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Cheung ESL. Neighborhood Gentrification and Food Insecurity Among Urban Older Adults: Evidence From New York City. THE GERONTOLOGIST 2024; 64:gnae048. [PMID: 38761043 DOI: 10.1093/geront/gnae048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Indexed: 05/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Gentrification is a prevalent neighborhood development process in urban areas across the United States. Prior studies have identified the influence of gentrification on late-life health and quality of life, yet little is known about its relationship with food insecurity, an important public health issue for older adult populations. Using New York City as a case study, this study investigated associations between living in a gentrifying neighborhood and food insecurity, as well as the mediating roles of neighborhood environment factors-social cohesion, public transportation, and food environment. RESEARCH DESIGN AND METHODS This study adopted 2 waves of annual data from the Poverty Tracker Study (2015-2016; N = 703) merged with American Community Survey and spatial data sets to measure gentrification and neighborhood factors. Adjusted logistic regressions were used to examine the associations between gentrification and food insecurity. Further mediation analyses were conducted to test the mechanisms of such associations. RESULTS Older adults in gentrifying neighborhoods were more likely to have food insecurity than those in moderate- to high-income neighborhoods. Compared to low-income neighborhoods, older adults in gentrifying neighborhoods had a lower likelihood of reporting food insecurity. Two significant mediators were found when comparing gentrification with moderate- to high-income neighborhoods: social cohesion and healthy food outlets. DISCUSSION AND IMPLICATIONS This study highlights the importance of gentrification in determining late-life food insecurity and identifies possible mechanisms with policy and social service implications to reduce the risk of food insecurity in urban areas.
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Affiliation(s)
- Ethan Siu Leung Cheung
- Department of Family and Consumer Studies, The University of Utah, Salt Lake City, Utah, USA
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Schousboe JT, Langsetmo L, Kats AM, Taylor BC, Boyd C, Van Riper D, Kado DM, Duan-Porter W, Cawthon PM, Ensrud KE. Neighborhood Socioeconomic Deprivation and Health Care Costs in Older Community-Dwelling Adults: Importance of Functional Impairment and Frailty. J Gen Intern Med 2024:10.1007/s11606-024-08875-8. [PMID: 38937364 DOI: 10.1007/s11606-024-08875-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 06/11/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Low neighborhood socioeconomic status is associated with adverse health outcomes, but its association with health care costs in older adults is uncertain. OBJECTIVES To estimate the association of neighborhood Area Deprivation Index (ADI) with total, inpatient, outpatient, skilled nursing facility (SNF), and home health care (HHC) costs among older community-dwelling Medicare beneficiaries, and determine whether these associations are explained by multimorbidity, phenotypic frailty, or functional impairments. DESIGN Four prospective cohort studies linked with each other and with Medicare claims. PARTICIPANTS In total, 8165 community-dwelling fee-for-service beneficiaries (mean age 79.2 years, 52.9% female). MAIN MEASURES ADI of participant residence census tract, Hierarchical Conditions Category multimorbidity score, self-reported functional impairments (difficulty performing four activities of daily living), and frailty phenotype. Total, inpatient, outpatient, post-acute SNF, and HHC costs (US 2020 dollars) for 36 months after the index examination. KEY RESULTS Mean incremental annualized total health care costs adjusted for age, race/ethnicity, and sex increased with ADI ($3317 [95% CI 1274 to 5360] for the most deprived vs least deprived ADI quintile, and overall p-value for ADI variable 0.009). The incremental cost for the most deprived vs least deprived ADI quintile was increasingly attenuated after separate adjustment for multimorbidity ($2407 [95% CI 416 to 4398], overall ADI p-value 0.066), frailty phenotype ($1962 [95% CI 11 to 3913], overall ADI p-value 0.22), or functional impairments ($1246 [95% CI -706 to 3198], overall ADI p-value 0.29). CONCLUSIONS Total health care costs are higher for older community-dwelling Medicare beneficiaries residing in the most socioeconomically deprived areas compared to the least deprived areas. This association was not significant after accounting for the higher prevalence of phenotypic frailty and functional impairments among residents of socioeconomically deprived neighborhoods.
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Affiliation(s)
- John T Schousboe
- HealthPartners Institute, Bloomington, MN, USA.
- Divison of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA.
| | - Lisa Langsetmo
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, MN, USA
| | - Allyson M Kats
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Brent C Taylor
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, MN, USA
| | - Cynthia Boyd
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Department of Health Policy & Management, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - David Van Riper
- Minnesota Population Center, University of Minnesota, Minneapolis, MN, USA
| | - Deborah M Kado
- Department of Medicine, Stanford University, Palo Alto, CA, USA
- Geriatric Research Education and Clinical Center (GRECC), VA Health Care System, Palo Alto, CA, USA
| | - Wei Duan-Porter
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, MN, USA
| | - Peggy M Cawthon
- California Pacific Medical Center Research Institute, San Francisco, CA, USA
| | - Kristine E Ensrud
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, MN, USA
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Cobert J, Jeon SY, Boscardin J, Chapman AC, Espejo E, Maley JH, Lee S, Smith AK. Resilience, Survival, and Functional Independence in Older Adults Facing Critical Illness. Chest 2024:S0012-3692(24)00700-1. [PMID: 38871280 DOI: 10.1016/j.chest.2024.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/25/2024] [Accepted: 04/28/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Older adults surviving critical illness often experience new or worsening functional impairments. Modifiable positive psychological constructs such as resilience may mitigate postintensive care morbidity. RESEARCH QUESTION Is pre-ICU resilience associated with: (1) post-ICU survival; (2) the drop in post-ICU functional independence; and (3) a lesser decline in independence before vs after the ICU? STUDY DESIGN AND METHODS This retrospective cohort study was performed by using Medicare-linked Health and Retirement Study surveys from 2006 to 2018. Older adults aged ≥ 65 years admitted to an ICU were included. Resilience was calculated prior to ICU admission. The resilience measure was defined from the Simplified Resilience Score, which was previously adapted and validated for the Health and Retirement Study. Resilience was scored by using the Leave-Behind survey normalized to 0 (lowest resilience) to 12 (highest resilience) point scale. Outcomes were survival and probability of functional independence. Survival was modeled by using Gompertz models and independence using joint survival models adjusting for sociodemographic and clinical variables. Average marginal effects were estimated to determine independence probabilities. RESULTS Across 3,409 patients ≥ 65 years old admitted to ICUs, preexisting frailty (30.5%) and cognitive impairment (24.3%) were common. Most patients were previously independent (82.7%). Mechanical ventilation occurred in 14.8% and sepsis in 43.2%. Highest vs lowest resilience had lower risk of post-ICU mortality (adjusted hazard ratio, 0.81; 95% CI, 0.70-0.94). Higher resilience was associated with greater likelihood in post-ICU independence (estimated probability of independence 5 years' post-ICU in highest-to-lowest resilience (adjusted hazard ratio [95% CI]): 0.53 (0.33-0.74), 0.47 (0.26-0.68), 0.49 (0.28-0.70), and 0.36 (0.17-0.55); P < .01. Resilience was not associated with a difference in the drop in independence across resilience groups, nor a difference in declines in independence post-ICU. INTERPRETATION ICU survivors with higher resilience had increased rates of survival and functional independence, although the slope of functional decline did not differ according to resilience group pre-ICU to post-ICU.
