Associations of Social Support With Physical and Mental Health Symptom Burden After COVID-19 Hospitalization Among Older Adults

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.

Rationale, Design, and Characteristics of the VALIANT (COVID-19 in Older Adults: A Longitudinal Assessment) Cohort

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.

The Contribution of Chronic Conditions to Hospitalization, Skilled Nursing Facility Admission, and Death: Variation by Race

Multimorbidity (≥2 chronic conditions) is a common and important marker of aging. To better understand racial differences in multimorbidity burden and associations with important health-related outcomes, we assessed differences in the contribution of chronic conditions to hospitalization, skilled nursing facility admission, and mortality among non-Hispanic Black and non-Hispanic White older adults in the United States. We used data from a nationally representative study, the National Health and Aging Trends Study, linked to Medicare claims from 2011-2015 (n = 4,871 respondents). This analysis improved upon prior research by identifying the absolute contributions of chronic conditions using a longitudinal extension of the average attributable fraction for Black and White Medicare beneficiaries. We found that cardiovascular conditions were the greatest contributors to outcomes among White respondents, while the greatest contributor to outcomes for Black respondents was renal morbidity. This study provides important insights into racial differences in the contributions of chronic conditions to costly health-care utilization and mortality, and it prompts policy-makers to champion delivery reforms that will expand access to preventive and ongoing care for diverse Medicare beneficiaries.

Patterns of Caregiving Among Older Adults With and Without Dementia: A Latent Class Analysis

OBJECTIVES

We identify common patterns of caregiving or "care types" among older adults with and without dementia. Prior research has focused on primary caregivers and on the independent effects of individual caregiving attributes. We examine multiple caregivers of older adults, including the primary caregiver, and how multiple caregiving attributes co-occur to shape caregiving types.

METHODS

We link 2015 care recipient (N = 1,423) and unpaid caregiver data (N = 2,146) from the National Health and Aging Trends Study and the National Study of Caregiving. Latent class analysis of caregiving attributes, representing care intensity and regularity, and various care activities, was used to construct care types. Multinomial logistic regression was used to examine if the recipients' dementia status and caregivers' background characteristics predicted membership in care types.

RESULTS

Five distinguishable care types were identified. Caregivers who were female, adult children, or coresidents, those caring for persons with dementia, and those who had paid help had higher odds of being in the more demanding care types. Conversely, older, White caregivers and those with support for their caregiving activities were less likely to be in a demanding care type.

DISCUSSION

Care types can help us understand sources of heterogeneity in caregiving and effectively target caregiver support services and interventions.

The geriatrics research instrument library: A resource for guiding instrument selection for researchers studying older adults with multiple chronic conditions

Background

After the passage of the 21st Century Cures Act in the U.S., the Inclusion Across the Lifespan policy eliminates upper-age limits for research participation unless risk justified. Broader inclusion will necessitate the use of reliable instruments in research that characterize the health status and function of older adults with multiple chronic conditions. As there is a plethora of such instruments, the Geriatrics Research Instrument Library (GRIL) was developed as freely available online resource of data collection instruments commonly used in gerontological research. GRIL has been revised and updated by the Advancing Geriatrics Infrastructure and Network Growth (AGING) Initiative, a joint endeavor of the Health Care Systems Research Network (HCSRN) and the Older Americans Independence Centers (OAICs).

Methods

Extensive PubMed literature searches and domain expert feedback were utilized to inventory and update GRIL through the addition of instruments and compiling of instrument metadata. GRIL is hosted on the National Institute on Aging OAIC Coordinating Center website with a platform utilizing Microsoft Structured Query Language (SQL) and an Adobe ColdFusion application server. Tracking statistics are collected using Google Analytics.

Results

Presently, GRIL includes 175 instruments across 18 domains, including instrument metadata such as instrument description, copyright information, completion time estimates, keywords, available translations, and a link and reference to the original manuscript describing the instrument. The GRIL website includes user-friendly features such as mobile platforming and resource links.

Conclusions

GRIL provides a user-friendly public resource that facilitates clinical researchers in efficiently selecting appropriate instruments to measure clinical outcomes relevant to older adults across a full range of domains.

Individual Heterogeneity in the Probability of Hospitalization, Skilled Nursing Facility Admission, and Mortality

BACKGROUND

Multimorbidity is common in adults aged 65 and older and is associated with health care utilization and mortality, but most methods ignore the interrelationship among concurrent outcome nor provide person-specific probabilities.

METHOD

A longitudinal cohort of 5300 older Americans from the 2011-2015 rounds of the National Health and Aging Study was linked to Center for Medicare and Medicaid Services claims. Odds ratios for 15 chronic conditions adjusted for sociodemographic factors were estimated using a joint model of hospitalization, skilled nursing facility (SNF) admission, and mortality. Additionally, we estimated the person-specific probability of an outcome while currently at risk for other outcomes for different chronic disease combinations demonstrating the heterogeneity across persons with identical chronic conditions.

