership to House and Care for Complex Patients with Unstable Housing. NEJM CATALYST INNOVATIONS IN CARE DELIVERY 2021; 2:10.1056/cat.21.0158. [PMID: 34514431 PMCID: PMC8425482 DOI: 10.1056/cat.21.0158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Rising homelessness, especially among older adults, has significant ramifications for our health care system. People experiencing homelessness tend to experience worse health and poorer access to needed health care than people with stable housing. Commonwealth Care Alliance (CCA), a not-for-profit payer and provider that offers health plans to people dually eligible for Medicare and Medicaid, sought to address homelessness among its beneficiaries through a partnership with a local community-based housing organization, Hearth. This partnership led to many CCA members gaining access to permanent supportive housing in a setting in which CCA and Hearth could monitor and address their medical, social, and behavioral needs. It also provided an opportunity to examine health care utilization and cost trends associated with permanent supportive housing. Our experience demonstrates that a community-based partnership can effectively address homelessness among older adults with significant medical needs and may be associated with reduced health care expenditures.
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Ryskina KL, Shultz K, Zhou Y, Lautenbach G, Brown RT. Older adults' access to primary care: Gender, racial, and ethnic disparities in telemedicine. J Am Geriatr Soc 2021; 69:2732-2740. [PMID: 34224577 DOI: 10.1111/jgs.17354] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/16/2021] [Accepted: 06/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND In 2020, primary care practices adopted telemedicine as an alternative to in-person visits. Little is known about whether access to telemedicine was equitable, especially among older patients. Our objectives were to (1) examine older adults' use of telemedicine versus in-person primary care visits and (2) compare hospitalization for ambulatory care sensitive conditions (ACSCs) between the groups. METHODS In this retrospective cross-sectional study of 17,103 patients aged ≥65 years seen at 32 clinics in the Mid-Atlantic, primary care patients were classified into two groups-telemedicine versus in person-based on the first visit between March and May 2020 and followed up for 14 days. Using multivariable logistic regression, we measured the odds of being seen via telemedicine versus in person as a function of patient demographics, comorbidities, and week of study period. We then measured the odds of ACSC hospitalization by visit modality. RESULTS Mean age was 75.1 years (SD, 7.5), 60.6% of patients were female, 64.6% white, 28.1% black, and 2.0% Hispanic. Overall, 60.3% of patients accessed primary care via telemedicine. Black (vs. white) patients had higher odds of using telemedicine (adjusted odds ratio [aOR], 1.30; 95% CI, 1.14-1.47) and Hispanic (vs. not Hispanic) patients had lower odds (aOR, 0.63; 95% CI, 0.42-0.92). Compared with the in-person group, patients in the telemedicine group had lower odds of ACSC hospitalization (aOR, 0.78; 95% CI, 0.61-1.00). Among patients who used telemedicine, black patients had 1.43 higher odds of ACSC hospitalization (95% CI, 1.02-2.01) compared with white patients. Patients aged 85 or older seen via telemedicine had higher odds of an ACSC hospitalization (aOR, 1.60; 95% CI, 1.03-2.47) compared with patients aged 65-74. CONCLUSIONS These findings support the use of telemedicine for primary care access for older adults. However, the observed disparities highlight the need to improve care quality and equity regardless of visit modality.
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Henwood BF, Rhoades H, Dzubur E, Madden DR, Redline B, Brown RT. Investigating Sleep Disturbance and Its Correlates Among Formerly Homeless Adults in Permanent Supportive Housing. Med Care 2021; 59:S206-S211. [PMID: 33710097 PMCID: PMC7959063 DOI: 10.1097/mlr.0000000000001446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adults experiencing homelessness have a high burden of sleep disturbance, which may be reduced by accessing permanent supportive housing. OBJECTIVES To assess sleep disturbances and their correlates, including demographics, activity level, health status, age-related health issues (eg, functionality and cognitive impairment), substance use, and homelessness history in a sample of permanent supportive housing (PSH) tenants. RESEARCH DESIGN Cross-sectional survey design. SUBJECTS A total of 237 formerly homeless adults between 45 and 80 years old. MEASURES The Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance short form was used to measure sleep disturbance. RESULTS Twenty-eight percent of our sample had PROMIS scores indicative of a moderate or severe sleep disturbance. Functional impairment, pain, and mental health comorbidities were associated with increased sleep disturbance in multivariable linear regression analyses. The number of years a person experienced homelessness was inversely associated with sleep disturbance. CONCLUSIONS This study supports the need to screen for sleep disturbances among PSH tenants. The findings suggest that supportive services in PSH may need to include integrated physical and behavioral health care, pain management, and interventions designed to address activities of daily livings to improve tenant sleep. They also suggest that improved sleep may help reduce PSH tenant pain, impairment, and mental health symptoms among PSH tenants.