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Affiliation(s)
- Julien Cobert
- Anesthesia Service, San Francisco VA Health Care System, San Francisco, CA; Department of Anesthesiology, University of California San Francisco, San Francisco, CA.
| | - Sun Young Jeon
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA; Geriatrics, Palliative, and Extended Care, Veterans Affairs Medical Center, San Francisco, CA
| | - John Boscardin
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA; Geriatrics, Palliative, and Extended Care, Veterans Affairs Medical Center, San Francisco, CA
| | - Allyson C Chapman
- Critical Care and Palliative Medicine, Department of Internal Medicine, University of California San Francisco, San Francisco, CA; Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Edie Espejo
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA; Geriatrics, Palliative, and Extended Care, Veterans Affairs Medical Center, San Francisco, CA
| | - Jason H Maley
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sei Lee
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA; Geriatrics, Palliative, and Extended Care, Veterans Affairs Medical Center, San Francisco, CA
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA; Geriatrics, Palliative, and Extended Care, Veterans Affairs Medical Center, San Francisco, CA
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Watson MA, Sandi M, Bixby J, Perry G, Offner PJ, Burnham EL, Jolley SE. An Exploratory Analysis of Sociodemographic Factors Associated With Physical Functional Impairment in ICU Survivors. Crit Care Explor 2024; 6:e1100. [PMID: 38836576 PMCID: PMC11155592 DOI: 10.1097/cce.0000000000001100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024] Open
Abstract
IMPORTANCE Physical functional impairment is one of three components of postintensive care syndrome (PICS) that affects up to 60% of ICU survivors. OBJECTIVES To explore the prevalence of objective physical functional impairment among a diverse cohort of ICU survivors, both at discharge and longitudinally, and to highlight sociodemographic factors that might be associated with the presence of objective physical functional impairment. DESIGN, SETTING, AND PARTICIPANTS This was a secondary analysis of 37 patients admitted to the ICU in New Orleans, Louisiana, and Denver, Colorado between 2016 and 2019 who survived with longitudinal follow-up data. MAIN OUTCOMES AND MEASURES Our primary outcome of physical functional impairment was defined by handgrip strength and the short physical performance battery. We explored associations between functional impairment and sociodemographic factors that included race/ethnicity, sex, primary language, education status, and medical comorbidities. RESULTS More than 75% of ICU survivors were affected by physical functional impairment at discharge and longitudinally at 3- to 6-month follow-up. We did not see a significant difference in the proportion of patients with physical functional impairment by race/ethnicity, primary language, or education status. Impairment was relatively higher in the follow-up period among women, compared with men, and those with comorbidities. Among 18 patients with scores at both time points, White patients demonstrated greater change in handgrip strength than non-White patients. Four non-White patients demonstrated diminished handgrip strength between discharge and follow-up. CONCLUSIONS AND RELEVANCE In this exploratory analysis, we saw that the prevalence of objective physical functional impairment among ICU survivors was high and persisted after hospital discharge. Our findings suggest a possible relationship between race/ethnicity and physical functional impairment. These exploratory findings may inform future investigations to evaluate the impact of sociodemographic factors on functional recovery.
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Affiliation(s)
- Megan A Watson
- Division of Pulmonary and Critical Care, University of Colorado, Aurora, CO
| | - Marie Sandi
- Section of Pulmonary/Critical Care, Louisiana State University, New Orleans, LA
| | - Johanna Bixby
- Division of Pulmonary and Critical Care, University of Colorado, Aurora, CO
| | - Grace Perry
- Division of Pulmonary and Critical Care, University of Colorado, Aurora, CO
| | - Patrick J Offner
- Division of Pulmonary and Critical Care, University of Colorado, Aurora, CO
| | - Ellen L Burnham
- Division of Pulmonary and Critical Care, University of Colorado, Aurora, CO
| | - Sarah E Jolley
- Division of Pulmonary and Critical Care, University of Colorado, Aurora, CO
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Palakshappa JA, Batt JAE, Bodine SC, Connolly BA, Doles J, Falvey JR, Ferrante LE, Files DC, Harhay MO, Harrell K, Hippensteel JA, Iwashyna TJ, Jackson JC, Lane-Fall MB, Monje M, Moss M, Needham DM, Semler MW, Lahiri S, Larsson L, Sevin CM, Sharshar T, Singer B, Stevens T, Taylor SP, Gomez CR, Zhou G, Girard TD, Hough CL. Tackling Brain and Muscle Dysfunction in Acute Respiratory Distress Syndrome Survivors: NHLBI Workshop Report. Am J Respir Crit Care Med 2024; 209:1304-1313. [PMID: 38477657 PMCID: PMC11146564 DOI: 10.1164/rccm.202311-2130ws] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/12/2024] [Indexed: 03/14/2024] Open
Abstract
Acute respiratory distress syndrome (ARDS) is associated with long-term impairments in brain and muscle function that significantly impact the quality of life of those who survive the acute illness. The mechanisms underlying these impairments are not yet well understood, and evidence-based interventions to minimize the burden on patients remain unproved. The NHLBI of the NIH assembled a workshop in April 2023 to review the state of the science regarding ARDS-associated brain and muscle dysfunction, to identify gaps in current knowledge, and to determine priorities for future investigation. The workshop included presentations by scientific leaders across the translational science spectrum and was open to the public as well as the scientific community. This report describes the themes discussed at the workshop as well as recommendations to advance the field toward the goal of improving the health and well-being of ARDS survivors.
