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Datta R, Kiwak E, Fried TR, Benjamin A, Iannone L, Krein SL, Carter W, Cohen AB. Diagnostic uncertainty and decision-making in home-based primary care: A qualitative study of antibiotic prescribing. J Am Geriatr Soc 2024; 72:1468-1475. [PMID: 38241465 PMCID: PMC11090732 DOI: 10.1111/jgs.18778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/19/2023] [Accepted: 12/23/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND Evaluating infection in home-based primary care is challenging, and these challenges may impact antibiotic prescribing. A refined understanding of antibiotic decision-making in this setting can inform strategies to promote antibiotic stewardship. This study investigated antibiotic decision-making by exploring the perspectives of clinicians in home-based primary care. METHODS Clinicians from the Department of Veterans Affairs Home-Based Primary Care Program were recruited. Semi-structured interviews were conducted from June 2022 through September 2022 using a discussion guide. Transcripts were analyzed using grounded theory. The constant comparative method was used to develop a coding structure and to identify themes. RESULTS Theoretical saturation was reached after 22 clinicians (physicians, n = 7; physician assistants, n = 2, advanced practice registered nurses, n = 13) from 19 programs were interviewed. Mean age was 48.5 ± 9.3 years, 91% were female, and 59% had ≥6 years of experience in home-based primary care. Participants reported uncertainty about the diagnosis of infection due to the characteristics of homebound patients (atypical presentations of disease, presence of multiple chronic conditions, presence of cognitive impairment) and the challenges of delivering medical care in the home (limited access to diagnostic testing, suboptimal quality of microbiological specimens, barriers to establishing remote access to the electronic health record). When faced with diagnostic uncertainty about infection, participants described many factors that influenced the decision to prescribe antibiotics, including those that promoted prescribing (desire to avoid hospitalization, pressure from caregivers, unreliable plans for follow-up) and those that inhibited prescribing (perceptions of antibiotic-associated harms, willingness to trial non-pharmacological interventions first, presence of caregivers who were trusted by clinicians to monitor symptoms). CONCLUSIONS Clinicians face the difficult task of balancing diagnostic uncertainty with many competing considerations during the treatment of infection in home-based primary care. Recognizing these issues provides insight into strategies to promote antibiotic stewardship in home care settings.
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Affiliation(s)
- Rupak Datta
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Eliza Kiwak
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Terri R. Fried
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Andrea Benjamin
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Lynne Iannone
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sarah L. Krein
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Warren Carter
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Andrew B. Cohen
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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Thomas C, Cohen AB, Mecca MC. Polypharmacy, deprescribing, and trust in the clinician-patient relationship. J Am Geriatr Soc 2024; 72:1562-1565. [PMID: 38232315 PMCID: PMC11090731 DOI: 10.1111/jgs.18756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/03/2023] [Accepted: 12/16/2023] [Indexed: 01/19/2024]
Affiliation(s)
- Columba Thomas
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
| | - Andrew B Cohen
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Marcia C Mecca
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Cohen AB, McDonald WM, O'Leary JR, Omer ZB, Fried TR. High-Intensity Care for Nursing Home Residents with Severe Dementia Hospitalized at the End of Life: A Mixed Methods Study. J Am Med Dir Assoc 2024; 25:871-875. [PMID: 38462230 PMCID: PMC11065599 DOI: 10.1016/j.jamda.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/23/2024] [Accepted: 02/01/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE For nursing home residents with severe dementia, high-intensity medical treatment offers little possibility of benefit but has the potential to cause significant distress. Nevertheless, mechanical ventilation and intensive care unit (ICU) transfers have increased in this population. We sought to understand how and why such care is occurring. DESIGN Mixed methods study, with retrospective collection of qualitative and quantitative data. SETTING Department of Veterans Affairs (VA) hospitals. METHODS Using the Minimum Data Set, we identified veterans aged ≥65 years who had severe dementia, lived in nursing homes, and died in 2013. We selected those who underwent mechanical ventilation or ICU transfer in the last 30 days of life. We restricted our sample to patients receiving care at VA hospitals because these hospitals share an electronic medical record, from which we collected structured information and constructed detailed narratives of how medical decisions were made. We used qualitative content analysis to identify distinct paths to high-intensity treatment in these narratives. RESULTS Among 163 veterans, 41 (25.2%) underwent mechanical ventilation or ICU transfer. Their median age was 85 (IQR, 80-94), 97.6% were male, and 67.5% were non-Hispanic white. More than a quarter had living wills declining some or all treatment. There were 5 paths to high-intensity care. The most common (18 of 41 patients) involved families who struggled with decisions. Other patients (15 of 41) received high-intensity care reflexively, before discussion with a surrogate. Four patients had families who advocated repeatedly for aggressive treatment, against clinical recommendations. In 2 cases, information about the patient's preferences was erroneous or unavailable. In 2 cases, there was difficulty identifying a surrogate. CONCLUSIONS AND IMPLICATIONS Our findings highlight the role of surrogates' difficulty with decision making and of health system-level factors in end-of-life ICU transfers and mechanical ventilation among nursing home residents with severe dementia.
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Affiliation(s)
- Andrew B Cohen
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA.
| | | | - John R O'Leary
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - Zehra B Omer
- Department of Medicine, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Terri R Fried
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
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Lee S, McAvay GJ, Geda M, Chattopadhyay S, Acampora D, Araujo K, Charpentier P, Gill TM, Hajduk AM, Cohen AB, Ferrante LE. Associations of Social Support With Physical and Mental Health Symptom Burden After COVID-19 Hospitalization Among Older Adults. J Gerontol A Biol Sci Med Sci 2024; 79:glae092. [PMID: 38558166 PMCID: PMC11059296 DOI: 10.1093/gerona/glae092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Despite significant support system disruptions during the coronavirus 2019 (COVID-19) pandemic, little is known about the relationship between social support and symptom burden among older adults following COVID-19 hospitalization. METHODS From a prospective cohort of 341 community-living persons aged ≥60 years hospitalized with COVID-19 between June 2020 and June 2021 who underwent follow-up at 1, 3, and 6 months after discharge, we identified 311 participants with ≥1 follow-up assessment. Social support prehospitalization was ascertained using a 5-item version of the Medical Outcomes Study Social Support Survey (range, 5-25), with low social support defined as a score ≤15. At hospitalization and each follow-up assessment, 14 physical symptoms were assessed using a modified Edmonton Symptom Assessment System inclusive of COVID-19-relevant symptoms. Mental health symptoms were assessed using Patient Health Questionnaire-4. Longitudinal associations between social support and physical and mental health symptoms, respectively, were evaluated through multivariable regression. RESULTS Participants' mean age was 71.3 years (standard deviation, 8.5), 52.4% were female, and 34.2% were of Black race or Hispanic ethnicity. 11.8% reported low social support. Over the 6-month follow-up period, low social support was independently associated with higher burden of physical symptoms (adjusted rate ratio [aRR], 1.26; 95% confidence interval [CI], 1.05-1.52), but not mental health symptoms (aRR, 1.14; 95% CI, 0.85-1.53). CONCLUSIONS Low social support is associated with greater physical, but not mental health, symptom burden among older survivors of COVID-19 hospitalization. Our findings suggest a potential need for social support screening and interventions to improve post-COVID-19 symptom management in this vulnerable group.
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Affiliation(s)
- Seohyuk Lee
- Yale School of Medicine, New Haven, Connecticut, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Gail J McAvay
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mary Geda
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sumon Chattopadhyay
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Denise Acampora
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Katy Araujo
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Thomas M Gill
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Alexandra M Hajduk
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Andrew B Cohen
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - 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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Ferrante LE, Cohen AB. All the Lonely People: Social Isolation and Loneliness in Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2023; 20:1703-1704. [PMID: 38038602 PMCID: PMC10704229 DOI: 10.1513/annalsats.202309-833ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023] Open
Affiliation(s)
| | - Andrew B Cohen
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; and
- VA Connecticut Healthcare System, West Haven, Connecticut
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Moye J, Cohen AB, Stolzmann K, Auguste EJ, Catlin CC, Sager ZS, Weiskittle RE, Woolverton CB, Connors HL, Sullivan JL. Guardianship Before and Following Hospitalization. HEC Forum 2023; 35:271-292. [PMID: 35072897 PMCID: PMC10281591 DOI: 10.1007/s10730-022-09469-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2022] [Indexed: 10/19/2022]
Abstract
When ethics committees are consulted about patients who have or need court-appointed guardians, they lack empirical evidence about several common issues, including the relationship between guardianship and prolonged, potentially medically unnecessary hospitalizations for patients. To provide information about this issue, we conducted quantitative and qualitative analyses using a retrospective cohort from Veterans Healthcare Administration. To examine the relationship between guardianship appointment and hospital length of stay, we first compared 116 persons hospitalized prior to guardianship appointment to a comparison group (n = 348) 3:1 matched for age, diagnosis, date of admission, and comorbidity. We then compared 91 persons hospitalized in the year following guardianship appointment to a second matched comparison group (n = 273). Mean length of stay was 30.75 days (SD = 46.70) amongst those admitted prior to guardianship, which was higher than the comparison group (M = 7.74, SD = 9.71, F = 20.75, p < .001). Length of stay was lower following guardianship appointment (11.65, SD = 12.02, t = 15.16, p < .001); while higher than the comparison group (M = 7.60, SD = 8.46), differences were not associated with guardianship status. In a separate analysis involving 35 individuals who were hospitalized both prior to and following guardianship, length of stay was longer in the year prior (M = 23.00, SD = 37.55) versus after guardianship (M = 10.37, SD = 10.89, F = 4.35, p = .045). In qualitative analyses, four themes associated with lengths of stay exceeding 45 days prior to guardianship appointment were: administrative issues, family conflict, neuropsychiatric comorbidity, and medical complications. Our results suggest that persons who are admitted to hospitals, and subsequently require a guardian, experience extended lengths of stay for multiple complex reasons. Once a guardian has been appointed, however, differences in hospital lengths of stay between patients with and without guardians are reduced.
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Affiliation(s)
- Jennifer Moye
- VA New England Geriatric Research Education and Clinical Center (GRECC), Boston, MA, USA.