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Nicosia FM, Spar MJ, Neumann A, Silvestrini MC, Barrientos M, Brown RT. "The More They Know, the Better Care They Can Give": Patient Perspectives on Measuring Functional Status in Primary Care. J Gen Intern Med 2020; 35:2947-2954. [PMID: 32749552 PMCID: PMC7573015 DOI: 10.1007/s11606-020-06075-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Despite its importance to care and outcomes for older adults, functional status is seldom routinely measured in primary care. Understanding patient perspectives is necessary to develop effective, patient-centered approaches for measuring function, yet we know little about patient views on this topic. OBJECTIVE To examine patient and caregiver perspectives on measuring activities of daily living (ADLs) and instrumental ADLs (IADLs). DESIGN Qualitative study using semi-structured interviews. PARTICIPANTS Twenty-eight patients aged 65 or older and five caregivers in primary care clinics at one Veterans Affairs Medical Center. APPROACH We conducted interviews to elicit patient and caregiver perspectives on the importance of measuring function, including preferences for method of screening and assessment, wording of questions, and provider communication style. We analyzed interviews using qualitative thematic analysis. KEY RESULTS We identified several themes related to measuring function in primary care. First, most participants reported that measuring function is part of quality, holistic care. However, a minority of participants noted that discussing function, especially IADLs, was not medically relevant. Second, in terms of preferences for measuring function, participants noted that interdisciplinary approaches to measuring function are optimal and that face-to-face assessment is most "intimate" and can prompt reflection on one's limitations. However, some participants indicated that self-assessment is less invasive than in-person assessment. Third, participants had varied preferences regarding communicating about function. Participants noted that asking about difficulty with activities versus need for help are distinct and complementary concepts and that providing context is essential when discussing sensitive topics such as functional decline. CONCLUSIONS Most patients and caregivers reported that measuring function was important, preferred face-to-face assessment, and emphasized the importance of providing context when asking about function. These findings suggest that incorporating patient and caregiver preferences for measuring function can improve satisfaction and experience with functional assessment in primary care.
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Brown RT, Covinsky KE. Moving prevention of functional impairment upstream: is middle age an ideal time for intervention? Womens Midlife Health 2020; 6:4. [PMID: 32695430 PMCID: PMC7366897 DOI: 10.1186/s40695-020-00054-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 07/13/2020] [Indexed: 12/20/2022] Open
Abstract
To live independently, individuals must be able to perform basic activities of daily living (ADLs), including bathing, dressing, and transferring out of a bed or chair. When older adults develop difficulty or the need for help performing ADLs, they experience decreased quality of life and an increased risk of acute care utilization, nursing home admission, and death. For these reasons, slowing or preventing the progression to functional problems is a key focus of the care of older adults. While preventive efforts currently focus mainly on older people, difficulty performing basic ADLs (“functional impairment”) affects nearly 15% of middle-aged adults, and this prevalence is increasing. People who develop functional impairment in middle age are at increased risk for adverse outcomes similar to those experienced by older adults. Developing ADL impairment in middle age also impacts work force participation and health expenditures, not just in middle age but also older age. Middle-aged adults have a high capacity for recovery from functional impairment, and many risk factors for developing functional impairment in middle and older age have their roots in mid-life. Taken together, these findings suggest that middle age may be an ideal period to intervene to prevent or delay functional impairment. To address the rising prevalence of functional impairment in middle age, we will need to work on several fronts. These include developing improved prognostic tools to identify middle-aged people at highest risk for functional impairment and developing interventions to prevent or delay impairment among middle-aged people. More broadly, we need to recognize functional impairment in middle age as a problem that is as prevalent and central to health outcomes as many chronic medical conditions.
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Silvestrini M, Nicosia F, Spar MJ, Gibson CJ, Brown RT. "We Have a Long Way to Go:" A Case Study Examination of Older Women Veterans' Experiences in VA Primary Care. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2020; 57:46958020931311. [PMID: 32525421 PMCID: PMC7290258 DOI: 10.1177/0046958020931311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Women Veterans are a growing population with complex care needs. While previous research has examined the experiences of women Veterans, little attention has been paid to the specific experiences of older women Veterans. These case studies present the experiences of 2 older women Veterans who have been enrolled in Veterans Affairs (VA) health care for several decades. Results suggest that these older women Veterans have faced gender-specific challenges and barriers throughout their time accessing VA care. The experiences of these participants suggest that they have gender-sensitive needs that are not always addressed by VA primary care and that women’s groups are important mechanisms by which they have gained psychological support in a gender-sensitive environment. These cases suggest that access to gender-sensitive services and women-centered spaces are important for these 2 older women Veterans and should be explored in future research.