RESULTS

During the 4-year follow-up period, 2867 (54.1%) individuals were hospitalized, 1029 (19.4%) were admitted to a SNF, and 1237 (23.3%) died. Chronic kidney disease, dementia, heart failure, and chronic obstructive pulmonary disease had significant increased odds for all 3 outcomes. By incorporating a person-specific random intercept, there was considerable range of person-specific probabilities for individuals with hypertension, diabetes, and depression with dementia, (hospitalization: 0.14-0.61; SNF admission: 0.04-0.28) and without dementia (hospitalization: 0.07-0.44; SNF admission: 0.02-0.15). Such heterogeneity was found among individuals with heart failure, ischemic heart disease, chronic kidney disease, hypertension, hyperlipidemia, and osteoarthritis with and without Medicare.

CONCLUSIONS

This approach of joint modeling of interrelated concurrent health care and mortality outcomes not only provides a cohort-level odds and probabilities but addresses the heterogeneity among otherwise similarly characterized persons identifying those with above-average probability of poor outcomes.

Diffusing capacity in normal-for-age spirometry and spirometric impairments, using reference equations from the global lung function initiative

BACKGROUND

Reference equations from the Global Lung Function Initiative (GLI) are now available for both spirometry and diffusion. However, respiratory phenotypes defined by GLI-based measures of diffusion have not yet been evaluated in GLI-based normal-for-age spirometry or spirometric impairments.

METHODS

We evaluated cross-sectional data from 2100 Caucasians, aged 40-85 years. GLI-based spirometric categories included normal-for-age and the impairments of restrictive-pattern and three-level severity of airflow-obstruction (mild, moderate, severe). GLI-based diffusion included diffusing capacity of the lung for carbon monoxide (D_LCO) and measured components of alveolar volume (V_A) and transfer coefficient (K_CO): D_LCO = [V_A]x[K_CO]. Using multivariable regression models, adjusted odds ratios (adjORs) for D_LCO, V_A, and K_CO < lower limit of normal (LLN) were calculated for spirometric impairments, relative to normal-for-age spirometry.

RESULTS

Relative to normal-for-age spirometry, the restrictive-pattern increased the adjORs (95% confidence intervals) for D_LCO and V_A < LLN-4.61 (3.62, 5.85) and 15.53 (11.8, 20.4), respectively, but not for K_CO < LLN-1.02 (0.79, 1.33). Also relative to normal-for-age spirometry, airflow-obstruction from mild to severe increased the adjORs for D_LCO < LLN-from 1.22 (0.80, 1.86) to 6.63 (4.91, 8.95), for V_A < LLN-from 1.37 (0.85, 2.18) to 7.01 (5.20, 9.43), and for K_CO < LLN-from 2.04 (1.33, 3.14) to 3.03 (2.29, 3.99). Notably, in normal-for-age spirometry, 34.5%, 19.7%, and 25.3% of participants had D_LCO, V_A, or K_CO < LLN, respectively.

CONCLUSION

Abnormal diffusion is most prevalent in spirometric impairments but also occurs in normal-for-age spirometry. These results further inform the respiratory phenotypes of GLI-based spirometric categories and, in turn, the spirometric evaluation of respiratory disease.

Re-evaluation of the Uplift Clinical Trial Using Age-Appropriate Spirometric Criteria

BACKGROUND

The clinical trial of tiotropium in COPD, UPLIFT, enrolled adults with a mean age of 65 years and moderate-to-severe airflow obstruction, based on criteria from the Global Initiative for Chronic Obstructive Lung Disease (GOLD). For the UPLIFT cohort, however, GOLD-based criteria are not age-appropriate.

RESEARCH QUESTION

Will the use of more age-appropriate criteria for airflow obstruction from the Global Lung Function Initiative (GLI) modify the spirometric classification of the UPLIFT cohort and, in turn, the mortality effect of tiotropium in COPD?

STUDY DESIGN AND METHODS

Baseline spirometric classifications were first cross-tabulated by GLI- and GOLD-based criteria. Next, in GLI- and GOLD-based airflow obstruction, modified intention-to-treat analyses evaluated differences in time to death over 4 years, comparing tiotropium vs placebo. Because treatment response may differ by COPD severity, the mortality effect also was evaluated within stratum defined by GLI- and GOLD-based moderate and severe airflow obstruction.

RESULTS

Of 5,898 participants with GOLD-based airflow-obstruction, staged as moderate in 2,739 (46.4%) and severe in 3,156 (53.5%), GLI-based criteria established airflow obstruction in 5,750 (97.5%), staged as moderate in 795 (13.5%) and severe in 4,947 (83.9%). Relative to placebo, tiotropium yielded statistically nonsignificant adjusted hazard ratios (adjHRs) (95% CI) for death of 0.91 (0.80-1.04) and 0.91 (0.79-1.03) in GLI- and GOLD-based airflow obstruction, respectively. However, statistically significant effect modification was observed, but only in GLI-based moderate and severe airflow-obstruction, with tiotropium yielding adjHRs for death of 0.53 (0.34-0.81) and 0.99 (0.86-1.13), respectively. The P value for interaction was .007.