- VA Boston Healthcare System, 150 South Huntington, Jamaica Plain, MA, 02130, USA.
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
| | - Andrew B Cohen
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Kelly Stolzmann
- VA Boston Healthcare System, 150 South Huntington, Jamaica Plain, MA, 02130, USA
- Center for Healthcare Organization and Implementation Research, Boston, MA, USA
| | - Elizabeth J Auguste
- VA New England Geriatric Research Education and Clinical Center (GRECC), Boston, MA, USA
- VA Boston Healthcare System, 150 South Huntington, Jamaica Plain, MA, 02130, USA
| | - Casey C Catlin
- VA Boston Healthcare System, 150 South Huntington, Jamaica Plain, MA, 02130, USA
- Boston VA Research Institute, Inc., Boston, MA, USA
| | - Zachary S Sager
- VA New England Geriatric Research Education and Clinical Center (GRECC), Boston, MA, USA
- VA Boston Healthcare System, 150 South Huntington, Jamaica Plain, MA, 02130, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Rachel E Weiskittle
- VA New England Geriatric Research Education and Clinical Center (GRECC), Boston, MA, USA
- VA Boston Healthcare System, 150 South Huntington, Jamaica Plain, MA, 02130, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Cindy B Woolverton
- VA Boston Healthcare System, 150 South Huntington, Jamaica Plain, MA, 02130, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | | | - Jennifer L Sullivan
- VA Boston Healthcare System, 150 South Huntington, Jamaica Plain, MA, 02130, USA
- Center for Healthcare Organization and Implementation Research, Boston, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
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Cohen AB, McAvay GJ, Geda M, Chattopadhyay S, Lee S, Acampora D, Araujo K, Charpentier P, Gill TM, Hajduk AM, Ferrante LE. Rationale, Design, and Characteristics of the VALIANT (COVID-19 in Older Adults: A Longitudinal Assessment) Cohort. J Am Geriatr Soc 2023; 71:832-844. [PMID: 36544250 PMCID: PMC9877652 DOI: 10.1111/jgs.18146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 10/08/2022] [Accepted: 10/29/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Most older adults hospitalized with COVID-19 survive their acute illness. The impact of COVID-19 hospitalization on patient-centered outcomes, including physical function, cognition, and symptoms, is not well understood. To address this knowledge gap, we collected longitudinal data about these issues from a cohort of older survivors of COVID-19 hospitalization. METHODS We undertook a prospective study of community-living persons age ≥ 60 years who were hospitalized with COVID-19 from June 2020-June 2021. A baseline interview was conducted during or up to 2 weeks after hospitalization. Follow-up interviews occurred at one, three, and six months post-discharge. Participants completed comprehensive assessments of physical and cognitive function, symptoms, and psychosocial factors. An abbreviated assessment could be performed with a proxy. Additional information was collected from the electronic health record. RESULTS Among 341 participants, the mean age was 71.4 (SD 8.4) years, 51% were women, and 37% were of Black race or Hispanic ethnicity. Median length of hospitalization was 8 (IQR 6-12) days. All but 4% of participants required supplemental oxygen, and 20% required care in an intensive care unit or stepdown unit. At enrollment, nearly half (47%) reported at least one preexisting disability in physical function, 45% demonstrated cognitive impairment, and 67% were pre-frail or frail. Participants reported a mean of 9 of 14 (SD 3) COVID-19-related symptoms. At the six-month follow-up interview, more than a third of participants experienced a decline from their pre-hospitalization function, nearly 20% had cognitive impairment, and burdensome symptoms remained highly prevalent. CONCLUSIONS We enrolled a diverse cohort of older adults hospitalized with COVID-19 and followed them after discharge. Functional decline was common, and there were high rates of persistent cognitive impairment and symptoms. Future analyses of these data will advance our understanding of patient-centered outcomes among older COVID-19 survivors.
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Affiliation(s)
- Andrew B. Cohen
- Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Gail J. McAvay
- Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Mary Geda
- Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Sumon Chattopadhyay
- Clinical and Translational Science InstituteUniversity of UtahSalt Lake CityUtahUSA
| | - Seohyuk Lee
- Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Denise Acampora
- Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Katy Araujo
- Department of MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Peter Charpentier
- Department of MedicineYale School of MedicineNew HavenConnecticutUSA
- CRI Web ToolsDurhamConnecticutUSA
| | - Thomas M. Gill
- Department of MedicineYale School of MedicineNew HavenConnecticutUSA
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Ali T, Mroz EL, Valeika S, Mendez EN, Cohen AB, Monin JK. Navigating the COVID-19 pandemic together: Discussions between persons with early-stage dementia and their adult children. Int J Geriatr Psychiatry 2023; 38:e5905. [PMID: 36929513 PMCID: PMC10590087 DOI: 10.1002/gps.5905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/11/2023] [Indexed: 03/18/2023]
Abstract
OBJECTIVES Studies have separately examined the health impacts of the COVID-19 pandemic on persons with dementia and their caregivers. Less attention has been paid to the social and emotional impacts of the pandemic in this population or how these individuals are mutually coping with the pandemic. Guided by the social citizenship theory, this qualitative study sought to characterize how persons with dementia and their adult children are coping during this time with a focus on the strengths demonstrated by persons with dementia. METHODS Participants were 43 dyads of individuals aged 55 and older with early-stage dementia and their adult children. Discussions between parent-child dyads were recorded. Using reflexive thematic analysis, themes related to social and emotional impacts of the pandemic and coping strategies were identified. RESULTS Adult children shared with their parents how the pandemic resulted in reduced social engagement and challenging work arrangements. Dyads described how the pandemic positively impacted their relationship, allowing some of them to spend more time together. In coping with the pandemic, adult children provided instrumental support to their parents and parents reciprocated with emotional support. Participants also coped by making meaning of their situation during discussions. CONCLUSIONS Findings characterize the resilience of persons with dementia and the mutuality of the relationship between both members of the care partner dyad, as both parents and adult children offered support to one another. Facilitating dyadic discussions may be a cost-effective way to sustain social connections and offer ongoing coping support through the pandemic or other challenging circumstances.
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Affiliation(s)
- Talha Ali
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Emily L. Mroz
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | - Andrew B. Cohen
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joan K. Monin
- Department of Social and Behavioral Science, Yale School of Public Health, New Haven, Connecticut, USA
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Ouellet GM, O’Leary JR, Leggett CG, Skinner J, Tinetti ME, Cohen AB. Benefits and harms of oral anticoagulants for atrial fibrillation in nursing home residents with advanced dementia. J Am Geriatr Soc 2023; 71:561-568. [PMID: 36310367 PMCID: PMC9957933 DOI: 10.1111/jgs.18108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/04/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Approximately 20% of older persons with dementia have atrial fibrillation (AF). Nearly all have stroke risks that exceed the guideline-recommended threshold for anticoagulation. Although individuals with dementia develop profound impairments and die from the disease, little evidence exists to guide anticoagulant discontinuation, and almost one-third of nursing home residents with advanced dementia and AF remain anticoagulated in the last 6 months of life. We aimed to quantify the benefits and harms of anticoagulation in this population. METHODS Using Minimum Data Set and Medicare claims, we conducted a retrospective cohort study with 14,877 long-stay nursing home residents aged ≥66 between 2013 and 2018 who had advanced dementia and AF. We excluded individuals with venous thromboembolism and valvular heart disease. We measured anticoagulant exposure quarterly, using Medicare Part D claims. The primary outcome was all-cause mortality; secondary outcomes were ischemic stroke and serious bleeding. We performed survival analyses with multivariable adjustment and inverse probability of treatment (IPT) weighting. RESULTS In the study sample, 72.0% were female, 82.7% were aged ≥80 years, and 13.5% were nonwhite. Mean CHA2 DS2 VASC score was 6.19 ± 1.58. In multivariable survival analysis, anticoagulation was associated with decreased risk of death (HR 0.71, 95% CI 0.67-0.75) and increased bleeding risk (HR 1.15, 95% CI 1.02-1.29); the association with stroke risk was not significant (HR 1.08, 95% CI 0.80-1.46). Results were similar in models with IPT weighting. While >50% of patients in both groups died within a year, median weighted survival was 76 days longer for anticoagulated individuals. CONCLUSION Persons with advanced dementia and AF derive clinically modest life prolongation from anticoagulation, at the cost of elevated risk of bleeding. The relevance of this benefit is unclear in a group with high dementia-related mortality and for whom the primary goal is often comfort.
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Affiliation(s)
- Gregory M. Ouellet
- Section of Geriatrics, Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - John R. O’Leary
- Section of Geriatrics, Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Christopher G. Leggett
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Hanover, NH
| | - Jonathan Skinner
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Hanover, NH
| | - Mary E. Tinetti
- Section of Geriatrics, Yale School of Medicine, New Haven, CT
| | - Andrew B. Cohen
- Section of Geriatrics, Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
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Gettel CJ, Serina PT, Uzamere I, Hernandez-Bigos K, Venkatesh AK, Rising KL, Goldberg EM, Feder SL, Cohen AB, Hwang U. Emergency department-to-community care transition barriers: A qualitative study of older adults. J Am Geriatr Soc 2022; 70:3152-3162. [PMID: 35779278 PMCID: PMC9669106 DOI: 10.1111/jgs.17950] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/02/2022] [Accepted: 06/15/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Over one-half of older adults are discharged to the community after emergency department (ED) visits, and studies have shown there is increased risk of adverse health outcomes in the immediate post-discharge period. Understanding the experiences of older adults during ED-to-community care transitions has the potential to improve geriatric emergency clinical care and inform intervention development. We therefore sought to assess barriers experienced by older adults during ED-to-community care transitions. METHODS We conducted a qualitative analysis of community-dwelling cognitively intact patients aged 65 years and older receiving care in four diverse EDs from a single U.S. healthcare system. We constructed a conceptual framework a priori to guide the development and iterative revision of a codebook, used purposive sampling, and conducted recorded, semi-structured interviews using a standardized guide. Two researchers coded the professionally transcribed data using a combined deductive and inductive approach and analyzed transcripts to identify dominant themes and representative quotations. RESULTS Among 25 participants, 20 (80%) were women and 17 (68%) were white. We identified four barriers during the ED-to-community care transition: (1) ED discharge process was abrupt with missing information regarding symptom explanation and performed testing, (2) navigating follow-up outpatient clinical care was challenging, (3) new physical limitations and fears hinder performance of baseline activities, and (4) major and minor ramifications for caregivers impact an older adult's willingness to request or accept assistance. CONCLUSIONS Older adults identified barriers to successful ED-to-community care transitions that can inform the development of novel and effective interventions.