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Henwood BF, Rhoades H, Lahey J, Pynoos J, Pitts D, Brown RT. Examining fall risk among formerly homeless older adults living in permanent supportive housing. HEALTH & SOCIAL CARE IN THE COMMUNITY 2020; 28:842-849. [PMID: 31815341 PMCID: PMC7124982 DOI: 10.1111/hsc.12915] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 11/15/2019] [Accepted: 11/21/2019] [Indexed: 06/10/2023]
Abstract
Although permanent supportive housing (PSH) has been credited with a decline in the number of chronically homeless adults in the United States since 2007, the extent to which PSH can accommodate the needs of a prematurely aging population, including reducing the likelihood of falls, is unclear. The objective of this study is to examine the prevalence and correlates of falls with a sample of 237 tenants (45- to 80-year olds) from two PSH programmes in Los Angeles from 1 January 2017 to 10 August 2017. We also explore the location and severity of fall-related injury using a subsample of 66 tenants. Standard surveys queried demographics, health status, history of homelessness and falls. Multivariable logistic regression assessed the correlates of falling in the past year. More than half of the sample had fallen and more than 40% had multiple falls in the past year. Functional impairment, frailty and persistent pain were all associated with increased fall risk. For the 66 tenants who provided more detailed fall information, more than 40% fell at home and of those nearly half fell in their bathroom. Fall-related injuries were common, with more than one-third of the subsample experiencing serious injury. These findings suggest that fall prevention is needed in PSH but that more research is needed to understand the degree to which individual and environmental risk factors are contributing to falls.
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Nicosia F, Spar MJ, Neumann A, Silvestrini MC, Barrientos M, Brown RT. OLDER VETERANS’ PERSPECTIVES ON MEASURING FUNCTIONAL STATUS IN VA PRIMARY CARE CLINICS. Innov Aging 2019. [PMCID: PMC6845496 DOI: 10.1093/geroni/igz038.2773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Little is known about older adults’ perspectives on measuring functional status (i.e., ability to perform basic and instrumental activities of daily living). This study used a qualitative design to understand older Veterans’ perspectives on measuring function in primary care settings. Thematic analysis of interviews conducted with 28 Veterans ≥65 years and 5 caregivers from one VA Medical Center identified several themes including: 1) importance and relevance of discussing function; 2) preferences for assessment method (e.g., provider- or self-assessment;) and 3) wording of questions (i.e., needing help vs. having difficultly). These findings suggest that effective approaches to measuring function must consider patient preferences on content and format and ensure that measurement is used to inform care. We applied these findings to develop an interprofessional intervention to improve functional status measurement for older Veterans in primary care.
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Brown RT, Guzman D, Kaplan LM, Ponath C, Lee CT, Kushel MB. Trajectories of functional impairment in homeless older adults: Results from the HOPE HOME study. PLoS One 2019; 14:e0221020. [PMID: 31408488 PMCID: PMC6692032 DOI: 10.1371/journal.pone.0221020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 07/30/2019] [Indexed: 01/18/2023] Open
Abstract
Difficulty performing activities of daily living ("functional impairment") is common in homeless adults aged 50 and older. However, little is known about the trajectory of these impairments, nor the extent to which these trajectories are similar to those of older adults in the general population. We identified trajectories of functional impairment in homeless adults aged 50 and older, and risk factors for differing trajectories. We conducted a prospective cohort study of 350 homeless adults, aged 50 and older, recruited via population-based sampling in Oakland, California and interviewed at 6-month intervals for up to 3 years. We assessed functional trajectories based on self-reported difficulty performing 5 activities of daily living. We used multivariable multinomial logistic regression to identify baseline risk factors for each trajectory. At baseline, participants' mean age was 58 years (SD, 5.3), 24.1% were women, 80.9% were African American, and 38.6% had difficulty performing 1 or more activities of daily living. We identified 4 distinct functional trajectories: minimal impairment in 136 participants (41.1%); persistent impairment in 81 (25.4%); partial improvement in 74 (23.5%); and decline in 28 (10.0%). Risk factors for persistent impairment included falls in the 6 months before baseline, depressive symptoms, and low physical performance. Although functional impairment improved in some homeless adults, it persisted or worsened in many others. These findings suggest that, similar to older adults in the general population, functional impairment among older homeless persons is not a transient phenomenon, but instead a chronic issue requiring long-term solutions.