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Affiliation(s)
| | - Jane A. E. Batt
- University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Sue C. Bodine
- Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma
- Oklahoma City Veterans Affairs Medical Center, Oklahoma City, Oklahoma
| | - Bronwen A. Connolly
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University, Belfast, United Kingdom
| | - Jason Doles
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Jason R. Falvey
- University of Maryland School of Medicine, Baltimore, Maryland
| | | | - D. Clark Files
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Michael O. Harhay
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | | | - Meghan B. Lane-Fall
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michelle Monje
- Howard Hughes Medical Institute, Stanford University, Stanford, California
| | - Marc Moss
- University of Colorado School of Medicine, Aurora, Colorado
| | - Dale M. Needham
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Shouri Lahiri
- Cedars Sinai Medical Center, Los Angeles, California
| | - Lars Larsson
- Center for Molecular Medicine, Karolinska Institute, Solna, Sweden
- Department of Physiology & Pharmacology, Karolinska Institute and Viron Molecular Medicine Institute, Boston, Massachusetts
| | - Carla M. Sevin
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Tarek Sharshar
- Anesthesia and Intensive Care Department, GHU Paris Psychiatry and Neurosciences, Institute of Psychiatry and Neurosciences of Paris, INSERM U1266, University Paris Cité, Paris, France
| | | | | | | | - Christian R. Gomez
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Guofei Zhou
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Timothy D. Girard
- Center for Research, Investigation, and Systems Modeling of Acute Illness, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Adam CE, Fitzpatrick AL, Leary CS, Ilango SD, Phelan EA, Semmens EO. The impact of falls on activities of daily living in older adults: A retrospective cohort analysis. PLoS One 2024; 19:e0294017. [PMID: 38170712 PMCID: PMC10763967 DOI: 10.1371/journal.pone.0294017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/25/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Falls contribute to impairments in activities of daily living (ADLs), resulting in significant declines in the quality of life, safety, and functioning of older adults. Understanding the magnitude and duration of the effect of falls on ADLs, as well as identifying the characteristics of older adults more likely to have post-fall ADL impairment is critical to inform fall prevention and post-fall intervention. The purpose of this study is to 1) Quantify the association between falls and post-fall ADL impairment and 2) Model trajectories of ADL impairment pre- and post-fall to estimate the long-term impact of falls and identify characteristics of older adults most likely to have impairment. METHOD Study participants were from the Ginkgo Evaluation of Memory Study, a randomized controlled trial in older adults (age 75+) in the United States. Self-reported incident falls and ADL scores were ascertained every 6 months over a 7-year study period. We used Cox proportional hazards analyses (n = 2091) to quantify the association between falls and ADL impairment and latent class trajectory modeling (n = 748) to visualize trajectories of ADL impairment pre-and post-fall. RESULTS Falls reported in the previous 6 months were associated with impairment in ADLs (HR: 1.42; 95% CI 1.32, 1.52) in fully adjusted models. Based on trajectory modeling (n = 748), 19% (n = 139) of participants had increased, persistent ADL impairment after falling. Participants who were female, lived in a neighborhood with higher deprivation, or experienced polypharmacy were more likely to have ADL impairment post-fall. CONCLUSIONS Falls are associated with increased ADL impairment, and this impairment can persist over time. It is crucial that all older adults, and particularly those at higher risk of post-fall ADL impairment have access to comprehensive fall risk assessment and evidence-based fall prevention interventions, to help mitigate the negative impacts on ADL function.
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Affiliation(s)
- Claire E. Adam
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana, United States of America
- Center for Population Health Research, University of Montana, Missoula, Montana, United States of America
| | - Annette L. Fitzpatrick
- Department of Family Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Cindy S. Leary
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana, United States of America
- Center for Population Health Research, University of Montana, Missoula, Montana, United States of America
| | - Sindana D. Ilango
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Elizabeth A. Phelan
- Division of Gerontology and Geriatric Medicine, School of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Erin O. Semmens
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana, United States of America
- Center for Population Health Research, University of Montana, Missoula, Montana, United States of America
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Gill TM, Han L, Feder SL, Gahbauer EA, Leo-Summers L, Becher RD. Relationship Between Distressing Symptoms and Changes in Disability After Major Surgery Among Community-living Older Persons. Ann Surg 2024; 279:65-70. [PMID: 37389893 PMCID: PMC10761592 DOI: 10.1097/sla.0000000000005984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
OBJECTIVES To evaluate the relationship between distressing symptoms and changes in disability after major surgery and to determine whether this relationship differs according to the timing of surgery (nonelective vs elective), sex, multimorbidity, and socioeconomic disadvantage. BACKGROUND Major surgery is a common and serious health event that has pronounced deleterious effects on both distressing symptoms and functional outcomes in older persons. METHODS From a cohort of 754 community-living persons, aged 70 or older, 392 admissions for major surgery were identified from 283 participants who were discharged from the hospital. The occurrence of 15 distressing symptoms and disability in 13 activities were assessed monthly for up to 6 months after major surgery. RESULTS Over the 6-month follow-up period, each unit increase in the number of distressing symptoms was associated with a 6.4% increase in the number of disabilities [adjusted rate ratio (RR): 1.064; 95% CI: 1.053, 1.074]. The corresponding increases were 4.0% (adjusted RR: 1.040; 95% CI: 1.030, 1.050) and 8.3% (adjusted RR: 1.083; 95% CI: 1.066, 1.101) for nonelective and elective surgeries. Based on exposure to multiple (ie, 2 or more) distressing symptoms, the adjusted RRs (95% CI) were 1.43 (1.35, 1.50), 1.24 (1.17, 1.31), and 1.61 (1.48, 1.75) for all, nonelective, and elective surgeries. Statistically significant associations were observed for each of the other subgroups with the exception of individual-level socioeconomic disadvantage for the number of distressing symptoms. CONCLUSIONS Distressing symptoms are independently associated with worsening disability, providing a potential target for improving functional outcomes after major surgery.
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Affiliation(s)
- Thomas M. Gill
- Yale School of Medicine, Department of Internal Medicine, New Haven, CT
| | - Ling Han
- Yale School of Medicine, Department of Internal Medicine, New Haven, CT
| | - Shelli L. Feder
- Yale School of Nursing, Orange, CT
- VA Connecticut Healthcare System, West Haven, CT
| | | | - Linda Leo-Summers
- Yale School of Medicine, Department of Internal Medicine, New Haven, CT
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Park YS, Joo HJ, Jang YS, Jeon H, Park EC, Shin J. Socioeconomic Status and Dementia Risk Among Intensive Care Unit Survivors: Using National Health Insurance Cohort in Korea. J Alzheimers Dis 2024; 97:273-281. [PMID: 38143351 DOI: 10.3233/jad-230715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2023]
Abstract
BACKGROUND In aging populations, more elderly patients are going to the intensive care unit (ICU) and surviving. However, the specific factors influencing the occurrence of post-intensive care syndrome in the elderly remain uncertain. OBJECTIVE To investigate the association between socioeconomic status (SES) and risk of developing dementia within two years following critical care. METHODS This study included participants from the Korean National Health Insurance Service Cohort Database who had not been diagnosed with dementia and had been hospitalized in the ICU from 2003 to 2019. Dementia was determined using specific diagnostic codes (G30, G31) and prescription of certain medications (rivastigmine, galantamine, memantine, or donepezil). SES was categorized into low (medical aid beneficiaries) and non-low (National Health Insurance) groups. Through a 1:3 propensity score matching based on sex, age, Charlson comorbidity index, and primary diagnosis, the study included 16,780 patients. We used Cox proportional hazard models to estimate adjusted hazard ratios (HR) of dementia. RESULTS Patients with low SES were higher risk of developing dementia within 2 years after receiving critical care than those who were in non-low SES (HR: 1.23, 95% CI: 1.04-1.46). Specifically, patients with low SES and those in the high-income group exhibited the highest incidence rates of developing dementia within two years after receiving critical care, with rates of 3.61 (95% CI: 3.13-4.17) for low SES and 2.58 (95% CI: 2.20-3.03) for high income, respectively. CONCLUSIONS After discharge from critical care, compared to the non-low SES group, the low SES group was associated with an increased risk of developing dementia.