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Affiliation(s)
- Cameron J. Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, USA
| | - Peter T. Serina
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ivie Uzamere
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Kizzy Hernandez-Bigos
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Arjun K. Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, USA
| | - Kristin L. Rising
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Center for Connected Care, Thomas Jefferson University, Philadelphia, PA, USA
- College of Nursing, Thomas Jefferson University, Philadelphia, PA, USA
| | - Elizabeth M. Goldberg
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Shelli L. Feder
- Yale University School of Nursing, Orange, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Andrew B. Cohen
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Geriatrics Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA
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Gettel CJ, Serina PT, Uzamere I, Hernandez‐Bigos K, Venkatesh AK, Cohen AB, Monin JK, Feder SL, Fried TR, Hwang U. Emergency department care transition barriers: A qualitative study of care partners of older adults with cognitive impairment. Alzheimers Dement (N Y) 2022; 8:e12355. [PMID: 36204349 PMCID: PMC9518973 DOI: 10.1002/trc2.12355] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/11/2022] [Accepted: 08/17/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION After emergency department (ED) discharge, persons living with cognitive impairment (PLWCI) and their care partners are particularly at risk for adverse outcomes. We sought to identify the barriers experienced by care partners of PLWCI during ED discharge care transitions. METHODS We conducted a qualitative study of 25 care partners of PLWCI discharged from four EDs. We used the validated 4AT and care partner-completed AD8 screening tools, respectively, to exclude care partners of older adults with concern for delirium and include care partners of older adults with cognitive impairment. We conducted recorded, semi-structured interviews using a standardized guide, and two team members coded and analyzed all professional transcriptions to identify emerging themes and representative quotations. RESULTS Care partners' mean age was 56.7 years, 80% were female, and 24% identified as African American. We identified four major barriers regarding ED discharge care transitions among care partners of PLWCI: (1) unique care considerations while in the ED setting impact the perceived success of the care transition, (2) poor communication and lack of care partner engagement was a commonplace during the ED discharge process, (3) care partners experienced challenges and additional responsibilities when aiding during acute illness and recovery phases, and (4) navigating the health care system after an ED encounter was perceived as difficult by care partners. DISCUSSION Our findings demonstrate critical barriers faced during ED discharge care transitions among care partners of PLWCI. Findings from this work may inform the development of novel care partner-reported outcome measures as well as ED discharge care transition interventions targeting care partners.
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Affiliation(s)
- Cameron J. Gettel
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
- Center for Outcomes Research and EvaluationYale School of MedicineNew HavenConnecticutUSA
| | - Peter T. Serina
- Department of Emergency MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Ivie Uzamere
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Kizzy Hernandez‐Bigos
- Section of GeriatricsDepartment of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Arjun K. Venkatesh
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
- Center for Outcomes Research and EvaluationYale School of MedicineNew HavenConnecticutUSA
| | - Andrew B. Cohen
- Section of GeriatricsDepartment of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
| | - Joan K. Monin
- Social and Behavioral SciencesYale School of Public HealthNew HavenConnecticutUSA
| | - Shelli L. Feder
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
- Yale University School of NursingOrangeConnecticutUSA
| | - Terri R. Fried
- Section of GeriatricsDepartment of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
| | - Ula Hwang
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
- Geriatrics ResearchEducation and Clinical CenterJames J. Peters VA Medical CenterBronxNew YorkUSA
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12
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Djulbegovic M, Chen K, Cohen AB, Heacock D, Canavan M, Cushing W, Agarwal R, Simonov M, Chaudhry SI. Associations between hospitalist physician workload, length of stay, and return to the hospital. J Hosp Med 2022; 17:445-455. [PMID: 35662410 PMCID: PMC9248905 DOI: 10.1002/jhm.12847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 04/03/2022] [Accepted: 04/20/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Hospitalist physicians' workload-the total number of patients they care for daily-is rising in the U.S. Hospitalists report that increased workload negatively affects patients care. OBJECTIVE Measure the associations between hospitalist physicians' workload and clinical outcomes. DESIGN, SETTINGS, AND PARTICIPANTS Observational study, using electronic health record (EHR) data, of adults hospitalized on the hospitalist service at Yale-New Haven Hospital from 2015-2018. MAIN OUTCOME AND MEASURES We defined hospitalists' workload as the number of patients they cared for on the first full hospital day of a given patient's encounter. We used multilevel Poisson and logistic regression to examine associations between workload and length of stay (LOS), return to the Emergency Department (ED), and readmission. We adjusted for sociodemographic factors, patient complexity and severity of illness, and weekend admission (for LOS) or discharge (for ED visits or readmission). RESULTS We analyzed 38,141 hospitalizations. Median patient age was 64 years (IQR 51-78 years), 53% were female, and 34% were nonwhite. Mean workload was 15 patients (SD 3 patients; range 10-34 patients). LOS was prolonged by 0.05 days (95% CI 0.02, 0.08; p(0.001) when comparing the 75th workload percentile (16 patients) to the 25th workload percentile (13 patients). There were no associations between workload and ED visits or readmission within 7 and 30 days. CONCLUSIONS There was a statistically significant but modest relationship between workload and LOS; workload was not associated with ED visits or readmissions.Given clinical reports of the deleterious effects of increased hospitalist workload, there is a need for prospective research assessing a range of outcomes, beyond those measurable in contemporary EHR data.
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Affiliation(s)
- Mia Djulbegovic
- National Clinician Scholars Program, Yale University School
of Medicine, New Haven, Connecticut, USA
- Veterans Affairs Connecticut Healthcare System, West Haven,
Connecticut, USA
- Department of Medicine, Division of Hematology &
Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,
USA
| | - Kevin Chen
- National Clinician Scholars Program, Yale University School
of Medicine, New Haven, Connecticut, USA
- Veterans Affairs Connecticut Healthcare System, West Haven,
Connecticut, USA
- Division of General Internal Medicine and Clinical
Innovation, New York University Grossman School of Medicine, New York, NY, USA
| | - Andrew B. Cohen
- Veterans Affairs Connecticut Healthcare System, West Haven,
Connecticut, USA
- Department of Internal Medicine, Yale University School of
Medicine, New Haven, CT, USA
| | | | - Maureen Canavan
- National Clinician Scholars Program, Yale University School
of Medicine, New Haven, Connecticut, USA
- Yale Cancer Outcomes, Public Policy and Effectiveness
Research (COPPER) Center, Yale School of Medicine, Department of Internal Medicine,
New Haven, Connecticut, USA
| | | | - Ritu Agarwal
- Joint Data Analyst Team, Yale New Haven Health System, New
Haven, CT
- Department of Internal Medicine, Yale University School of
Medicine, New Haven, CT, USA
| | | | - Sarwat I. Chaudhry
- National Clinician Scholars Program, Yale University School
of Medicine, New Haven, Connecticut, USA
- Department of Internal Medicine, Yale University School of
Medicine, New Haven, CT, USA
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13
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Lee YK, Fried TR, Costello DM, Hajduk AM, O'Leary JR, Cohen AB. Perceived dementia risk and advance care planning among older adults. J Am Geriatr Soc 2022; 70:1481-1486. [PMID: 35274737 PMCID: PMC9106856 DOI: 10.1111/jgs.17721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/12/2022] [Accepted: 01/16/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although advance care planning (ACP) is beneficial if dementia develops, and virtually all older adults are at risk for this disease, older adults do not consistently engage in ACP. Health behavior models have highlighted the importance of perceived susceptibility to medical conditions in motivating behavior. Following these models, we sought to determine how often older adults believe they are not at risk of developing dementia and to examine the association between perceived dementia risk and ACP participation. METHODS We performed a cross-sectional study of community-dwelling adults without cognitive impairment, aged ≥65 years, who were interviewed for the Health and Retirement Study in 2016 and asked about their perceived dementia risk (n = 711). Perceived dementia risk was ascertained with this question: "on a scale of 0 to 100, what is the percent chance that you will develop dementia sometime in the future?" We used multivariable-adjusted logistic regression to evaluate the association between perceived risk (0% versus >0%) and completion of a living will, appointment of a durable power of attorney for healthcare decisions, and discussion of treatment preferences. RESULTS Among respondents, 10.5% reported a perceived dementia risk of 0%. Perceived risk of 0% was associated with lower odds of completing a living will (OR 0.53; 95% CI, 0.30-0.93) and discussing treatment preferences (OR 0.51; 95% CI, 0.28-0.93) but not appointment of a durable power of attorney (OR 0.77; 95% CI, 0.42-1.39). Many respondents with perceived dementia risk >0% had not completed ACP activities, including a substantial minority of those with perceived risk >50%. CONCLUSIONS Older adults with no perceived dementia risk are less likely to participate in several forms of ACP, but the fact that many older adults with high levels of perceived risk had not completed ACP activities suggests that efforts beyond raising risk awareness are needed to increase engagement.