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Henwood BF, Lahey J, Rhoades H, Pitts DB, Pynoos J, Brown RT. Geriatric Conditions Among Formerly Homeless Older Adults Living in Permanent Supportive Housing. J Gen Intern Med 2019; 34:802-803. [PMID: 30604125 PMCID: PMC6544727 DOI: 10.1007/s11606-018-4793-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Brown RT, Diaz-Ramirez LG, Boscardin WJ, Lee SJ, Williams BA, Steinman MA. Association of Functional Impairment in Middle Age With Hospitalization, Nursing Home Admission, and Death. JAMA Intern Med 2019; 179:668-675. [PMID: 30958504 PMCID: PMC6503566 DOI: 10.1001/jamainternmed.2019.0008] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
IMPORTANCE Difficulty performing daily activities such as bathing and dressing ("functional impairment") affects nearly 15% of middle-aged adults. Older adults who develop such difficulties, often because of frailty and other age-related conditions, are at increased risk of acute care use, nursing home admission, and death. However, it is unknown if functional impairments that develop among middle-aged people, which may have different antecedents, have similar prognostic significance. OBJECTIVE To determine whether middle-aged individuals who develop functional impairment are at increased risk for hospitalization, nursing home admission, and death. DESIGN, SETTING, AND PARTICIPANTS This matched cohort study analyzed longitudinal data from the Health and Retirement Study, a nationally representative prospective cohort study of US adults. The study population included 5540 adults aged 50 to 56 years who did not have functional impairment at study entry in 1992, 1998, or 2004. Participants were followed biennially through 2014. Individuals who developed functional impairment between 50 and 64 years were matched by age, sex, and survey wave with individuals without impairment as of that age and survey wave. Statistical analysis was conducted from March 15, 2017, to December 11, 2018. EXPOSURES Impairment in activities of daily living (ADLs), defined as self-reported difficulty performing 1 or more ADLs, and impairment in instrumental ADLs (IADLs), defined similarly. MAIN OUTCOMES AND MEASURES The 3 primary outcomes were time from the first episode of functional impairment (or matched survey wave, in controls) to hospitalization, nursing home admission, and death. Follow-up assessments occurred every 2 years until 2014. Competing risks survival analysis was used to assess the association of functional impairment with hospitalization and nursing home admission and Cox proportional hazards regression analysis was used to assess the association with death. RESULTS Of the 5540 study participants (2739 women and 2801 men; median age, 53.7 years [interquartile range, 52.3-55.2 years]), 1097 (19.8%) developed ADL impairment between 50 and 64 years, and 857 (15.5%) developed IADL impairment. Individuals with ADL impairment had an increased risk of each adverse outcome compared with those without impairment, including hospitalization (subhazard ratio, 1.97; 95% CI, 1.77-2.19), nursing home admission (subhazard ratio, 2.62; 95% CI, 1.99-3.45), and death (hazard ratio, 2.06; 95% CI, 1.74-2.45). After multivariable adjustment, the risks of hospitalization (subhazard ratio, 1.54; 95% CI, 1.36-1.75) and nursing home admission (subhazard ratio, 1.73; 95% CI, 1.24-2.43) remained significantly higher among individuals with ADL impairment, but the risk of death was not statistically significant (hazard ratio, 1.06; 95% CI, 0.85-1.32). Individuals with IADL impairment had an increased risk of all 3 outcomes in adjusted and unadjusted analyses. CONCLUSIONS AND RELEVANCE Similar to older adults, middle-aged adults who develop functional impairment appear to be at increased risk for adverse outcomes. Even among relatively young people, functional impairment has important clinical implications.
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Nicosia FM, Spar MJ, Steinman MA, Lee SJ, Brown RT. Making Function Part of the Conversation: Clinician Perspectives on Measuring Functional Status in Primary Care. J Am Geriatr Soc 2019; 67:493-502. [PMID: 30506667 PMCID: PMC6402957 DOI: 10.1111/jgs.15677] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 10/03/2018] [Accepted: 10/06/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Although there is increasing interest in using functional status to guide clinical decision making, function is seldom routinely assessed in primary care. We explored clinician perspectives on barriers and facilitators to routine measurement of older adults' functional status in primary care settings. DESIGN Qualitative study using semistructured interviews. SETTING Primary care and geriatrics clinics at six Veterans Affairs Medical Centers. PARTICIPANTS Twenty-four primary care providers, including 17 from primary care clinics and 7 from geriatrics clinics. MEASUREMENTS We conducted interviews to elicit clinician perspectives about functional status measurement, including barriers and facilitators to routine assessment. We analyzed transcripts iteratively using a hybrid inductive and deductive thematic approach. RESULTS Interviews revealed three distinct aspects to measuring function: screening and assessment, documentation, and use of data to inform care. Barriers and facilitators to screening and assessment included time availability, clinic processes, and degree of interdisciplinary environment. Barriers and facilitators to documentation included the usability and integration of electronic instruments into workflows and the availability of a standardized location to document function in the electronic medical record. Barriers and facilitators to use of data included the availability of a standardized location to retrieve data on function, the availability of appropriate referrals and services, and provider knowledge of available resources to address functional impairments. To address these barriers, providers emphasized the critical importance of connecting measurement of function directly to improved patient care. CONCLUSION Although clinicians emphasized the importance of measuring function, they also cautioned against additional workload burdens, cumbersome electronic documentation, and measurement of function without ensuring that these data are used to improve care. Approaches to functional status measurement must address these barriers to improve care and outcomes for older adults. J Am Geriatr Soc 67:493-502, 2019.