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Affiliation(s)
- Yu Shin Park
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
| | - Hye Jin Joo
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
- Department of Preventive Medicine, Gachon University College of Medicine, Seoul, Republic of Korea
| | - Yun Seo Jang
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
| | - Hajae Jeon
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
| | - Eun-Cheol Park
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jaeyong Shin
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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Stewart J, Bradley J, Smith S, McPeake J, Walsh T, Haines K, Leggett N, Hart N, McAuley D. Do critical illness survivors with multimorbidity need a different model of care? Crit Care 2023; 27:485. [PMID: 38066562 PMCID: PMC10709866 DOI: 10.1186/s13054-023-04770-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/30/2023] [Indexed: 12/18/2023] Open
Abstract
There is currently a lack of evidence on the optimal strategy to support patient recovery after critical illness. Previous research has largely focussed on rehabilitation interventions which aimed to address physical, psychological, and cognitive functional sequelae, the majority of which have failed to demonstrate benefit for the selected outcomes in clinical trials. It is increasingly recognised that a person's existing health status, and in particular multimorbidity (usually defined as two or more medical conditions) and frailty, are strongly associated with their long-term outcomes after critical illness. Recent evidence indicates the existence of a distinct subgroup of critical illness survivors with multimorbidity and high healthcare utilisation, whose prior health trajectory is a better predictor of long-term outcomes than the severity of their acute illness. This review examines the complex relationships between multimorbidity and patient outcomes after critical illness, which are likely mediated by a range of factors including the number, severity, and modifiability of a person's medical conditions, as well as related factors including treatment burden, functional status, healthcare delivery, and social support. We explore potential strategies to optimise patient recovery after critical illness in the presence of multimorbidity. A comprehensive and individualized approach is likely necessary including close coordination among healthcare providers, medication reconciliation and management, and addressing the physical, psychological, and social aspects of recovery. Providing patient-centred care that proactively identifies critical illness survivors with multimorbidity and accounts for their unique challenges and needs is likely crucial to facilitate recovery and improve outcomes.
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Affiliation(s)
- Jonathan Stewart
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland.
| | - Judy Bradley
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
| | - Susan Smith
- Department of Public Health and Primary Care, Trinity College Dublin, Dublin 2, Ireland
| | - Joanne McPeake
- The Healthcare Improvement Studies Institute, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Timothy Walsh
- Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Kimberley Haines
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Nina Leggett
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Nigel Hart
- Centre for Medical Education, Queen's University Belfast, Belfast, Northern Ireland
| | - Danny McAuley
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
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McNicholas B, Akcan Arikan A, Ostermann M. Quality of life after acute kidney injury. Curr Opin Crit Care 2023; 29:566-579. [PMID: 37861184 DOI: 10.1097/mcc.0000000000001090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW Deciphering the effect of acute kidney injury (AKI) during critical illness on long-term quality of life versus the impact of conditions that brought on critical illness is difficult. RECENT FINDINGS Reports on patient-centred outcomes such as health-related quality of life (HRQOL) have provided insight into the long-lasting impact of critical illness complicated by AKI. However, these data stem from observational studies and randomized controlled trials, which have been heterogeneous in their patient population, timing, instruments used for assessment and reporting. Recent studies have corroborated these findings including lack of effect of renal replacement therapy compared to severe AKI on outcomes and worse physical compared to cognitive dysfunction. SUMMARY In adults, more deficits in physical than mental health domains are found in survivors of AKI in critical care, whereas memory deficits and learning impairments have been noted in children. Further study is needed to understand and develop interventions that preserve or enhance the quality of life for individual patients who survive AKI following critical illness, across all ages.
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Affiliation(s)
- Bairbre McNicholas
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital
- School of Medicine, University of Galway, Galway, Ireland
| | - Ayse Akcan Arikan
- Department of Pediatrics, Divisions of Critical Care Medicine and Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital, Department of Critical Care, Westminster Bridge Road, London, UK
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Kellett W, Jalilvand A, Collins C, Ireland M, Baselice H, Abboud G, Wisler J. Area Deprivation Index Predicts Mortality for Critically Ill Surgical Patients With Sepsis. Surg Infect (Larchmt) 2023; 24:879-886. [PMID: 38079187 PMCID: PMC10714256 DOI: 10.1089/sur.2023.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Abstract
Background: The impact of socioeconomic status on outcomes after sepsis has been challenging to define, and no polysocial metric has been shown to predict mortality in sepsis. The primary objective of this study was to evaluate the association between the Area Deprivation Index (ADI) and mortality in patients admitted to the surgical intensive care unit (SICU) with sepsis. Patients and Methods: All patients admitted to the SICU with sepsis (Sequential Organ Failure Assessment [SOFA] score ≥2) were retrospectively reviewed. The ADI scores were obtained and classified as "high ADI" (≥85th percentile, n = 400, representative of high socioeconomic deprivation) and "control ADI" (ADI <85th percentile, n = 976). Baseline demographic and clinical characteristics were compared between groups. The primary outcome was 90-day mortality. Results: High ADI patients were younger (mean age 58.5 vs. 60.8; p = 0.01) and more likely to be non-white (23.7% vs. 10.0%; p < 0.0005) and to present with chronic obstructive pulmonary disease (26.5% vs. 19.0%; p = 0.002). High ADI patients had increased in-hospital (27.3% vs. 21.6%; p = 0.025) and 90-day mortality (35.0% vs. 28.9%; p = 0.03). High ADI patients also had increased rates of renal failure (20.3% vs. 15.3%; p = 0.02). Both cohorts had similar intensive care unit (ICU) lengths of stay and median hospital stay, Charlson comorbidity index, and rate of discharge to home. High ADI is an independent risk factor for 90-day mortality after admission for surgical sepsis (odds ratio [OR], 1.39 ± 0.24; p = 0.014). Conclusions: High ADI is an independent predictor of 90-day mortality in patients with surgical sepsis. Targeted community interventions are needed to reduce sepsis mortality for these at-risk patients.
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Affiliation(s)
- Whitney Kellett
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Anahita Jalilvand
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Courtney Collins
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Megan Ireland
- Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Holly Baselice
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - George Abboud
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jon Wisler
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Jain S, Han L, Gahbauer EA, Leo-Summers L, Feder SL, Ferrante LE, Gill TM. Changes in Restricting Symptoms after Critical Illness among Community-Living Older Adults. Am J Respir Crit Care Med 2023; 208:1206-1215. [PMID: 37769149 PMCID: PMC10868351 DOI: 10.1164/rccm.202304-0693oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 09/28/2023] [Indexed: 09/30/2023] Open
Abstract
Rationale: Survivors of critical illness have multiple symptoms, but how restricting symptoms change after critical illness and whether these changes differ among vulnerable subgroups is unknown. Objectives: To evaluate changes in restricting symptoms over the six months after critical illness among older adults and to determine whether these changes differ by sex, multimorbidity, and individual- and neighborhood-level socioeconomic disadvantage. Methods: From a prospective longitudinal study of 754 community-living adults ⩾70 years old interviewed monthly (1998-2018), we identified 233 admissions from 193 participants to the ICU. The occurrence of 15 restricting symptoms, defined as those leading to restricted activity, were ascertained during interviews in the month before ICU admission (baseline) and each of the six months after hospital discharge. Measurements and Main Results: The occurrence and number of restricting symptoms increased more than threefold in the six months after a critical illness hospitalization (adjusted rate ratio [95% confidence interval], 3.1 [2.1-4.6] and 3.3 [2.1-5.3], respectively), relative to baseline. These increases were largest in the first month after hospitalization (adjusted rate ratio [95% confidence interval], 5.3 [3.8-7.3] and 5.4 [3.9-7.5], respectively] before declining and becoming nonsignificant in the third month. Increases in restricting symptoms did not differ significantly by sex, multimorbidity, or individual- or neighborhood-level socioeconomic disadvantage. Conclusions: Restricting symptoms increase substantially after a critical illness before returning to baseline three months after hospital discharge. Our findings highlight the need to incorporate symptom management into post-ICU care and for further investigation into whether addressing restricting symptoms can improve quality of life and functional recovery among older ICU survivors.