INTERPRETATION

Mortality reduction by tiotropium was only statistically significant in GLI-based moderate airflow-obstruction, a group that was underrepresented in UPLIFT because of severity misclassification by the original GOLD-based enrollment criteria.

FEV1 as a Standalone Spirometric Predictor and the Attributable Fraction for Death in Older Persons

BACKGROUND

Commonly used thresholds for staging FEV₁ have not been evaluated as standalone spirometric predictors of death in older persons. Specifically, the proportion of deaths attributed to a reduced FEV₁, when staged by commonly used thresholds in L, percent of predicted (% pred), and Z scores, has not been previously reported.

METHODS

In 4,232 white persons ≥ 65 y old, sampled from the Cardiovascular Health Study, FEV₁ was stratified as stage 1 (FEV₁ ≥ 2.00 L, ≥80% pred, and Z score ≥-1.64), stage 2 (FEV₁ 1.50-1.99 L, 50-79%pred, and Z score -2.55 to -1.63), and stage 3 (FEV₁ < 1.50 L, < 50% pred, and Z score < -2.55). Notably, a Z score threshold of -1.64 defines normal-for-age lung function as the lower limit of normal (ie, 5th percentile of distribution), and accounts for differences in age, sex, height, and ethnicity. Next, adjusted odds ratios and average attributable fractions for 10-y all-cause mortality were calculated, comparing FEV₁ stages 2 and 3 against stage 1, expressed in L, % pred, and Z scores. The average attributable fraction estimates the proportion of deaths attributed to a predictor by combining the prevalence of the predictor with the relative risk of death conferred by that predictor.

RESULTS

FEV₁ stage 2 and 3 in L, % pred, and Z scores yielded similar adjusted odds ratios of death: 1.40-1.51 for stage 2 and 2.35-2.66 for stage 3. Conversely, FEV₁ stages 2 and 3 in L, % pred, and Z scores differed in prevalence: 12.8-28.6% for stage 2 and 6.4-17.5% for stage 3, and also differed in the adjusted average attributable fraction for death: 3.2-6.4% for stage 2 and 4.5-9.1% for stage 3.

CONCLUSIONS

In older persons, the proportion of deaths attributed to a reduced FEV₁ is best stratified by Z score staging thresholds because these yield a similar relative risk of death but a more age- and sex-appropriate prevalence of FEV₁ stage.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Contributions of COPD, asthma, and ten comorbid conditions to health care utilization and patient-centered outcomes among US adults with obstructive airway disease

Background

Among persons with obstructive airway disease, the relative contributions of chronic obstructive pulmonary disease (COPD), asthma, and common comorbid conditions to health care utilization and patient-centered outcomes (PCOs) have not been previously reported.

Methods

We followed a total of 3,486 persons aged ≥40 years with COPD, asthma, or both at baseline, from the Medical Expenditure Panel Survey (MEPS) cohorts enrolled annually from 2008 through 2012 for 1 year. MEPS is a prospective observational study of US households recording self-reported COPD, asthma, and ten medical conditions: angina, arthritis, cancer, coronary heart disease, cognitive impairment, diabetes, hypertension, lung cancer, myocardial infarction, and stroke/transient ischemic attack. We studied the separate contributions of these conditions to health care utilization (all-cause and respiratory disease hospitalization, any emergency department [ED] visit, and six or more outpatient visits) and PCOs (seven or more days spent in bed due to illness, incident loss of mobility, and incident decline in self-perceived health).

Results

COPD made the largest contributions to all-cause and respiratory disease hospitalization and ED visits, while arthritis made the largest contribution to outpatient health care. Arthritis and COPD, respectively, made the greatest contributions to the PCOs.

Conclusion

COPD made the largest and second largest contributions to health care utilization and PCOs among US adults with obstructive airway disease. The twelve medical conditions collectively accounted for between 52% and 61% of the health care utilization outcomes and between 53% and 68% of the PCOs. Cognitive impairment, diabetes, hypertension, and stroke also made significant contributions.

Asthma-COPD overlap syndrome in the US: a prospective population-based analysis of patient-reported outcomes and health care utilization

Background

Prior work suggests that asthma–COPD overlap syndrome (ACOS) has a greater health burden than asthma alone or COPD alone. In the current study, we have further evaluated the health burden of ACOS in a nationally representative sample of the US population, focusing on patient-reported outcomes and health care utilization and on comparisons with asthma alone and COPD alone. Patient-reported outcomes are especially meaningful, as these include functional activities that are highly valued by patients and are the basis for patient-centered care.

Methods

Using data from the Medical Expenditure Panel Survey (MEPS), we evaluated patient-reported outcomes and health care utilization among participants who were aged 40–85 years and had self-reported, physician-diagnosed asthma or COPD. MEPS administered five rounds of interviews, at baseline and approximately every 6 months over 2.5 years. Patient-reported outcomes included activities of daily living (ADLs), mobility, social/recreational activities, disability days in bed, and health status (Short Form 12, Version 2). Health care utilization included outpatient and emergency department (ED) visits, and hospitalization.