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Affiliation(s)
- Yu Kyung Lee
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Terri R Fried
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Health System, West Haven, Connecticut, USA
| | - Darcé M Costello
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Alexandra M Hajduk
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - John R O'Leary
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Andrew B Cohen
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Health System, West Haven, Connecticut, USA
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14
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Falvey JR, Cohen AB, O’Leary JR, Leo-Summers L, Murphy TE, Ferrante LE. Association of Social Isolation With Disability Burden and 1-Year Mortality Among Older Adults With Critical Illness. JAMA Intern Med 2021; 181:1433-1439. [PMID: 34491282 PMCID: PMC8424527 DOI: 10.1001/jamainternmed.2021.5022] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/18/2021] [Indexed: 12/27/2022]
Abstract
Importance Disability and mortality are common among older adults with critical illness. Older adults who are socially isolated may be more vulnerable to adverse outcomes for various reasons, including fewer supports to access services needed for optimal recovery; however, whether social isolation is associated with post-intensive care unit (ICU) disability and mortality is not known. Objectives To evaluate whether social isolation is associated with disability and with 1-year mortality after critical illness. Design, Setting, and Participants This observational cohort study included community-dwelling older adults who participated in the National Health and Aging Trends Study (NHATS) from May 2011 through November 2018. Hospitalization data were collected through 2017 and interview data through 2018. Data analysis was conducted from February 2020 through February 2021. The mortality sample included 997 ICU admissions of 1 day or longer, which represented 5 705 675 survey-weighted ICU hospitalizations. Of these, 648 ICU stays, representing 3 821 611 ICU hospitalizations, were eligible for the primary outcome of post-ICU disability. Exposures Social isolation from the NHATS survey response in the year most closely preceding ICU admission, which was assessed using a validated measure of social connectedness with partners, families, and friends as well as participation in valued life activities (range 0-6; higher scores indicate more isolation). Main Outcomes and Measures The primary outcome was the count of disability assessed during the first interview following hospital discharge. The secondary outcome was time to death within 1 year of hospital admission. Results A total of 997 participants were in the mortality cohort (511 women [51%]; 45 Hispanic [5%], 682 non-Hispanic White [69%], and 228 non-Hispanic Black individuals [23%]) and 648 in the disability cohort (331 women [51%]; 29 Hispanic [5%], 457 non-Hispanic White [71%], and 134 non-Hispanic Black individuals [21%]). The median (interquartile range [IQR]) age was 81 (75.5-86.0) years (range, 66-102 years), the median (IQR) preadmission disability count was 0 (0-1), and the median (IQR) social isolation score was 3 (2-4). After adjustment for demographic characteristics and illness severity, each 1-point increase in the social isolation score (from 0-6) was associated with a 7% greater disability count (adjusted rate ratio, 1.07; 95% CI, 1.01-1.15) and a 14% increase in 1-year mortality risk (adjusted hazard ratio, 1.14; 95% CI, 1.03-1.25). Conclusions and Relevance In this cohort study, social isolation before an ICU hospitalization was associated with greater disability burden and higher mortality in the year following critical illness. The study findings suggest a need to develop social isolation screening and intervention frameworks for older adults with critical illness.
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Affiliation(s)
- Jason R. Falvey
- Department of Physical Therapy and Rehabilitation Science and Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Andrew B. Cohen
- Section of Geriatrics, Yale School of Medicine, New Haven, Connecticut
| | - John R. O’Leary
- Section of Geriatrics, Yale School of Medicine, New Haven, Connecticut
| | - Linda Leo-Summers
- Section of Geriatrics, Yale School of Medicine, New Haven, Connecticut
| | | | - Lauren E. Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut
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15
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Ouellet GM, Fried TR, Gilstrap LG, O'Leary JR, Austin AM, Skinner JS, Cohen AB. Anticoagulant Use for Atrial Fibrillation Among Persons With Advanced Dementia at the End of Life. JAMA Intern Med 2021; 181:1121-1123. [PMID: 33970197 PMCID: PMC8111560 DOI: 10.1001/jamainternmed.2021.1819] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This cross-sectional study evaluates the degree of anticoagulant use among nursing home residents with advanced dementia and atrial fibrillation at the end of life.
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Affiliation(s)
- Gregory M Ouellet
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Terri R Fried
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Lauren G Gilstrap
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - John R O'Leary
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Andrew B Cohen
- VA Connecticut Healthcare System, West Haven, Connecticut
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16
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Moye J, Stolzmann K, Auguste EJ, Cohen AB, Catlin CC, Sager ZS, Weiskittle RE, Woolverton CB, Connors HL, Sullivan JL. End-of-Life Care for Persons Under Guardianship. J Pain Symptom Manage 2021; 62:81-90.e2. [PMID: 33212143 PMCID: PMC8124075 DOI: 10.1016/j.jpainsymman.2020.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/06/2020] [Accepted: 11/06/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT Guardians are surrogate decision makers appointed by a court when other health care decision-makers are unable, unwilling, or unavailable to make decisions. Prior studies suggest that persons under guardianship may experience delays in transitions of care. OBJECTIVES To compare quality of end-of-life care for persons under guardianship to a matched group on objective indicators and to identify narrative themes characterizing potential obstacles to quality end-of-life care. METHODS One hundred sixty-seven persons under guardianship who died between 2003 and 2019 within the Veterans Healthcare Administration in Massachusetts and Connecticut matched on a 1:1 basis to persons without guardians. The groups were compared on treatment specialty at death, days of hospice and intensive care unit care, and receipt of palliative care consultation. Additionally, patient narratives for those under guardianship with extended lengths in intensive care unit were subjected to qualitative analysis. RESULTS Overall, <1% were under guardianship. Within this sample of persons who died within the Veterans Health Administration, persons under guardianship were as likely as patients in the comparison group to receive palliative care consultation (odds ratio [CI] = 0.93 [.590-1.46], P = .359), but were more likely to have ethics consultation (odds ratio [CI] = 0.25 [0.66-0.92], P = .036) and have longer lengths of ICU admission (β = -.34, t = -2.70, P = .009). Qualitative findings suggest that issues related to family conflict, fluctuating medical course, and limitations in guardian authority may underlie extended lengths of stay. CONCLUSION Guardianship appears to be rare, and as a rule, those under guardianship have equal access to hospice and palliative care within Veterans Health Administration. Guardianship may be associated with health-care challenges in a small number of cases, and this may drive perceptions of adverse outcomes.
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Affiliation(s)
- Jennifer Moye
- VA New England Geriatric Research Education and Clinical Center (GRECC), Boston and Bedford, Massachusetts, USA; VA Boston Healthcare System, Boston, Massachusetts, USA; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA.
| | - Kelly Stolzmann
- VA Boston Healthcare System, Boston, Massachusetts, USA; Center for Healthcare Organization and Implementation Research, Boston and Bedford, Massachusetts, USA
| | - Elizabeth J Auguste
- VA New England Geriatric Research Education and Clinical Center (GRECC), Boston and Bedford, Massachusetts, USA; VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Andrew B Cohen
- VA Connecticut Healthcare System, West Haven, Connecticut, USA; Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Zachary S Sager
- VA New England Geriatric Research Education and Clinical Center (GRECC), Boston and Bedford, Massachusetts, USA; VA Boston Healthcare System, Boston, Massachusetts, USA; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Rachel E Weiskittle
- VA New England Geriatric Research Education and Clinical Center (GRECC), Boston and Bedford, Massachusetts, USA; VA Boston Healthcare System, Boston, Massachusetts, USA; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Cindy B Woolverton
- VA Boston Healthcare System, Boston, Massachusetts, USA; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jennifer L Sullivan
- VA Boston Healthcare System, Boston, Massachusetts, USA; Center for Healthcare Organization and Implementation Research, Boston and Bedford, Massachusetts, USA; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
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17
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Travers JL, Naylor MD, Coe NB, Meng C, Li F, Cohen AB. Demographic Characteristics Driving Disparities in Receipt of Long-term Services and Supports in the Community Setting. Med Care 2021; 59:537-542. [PMID: 33827107 PMCID: PMC8119333 DOI: 10.1097/mlr.0000000000001544] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Research suggests that growth in Black and Hispanic (minority) older adults' nursing home (NH) use may be the result of disparities in access to community-based and alternative long-term services and supports (LTSS). OBJECTIVE We aimed to determine whether minority groups receiving care in NHs versus the community had fewer differences in their functional needs compared with the differences in nonminority older adults, suggesting a disparity. METHODS We identified respondents aged 65 years or above with a diagnosis of Alzheimer disease or dementia in the 2016 Health and Retirement Study who reported requiring LTSS help. We performed unadjusted analyses to assess the difference in functional need between community and NH care. Functional need was operationalized using a functional limitations score and 6 individual activities of daily living. We compared the LTSS setting for minority older adults to White older adults using difference-in-differences. RESULTS There were 186 minority older adults (community=75%, NH=25%) and 357 White older adults (community=50%, NH=50%). Between settings, minority older adults did not differ in education or marital status, but were younger and had greater income in the NH versus the community. The functional limitations score was higher in NHs than in the community for both groups. Functional needs for all 6 activities of daily living for the minority group were greater in NHs compared with the community. CONCLUSION Functional need for minority older adults differed by setting while demographics varied in unexpected ways. Factors such as familial and financial support are important to consider when implementing programs to keep older adults out of NHs.
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Affiliation(s)
| | - Mary D. Naylor
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing
| | - Norma B. Coe
- University of Pennsylvania Perelman School of Medicine
| | - Can Meng
- Yale Center for Analytical Sciences, Department of Biostatistics, Yale School of Public Health
| | - Fangyong Li
- Yale Center for Analytical Sciences, Department of Biostatistics, Yale School of Public Health
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18
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Cohen AB, DeMartino ES. How should advance care planning be done when a surrogate is making decisions? J Am Geriatr Soc 2021; 69:2103-2105. [PMID: 34002373 DOI: 10.1111/jgs.17222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/02/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Andrew B Cohen
- Section of Geriatrics, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Erin S DeMartino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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19
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Fried TR, Cohen AB, Harris JE, Moreines L. Cognitively Impaired Older Persons' and Caregivers' Perspectives on Dementia-Specific Advance Care Planning. J Am Geriatr Soc 2020; 69:932-937. [PMID: 33216955 DOI: 10.1111/jgs.16953] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/28/2020] [Accepted: 11/01/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Advance care planning (ACP) traditionally involves asking individuals about their treatment preferences during a brief period of incapacity near the end of life. Because dementia leads to prolonged incapacity, with many decisions arising before a terminal event, it has been suggested that dementia-specific ACP is necessary. We sought to elicit the perspectives of older adults with early cognitive impairment and their caregivers on traditional and dementia-specific ACP. DESIGN Qualitative study with separate focus groups for patients and caregivers. SETTING Memory disorder clinics. PARTICIPANTS Twenty eight persons aged 65+ with mild cognitive impairment or early dementia and 19 caregivers. MEASUREMENTS Understanding of dementia trajectory and types of planning done; how medical decisions would be made in the future; thoughts about these decisions. RESULTS No participants had engaged in any written form of dementia-specific planning. Barriers to dementia-specific ACP emerged, including lack of knowledge about the expected trajectory of dementia and potential medical decisions, the need to stay focused in the present because of fear of loss of self, disinterest in planning because the patient will not be aware of decisions, and the expectation that involved family members would take care of issues. Some patients had trouble engaging in the discussion. Patients had highly variable views on what the quality of their future life would be and on the leeway their surrogates should have in decision making. CONCLUSIONS Even among patients with early cognitive impairment seen in specialty clinics and their caregivers, most were unaware of the decisions they could face, and there were many barriers to planning for these decisions. These issues would likely be magnified in more representative populations, and highlight challenges to the use of dementia-specific advance directive documents.