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Affiliation(s)
- Snigdha Jain
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Ling Han
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Evelyne A. Gahbauer
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Linda Leo-Summers
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Shelli L. Feder
- School of Nursing, Yale University, New Haven, Connecticut; and
- Pain Research, Informatics, Multiple Morbidities, and Education Center of Excellence, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Lauren E. Ferrante
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Thomas M. Gill
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
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Allgood KL, Whittington B, Xie Y, Hirschtick JL, Ro A, Orellana RC, Fleischer NL. Social vulnerability and new mobility disability among adults with polymerase chain reaction (PCR)-confirmed SARS-CoV-2: Michigan COVID-19 Recovery Surveillance Study. Prev Med 2023; 177:107719. [PMID: 37788721 DOI: 10.1016/j.ypmed.2023.107719] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/22/2023] [Accepted: 09/29/2023] [Indexed: 10/05/2023]
Abstract
OBJECTIVE Understanding the relationship between social factors and persistent COVID-19 health outcomes, such as onset of a disability after a SARS-CoV-2 (the virus that causes COVID-19) infection, is an increasingly important public health issue. The purpose of this paper is to examine associations between social vulnerability and new onset of a mobility disability post-COVID-19 diagnosis. METHODS We used data from the Michigan COVID-19 Recovery Surveillance Study, a population-based probability survey of adults with PCR-confirmed SARS-CoV-2 infection in Michigan between January 2020-May 2022 (n = 4295). We used the Minority Health Social Vulnerability Index (MHSVI), with high county-level social vulnerability defined at or above the 75th percentile. Mobility disability was defined as new difficulty walking or climbing stairs. We regressed mobility disability on the overall MHSVI, as well as sub-themes of the index (socioeconomic status, household composition/disability, minority and language, housing type, healthcare access, and medical vulnerability), using multivariable logistic regression, adjusting for age, race, sex, education, employment, and income. RESULTS Living in a county with high (vs. low) social vulnerability was associated with 1.38 times higher odds (95% confidence interval [CI]:1.18-1.61) of reporting a new mobility disability after a COVID-19 diagnosis after adjustment. Similar results were observed for the socioeconomic status and household composition/disability sub-themes. In contrast, residents of highly racially diverse counties had lower odds (odds ratio 0.74, 95% CI: 0.61, 0.89) of reporting a new mobility disability compared to low diversity counties. CONCLUSIONS Mitigating the effects of social vulnerabilities requires additional resources and attention to support affected individuals.
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Affiliation(s)
- Kristi L Allgood
- University of Michigan School of Public Health, Department of Epidemiology, Center for Social Epidemiology and Population Health. 1415 Washington Heights, 2649A, SPH Tower, Ann Arbor, MI 48109, USA; Texas A&M University School of Public Health, Department of Epidemiology & Biostatistics, USA.
| | - Blair Whittington
- University of Michigan School of Public Health, Department of Epidemiology, Center for Social Epidemiology and Population Health. 1415 Washington Heights, 2649A, SPH Tower, Ann Arbor, MI 48109, USA
| | - Yanmei Xie
- University of Michigan School of Public Health, Department of Epidemiology, Center for Social Epidemiology and Population Health. 1415 Washington Heights, 2649A, SPH Tower, Ann Arbor, MI 48109, USA
| | - Jana L Hirschtick
- University of Michigan School of Public Health, Department of Epidemiology, Center for Social Epidemiology and Population Health. 1415 Washington Heights, 2649A, SPH Tower, Ann Arbor, MI 48109, USA
| | - Annie Ro
- University of California - Irvine, Department of Health, Society, & Behavior. UCI Health Sciences Complex, 856 Health Sciences Quad, Suite 3600, Irvine, CA 92617, USA
| | - Robert C Orellana
- CDC Foundation, 600 Peachtree St NE #1000, Atlanta, GA 30308, USA; Bureau of Infectious Disease Prevention, Michigan Department of Health and Human Services, 333 S Grand Ave, P.O. Box 30195, Lansing, MI 48933, USA
| | - Nancy L Fleischer
- University of Michigan School of Public Health, Department of Epidemiology, Center for Social Epidemiology and Population Health. 1415 Washington Heights, 2649A, SPH Tower, Ann Arbor, MI 48109, USA
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Blank JA, Armstrong-Hough M, Valley TS. Disparities among patients with respiratory failure. Curr Opin Crit Care 2023; 29:493-504. [PMID: 37641499 PMCID: PMC10599128 DOI: 10.1097/mcc.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW Disparities are common within healthcare, and critical illness is no exception. This review summarizes recent literature on health disparities within respiratory failure, focusing on race, ethnicity, socioeconomic status, and sex. RECENT FINDINGS Current evidence indicates that Black patients have higher incidence of respiratory failure, while the relationships among race, ethnicity, and mortality remains unclear. There has been renewed interest in medical device bias, specifically pulse oximetry, for which data demonstrate patients with darker skin tones may be at risk for undetected hypoxemia and worse outcomes. Lower socioeconomic status is associated with higher mortality, and respiratory failure can potentiate socioeconomic inequities via illness-related financial toxicity. Literature on sex-based disparities is limited; however, evidence suggests males receive more invasive care, including mechanical ventilation. SUMMARY Most studies focused on disparities in incidence and mortality associated with respiratory failure, but few relied on granular clinical data of patients from diverse backgrounds. Future studies should evaluate processes of care for respiratory failure that may mechanistically contribute to disparities in order to develop interventions that improve outcomes.
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Affiliation(s)
| | - Mari Armstrong-Hough
- New York University School of Global Public Health, Department of Social & Behavioral Sciences, Department of Epidemiology
| | - Thomas S. Valley
- University of Michigan, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine
- VA Center for Clinical Management Research, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan
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15
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Gill TM, Han L, Murphy TE, Feder SL, Gahbauer EA, Leo-Summers L, Becher RD. Distressing symptoms after major surgery among community-living older persons. J Am Geriatr Soc 2023; 71:2430-2440. [PMID: 37010784 PMCID: PMC10524276 DOI: 10.1111/jgs.18357] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/17/2023] [Accepted: 03/07/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Relatively little is known about how distressing symptoms change among older persons in the setting of major surgery. Our objective was to evaluate changes in distressing symptoms after major surgery and determine whether these changes differ according to the timing of surgery (nonelective vs. elective), sex, multimorbidity, and socioeconomic disadvantage. METHODS From a prospective longitudinal study of 754 nondisabled community-living persons, 70 years of age or older, 368 admissions for major surgery were identified from 274 participants who were discharged from the hospital from March 1998 to December 2017. The occurrence of 15 distressing symptoms was ascertained in the month before and 6 months after major surgery. Multimorbidity was defined as more than two chronic conditions. Socioeconomic disadvantage was assessed at the individual level, based on Medicaid eligibility, and neighborhood level, based on an area deprivation index (ADI) score above the 80th state percentile. RESULTS In the month before major surgery, the occurrence and mean number of distressing symptoms were 19.6% and 0.75, respectively. In multivariable analyses, the rate ratios, denoting proportional increases in the 6 months after major surgery relative to presurgery values, were 2.56 (95% confidence interval [CI], 1.91-3.44) and 2.90 (95% CI, 2.01-4.18) for the occurrence and number of distressing symptoms, respectively. The corresponding values were 3.54 (95% CI, 2.06-6.08) and 4.51 for nonelective surgery (95% CI, 2.32-8.76) and 2.12 (95% CI, 1.53-2.92) and 2.20 (95% CI, 1.48-3.29) for elective surgery; p-values for interaction were 0.030 and 0.009. None of the other subgroup differences were statistically significant, although men had a greater proportional increase in the occurrence and number of distressing symptoms than women. CONCLUSIONS Among community-living older persons, the burden of distressing symptoms increases substantially after major surgery, especially in those having nonelective procedures. Reducing symptom burden has the potential to improve quality of life and enhance functional outcomes after major surgery.