Results

Of 3,486 participants with asthma or COPD, 1,585 (45.4%) had asthma alone, 1,294 (37.1%) had COPD alone, and 607 (17.4%) had ACOS. Relative to asthma alone, ACOS was significantly associated with higher odds of prevalent disability in ADLs and limitations in mobility and social/recreational activities (adjusted odds ratios [adjORs]: 1.91–3.98), as well as with higher odds of incident limitations in mobility and social/recreational activities, disability days in bed, and respiratory-based outpatient and ED visits, and hospitalization (adjORs: 1.86–2.35). In addition, ACOS had significantly worse physical and mental health scores than asthma alone (P-values <0.0001). Relative to COPD alone, ACOS was significantly associated with higher odds of prevalent limitations in mobility and social/recreational activities (adjORs: 1.68–2.06), as well as with higher odds of incident disability days in bed and respiratory-based outpatient and ED visits (adjORs: 1.48–1.74). In addition, ACOS had a significantly worse physical health score, but similar mental health score, as compared with COPD alone (P-values 0.0025 and 0.1578, respectively).

Conclusion

In the US, ACOS is associated with a greater health burden, including patient-reported outcomes and health care utilization, relative to asthma alone and COPD alone.

Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults

IMPORTANCE The effect of serious injuries, such as hip fracture and head injury, on mortality and function is comparable to that of cardiovascular events. Concerns have been raised about the risk of fall injuries in older adults taking antihypertensive medications. The low risk of fall injuries reported in clinical trials of healthy older adults may not reflect the risk in older adults with multiple chronic conditions. OBJECTIVE To determine whether antihypertensive medication use was associated with experiencing a serious fall injury in a nationally representative sample of older adults. DESIGN, PARTICIPANTS, AND SETTING Competing risk analysis as performed with propensity score adjustment and matching in the nationally representative Medicare Current Beneficiary Survey cohort during a 3-year follow-up through 2009. Participants included 4961 community-living adults older than 70 years with hypertension. EXPOSURES Antihypertensive medication intensity based on the standardized daily dose for each antihypertensive medication class that participants used. MAIN OUTCOMES AND MEASURES Serious fall injuries, including hip and other major fractures, traumatic brain injuries, and joint dislocations, ascertained through Centers for Medicare & Medicaid Services claims. RESULTS Of the 4961 participants, 14.1% received no antihypertensive medications; 54.6% were in the moderate-intensity and 31.3% in the high-intensity antihypertensive groups. During follow-up, 446 participants (9.0%) experienced serious fall injuries, and 837 (16.9%) died. The adjusted hazard ratios for serious fall injury were 1.40 (95% CI, 1.03-1.90) in the moderate-intensity and 1.28 (95% CI, 0.91-1.80) in the high-intensity antihypertensive groups compared with nonusers. Although the difference in adjusted hazard ratios across the groups did not reach statistical significance, results were similar in the propensity score-matched subcohort. Among 503 participants with a previous fall injury, the adjusted hazard ratios were 2.17 (95% CI, 0.98-4.80) for the moderate-intensity and 2.31 (95% CI, 1.01-5.29) for the high-intensity antihypertensive groups. CONCLUSIONS AND RELEVANCE Antihypertensive medications were associated with an increased risk of serious fall injuries, particularly among those with previous fall injuries. The potential harms vs benefits of antihypertensive medications should be weighed in deciding to continue treatment with antihypertensive medications in older adults with multiple chronic conditions.

Anti-hypertensive medications and cardiovascular events in older adults with multiple chronic conditions

IMPORTANCE

Randomized trials of anti-hypertensive treatment demonstrating reduced risk of cardiovascular events in older adults included participants with less comorbidity than clinical populations. Whether these results generalize to all older adults, most of whom have multiple chronic conditions, is uncertain.

OBJECTIVE

To determine the association between anti-hypertensive medications and CV events and mortality in a nationally representative population of older adults.

DESIGN

Competing risk analysis with propensity score adjustment and matching in the Medicare Current Beneficiary Survey cohort over three-year follow-up through 2010.

PARTICIPANTS AND SETTING

4,961 community-living participants with hypertension.

EXPOSURE

Anti-hypertensive medication intensity, based on standardized daily dose for each anti-hypertensive medication class participants used.

MAIN OUTCOMES AND MEASURES

Cardiovascular events (myocardial infarction, unstable angina, cardiac revascularization, stroke, and hospitalizations for heart failure) and mortality.

RESULTS

Of 4,961 participants, 14.1% received no anti-hypertensives; 54.6% received moderate, and 31.3% received high, anti-hypertensive intensity. During follow-up, 1,247 participants (25.1%) experienced cardiovascular events; 837 participants (16.9%) died. Of deaths, 430 (51.4%) occurred in participants who experienced cardiovascular events during follow-up. In the propensity score adjusted cohort, after adjusting for propensity score and other covariates, neither moderate (adjusted hazard ratio, 1.08 [95% CI, 0.89-1.32]) nor high (1.16 [0.94-1.43]) anti-hypertensive intensity was associated with experiencing cardiovascular events. The hazard ratio for death among all participants was 0.79 [0.65-0.97] in the moderate, and 0.72 [0.58-0.91] in the high intensity groups compared with those receiving no anti-hypertensives. Among participants who experienced cardiovascular events, the hazard ratio for death was 0.65 [0.48-0.87] and 0.58 [0.42-0.80] in the moderate and high intensity groups, respectively. Results were similar in the propensity score-matched subcohort.