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Affiliation(s)
- Terri R Fried
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Andrew B Cohen
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joanna E Harris
- Alzheimer's Disease Research Unit, Yale School of Medicine, New Haven, Connecticut, USA
| | - Laura Moreines
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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20
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Cohen AB, Han L, OʼLeary JR, Fried TR. Guardianship and End-of-Life Care for Veterans with Dementia in Nursing Homes. J Am Geriatr Soc 2020; 69:342-348. [PMID: 33170957 DOI: 10.1111/jgs.16900] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/20/2020] [Accepted: 08/30/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND/OBJECTIVES Experts have suggested that patients represented by professional guardians receive higher intensity end-of-life treatment than other patients, but there is little corresponding empirical data. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS Among veterans aged 65 and older who died from 2011 to 2013, we used Minimum Data Set assessments to identify those who were nursing home residents and had moderately severe or severe dementia. We applied methods developed in prior work to determine which of these veterans had professional guardians. Decedent veterans with professional guardians were matched to decedent veterans without guardians in a 1:4 ratio, according to age, sex, race, dementia severity, and nursing facility type (VA based vs non-VA). MEASUREMENTS Our primary outcome was intensive care unit (ICU) admission in the last 30 days of life. Secondary outcomes included mechanical ventilation and cardiopulmonary resuscitation in the last 30 days of life, feeding tube placement in the last 90 days of life, three or more nursing home-to-hospital transfers in the last 90 days of life, and in-hospital death. RESULTS ICU admission was more common among patients with professional guardians than matched controls (17.5% vs 13.7%), but the difference was not statistically significant (adjusted odds ratio = 1.33; 95% confidence interval = .89-1.99). There were no significant differences in receipt of any other treatment; nor was there a consistent pattern. Mechanical ventilation and cardiopulmonary resuscitation were more common among patients with professional guardians, and feeding tube placement, three or more end-of-life hospitalizations, and in-hospital death were more common among matched controls. CONCLUSION Rates of high-intensity treatment were similar whether or not a nursing home resident with dementia was represented by a professional guardian. This is in part because high-intensity treatment occurred more frequently than expected among patients without guardians.
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Affiliation(s)
- Andrew B Cohen
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Health System, West Haven, Connecticut, USA
| | - Ling Han
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - John R OʼLeary
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Terri R Fried
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Health System, West Haven, Connecticut, USA
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21
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Cohen AB, Parks AL, Whitson HE, Zieman S, Brown CJ, Boyd C, Covinsky KE, Steinman MA. Succeeding in Aging Research During the Pandemic: Strategies for Fellows and Junior Faculty. J Am Geriatr Soc 2020; 69:8-11. [PMID: 33047812 PMCID: PMC7675665 DOI: 10.1111/jgs.16868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 09/21/2020] [Indexed: 11/26/2022]
Abstract
Fellows and junior faculty conducting aging research have encountered substantial new challenges during the COVID-19 pandemic. They report that they have been uncertain how and whether to modify existing research studies, have faced difficulties with job searches, and have struggled to balance competing pressures including greater clinical obligations and increased responsibilities at home. Many have also wondered if they should shift gears and make COVID-19 the focus of their research. We asked a group of accomplished scientists and mentors to grapple with these concerns and to share their thoughts with readers of this journal.
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Affiliation(s)
| | - Anna L Parks
- University of California - San Francisco School of Medicine and the San Francisco VA Medical Center, San Francisco, California
| | - Heather E Whitson
- Duke University School of Medicine and Durham VA Medical Center, Durham, North Carolina
| | - Susan Zieman
- National Institute on Aging, National Institutes of Health, Bethesda, Maryland
| | - Cynthia J Brown
- University of Alabama at Birmingham School of Medicine and the Birmingham/Atlanta VA Geriatric Research, Education, and Clinical Center (GRECC), Birmingham, Alabama
| | - Cynthia Boyd
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kenneth E Covinsky
- University of California - San Francisco School of Medicine and the San Francisco VA Medical Center, San Francisco, California
| | - Michael A Steinman
- University of California - San Francisco School of Medicine and the San Francisco VA Medical Center, San Francisco, California
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22
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Cohen AB, Costello DM, OʼLeary JR, Fried TR. Older Adults without Desired Surrogates in a Nationally Representative Sample. J Am Geriatr Soc 2020; 69:114-121. [PMID: 32898285 DOI: 10.1111/jgs.16813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/29/2020] [Accepted: 08/07/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES Little is known about older adults who have intact capacity but do not have a desired surrogate to make decisions if their capacity becomes impaired. DESIGN Cross-sectional study of a nationally representative sample. SETTING National Social Life, Health, and Aging Project (NSHAP), 2005-2006. PARTICIPANTS Community-dwelling older adults without known cognitive impairment, aged 57 to 85, interviewed as part of NSHAP (n = 2,767). MEASUREMENTS We examined demographic, medical, and social connectedness characteristics associated with answering "no" to this question: "Do you have someone who you would like to make medical decisions for you if you were unable, as for example if you were seriously injured or very sick?" Because many states permit nuclear family to make decisions for persons with no legally appointed health care agent, we used logistic regression to identify factors associated with individuals who were ill suited to this paradigm in the sense that they had nuclear family but did not have a desired surrogate. RESULTS Among NSHAP respondents, 7.5% (95% confidence interval = 6.4-8.7) did not have a desired surrogate. Nearly 90% of respondents without desired surrogates had nuclear family. Compared with respondents with desired surrogates, those without desired surrogates had lower indicators of social connectedness. On average, however, they had four confidants, approximately 70% socialized at least monthly, and more than 90% could discuss their health with a confidant. Among respondents who had nuclear family, few characteristics distinguished those with and without desired surrogates. CONCLUSION Nearly 8% of older adults did not have a desired surrogate. Most had nuclear family and were not socially disconnected. Older adults should be asked explicitly about a desired surrogate, and strategies are needed to identify surrogates for those who do not have family or would not choose family to make decisions for them.
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Affiliation(s)
- Andrew B Cohen
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Health System, West Haven, Connecticut, USA
| | - Darcé M Costello
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - John R OʼLeary
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Terri R Fried
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Health System, West Haven, Connecticut, USA
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Pope TM, Bennett J, Carson SS, Cederquist L, Cohen AB, DeMartino ES, Godfrey DM, Goodman-Crews P, Kapp MB, Lo B, Magnus DC, Reinke LF, Shirley JL, Siegel MD, Stapleton RD, Sudore RL, Tarzian AJ, Thornton JD, Wicclair MR, Widera EW, White DB. Making Medical Treatment Decisions for Unrepresented Patients in the ICU. An Official American Thoracic Society/American Geriatrics Society Policy Statement. Am J Respir Crit Care Med 2020; 201:1182-1192. [PMID: 32412853 PMCID: PMC7233335 DOI: 10.1164/rccm.202003-0512st] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and Rationale: ICU clinicians regularly care for patients who lack capacity, an applicable advance directive, and an available surrogate decision-maker. Although there is no consensus on terminology, we refer to these patients as “unrepresented.” There is considerable controversy about how to make treatment decisions for these patients, and there is significant variability in both law and clinical practice. Purpose and Objectives: This multisociety statement provides clinicians and hospital administrators with recommendations for decision-making on behalf of unrepresented patients in the critical care setting. Methods: An interprofessional, multidisciplinary expert committee developed this policy statement by using an iterative consensus process with a diverse working group representing critical care medicine, palliative care, pediatric medicine, nursing, social work, gerontology, geriatrics, patient advocacy, bioethics, philosophy, elder law, and health law. Main Results: The committee designed its policy recommendations to promote five ethical goals: 1) to protect highly vulnerable patients, 2) to demonstrate respect for persons, 3) to provide appropriate medical care, 4) to safeguard against unacceptable discrimination, and 5) to avoid undue influence of competing obligations and conflicting interests. These recommendations also are intended to strike an appropriate balance between excessive and insufficient procedural safeguards. The committee makes the following recommendations: 1) institutions should offer advance care planning to prevent patients at high risk for becoming unrepresented from meeting this definition; 2) institutions should implement strategies to determine whether seemingly unrepresented patients are actually unrepresented, including careful capacity assessments and diligent searches for potential surrogates; 3) institutions should manage decision-making for unrepresented patients using input from a diverse interprofessional, multidisciplinary committee rather than ad hoc by treating clinicians; 4) institutions should use all available information on the patient’s preferences and values to guide treatment decisions; 5) institutions should manage decision-making for unrepresented patients using a fair process that comports with procedural due process; 6) institutions should employ this fair process even when state law authorizes procedures with less oversight. Conclusions: This multisociety statement provides guidance for clinicians and hospital administrators on medical decision-making for unrepresented patients in the critical care setting.
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24
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Fried TR, Street RL, Cohen AB. Reply to: Outcomes and Patient Goals: Comment on "Chronic Disease Decision Making and 'What Matters Most'". J Am Geriatr Soc 2020; 68:1615-1616. [PMID: 32391923 DOI: 10.1111/jgs.16505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Terri R Fried
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Richard L Street
- Department of Communication, Texas A&M University, College Station, Texas, USA.,The Houston Center for Quality of Care and Utilization Studies and Baylor College of Medicine, Houston, Texas, USA
| | - Andrew B Cohen
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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25
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Cohen AB, Fried TR. Reply to Comment on: End-of-Life Decision Making and Treatment for Patients With Professional Guardians. J Am Geriatr Soc 2020; 68:896-897. [PMID: 32112564 PMCID: PMC8299534 DOI: 10.1111/jgs.16387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/09/2020] [Indexed: 11/29/2022]
Abstract
This letter comments on the letter by Marisa LaRock.