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Affiliation(s)
- Thomas M. Gill
- Yale School of Medicine, Department of Internal Medicine, New Haven, CT
| | - Ling Han
- Yale School of Medicine, Department of Internal Medicine, New Haven, CT
| | - Terrence E. Murphy
- Pennsylvania State University, Department of Public Health Sciences, Hershey, PA
| | - Shelli L. Feder
- Yale School of Nursing, Orange, CT
- VA Connecticut Healthcare System, West Haven, CT
| | | | - Linda Leo-Summers
- Yale School of Medicine, Department of Internal Medicine, New Haven, CT
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McNicholas BA, Haines R, Ostermann M. Survive or thrive after ICU: what's the score? Ann Intensive Care 2023; 13:43. [PMID: 37202549 DOI: 10.1186/s13613-023-01140-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 05/06/2023] [Indexed: 05/20/2023] Open
Affiliation(s)
- Bairbre A McNicholas
- Department of Anaesthesia and Intensive Care Medicine, School of Medicine, University of Galway, Galway, H91 YR71, Ireland.
| | - Ryan Haines
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Marlies Ostermann
- Department of Intensive Care, King's College London, Guy's and St Thomas' Hospital, London, UK
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Albrecht JS, Kumar A, Falvey JR. Association Between Race and Receipt of Home- and Community-Based Rehabilitation After Traumatic Brain Injury Among Older Medicare Beneficiaries. JAMA Surg 2023; 158:350-358. [PMID: 36696119 PMCID: PMC9878433 DOI: 10.1001/jamasurg.2022.7081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 09/22/2022] [Indexed: 01/26/2023]
Abstract
Importance Non-Hispanic Black (hereafter Black) patients with traumatic brain injury (TBI) experience worse long-term outcomes and residual disability compared with non-Hispanic White (hereafter White) patients. Receipt of appropriate rehabilitation can improve function among older adults after TBI. Objective To assess the association between race and receipt of home- and community-based rehabilitation among a nationally representative sample of older Medicare beneficiaries with TBI. Design, Setting, and Participants This cohort study analyzed a random sample of Medicare administrative claims data for community-dwelling Medicare beneficiaries aged 65 years or older who were hospitalized with a primary diagnosis of TBI and discharged alive to a nonhospice setting from 2010 through 2018. Claims data for Medicare beneficiaries of other races and ethnicities were excluded due to the small sample sizes within each category. Data were analyzed January 21 to August 30, 2022. Exposures Black or White race. Main Outcomes and Measures Monthly use rates of home-based or outpatient rehabilitation were calculated over the 6 months after discharge from the hospital. The denominator for rate calculations accounted for variation in length of hospital and rehabilitation facility stays and loss to follow-up due to death. Rates over time were modeled using generalized estimating equations, controlling for TBI acuity, demographic characteristics, comorbidities, and socioeconomic factors. Results Among 19 026 Medicare beneficiaries (mean [SD] age, 81.6 [8.1] years; 10 781 women [56.7%]; and 994 Black beneficiaries [5.2%] and 18 032 White beneficiaries [94.8%]), receipt of 1 or more home health rehabilitation visits did not differ by race (Black vs White, 47.4% vs 46.2%; P = .46), but Black beneficiaries were less likely to receive 1 or more outpatient rehabilitation visits compared with White beneficiaries (3.4% vs 7.1%; P < .001). In fully adjusted regression models, Black beneficiaries received less outpatient therapy over the 6 months after TBI (rate ratio, 0.60; 95% CI, 0.38-0.93). However, Black beneficiaries received more home health rehabilitation therapy over the 6 months after TBI than White beneficiaries (rate ratio, 1.15; 95% CI, 1.00-1.32). Conclusions and Relevance This cohort study found relative shifts in rehabilitation use, with markedly lower outpatient therapy use and modestly higher home health care use among Black patients compared with White patients with TBI. These disparities may contribute to reduced functional recovery and residual disability among racial and ethnic minority groups. Additional studies are needed to assess the association between the amount of outpatient rehabilitation care and functional recovery after TBI in socioeconomically disadvantaged populations.
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Affiliation(s)
- Jennifer S. Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Amit Kumar
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City
| | - Jason R. Falvey
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore
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Olszewski AE, Dervan LA, Smith MB, Asaro LA, Wypij D, Curley MAQ, Watson RS. Risk Factors for Positive Post-Traumatic Stress Disorder Screening and Associated Outcomes in Children Surviving Acute Respiratory Failure: A Secondary Analysis of the Randomized Evaluation of Sedation Titration for Respiratory Failure Clinical Trial. Pediatr Crit Care Med 2023; 24:222-232. [PMID: 36728954 PMCID: PMC9992163 DOI: 10.1097/pcc.0000000000003150] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To identify risk factors and outcomes associated with a positive post-traumatic stress disorder (PTSD) screen following pediatric acute respiratory failure treated with invasive mechanical ventilation. DESIGN Nonprespecified secondary analysis of a randomized clinical trial. SETTING Thirty-one U.S. PICUs. PATIENTS Children in the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) trial (NCT00814099, ClinicalTrials.gov ) over 8 years old who completed PTSD screening 6 months after discharge. INTERVENTIONS RESTORE sites were randomized to a targeted, nurse-directed sedation strategy versus usual care. MEASUREMENTS AND MAIN RESULTS PTSD screening was completed by 102 subjects using the Child Post-Traumatic Stress Disorder Symptom Scale; a score of greater than or equal to 11 was considered screening positive for PTSD. Cognitive status was categorized using Pediatric Cerebral Performance Category; health-related quality of life (HRQL) was evaluated using child-reported Pediatric Quality of Life Inventory, Version 4.0. Thirty-one children (30%) screened positive for PTSD. Children with a positive screen endorsed symptoms in all categories: reexperiencing, avoidance, and hyperarousal. Most endorsed that symptoms interfered with schoolwork ( n = 18, 58%) and happiness ( n = 17, 55%). Screening positive was not associated with RESTORE treatment group. In a multivariable logistic model adjusting for age, sex, and treatment group, screening positive was independently associated with lower median income in the family's residential zip code (compared with income ≥ $80,000; income < $40,000 odds ratio [OR], 32.8; 95% CI, 2.3-458.1 and $40,000-$79,999 OR, 15.6; 95% CI, 1.3-182.8), renal dysfunction (OR 5.3, 95% CI 1.7-16.7), and clinically significant pain in the PICU (OR, 8.3; 95% CI, 1.9-35.7). Children with a positive screen experienced decline in cognitive function and impaired HRQL more frequently than children with a negative screen. CONCLUSIONS Screening positive for PTSD is common among children following acute respiratory failure and is associated with lower HRQL and decline in cognitive function. Routine PTSD screening may be warranted to optimize recovery.