CONCLUSIONS AND RELEVANCE

In this nationally representative cohort of older adults, anti-hypertensive treatment was associated with reduced mortality but not cardiovascular events. Whether RCT results generalize to older adults with multiple chronic conditions remains uncertain.

Effect of β-blockers on cardiac and pulmonary events and death in older adults with cardiovascular disease and chronic obstructive pulmonary disease

CONTEXT

In older adults with multiple conditions, medications may not impart the same benefits seen in patients who are younger or without multimorbidity. Furthermore, medications given for one condition may adversely affect other outcomes. β-Blocker use with coexisting cardiovascular disease (CVD) and chronic obstructive pulmonary disease (COPD) is such a situation.

OBJECTIVE

To determine the effect of β-blocker use on cardiac and pulmonary outcomes and mortality in older adults with coexisting COPD and CVD.

DESIGN, SETTING, PARTICIPANTS

The study included 1062 participants who were members of the 2004-2007 Medicare Current Beneficiary Survey cohorts, a nationally representative sample of Medicare beneficiaries. Study criteria included age over 65 years plus coexisting CVD and COPD/asthma. Follow-up occurred through 2009. We determined the association between β-blocker use and the outcomes with propensity score-adjusted and covariate-adjusted Cox proportional hazards.

MAIN OUTCOME MEASURES

The 3 outcomes were major cardiac events, pulmonary events, and all-cause mortality.

RESULTS

Half of the participants used β-blockers. During follow-up, 179 participants experienced a major cardiac event; 389 participants experienced a major pulmonary event; and 255 participants died. Each participant could have experienced any ≥1 of these events. The hazard ratio for β-blocker use was 1.18 [95% confidence interval (CI), 0.85-1.62] for cardiac events, 0.91 (95% CI, 0.73-1.12) for pulmonary events, and 0.87 (95% CI, 0.67-1.13) for death.

CONCLUSION

In this population of older adults, β-blockers did not seem to affect occurrence of cardiac or pulmonary events or death in those with CVD and COPD.

Effect of coexisting chronic obstructive pulmonary disease and cognitive impairment on health outcomes in older adults

OBJECTIVES

To determine the extent to which the co-occurrence of chronic obstructive pulmonary disease (COPD) and cognitive impairment affect adverse health outcomes in older adults.

DESIGN

Multicenter longitudinal cohort study.

SETTING

California, Pennsylvania, Maryland, and North Carolina.

PARTICIPANTS

Three thousand ninety-three community-dwelling adults aged 65 and older from the Cardiovascular Health Study. Four hundred thirty-one had chronic obstructive pulmonary disease (COPD) at study baseline.

MEASUREMENTS

Follow-up began at the second CHS visit and continued for 3 years. Spirometric criteria for airflow limitation served to establish COPD using the Lambda-Mu-Sigma method, which accounts for age-related changes in lung function. Cognitive impairment was evaluated using the modified Mini-Mental State Examination and claims data. Outcomes were respiratory-related and all-cause hospitalizations and death.

RESULTS

Participants with coexisting COPD and cognitive impairment had the highest rates of respiratory-related (adjusted hazard ratio (aHR) = 4.10, 95% confidence interval (CI) = 1.86-9.05) and all-cause hospitalizations (aHR = 1.34, 95% CI = 1.00-1.80) and death (aHR = 2.29, 95% CI = 1.18-4.45). In particular, individuals with both conditions had a 48% higher rate of all-cause hospitalizations (adjusted synergy index (aSI) = 1.48, 95% CI = 0.19-11.31) and a rate of death nearly three times as high (aSI = 2.74, 95% CI = 0.43-17.32) as the sum of risks for each respective outcome associated with having COPD or cognitive impairment alone. Nevertheless, tests for interaction were not statistically significant for the presence of synergism between the two conditions contributing to each of the outcomes. Therefore, it cannot be concluded that the combined effect of COPD and cognitive impairment is greater than additive.

CONCLUSION

Coexisting COPD and cognitive impairment have an additive effect on respiratory-related and all-cause hospitalizations and death. Optimizing outcomes in older adults with COPD and cognitive impairment will require that how to improve concurrent management of both conditions be determined.

Contribution of individual diseases to death in older adults with multiple diseases

OBJECTIVES

To determine empirically the diseases contributing most commonly and strongly to death in older adults, accounting for coexisting diseases.

DESIGN

Longitudinal.

SETTING

United States.

PARTICIPANTS

Twenty-two thousand eight hundred ninety Medicare Current Beneficiary Survey participants, a national representative sample of Medicare beneficiaries, enrolled during 2002 to 2006.