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Nicosia F, Spar MJ, A Steinman M, Brown RT. DEVELOPMENT OF AN INTERPROFESSIONAL INTERVENTION TO IMPROVE FUNCTIONAL STATUS MEASUREMENT IN VA PRIMARY CARE. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.2973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Brown RT, Hemati K, Riley ED, Lee CT, Ponath C, Tieu L, Guzman D, Kushel MB. Geriatric Conditions in a Population-Based Sample of Older Homeless Adults. THE GERONTOLOGIST 2018; 57:757-766. [PMID: 26920935 DOI: 10.1093/geront/gnw011] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 11/17/2015] [Indexed: 01/23/2023] Open
Abstract
Purpose of the Study Older homeless adults living in shelters have high rates of geriatric conditions, which may increase their risk for acute care use and nursing home placement. However, a minority of homeless adults stay in shelters and the prevalence of geriatric conditions among homeless adults living in other environments is unknown. We determined the prevalence of common geriatric conditions in a cohort of older homeless adults, and whether the prevalence of these conditions differs across living environments. Design and Methods We interviewed 350 homeless adults, aged 50 and older, recruited via population-based sampling in Oakland, CA. We evaluated participants for common geriatric conditions. We assessed living environment using a 6-month follow-back residential calendar, and used cluster analysis to identify participants' primary living environment over the prior 6 months. Results Participants stayed in 4 primary environments: unsheltered locations (n = 162), multiple locations including shelters and hotels (n = 88), intermittently with family/friends (n = 57), and, in a recently homeless group, rental housing (n = 43). Overall, 38.9% of participants reported difficulty performing 1 or more activities of daily living, 33.7% reported any falls in the past 6 months, 25.8% had cognitive impairment, 45.1% had vision impairment, and 48.0% screened positive for urinary incontinence. The prevalence of geriatric conditions did not differ significantly across living environments. Implications Geriatric conditions were common among older homeless adults living in diverse environments, and the prevalence of these conditions was higher than that seen in housed adults 20 years older. Services that address geriatric conditions are needed for older homeless adults living across varied environments.
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Brown RT, Covinsky KE. Frailty as an Outcome in Geriatrics Research: Not Ready for Prime Time? Ann Intern Med 2018; 168:361-362. [PMID: 29310132 PMCID: PMC5840034 DOI: 10.7326/m17-3048] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Brown RT, Diaz-Ramirez LG, Boscardin WJ, Lee SJ, Steinman MA. Functional Impairment and Decline in Middle Age: A Cohort Study. Ann Intern Med 2017; 167:761-768. [PMID: 29132150 PMCID: PMC5716833 DOI: 10.7326/m17-0496] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Difficulties with daily functioning are common in middle-aged adults. However, little is known about the epidemiology or clinical course of these problems, including the extent to which they share common features with functional impairment in older adults. OBJECTIVE To determine the epidemiology and clinical course of functional impairment and decline in middle age. DESIGN Cohort study. SETTING The Health and Retirement Study. PARTICIPANTS 6874 community-dwelling adults aged 50 to 56 years who did not have functional impairment at enrollment. MEASUREMENTS Impairment in activities of daily living (ADLs), defined as self-reported difficulty performing 1 or more ADLs, assessed every 2 years for a maximum follow-up of 20 years, and impairment in instrumental ADLs (IADLs), defined similarly. Data were analyzed by using multistate models that estimate probabilities of different outcomes. RESULTS Impairment in ADLs developed in 22% of participants aged 50 to 64 years, in whom further functional transitions were common. Two years after the initial impairment, 4% (95% CI, 3% to 5%) of participants had died, 9% (CI, 8% to 11%) had further ADL decline, 50% (CI, 48% to 52%) had persistent impairment, and 37% (CI, 35% to 39%) had recovered independence. In the 10 years after the initial impairment, 16% (CI, 14% to 18%) had 1 or more episodes of functional decline and 28% (CI, 26% to 30%) recovered from their initial impairment and remained independent throughout this period. The pattern of findings was similar for IADLs. LIMITATION Functional status was self-reported. CONCLUSION Functional impairment and decline are common in middle age, as are transitions from impairment to independence and back again. Because functional decline in older adults has similar features, current interventions used for prevention in older adults may hold promise for those in middle age. PRIMARY FUNDING SOURCE National Institute on Aging and National Center for Advancing Translational Sciences through the University of California, San Francisco, Clinical and Translational Sciences Institute.