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Affiliation(s)
- Aleksandra E Olszewski
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington, Seattle, WA
| | - Leslie A Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Clinical & Translational Research, Seattle Children's Research Institute, Seattle, WA
| | - Mallory B Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA
| | - Lisa A Asaro
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - David Wypij
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington, Seattle, WA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Clinical & Translational Research, Seattle Children's Research Institute, Seattle, WA
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
- Center for Child Health, Behavior, & Development, Seattle Children's Research Institute, Seattle, WA
| | - Martha A Q Curley
- Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
| | - R Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Child Health, Behavior, & Development, Seattle Children's Research Institute, Seattle, WA
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McHenry RD, Moultrie CEJ, Quasim T, Mackay DF, Pell JP. Association Between Socioeconomic Status and Outcomes in Critical Care: A Systematic Review and Meta-Analysis. Crit Care Med 2023; 51:347-356. [PMID: 36728845 DOI: 10.1097/ccm.0000000000005765] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Socioeconomic status is well established as a key determinant of inequalities in health outcomes. Existing literature examining the impact of socioeconomic status on outcomes in critical care has produced inconsistent findings. Our objective was to synthesize the available evidence on the association between socioeconomic status and outcomes in critical care. DATA SOURCES A systematic search of CINAHL, Ovid MEDLINE, and EMBASE was undertaken on September 13, 2022. STUDY SELECTION Observational cohort studies of adults assessing the association between socioeconomic status and critical care outcomes including mortality, length of stay, and functional outcomes were included. Two independent reviewers assessed titles, abstracts, and full texts against eligibility and quality criteria. DATA EXTRACTION Details of study methodology, population, exposure measures, and outcomes were extracted. DATA SYNTHESIS Thirty-eight studies met eligibility criteria for systematic review. Twenty-three studies reporting mortality to less than or equal to 30 days following critical care admission, and eight reporting length of stay, were included in meta-analysis. Random-effects pooled analysis showed that lower socioeconomic status was associated with higher mortality at less than or equal to 30 days following critical care admission, with pooled odds ratio of 1.13 (95% CIs, 1.05-1.22). Meta-analysis of ICU length of stay demonstrated no significant difference between socioeconomic groups. Socioeconomic status may also be associated with functional status and discharge destination following ICU admission. CONCLUSIONS Lower socioeconomic status was associated with higher mortality following admission to critical care.
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Affiliation(s)
- Ryan D McHenry
- ScotSTAR, Scottish Ambulance Service, Glasgow, United Kingdom
| | | | - Tara Quasim
- School of Medicine, Dentistry & Nursing, Academic Unit of Anaesthesia, Critical Care and Perioperative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Daniel F Mackay
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Jill P Pell
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
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Brunker LB, Boncyk CS, Rengel KF, Hughes CG. Elderly Patients and Management in Intensive Care Units (ICU): Clinical Challenges. Clin Interv Aging 2023; 18:93-112. [PMID: 36714685 PMCID: PMC9879046 DOI: 10.2147/cia.s365968] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/12/2023] [Indexed: 01/23/2023] Open
Abstract
There is a growing population of older adults requiring admission to the intensive care unit (ICU). This population outpaces the ability of clinicians with geriatric training to assist in their management. Specific training and education for intensivists in the care of older patients is valuable to help understand and inform clinical care, as physiologic changes of aging affect each organ system. This review highlights some of these aging processes and discusses clinical implications in the vulnerable older population. Other considerations when caring for these older patients in the ICU include functional outcomes and morbidity, as opposed to merely a focus on mortality. An overall holistic approach incorporating physiology of aging, applying current evidence, and including the patient and their family in care should be used when caring for older adults in the ICU.
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Affiliation(s)
- Lucille B Brunker
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina S Boncyk
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kimberly F Rengel
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher G Hughes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
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21
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Abstract
PURPOSE OF REVIEW The population is aging, and recent epidemiologic work reveals that an increasing number of older adults are presenting to the ICU with preexisting geriatric syndromes. In this update, we discuss recent literature pertaining to the long-term recovery of older ICU patients and highlight gaps in current knowledge. RECENT FINDINGS A recent longitudinal study demonstrated that the incidence of frailty, disability, and multimorbidity among older ICU patients is rising; these geriatric syndromes have all previously been shown to impact long-term recovery. Recent studies have demonstrated the impact of social factors in long-term outcomes after critical illness; for example, social isolation was recently shown to be associated with disability and mortality among older adults in the year after critical illness. Socioeconomic disadvantage is associated with higher rates of dementia and disability following critical illness impacting recovery, and further studies are necessary to better understand factors influencing this disparity. The COVID-19 pandemic disproportionately impacted older adults, resulting in worse outcomes and increased rates of functional decline and social isolation. In considering how to best facilitate recovery for older ICU survivors, transitional care programs may address the unique needs of older adults and help them adapt to new disability if recovery has not been achieved. SUMMARY Recent work demonstrates increasing trends of geriatric syndromes in the ICU, all of which are known to confer increased vulnerability among critically ill older adults and decrease the likelihood of post-ICU recovery. Risk factors are now known to extend beyond geriatric syndromes and include social risk factors and structural inequity. Strategies to improve post-ICU recovery must be viewed with a lens across the continuum of care, with post-ICU recovery programs targeted to the unique needs of older adults.
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Affiliation(s)
| | - Lauren E Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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22
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McPeake J, Boehm L, Hibbert E, Hauschildt K, Bakhru R, Bastin A, Butcher B, Eaton T, Harris W, Hope A, Jackson J, Johnson A, Kloos J, Korzick K, McCartney J, Meyer J, Montgomery-Yates A, Quasim T, Slack A, Wade D, Still M, Netzer G, Hopkins RO, Mikkelsen ME, Iwashyna T, Haines K, Sevin C. Modification of social determinants of health by critical illness and consequences of that modification for recovery: an international qualitative study. BMJ Open 2022; 12:e060454. [PMID: 36167379 PMCID: PMC9516069 DOI: 10.1136/bmjopen-2021-060454] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 08/11/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Social determinants of health (SDoH) contribute to health outcomes. We identified SDoH that were modified by critical illness, and the effect of such modifications on recovery from critical illness. DESIGN In-depth semistructured interviews following hospital discharge. Interview transcripts were mapped against a pre-existing social policy framework: money and work; skills and education; housing, transport and neighbourhoods; and family, friends and social connections. SETTING 14 hospital sites in the USA, UK and Australia. PARTICIPANTS Patients and caregivers, who had been admitted to critical care from three continents. RESULTS 86 interviews were analysed (66 patients and 20 caregivers). SDoH, both financial and non-financial in nature, could be negatively influenced by exposure to critical illness, with a direct impact on health-related outcomes at an individual level. Financial modifications included changes to employment status due to critical illness-related disability, alongside changes to income and insurance status. Negative health impacts included the inability to access essential healthcare and an increase in mental health problems. CONCLUSIONS Critical illness appears to modify SDoH for survivors and their family members, potentially impacting recovery and health. Our findings suggest that increased attention to issues such as one's social network, economic security and access to healthcare is required following discharge from critical care.