MEASUREMENTS

Information on chronic and acute diseases was ascertained from Medicare claims data. Diseases contributing to death during follow-up were identified empirically using regression models for all diseases with a frequency of 1% or greater and hazard ratio for death of greater than 1. The additive contributions of these diseases, adjusting for coexisting diseases, were calculated using a longitudinal extension of average attributable fraction; 95% confidence intervals were estimated from bootstrapping.

RESULTS

Fifteen diseases and acute events contributed significantly to death, together accounting for nearly 70% of death. Heart failure (20.0%), dementia (13.6%), chronic lower respiratory disease (12.4%), and pneumonia (5.3%) made the largest contributions to death. Cancer, including lung, colorectal, lymphoma, and head and neck, together contributed to 5.6% of death. Other diseases and events included acute kidney injury, stroke, septicemia, liver disease, myocardial infarction, and unintentional injuries.

CONCLUSION

The use of methods that focus on determining a single underlying cause may lead to underestimation of the extent of the contribution of some diseases such as dementia and respiratory disease to death in older adults and overestimation of the contribution of other diseases. Current conceptualization of a single underlying cause may not account adequately for the contribution to death of coexisting diseases that older adults experience.

Contribution of multiple chronic conditions to universal health outcomes

OBJECTIVES

To determine the relative effect of five chronic conditions on four representative universal health outcomes.

DESIGN

Cross-sectional.

SETTING

Cardiovascular Health Study.

PARTICIPANTS

Five thousand two hundred and ninety-eight community-living participants aged 65 and older.

MEASUREMENTS

Multiple regression and Cox models were used to determine the effect of heart failure (HF), chronic obstructive pulmonary disease (COPD), osteoarthritis, depression, and cognitive impairment on self-rated health, 12 basic and instrumental activities of daily living (ADLs and IADLs), six-item symptom burden scale, and death.

RESULTS

Each condition adversely affected self-rated health (P < .001) and ADLs and IADLs (P < .001). For example, persons with HF performed 0.70 ± 0.08 fewer ADLs and IADLs than those without; persons with depression and persons with cognitive impairment performed 0.59 ± 0.04 and 0.58 ± 0.06 fewer activities, respectively, than those without these conditions. Depression, HF, COPD, and osteoarthritis were associated with 1.18 ± 0.04, 0.40 ± 0.08, 0.40 ± 0.05, and 0.57 ± 0.03 more symptoms, respectively, in individuals with these conditions than in those without. HF (hazard ratio (HR) = 2.84, 95% confidence interval (CI) = 1.97-4.10), COPD (2.62, 95% CI = 1.94-3.53), cognitive impairment (2.05, 95% CI = 1.47-2.85), and depression (1.47, 95% CI = 1.08-2.01) were each associated with death within 2 years. Several paired combinations of conditions had synergistic effects on ADLs and IADLs. For example, individuals with HF plus depression performed 2.0 fewer activities than persons with neither condition, versus the 1.3 fewer activities expected from adding the effects of the two conditions together.

CONCLUSION

Universal health outcomes may provide a common metric for measuring the effects of multiple conditions and their treatments. The varying effects of the conditions across universal outcomes could inform care priorities.

Health outcome priorities among competing cardiovascular, fall injury, and medication-related symptom outcomes

OBJECTIVES

To determine the priority that older adults with coexisting hypertension and fall risk give to optimizing cardiovascular outcomes versus fall- and medication symptom-related outcomes.

DESIGN

Interview.

SETTING

Community.

PARTICIPANTS

One hundred twenty-three cognitively intact persons aged 70 and older with hypertension and fall risk.

MEASUREMENTS

Discrete choice task was used to elicit the relative importance placed on reducing the risk of three outcomes: cardiovascular events, serious fall injuries, and medication symptoms. Risk estimates with and without antihypertensive medications were obtained from the literature. Participants chose between 11 pairs of options that displayed lower risks for one or two outcomes and a higher risk for the other outcome(s), versus the reverse. Results were used to calculate relative importance scores for the three outcomes. These scores, which sum to 100, reflect the relative priority participants placed on the difference between the risk estimates of each outcome.

RESULTS

Sixty-two participants (50.4%) placed greater importance on reducing risk of cardiovascular events than reducing risk of the combination of fall injuries and medication symptoms; 61 participants did the converse. A lower percentage of participants with chronic obstructive pulmonary disease (P=.02), unsteadiness (P=.02), functional dependency (P=.04), lower cognition (P=.02) and depressive symptoms (P=.03) prioritized cardiovascular outcomes over fall injuries and medication symptoms than did participants without these characteristics.

CONCLUSION

Interindividual variability in the face of competing outcomes supports individualizing decision-making to individual priorities. In the current example, this may mean forgoing antihypertensive medications or compromising on blood pressure reduction for some individuals.

Development of a tool for eliciting patient priority from among competing cardiovascular disease, medication-symptoms, and fall injury outcomes

OBJECTIVES

To develop a choice task for eliciting priorities in the face of competing cardiovascular disease (CVD) outcomes, medication-related symptoms, and fall injuries.