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Makaroun LK, Brown RT, Diaz-Ramirez LG, Ahalt C, Boscardin WJ, Lang-Brown S, Lee S. Wealth-Associated Disparities in Death and Disability in the United States and England. JAMA Intern Med 2017; 177:1745-1753. [PMID: 29059279 PMCID: PMC5820733 DOI: 10.1001/jamainternmed.2017.3903] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 07/15/2017] [Indexed: 12/29/2022]
Abstract
Importance Low income has been associated with poor health outcomes. Owing to retirement, wealth may be a better marker of financial resources among older adults. Objective To determine the association of wealth with mortality and disability among older adults in the United States and England. Design, Setting, and Participants The US Health and Retirement Study (HRS) and English Longitudinal Study of Aging (ELSA) are nationally representative cohorts of community-dwelling older adults. We examined 12 173 participants enrolled in HRS and 7599 enrolled in ELSA in 2002. Analyses were stratified by age (54-64 years vs 66-76 years) because many safety-net programs commence around age 65 years. Participants were followed until 2012 for mortality and disability. Exposures Wealth quintile, based on total net worth in 2002. Main Outcomes and Measures Mortality and disability, defined as difficulty performing an activity of daily living. Results A total of 6233 US respondents and 4325 English respondents aged 54 to 64 years (younger cohort) and 5940 US respondents and 3274 English respondents aged 66 to 76 years (older cohort) were analyzed for the mortality outcome. Slightly over half of respondents were women (HRS: 6570, 54%; ELSA: 3974, 52%). A higher proportion of respondents from HRS were nonwhite compared with ELSA in both the younger (14% vs 3%) and the older (13% vs 3%) age cohorts. We found increased risk of death and disability as wealth decreased. In the United States, participants aged 54 to 64 years in the lowest wealth quintile (Q1) (≤$39 000) had a 17% mortality risk and 48% disability risk over 10 years, whereas in the highest wealth quintile (Q5) (>$560 000) participants had a 5% mortality risk and 15% disability risk (mortality hazard ratio [HR], 3.3; 95% CI, 2.0-5.6; P < .001; disability subhazard ratio [sHR], 4.0; 95% CI, 2.9-5.6; P < .001). In England, participants aged 54 to 64 years in Q1 (≤£34,000) had a 16% mortality risk and 42% disability risk over 10 years, whereas Q5 participants (>£310,550) had a 4% mortality risk and 17% disability risk (mortality HR, 4.4; 95% CI, 2.7-7.0; P < .001; disability sHR, 3.0; 95% CI, 2.1-4.2; P < .001). In 66- to 76-year-old participants, the absolute risks of mortality and disability were higher, but risk gradients across wealth quintiles were similar. When adjusted for sex, age, race, income, and education, HR for mortality and sHR for disability were attenuated but remained statistically significant. Conclusions and Relevance Low wealth was associated with death and disability in both the United States and England. This relationship was apparent from age 54 years and continued into later life. Access to health care may not attenuate wealth-associated disparities in older adults.
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Spar MJ, Nicosia FM, Steinman MA, Brown RT. Current approaches to measuring functional status among older adults in VA primary care clinics. Fed Pract 2017; 34:26-31. [PMID: 29706753 PMCID: PMC5915328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
VA primary care clinics had widely varying approaches for assessing and documenting the functional status of geriatric patients.
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Brown RT, Ahalt C, Rivera J, Cenzer IS, Wilhelm A, Williams BA. Good Cop, Better Cop: Evaluation of a Geriatrics Training Program for Police. J Am Geriatr Soc 2017; 65:1842-1847. [PMID: 28436006 PMCID: PMC5555774 DOI: 10.1111/jgs.14899] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To develop, implement, and evaluate a training program in aging-related health for police officers. DESIGN Cross-sectional. SETTING Crisis intervention training program for police officers in San Francisco. PARTICIPANTS Police officers attending one of five 2-hour trainings (N = 143). INTERVENTION A lecture on aging-related health conditions pertinent to police work followed by three experiential trainings on how it feels to be "old." MEASUREMENTS Participants evaluated the quality of the training and the likelihood that they would apply new knowledge to their work and rated their knowledge using a retrospective pre-post evaluation. In open-ended responses, participants reported work-related changes they anticipated making in response to the training. RESULTS All 143 participants completed the evaluation. Eighty-four percent reported interacting with older adults at least monthly; 45% reported daily interactions. Participants rated the training quality at 4.6/5 and the likelihood they would apply new knowledge to their work at 4.4/5. Retrospective pre-post knowledge scores increased for all domains, including how to identify aging-related health conditions that can affect safety during police interactions (2.9/5 to 4.2/5; P < .001). In open-ended responses, participants anticipated having more empathy for and awareness of aging-related conditions and greater ability to provide older adults with appropriate community referrals. CONCLUSION A brief training in aging-related health significantly increased police officers' self-reported knowledge and skills. Clinicians have an important opportunity to help enhance safe and effective community policing for older adults.