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Affiliation(s)
- Joanne McPeake
- Critical Care, The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
- Critical Care, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Leanne Boehm
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Elizabeth Hibbert
- Department of Physiotherapy, Western Health Foundation, Sunshine, Victoria, Australia
| | - Katrina Hauschildt
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Rita Bakhru
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Anthony Bastin
- Department of Peri-operative Medicine, Barts Health NHS Trust, London, UK
| | - Brad Butcher
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Tammy Eaton
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy, University of Michigan, Ann Arbor, Michigan, US
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan, US
| | - Wendy Harris
- Intensive Care Unit, University College London, London, UK
| | - Aluko Hope
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health & Science University (OHSU), Portland, Oregon, USA
| | - James Jackson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University, Nashville, Tennessee, USA
| | - Annie Johnson
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Janet Kloos
- Department of Acute and Critical Care Nursing, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Karen Korzick
- Department of Pulmonary and Critical Care Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | | | - Joel Meyer
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Tara Quasim
- Critical Care, NHS Greater Glasgow and Clyde, Glasgow, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow College of Medical Veterinary and Life Sciences, Glasgow, UK
| | - Andrew Slack
- Department of Critical Care, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Dorothy Wade
- Critical Care, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mary Still
- Critical Care, Emory University Hospital, Atlanta, Georgia, USA
| | - Giora Netzer
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ramona O Hopkins
- Center for Humanizing Critical Care and Pulmonary/Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
- Psychology and Neuroscience, Brigham Young University, Provo, Utah, USA
| | - Mark E Mikkelsen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Theodore Iwashyna
- Department of Internal Medicine, Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, Michigan, USA
| | - Kimberley Haines
- Department of Physiotherapy, Sunshine Hospital, Melbourne, Victoria, Australia
| | - Carla Sevin
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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23
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Swan L, Horgan NF, Fan CW, Warters A, O’Sullivan M. Residential Area Socioeconomic Deprivation is Associated with Physical Dependency and Polypharmacy in Community-Dwelling Older Adults: An Analysis of Health Administrative Data in Ireland. J Multidiscip Healthc 2022; 15:1955-1963. [PMID: 36081581 PMCID: PMC9447443 DOI: 10.2147/jmdh.s380456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/24/2022] [Indexed: 12/01/2022] Open
Abstract
Introduction Socioeconomic disadvantage is associated with multiple adverse health outcomes in ageing. Whether this negative impact persists in populations of more advanced age and dependency is less clear. We aimed to determine the association between residential area deprivation and pre-specified health characteristics among community-dwelling dependent older adults. Methods We conducted a cross-sectional analysis of data from 1591 community-dwelling adults aged 65 years and older of mean age 83.9 ± 7.1 years and in receipt of state home support in Ireland. The HP Pobal Deprivation Index was used to categorize residential areas by socioeconomic deprivation. Health variables analysed included physical dependency (Barthel Index), polypharmacy (≥5 medications), previous acute hospital admission, cognitive impairment, and mental health diagnoses. Associations between residential area deprivation and prespecified health outcomes were explored in multivariable logistic regression analysis. Results In socioeconomically disadvantaged areas, high physical dependency was twice that observed in affluent areas (16.2% vs 6.9%, p = 0.009). Similarly, acute hospitalization, as the trigger for increased dependency, was more common in deprived settings (41.6% v 29.1%, p < 0.001). Polypharmacy was common in this population (67.6%), but significantly higher in deprived vs affluent settings (74.7% v 64.5%, p = 0.030). The findings persisted in multivariable analyses when adjusted for age and gender. While all participants were accessing home support, those in deprived areas were on average 6.5 years younger than in affluent areas. Associations between residential deprivation and mental health conditions or cognitive impairment, however, were not observed in this study. Conclusion Community-dwelling older adults living in socioeconomically disadvantaged areas experienced greater polypharmacy, high physical dependency, hospitalization-associated dependency, and a 6.5-year earlier need for state home support than in affluent settings. The findings suggest that health inequality persists in populations of more advanced age and dependency and highlight a need for further research as well as community-based health and social care initiatives.
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Affiliation(s)
- Lauren Swan
- Department of Clinical Medicine, Trinity College Dublin (TCD), Dublin, Ireland
- North Dublin Homecare Ltd, Dublin, Ireland
- Correspondence: Lauren Swan, Email
| | - N Frances Horgan
- School of Physiotherapy, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Chie Wei Fan
- Department of Geriatric Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Austin Warters
- Older Person Services CHO9, Health Service Executive (HSE), Dublin, Ireland
| | - Maria O’Sullivan
- Department of Clinical Medicine, Trinity College Dublin (TCD), Dublin, Ireland
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24
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Gill TM, Murphy TE, Gahbauer EA, Leo-Summers L, Becher RD. Geriatric vulnerability and the burden of disability after major surgery. J Am Geriatr Soc 2022; 70:1471-1480. [PMID: 35199332 PMCID: PMC9106872 DOI: 10.1111/jgs.17693] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/05/2022] [Accepted: 01/15/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Strong epidemiologic evidence linking indicators of geriatric vulnerability to long-term functional outcomes after major surgery is lacking. The objective of this study was to evaluate the association between geriatric vulnerability and the burden of disability after hospital discharge for major surgery. METHODS From a prospective longitudinal study of 754 nondisabled community-living persons, aged 70 years or older, 327 admissions for major surgery were identified from 247 participants who were discharged from the hospital from March 1997 to December 2017. The indicators of geriatric vulnerability were ascertained immediately prior to the major surgery or during the prior comprehensive assessment, which was completed every 18 months. Disability in 13 essential, instrumental and mobility activities was assessed each month. RESULTS The burden of disability over the 6 months after major surgery was considerably greater for non-elective than elective surgery. In multivariable analysis, 10 factors were independently associated with disability burden: age 85 years or older, female sex, Black race or Hispanic ethnicity, neighborhood disadvantage, multimorbidity, frailty, one or more disabilities, low functional self-efficacy, smoking, and obesity. The burden of disability increased with each additional vulnerability factor, with mean values (credible intervals) increasing from 1.6 (1.4-1.9) disabilities for 0-1 vulnerability factors to 6.6 (6.0-7.2) disabilities for 7 or more vulnerability factors. The corresponding values were 1.2 (0.9-1.5) and 5.9 (5.0-6.7) disabilities for elective surgery and 2.6 (2.1-3.1) and 8.2 (7.3-9.2) disabilities for non-elective surgery. CONCLUSIONS The burden of disability after hospital discharge for major surgery increases progressively as the number of geriatric vulnerability factors increases. These factors can be used to identify older persons who are particularly susceptible to poor functional outcomes after major surgery, and a subset may be amenable to intervention, including frailty, low functional self-efficacy, smoking, and obesity.
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Affiliation(s)
- Thomas M Gill
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Terrence E Murphy
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Evelyne A Gahbauer
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Linda Leo-Summers
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Robert D Becher
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
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