DESIGN

Conjoint analysis.

SETTING

Senior housing site.

PARTICIPANTS

Convenience sample of 15 senior housing residents for the pretest, 13 residents for the pilot test.

MEASUREMENTS

The final task included 11 sets of choices. In each, one option optimized the risk of one or two of the three outcomes at the expense of the other(s); the second option did the reverse. Relative importance scores for CVD, fall injury, and medication-symptom outcomes were calculated. Reliability was assessed for two administrations using intraclass correlations (ICCs). Wilcoxon rank sum tests were used to evaluate order effects.

RESULTS

The ICCs between choice task administrations were 0.70 for fall injuries, 0.73 for medication symptoms, and 0.56 for CVD outcomes. The ICCs with removal of two outliers were 0.84, 0.72, and 0.84, respectively. Whether CVD or fall injuries appeared first had no effect on scores.

CONCLUSION

Preliminary evidence of comprehensibility and reliability supports using the choice task to determine whether individuals' priorities differ in the face of competing outcomes.

The impact of chronic illnesses on the use and effectiveness of adjuvant chemotherapy for colon cancer

BACKGROUND

It is unclear how noncancer conditions affect the use or effectiveness of adjuvant therapy among older patients with colon cancer.

METHODS

The authors conducted a cohort study of older patients with stage III colon cancer who were diagnosed from 1993 to 1999 in the Surveillance, Epidemiology, and End Results-Medicare database. The correlations between receipt of adjuvant chemotherapy and heart failure, diabetes, and chronic obstructive pulmonary disease (COPD) were assessed. Multivariable regression analysis was used to assess the risk of death and hospitalization as a function of treatment and comorbidity status.

RESULTS

The study sample consisted of 5330 patients (median age, 76 years). The use of adjuvant therapy was related significantly to heart failure (36.2% vs 64.9% of patients with vs without heart failure, respectively; adjusted odds ratio [OR], 0.49; 95% confidence interval [95% CI], 0.40-0.60). More moderate correlations were observed for COPD (OR, 0.83; 95% CI, 0.70-0.99) and diabetes (OR, 0.81; 95% CI, 0.68-0.97). Among patients who had heart failure, the 5-year survival was significantly higher among those who received adjuvant chemotherapy (adjusted 5-year survival rate, 43%; 95% CI, 40-47%) than among those who did not receive adjuvant chemotherapy (30%; 95% CI, 27-34%). Among patients without heart failure, the 5-year survival estimates among treated and untreated patients were 54% (95% CI, 52-56%) and 41% (95% CI, 38-44%), respectively. The probability of all-cause, condition-specific, or toxicity-related hospitalization associated with adjuvant therapy was not altered by the presence of any of the 3 conditions.

CONCLUSIONS

Although chronic conditions appeared to be a strong barrier to the receipt of adjuvant chemotherapy, adjuvant therapy appeared to provide a significant survival benefit to patients who had colon cancer with the conditions studied.

Depressive symptoms and the risk of incident delirium in older hospitalized adults

OBJECTIVES

To determine whether specific subsets of symptoms from the Geriatric Depression Scale (GDS), assessed at hospital admission, were associated with the incidence of delirium.

DESIGN

Secondary analysis of a prospective cohort study of patients from the Delirium Prevention Trial.

SETTING

General medicine service at Yale New Haven Hospital, March 25, 1995, through March 18, 1998.

PARTICIPANTS

Four hundred sixteen patients aged 70 and older who were at intermediate or high risk for delirium and were not taking antidepressants at hospital admission.

MEASUREMENTS

Depressive symptoms were assessed GDS, and daily assessments of delirium were obtained using the Confusion Assessment Method.

RESULTS

Of the 416 patients in the analysis sample, 36 (8.6%) developed delirium within the first 5 days of hospitalization. Patients who developed delirium reported 5.7 depressive symptoms on average, whereas patients without delirium reported an average of 4.2 symptoms. Using a Cox proportional hazards model, it was found that depressive symptoms assessing dysphoric mood and hopelessness were predictive of incident delirium, controlling for measures of physical and mental health. In contrast, symptoms of withdrawal, apathy, and vigor were not significantly associated with delirium.

CONCLUSION

These findings suggest that assessing symptoms of dysphoric mood and hopelessness could help identify patients at risk for incident delirium. Future studies should evaluate whether nonpharmacological treatment for these symptoms reduces the risk of delirium.

Multimorbidity and survival in older persons with colorectal cancer

OBJECTIVES

To ascertain the effect of common chronic conditions on mortality in older persons with colorectal cancer.

DESIGN

Retrospective cohort study.

SETTING

Population-based cancer registry.

PARTICIPANTS

Patients in the Surveillance Epidemiology and End Results-Medicare linked database who were aged 67 and older and had a primary diagnosis of Stage 1 to 3 colorectal cancer during 1993 through 1999.