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Affiliation(s)
- Andrew B. Cohen
- Department of Medicine, Yale School of Medicine, New Haven,
CT
| | - Terri R. Fried
- Department of Medicine, Yale School of Medicine, New Haven,
CT
- Clinical Epidemiology Research Center, VA Connecticut
Health System, West Haven, CT
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26
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Fried TR, Street RL, Cohen AB. Chronic Disease Decision Making and "What Matters Most". J Am Geriatr Soc 2020; 68:474-477. [PMID: 32043559 DOI: 10.1111/jgs.16371] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/18/2019] [Accepted: 12/20/2019] [Indexed: 01/08/2023]
Abstract
The increasing use of the question, "What matters most to you?" is a welcome development in the effort to provide patient-centered care. However, it is difficult for clinicians to translate answers to this question into treatment plans for chronic conditions, including recognizing when to consider options other than clinical practice guideline (CPG)-directed therapy. Goal elicitation is most helpful when a patient has different treatment options with clearly identifiable trade-offs. In the face of trade-offs, goal elicitation helps patients to prioritize among potentially competing outcomes. While decision aids (DAs) focus on trade-offs by delineating options and outcomes, the robust outcome data necessary to create DAs for older patients with multimorbidity are often lacking and even mild cognitive impairment makes the use of DAs difficult. The challenges for providing chronic disease care to older patients who are at risk for adverse events from CPG-directed therapy because of multimorbidity and/or frailty are to organize the complexity of individual combinations of diseases, conditions, and syndromes into common sets of trade-offs and to identify those goals or priorities that will directly inform a plan of care. J Am Geriatr Soc 68:474-477, 2020.
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Affiliation(s)
- Terri R Fried
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Richard L Street
- Department of Communication, Texas A&M University, College Station, Texas.,Department of Medicine, The Houston Center for Quality of Care and Utilization Studies and Baylor College of Medicine, Houston, Texas
| | - Andrew B Cohen
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
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Cohen AB, Benjamin AZ, Fried TR. End-of-Life Decision Making and Treatment for Patients with Professional Guardians. J Am Geriatr Soc 2019; 67:2161-2166. [PMID: 31301189 DOI: 10.1111/jgs.16072] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/01/2019] [Accepted: 06/10/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Concerns have repeatedly been raised about end-of-life decision making when a patient with diminished capacity is represented by a professional guardian, a paid official appointed by a judge. Such guardians are said to choose high-intensity treatment even when it is unlikely to be beneficial or to leave pivotal decisions to the court. End-of-life decision making by professional guardians has not been examined systematically, however. DESIGN Retrospective cohort study. SETTING Inpatient and outpatient facilities in the Department of Veterans Affairs (VA) Connecticut Healthcare System. PARTICIPANTS Decedent patients represented by professional guardians who received care at Connecticut VA facilities from 2003 to 2013 and whose care in the last month of life was documented in the VA record. MEASUREMENTS Through chart reviews, we collected data about the guardianship appointment, the patient's preferences, the guardian's decision-making process, and treatment outcomes. RESULTS There were 33 patients with professional guardians who died and had documentation of their end-of-life care. The guardian sought judicial review for 33%, and there were delays in decision making for 42%. In the last month of life, 29% of patients were admitted to the intensive care unit, intubated, or underwent cardiopulmonary resuscitation; 45% received hospice care. Judicial review and high-intensity treatment were less common when information about the patient's preferences was available. CONCLUSION Rates of high-intensity treatment and hospice care were similar to older adults overall. Because high-intensity treatment was less likely when the guardian had information about a patient's preferences, future work should focus on advance care planning for individuals without an appropriate surrogate. J Am Geriatr Soc 67:2161-2166, 2019.
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Affiliation(s)
- Andrew B Cohen
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Andrea Z Benjamin
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Terri R Fried
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,Clinical Epidemiology Research Center, Veterans Affairs (VA) Connecticut Health System, West Haven, Connecticut
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28
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Cohen AB, Trentalange M, Benjamin AZ, Fried TR. Characteristics of Patients With Professional Guardians in the Department of Veterans Affairs Health Care System. JAMA Intern Med 2019; 179:107-108. [PMID: 30398533 PMCID: PMC6500761 DOI: 10.1001/jamainternmed.2018.4849] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Andrew B Cohen
- Section of Geriatrics, Yale School of Medicine, New Haven, Connecticut
| | - Mark Trentalange
- Department of Anesthesiology, James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Andrea Z Benjamin
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Terri R Fried
- Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven
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29
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McAvay G, Allore HG, Cohen AB, Gnjidic D, Murphy TE, Tinetti ME. Guideline-Recommended Medications and Physical Function in Older Adults with Multiple Chronic Conditions. J Am Geriatr Soc 2017; 65:2619-2626. [PMID: 28905359 DOI: 10.1111/jgs.15065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND/OBJECTIVES The benefit or harm of a single medication recommended for one specific condition can be difficult to determine in individuals with multiple chronic conditions and polypharmacy. There is limited information on the associations between guideline-recommended medications and physical function in older adults with multiple chronic conditions. The objective of this study was to estimate the beneficial or harmful associations between guideline-recommended medications and decline in physical function in older adults with multiple chronic conditions. DESIGN Prospective observational cohort. SETTING National. PARTICIPANTS Community-dwelling adults aged 65 and older from the Medicare Current Beneficiary Survey study (N = 3,273). Participants with atrial fibrillation, coronary artery disease, depression, diabetes mellitus, or heart failure were included. MEASUREMENTS Self-reported decline in physical function; guideline-recommended medications; polypharmacy (taking <7 vs ≥7 concomitant medications); chronic conditions; and sociodemographic, behavioral, and health risk factors. RESULTS The risk of decline in function in the overall sample was highest in participants with heart failure (35.4%, 95% confidence interval (CI) = 26.3-44.5) and lowest for those with atrial fibrillation (20.6%, 95% CI = 14.9-26.2). In the overall sample, none of the six guideline-recommended medications was associated with decline in physical function across the five study conditions, although in the group with low polypharmacy exposure, there was lower risk of decline in those with heart failure taking renin angiotensin system blockers (hazard ratio (HR) = 0.40, 95% CI = 0.16-0.99) and greater risk of decline in physical function for participants with diabetes mellitus taking statins (HR = 2.27, 95% CI = 1.39-3.69). CONCLUSIONS In older adults with multiple chronic conditions, guideline-recommended medications for atrial fibrillation, coronary artery disease, depression, diabetes mellitus, and heart failure were largely not associated with self-reported decline in physical function, although there were associations for some medications in those with less polypharmacy.
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Affiliation(s)
- Gail McAvay
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Heather G Allore
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut.,Department of Biostatistics, School of Public Health, Yale University, New Haven, Connecticut
| | - Andrew B Cohen
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Danijela Gnjidic
- Faculty of Pharmacy and Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Terrence E Murphy
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut.,Department of Biostatistics, School of Public Health, Yale University, New Haven, Connecticut
| | - Mary E Tinetti
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
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Abstract
OBJECTIVES To determine how do-not-hospitalize (DNH) orders are interpreted and used in nursing homes (NHs) once they are in place. DESIGN Qualitative study using in-depth semi-structured interviews performed from December 2013 to April 2014. SETTING Eight skilled nursing facilities in Connecticut that ranked in the top 10% or bottom 10% in hospitalization rates from 2008 to 2010. PARTICIPANTS Nursing facility staff members (N = 31). MEASUREMENTS A multidisciplinary team performed qualitative content analysis. The constant comparative method was used to develop a coding structure and identify themes. RESULTS DNH orders were uncommon at low- and high-hospitalizing facilities. Participants reported that they did not interpret these orders literally. A DNH order was not a prohibition against hospitalization but was understood to have a variety of exceptions. These orders functioned primarily as a signal that hospitalization should be questioned and discussed with the family when an acute event occurred. CONCLUSION In-the-moment discussions about hospitalization are still necessary even when a DNH order is in place. Work to reduce potentially burdensome NH-hospital transfers needs to focus not just on eliciting preferences in advance, but also on preparing residents and their families to make the best decisions about hospitalization when the time comes.
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Affiliation(s)
- Andrew B Cohen
- Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - M Tish Knobf
- Division of Acute Care/Health Systems, Yale School of Nursing, Yale University, New Haven, Connecticut
| | - Terri R Fried
- Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut.,Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
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31
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Affiliation(s)
- Andrew B Cohen
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - M Tish Knobf
- Division of Acute Care/Health Systems, Yale School of Nursing, New Haven, Connecticut
| | - Terri R Fried
- Clinical Epidemiology Research Center, VA Connecticut Health System, West Haven
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32
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Locklear MN, Cohen AB, Jone A, Kritzer MF. Sex Differences Distinguish Intracortical Glutamate Receptor-Mediated Regulation of Extracellular Dopamine Levels in the Prefrontal Cortex of Adult Rats. Cereb Cortex 2016; 26:599-610. [PMID: 25260707 PMCID: PMC4712796 DOI: 10.1093/cercor/bhu222] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Executive functions of the prefrontal cortex (PFC) are sensitive to local dopamine (DA) levels. Although sex differences distinguish these functions and their dysfunction in disease, the basis for this is unknown. We asked whether sex differences might result from dimorphisms in the glutamatergic mechanisms that regulate PFC DA levels. Using antagonists selective for α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) and N-methyl-d-aspartate (NMDA) receptors, we compared drug effects on in vivo microdialysis DA measurements in the PFC of adult male and female rats. We found that baseline DA levels were similar across sex, AMPA antagonism decreased PFC DA in both sexes, and NMDA antagonism increased DA in males but decreased DA in females. We also found that, at subseizure-producing drug levels, γ-aminobutyric acid (GABA)-A antagonism did not affect DA in either sex but that GABA-B antagonism transiently increased PFC DA in both sexes, albeit more so in females. Finally, when NMDA antagonism was coincident with GABA-B antagonism, PFC DA levels in males responded as if to GABA-B antagonism alone, whereas in females, DA effects mirrored those induced by NMDA antagonism. Taken together, these data suggest commonalities and fundamental differences in the intracortical amino acid transmitter mechanisms that regulate DA homeostasis in the male and female rat PFCs.