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Brown RT, Komaiko KD, Shi Y, Fung KZ, Boscardin WJ, Au-Yeung A, Tarasovsky G, Jacob R, Steinman MA. Bringing functional status into a big data world: Validation of national Veterans Affairs functional status data. PLoS One 2017; 12:e0178726. [PMID: 28570678 PMCID: PMC5453575 DOI: 10.1371/journal.pone.0178726] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 05/17/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The ability to perform basic daily activities ("functional status") is key to older adults' quality of life and strongly predicts health outcomes. However, data on functional status are seldom collected during routine clinical care in a way that makes them available for clinical use and research. OBJECTIVES To validate functional status data that Veterans Affairs (VA) medical centers recently started collecting during routine clinical care, compared to the same data collected in a structured research setting. DESIGN Prospective validation study. SETTING Seven VA medical centers that collected complete data on 5 activities of daily living (ADLs) and 8 instrumental activities of daily living (IADLs) from older patients attending primary care appointments. PARTICIPANTS Randomly selected patients aged 75 and older who had new ADL and IADL data collected during a primary care appointment (N = 252). We oversampled patients with ADL dependence and applied these sampling weights to our analyses. MEASUREMENTS Telephone-based interviews using a validated measure to assess the same 5 ADLs and 8 IADLs. RESULTS Mean age was 83 years, 96% were male, and 75% were white. Of 85 participants whom VA data identified as dependent in 1 or more ADLs, 74 (87%) reported being dependent by interview; of 167 whom VA data identified as independent in ADLs, 149 (89%) reported being independent. The sample-weighted sensitivity of the VA data for identifying ADL dependence was 45% (95% CI, 29%, 62%) compared to the reference standard, the specificity was 99% (95% CI, 99%, >99%), and the positive predictive value was 87% (95% CI, 79%, 93%). The weighted kappa statistic was 0.55 (95% CI, 0.41, 0.68) for the agreement between VA data and research-collected data in identifying ADL dependence. CONCLUSION Overall agreement of VA functional status data with a reference standard was moderate, with fair sensitivity but high specificity and positive predictive value.
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Brown RT, Goodman L, Guzman D, Tieu L, Ponath C, Kushel MB. Pathways to Homelessness among Older Homeless Adults: Results from the HOPE HOME Study. PLoS One 2016; 11:e0155065. [PMID: 27163478 PMCID: PMC4862628 DOI: 10.1371/journal.pone.0155065] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 04/23/2016] [Indexed: 11/19/2022] Open
Abstract
Little is known about pathways to homelessness among older adults. We identified life course experiences associated with earlier versus later onset of homelessness in older homeless adults and examined current health and functional status by age at first homelessness. We interviewed 350 homeless adults, aged 50 and older, recruited via population-based sampling. Participants reported age at first episode of adult homelessness and their life experiences during 3 time periods: childhood (<18 years), young adulthood (ages 18–25), and middle adulthood (ages 26–49). We used a structured modeling approach to identify experiences associated with first adult homelessness before age 50 versus at age 50 or older. Participants reported current health and functional status, including recent mental health and substance use problems. Older homeless adults who first became homeless before 50 had more adverse life experiences (i.e., mental health and substance use problems, imprisonment) and lower attainment of adult milestones (i.e., marriage, full-time employment) compared to individuals with later onset. After multivariable adjustment, adverse experiences were independently associated with experiencing a first episode of homelessness before age 50. Individuals who first became homeless before age 50 had higher prevalence of recent mental health and substance use problems and more difficulty performing instrumental activities of daily living. Life course experiences and current vulnerabilities of older homeless adults with first homelessness before age 50 differed from those with later onset of homelessness. Prevention and service interventions should be adapted to meet different needs.
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Cimino T, Steinman MA, Mitchell SL, Miao Y, Bharel M, Barnhart CE, Brown RT. The Course of Functional Impairment in Older Homeless Adults: Disabled on the Street. JAMA Intern Med 2015; 175:1237-9. [PMID: 26011591 PMCID: PMC4494897 DOI: 10.1001/jamainternmed.2015.1562] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Brown RT, Miao Y, Mitchell SL, Bharel M, Patel M, Ard KL, Grande LJ, Blazey-Martin D, Floru D, Steinman MA. Health Outcomes of Obtaining Housing Among Older Homeless Adults. Am J Public Health 2015; 105:1482-8. [PMID: 25973822 DOI: 10.2105/ajph.2014.302539] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We determined the impact of obtaining housing on geriatric conditions and acute care utilization among older homeless adults. METHODS We conducted a 12-month prospective cohort study of 250 older homeless adults recruited from shelters in Boston, Massachusetts, between January and June 2010. We determined housing status at follow-up, determined number of emergency department visits and hospitalizations over 12 months, and examined 4 measures of geriatric conditions at baseline and 12 months. Using multivariable regression models, we evaluated the association between obtaining housing and our outcomes of interest. RESULTS At 12-month follow-up, 41% of participants had obtained housing. Compared with participants who remained homeless, those with housing had fewer depressive symptoms. Other measures of health status did not differ by housing status. Participants who obtained housing had a lower rate of acute care use, with an adjusted annualized rate of acute care visits of 2.5 per year among participants who obtained housing and 5.3 per year among participants who remained homeless. CONCLUSIONS Older homeless adults who obtained housing experienced improved depressive symptoms and reduced acute care utilization compared with those who remained homeless.
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Brown RT, Ahalt C, Steinman MA, Kruger K, Williams BA. Police on the front line of community geriatric health care: challenges and opportunities. J Am Geriatr Soc 2014; 62:2191-8. [PMID: 25378267 DOI: 10.1111/jgs.13093] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
As the population ages, police increasingly serve as first responders to incidents involving older adults in which aging-related health plays a critical role. The goals of this study were to assess police officers' knowledge of aging-related health, to identify challenges police experience in their encounters with older adults, and to describe their recommendations for how to address those challenges. This was a mixed-methods study of 141 San Francisco police officers recruited from mandatory police trainings between 2011 and 2013. Descriptive statistics were used to analyze 141 self-administered questionnaires, and principles of grounded theory were used to analyze open-ended questionnaire responses and 11 additional qualitative interviews. Eighty-nine percent of officers reported interacting with older adults at least monthly. Although 84% of police reported prior training in working with older adults, only 32% rated themselves as knowledgeable about aging-related health. Participants described themselves as first responders to medical and social emergencies involving older adults and identified several challenges, including identifying and responding to aging-related conditions and ensuring appropriate medical and social service handoffs. To address these challenges, officers recommended developing trainings focused on recognizing and responding to aging-related conditions and improving police knowledge of community resources for older adults. They also called for enhanced communication and collaboration between police and clinicians. These findings suggest that, because they assume a front-line role in responding to older adults with complex medical and social needs, many police may benefit from additional knowledge about aging-related health and community resources. Collaboration between police and healthcare providers presents an important opportunity to develop geriatrics training and interprofessional systems of care to support police work with a rapidly aging population.
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Brown RT, Pierluissi E, Guzman D, Kessell ER, Goldman LE, Sarkar U, Schneidermann M, Critchfield JM, Kushel MB. Functional disability in late-middle-aged and older adults admitted to a safety-net hospital. J Am Geriatr Soc 2014; 62:2056-63. [PMID: 25367281 DOI: 10.1111/jgs.13103] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine the prevalence of preadmission functional disability in late-middle-aged and older safety-net inpatients and to identify characteristics associated with functional disability by age. DESIGN Cross-sectional analysis. SETTING Safety-net hospital in San Francisco, California. PARTICIPANTS English-, Spanish-, and Chinese-speaking community-dwelling individuals aged 55 and older admitted to a safety-net hospital with anticipated return to the community (N = 699). MEASUREMENTS At hospital admission, participants reported their need for help performing five activities of daily living (ADLs) and seven instrumental activities of daily living (IADLs) 2 weeks before admission. ADL disability was defined as needing help performing one or more ADLs and IADL disability as needing help performing two or more IADLs. Participant characteristics were assessed, including sociodemographic characteristics, health status, health-related behaviors, and health-seeking behaviors. RESULTS Overall, 28.3% of participants reported that they had an ADL disability 2 weeks before admission, and 40.4% reported an IADL disability. The prevalence of preadmission ADL disability was 28.9% of those aged 55 to 59, 20.7% of those aged 60 to 69, and 41.2% of those aged 70 and older (P < .001). The prevalence of IADL disability had a similar distribution. The characteristics associated with functional disability differed according to age; in participants aged 55 to 59, African Americans had a higher odds of ADL and IADL disability, whereas in participants aged 60 to 69 and aged 70 and older, inadequate health literacy was associated with functional disability. CONCLUSION Preadmission functional disability is common in individuals aged 55 and older admitted to a safety-net hospital. Late-middle-aged individuals admitted to safety-net hospitals may benefit from models of acute care currently used for older adults that prevent adverse outcomes associated with functional disability.
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