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Affiliation(s)
- M N Locklear
- Graduate Program in Neuroscience Department of Neurobiology and Behavior, Stony Brook University, Stony Brook, NY 11794-5230, USA
| | - A B Cohen
- Department of Neurobiology and Behavior, Stony Brook University, Stony Brook, NY 11794-5230, USA
| | - A Jone
- Graduate Program in Neuroscience Department of Neurobiology and Behavior, Stony Brook University, Stony Brook, NY 11794-5230, USA
| | - M F Kritzer
- Department of Neurobiology and Behavior, Stony Brook University, Stony Brook, NY 11794-5230, USA
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33
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Allore HG, Zhan Y, Cohen AB, Tinetti ME, Trentalange M, McAvay G. Methodology to Estimate the Longitudinal Average Attributable Fraction of Guideline-recommended Medications for Death in Older Adults With Multiple Chronic Conditions. J Gerontol A Biol Sci Med Sci 2016; 71:1113-6. [PMID: 26748093 DOI: 10.1093/gerona/glv223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 11/30/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Persons with multiple chronic conditions receive multiple guideline-recommended medications to improve outcomes such as mortality. Our objective was to estimate the longitudinal average attributable fraction for 3-year survival of medications for cardiovascular conditions in persons with multiple chronic conditions and to determine whether heterogeneity occurred by age. METHODS Medicare Current Beneficiary Survey participants (N = 8,578) with two or more chronic conditions, enrolled from 2005 to 2009 with follow-up through 2011, were analyzed. We calculated the longitudinal extension of the average attributable fraction for oral medications (beta blockers, renin-angiotensin system blockers, and thiazide diuretics) indicated for cardiovascular conditions (atrial fibrillation, coronary artery disease, heart failure, and hypertension), on survival adjusted for 18 participant characteristics. Models stratified by age (≤80 and >80 years) were analyzed to determine heterogeneity of both cardiovascular conditions and medications. RESULTS Heart failure had the greatest average attributable fraction (39%) for mortality. The fractional contributions of beta blockers, renin-angiotensin system blockers, and thiazides to improve survival were 10.4%, 9.3%, and 7.2% respectively. In age-stratified models, of these medications thiazides had a significant contribution to survival only for those aged 80 years or younger. The effects of the remaining medications were similar in both age strata. CONCLUSIONS Most cardiovascular medications were attributed independently to survival. The two cardiovascular conditions contributing independently to death were heart failure and atrial fibrillation. The medication effects were similar by age except for thiazides that had a significant contribution to survival in persons younger than 80 years.
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Affiliation(s)
- Heather G Allore
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut. Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut.
| | - Yilei Zhan
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut. Department of Statistics and Biostatistics, Rutgers University, New Brunswick, New Jersey
| | - Andrew B Cohen
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Mary E Tinetti
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Mark Trentalange
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Gail McAvay
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
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Tinetti ME, McAvay G, Trentalange M, Cohen AB, Allore HG. Association between guideline recommended drugs and death in older adults with multiple chronic conditions: population based cohort study. BMJ 2015; 351:h4984. [PMID: 26432468 PMCID: PMC4591503 DOI: 10.1136/bmj.h4984] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To estimate the association between guideline recommended drugs and death in older adults with multiple chronic conditions. DESIGN Population based cohort study. SETTING Medicare Current Beneficiary Survey cohort, a nationally representative sample of Americans aged 65 years or more. PARTICIPANTS 8578 older adults with two or more study chronic conditions (atrial fibrillation, coronary artery disease, chronic kidney disease, depression, diabetes, heart failure, hyperlipidemia, hypertension, and thromboembolic disease), followed through 2011. EXPOSURES Drugs included β blockers, calcium channel blockers, clopidogrel, metformin, renin-angiotensin system (RAS) blockers; selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs); statins; thiazides; and warfarin. MAIN OUTCOME MEASURE Adjusted hazard ratios for death among participants with a condition and taking a guideline recommended drug relative to participants with the condition not taking the drug and among participants with the most common combinations of four conditions. RESULTS Over 50% of participants with each condition received the recommended drugs regardless of coexisting conditions; 1287/8578 (15%) participants died during the three years of follow-up. Among cardiovascular drugs, β blockers, calcium channel blockers, RAS blockers, and statins were associated with reduced mortality for indicated conditions. For example, the adjusted hazard ratio for β blockers was 0.59 (95% confidence interval 0.48 to 0.72) for people with atrial fibrillation and 0.68 (0.57 to 0.81) for those with heart failure. The adjusted hazard ratios for cardiovascular drugs were similar to those with common combinations of four coexisting conditions, with trends toward variable effects for β blockers. None of clopidogrel, metformin, or SSRIs/SNRIs was associated with reduced mortality. Warfarin was associated with a reduced risk of death among those with atrial fibrillation (adjusted hazard ratio 0.69, 95% confidence interval 0.56 to 0.85) and thromboembolic disease (0.44, 0.30 to 0.62). Attenuation in the association with reduced risk of death was found with warfarin in participants with some combinations of coexisting conditions. CONCLUSIONS Average effects on survival, particularly for cardiovascular study drugs, were comparable to those reported in randomized controlled trials but varied for some drugs according to coexisting conditions. Determining treatment effects in combinations of conditions may guide prescribing in people with multiple chronic conditions.
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Affiliation(s)
- Mary E Tinetti
- Department of Internal Medicine (Geriatrics), Yale School of Medicine, New Haven, CT 06520, USA
| | - Gail McAvay
- Section of Geriatrics, Yale School of Medicine, New Haven, CT, USA
| | - Mark Trentalange
- Section of Geriatrics, Yale School of Medicine, New Haven, CT, USA
| | - Andrew B Cohen
- Section of Geriatrics, Yale School of Medicine, New Haven, CT, USA
| | - Heather G Allore
- Section of Geriatrics, Yale School of Medicine, New Haven, CT, USA
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35
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Abstract
As the population ages, more adults will develop impaired decision-making capacity and have no family members or friends available to make medical decisions on their behalf. In such situations, a professional guardian is often appointed by the court. This official has no preexisting relationship with the impaired individual but is paid to serve as a surrogate decision maker. When a professional guardian is faced with decisions concerning life-sustaining treatment, substituted judgment may be impossible, and reports have repeatedly suggested that guardians are reluctant to make the decision to limit care. Physicians are well positioned to assist guardians with these decisions and safeguard the rights of the vulnerable persons they represent. Doing so effectively requires knowledge of the laws governing end-of-life decisions by guardians. However, physicians are often uncertain about whether guardians are empowered to withhold treatment and when their decisions require judicial review. To address this issue, we analyzed state guardianship statutes and reviewed recent legal cases to characterize the authority of a guardian over choices about end-of-life treatment. We found that most state guardianship statutes have no language about end-of-life decisions. We identified 5 legal cases during the past decade that addressed a guardian's authority over these decisions, and only 1 case provided a broad framework applicable to clinical practice. Work to improve end-of-life decision making by guardians may benefit from a multidisciplinary effort to develop comprehensive standards to guide clinicians and guardians when treatment decisions need to be made.
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Affiliation(s)
- Andrew B Cohen
- Section of Geriatrics, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Leo Cooney
- Section of Geriatrics, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Terri Fried
- Section of Geriatrics, Department of Medicine, Yale School of Medicine, New Haven, Connecticut3Clinical Epidemiology Research Center, Veterans Affairs Connecticut Health System, West Haven
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36
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Cohen AB, Trentalange M, Fried T. Surrogate Decision Making for Patients Without Nuclear Family. JAMA 2015. [PMID: 26219065 DOI: 10.1001/jama.2015.7253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Andrew B Cohen
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Mark Trentalange
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Terri Fried
- VA Connecticut Health System, West Haven, Connecticut
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37
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Affiliation(s)
- Andrew B. Cohen
- Department of Medicine, Yale School of Medicine, New Haven, CT
| | | | - Terri Fried
- VA Connecticut Health System, West Haven, CT
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38
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Cohen AB. Nascher's Geriatrics at 100. J Am Geriatr Soc 2014; 62:2428-9. [PMID: 25516038 DOI: 10.1111/jgs.13155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Ignatz Nascher's Geriatrics—the first American medical textbook on aging—turns 100 this year. This essay is a reappraisal, on its centennial, of Nascher's landmark work.
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Affiliation(s)
- Andrew B Cohen
- Section of Geriatrics, School of Medicine, Yale University, New Haven, Connecticut
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39
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Abstract
The patient's apartment is full of books. A whole shelf is devoted to Virginia Woolf. I ask which novel she likes the best and am surprised when she says The Waves, a lyrical book of sensation and consciousness, with hardly a narrative at all. This, I think, is the way to live at ninety-five. She tells me she wants to die. She can see how things are likely to go. She will fall one morning, and paramedics will be summoned to pick her up. Caregivers will be invited into her home. The pain in her knees and back will worsen. Disability is coming, it cannot be avoided, she says, and it would be better if her life were now simply to cease. I struggle to find a name for this state of thinking. A senior geriatrician in my department tells me that she sees elderly patients like mine all the time. What word does she use for these men and women, I ask?
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40
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Cohen AB. Medicare and the 3-day rule. J Am Geriatr Soc 2013; 61:2266-2267. [PMID: 24329847 DOI: 10.1111/jgs.12579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Andrew B Cohen
- Section of Geriatrics, School of Medicine, Yale University, New Haven, Connecticut
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Gauld R, Burgers J, Dobrow M, Luxford K, Minhas R, Wendt C, Cohen AB. Quality improvement, information technology and primary care can improve healthcare system performance. But are policy makers promoting them? Int J Clin Pract 2012; 66:827-33. [PMID: 22897459 DOI: 10.1111/j.1742-1241.2012.02989.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- R Gauld
- Centre for Health Systems, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand.
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42
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Klein JP, Arora A, Neema M, Healy BC, Tauhid S, Goldberg-Zimring D, Chavarro-Nieto C, Stankiewicz JM, Cohen AB, Buckle GJ, Houtchens MK, Ceccarelli A, Dell'Oglio E, Guttmann CRG, Alsop DC, Hackney DB, Bakshi R. A 3T MR imaging investigation of the topography of whole spinal cord atrophy in multiple sclerosis. AJNR Am J Neuroradiol 2011; 32:1138-42. [PMID: 21527570 DOI: 10.3174/ajnr.a2459] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Spinal cord atrophy is a common feature of MS. However, it is unknown which cord levels are most susceptible to atrophy. We performed whole cord imaging to identify the levels most susceptible to atrophy in patients with MS versus controls and also tested for differences among MS clinical phenotypes. MATERIALS AND METHODS Thirty-five patients with MS (2 with CIS, 27 with RRMS, 2 with SPMS, and 4 with PPMS phenotypes) and 27 healthy controls underwent whole cord 3T MR imaging. The spinal cord contour was segmented and assigned to bins representing each C1 to T12 vertebral level. Volumes were normalized, and group comparisons were age-adjusted. RESULTS There was a trend toward decreased spinal cord volume at the upper cervical levels in PPMS/SPMS versus controls. A trend toward increased spinal cord volume throughout the cervical and thoracic cord in RRMS/CIS versus controls reached statistical significance at the T10 vertebral level. A statistically significant decrease was found in spinal cord volume at the upper cervical levels in PPMS/SPMS versus RRMS/CIS. CONCLUSIONS Opposing pathologic factors impact spinal cord volume measures in MS. Patients with PPMS demonstrated a trend toward upper cervical cord atrophy. However patients with RRMS showed a trend toward increased volume at the cervical and thoracic levels, which most likely reflects inflammation or edema-related cord expansion. With the disease causing both expansion and contraction of the cord, the specificity of spinal cord volume measures for neuroprotective therapeutic effect may be limited.
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Affiliation(s)
- J P Klein
- Laboratory for Neuroimaging Research, Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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43
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Abstract
Historians of medicine generally credit the hospital standardization movement of the early 20th century with establishing the record as a sign of hospital and staff quality. The medical record's role had already been the subject of intense interest at the New York Hospital several decades before, however. In the 1880s malpractice and insurance concerns caused the administration to attempt to supervise record creation, quality, and access, over the objections of physicians. Contemporary concerns about the uses of the medical record were in play well before 1910.
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44
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Abstract
It is widely assumed that body image dissatisfaction is increasing, particularly in females. We examined data from comparable samples, University of Pennsylvania introductory psychology students, over a span of about 15 years (1983-1984 versus 1995-1998). Ratings of current and ideal body figure were obtained using silhouettes, along with self-reported height and weight. While males always had a much smaller discrepancy between current and ideal than females, levels of dissatisfaction and gender differences in satisfaction have remained the same in these samples. This finding contrasts with the conclusion of a meta-analysis by Feingold and Mazzella in 1998 (Psychological Science 9 (3), 190-195), which indicates an increased difference in body image satisfaction between men and women over the last two decades. Possible accounts for this difference in results are discussed.
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Affiliation(s)
- P Rozin
- Department of Psychology, University of Pennsylvania, Philadelphia, PA 19104-6196, USA.
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45
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Cohen AB, Rozin P. Religion and the morality of mentality. J Pers Soc Psychol 2001; 81:697-710. [PMID: 11642355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Christian doctrine considers mental states important in judging a person's moral status, whereas Jewish doctrine considers them less important. The authors provide evidence from 4 studies that American Jews and Protestants differ in the moral import they attribute to mental states (honoring one's parents, thinking about having a sexual affair, and thinking about harming an animal). Although Protestants and Jews rated the moral status of the actions equally. Protestants rated a target person with inappropriate mental states more negatively than did Jews. These differences in moral judgment were partially mediated by Protestants' beliefs that mental states are controllable and likely to lead to action and were strongly related to agreement with general statements claiming that thoughts are morally relevant. These religious differences were not related to differences in collectivistic (interdependent) and individualistic (independent) tendencies.
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Affiliation(s)
- A B Cohen
- Solomon Asch Center for Study of Ethnopolitical Conflict and Department of Psychology, University of Pennsylvania, USA.
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46
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Abstract
Using a habituation-discrimination paradigm, the authors investigated what cues male golden hamsters (Mesocricetus auratus) use to determine the top and bottom positions in flank gland over-marks. A difference in the ages of 2 hamsters' marks did not, by itself, produce differential memory or evaluation of the 2 scents. A spatial configuration of marks suggestive of an overlap was sufficient for the apparently overlapping scent to be remembered or valued more than the apparently underlying scent. Cues from the overlap of 2 hamsters' marks were also sufficient. These results, consistent with those previously found for responses to hamster vaginal scent over-marks, suggest that hamsters use similar cues to analyze scent over-marks that are different in chemical composition and in social functions.
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Affiliation(s)
- A B Cohen
- Department of Psychology, Cornell University, USA
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48
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Hayashi S, Kurdowska A, Cohen AB, Stevens MD, Fujisawa N, Miller EJ. A synthetic peptide inhibitor for alpha-chemokines inhibits the growth of melanoma cell lines. J Clin Invest 1997; 99:2581-7. [PMID: 9169487 PMCID: PMC508103 DOI: 10.1172/jci119446] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Melanoma growth stimulatory activity (MGSA/GROalpha) is a 73 amino acid peptide sharing sequence characteristics with the alpha-chemokine superfamily. MGSA/GROalpha is produced by diverse melanoma cell lines and reported to act as an autocrine growth factor for the cells. We tested the binding of MGSA/GROalpha to melanoma cell lines, Hs 294T and RPMI7951, and found that these cells could bind to MGSA/GROalpha but not to interleukin-8. Recently, we defined a novel hexapeptide, antileukinate, which is a potent inhibitor of binding of alpha-chemokines to their receptors on neutrophils. When antileukinate was added to melanoma cells, it inhibited the binding of MGSA/ GROalpha. The growth of cells from both melanoma cell lines was suppressed completely in the presence of 100 microM peptide. The cell growth inhibition was reversed by the removal of the peptide from the culture media or by the addition of the excess amount of MGSA/GROalpha. The viability of Hs 294T cells in the presence of 100 microM peptide was > 92%. These findings suggest that MGSA/GROalpha is an essential autostimulatory growth factor for melanoma cells and antileukinate inhibits their growth by preventing MGSA/GROalpha from binding to its receptors.
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Affiliation(s)
- S Hayashi
- Department of Biochemistry, University of Texas Health Center at Tyler, Tyler, Texas 75710, USA
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Turino GM, Barker AF, Brantly ML, Cohen AB, Connelly RP, Crystal RG, Eden E, Schluchter MD, Stoller JK. Clinical features of individuals with PI*SZ phenotype of alpha 1-antitrypsin deficiency. alpha 1-Antitrypsin Deficiency Registry Study Group. Am J Respir Crit Care Med 1996; 154:1718-25. [PMID: 8970361 DOI: 10.1164/ajrccm.154.6.8970361] [Citation(s) in RCA: 131] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
This report describes the clinical characteristics of a group of 59 individuals with the PI*SZ phenotype and alpha 1-antitrypsin (alpha 1-AT) deficiency, identified during recruitment of a registry for subjects with severe alpha 1-antitrypsin deficiency. Currently, 1,129 individuals with levels of alpha 1-AT of 11 microM or below have been enrolled in this registry. Individuals with the SZ phenotype whose alpha 1-AT levels are at or below 11 microM will be followed in the registry; those whose levels exceeded 11 microM had baseline studies and are included in this report. Baseline pulmonary function tests included spirometry before and after an inhaled bronchodilator, diffusing capacity for carbon monoxide (DLCO), and chest roentgenograms. Among nonsmokers, subjects with the SZ phenotype demonstrated airflow obstruction less frequently than those with with the ZZ phenotype. Among ex- and current smokers, the frequency and severity of airflow obstruction was similar between SZ and ZZ subjects. Individuals with the SZ phenotype reported respiratory symptoms less frequently than did ZZ subjects. Overall, airflow obstruction was less common and milder among PI*SZ than PI*ZZ subjects. Cigarette smoking correlated more strongly with airflow obstruction among PI*SZ than PI*ZZ subjects. These observations indicate that in smokers, the PI*SZ phenotype confers a significant risk of the development of chronic obstructive pulmonary disease (COPD). Of itself, except in rare instances in nonsmoking individuals, the PI*SZ phenotype may confer little or no added risk of developing COPD.
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Affiliation(s)
- G M Turino
- Department of Medicine, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians & Surgeons, New York, NY 10019, USA
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Kurdowska A, Miller EJ, Noble JM, Baughman RP, Matthay MA, Brelsford WG, Cohen AB. Anti-IL-8 autoantibodies in alveolar fluid from patients with the adult respiratory distress syndrome. J Immunol 1996; 157:2699-706. [PMID: 8805676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IL-8 is a potent neutrophil attractant and activator. IL-8 has been reported to be involved in the pathogenesis of several diseases, including rheumatoid arthritis, sepsis, psoriasis, and the adult respiratory distress syndrome (ARDS). Our previous studies demonstrated that high concentrations of IL-8 were present in alveolar fluids from patients with ARDS and were associated with increased mortality. In this study we report that a major portion of IL-8 in bronchoalveolar fluids from patients with ARDS is associated with anti-IL-8 autoantibody (anti-IL-8:IL-8 complexes). Free autoantibodies that recognize IL-8 were also detected in these fluids. Next, we examined the properties of anti-IL-8 autoantibodies present in lung fluids from ARDS patients and compared them with autoantibodies from normal plasma and arthritic synovial fluids. The anti-IL-8 autoantibody was polyclonal, and IgG3 and IgG4 were the primary IgG subclasses. Anti-IL-8:IL-8 complexes consisted of one IgG and one IL-8 molecule. In addition, anti-IL-8 autoantibody bound IL-8 with a high affinity (approximately 10(-12) M) and inhibited IL-8 interaction with its specific receptors on neutrophils. The results suggest that anti-IL-8 autoantibodies may regulate IL-8 activity.
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Affiliation(s)
- A Kurdowska
- Department of Biochemistry, University of Texas Health Center, Tyler 75710, USA
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