MEASUREMENTS

Chronic conditions were identified using claims data, and vital status was determined from the Medicare enrollment files. After estimating the adjusted hazard ratios for mortality associated with each condition using a Cox model, the population attributable risk (PAR) was calculated for the full sample and by age subgroup.

RESULTS

The study sample consisted of 29,733 patients, 88% of whom were white and 55% were female. Approximately 9% of deaths were attributable to congestive heart failure (CHF; PAR = 9.4%, 95% confidence interval (CI) = 8.4-10.5%), more than 5% were attributable to chronic obstructive pulmonary disease (COPD; PAR = 5.3%, 95% CI = 4.7-6.6%), and nearly 4% were attributable to diabetes mellitus (PAR = 3.9%, 95% CI = 3.1-4.8%). The PAR associated with CHF increased with age, from 6.3% (95% CI = 4.4-8.8%) in patients aged 67 to 70 to 14.5% (95% CI = 12.0-17.5%) in patients aged 81 to 85. Multiple conditions were common. More than half of the patients who had CHF also had diabetes mellitus or COPD. The PAR associated with CHF alone (4.29%, 95% CI = 3.68-4.94%) was similar to the PAR for CHF in combination with diabetes mellitus (3.08, 95% CI = 2.60-3.61%) or COPD (3.93, 95% CI = 3.41-4.54%).

CONCLUSION

A substantial proportion of deaths in older persons with colorectal cancer can be attributed to CHF, diabetes mellitus, and COPD. Multimorbidity is common and exerts a substantial effect on colorectal cancer survival.

Relation between Medicare screening reimbursement and stage at diagnosis for older patients with colon cancer

CONTEXT

Medicare's reimbursement policy was changed in 1998 to provide coverage for screening colonoscopies for patients with increased colon cancer risk, and expanded further in 2001 to cover screening colonoscopies for all individuals.

OBJECTIVE

To determine whether the Medicare reimbursement policy changes were associated with an increase in either colonoscopy use or early stage colon cancer diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

Patients in the Surveillance, Epidemiology, and End Results Medicare linked database who were 67 years of age and older and had a primary diagnosis of colon cancer during 1992-2002, as well as a group of Medicare beneficiaries who resided in Surveillance, Epidemiology, and End Results areas but who were not diagnosed with cancer.

MAIN OUTCOME MEASURES

Trends in colonoscopy and sigmoidoscopy use among Medicare beneficiaries without cancer were assessed using multivariate Poisson regression. Among the patients with cancer, stage was classified as early (stage I) vs all other (stages II-IV). Time was categorized as period 1 (no screening coverage, 1992-1997), period 2 (limited coverage, January 1998-June 2001), and period 3 (universal coverage, July 2001-December 2002). A multivariate logistic regression (outcome = early stage) was used to assess temporal trends in stage at diagnosis; an interaction term between tumor site and time was included.

RESULTS

Colonoscopy use increased from an average rate of 285/100,000 per quarter in period 1 to 889 and 1919/100,000 per quarter in periods 2 (P<.001) and 3 (P vs 2<.001), respectively. During the study period, 44,924 eligible patients were diagnosed with colorectal cancer. The proportion of patients diagnosed at an early stage increased from 22.5% in period 1 to 25.5% in period 2 and 26.3% in period 3 (P<.001 for each pairwise comparison). The changes in Medicare coverage were strongly associated with early stage at diagnosis for patients with proximal colon lesions (adjusted relative risk period 2 vs 1, 1.19; 95% confidence interval, 1.13-1.26; adjusted relative risk period 3 vs 2, 1.10; 95% confidence interval, 1.02-1.17) but weakly associated, if at all, for patients with distal colon lesions (adjusted relative risk period 2 vs 1, 1.07; 95% confidence interval, 1.01-1.13; adjusted relative risk period 3 vs 2, 0.97; 95% confidence interval, 0.90-1.05).

CONCLUSIONS

Expansion of Medicare reimbursement to cover colon cancer screening was associated with an increased use of colonoscopy for Medicare beneficiaries, and for those who were diagnosed with colon cancer, an increased probability of being diagnosed at an early stage. The selective effect of the coverage change on proximal colon lesions suggests that increased use of whole-colon screening modalities such as colonoscopy may have played a pivotal role.

The effect of age and chronic illness on life expectancy after a diagnosis of colorectal cancer: implications for screening

BACKGROUND

Older adults with shorter life expectancies may receive less benefit from colorectal cancer screening than younger, healthier patients.

OBJECTIVE

To determine the degree to which life expectancy after diagnosis of an early-stage cancer varies according to age or coexisting chronic illness.

DESIGN

Retrospective cohort study.

SETTING

Population-based cancer registry with linked administrative claims data.

PATIENTS

Patients 67 years of age or older who received a diagnosis of colorectal cancer from 1993 through 1999.

MEASUREMENTS

Chronic conditions were identified by searching Medicare claims. Using a life-table approach, the authors quantified the degree to which life expectancy associated with each cancer stage at diagnosis varied with patient age, sex, and burden of chronic conditions.

RESULTS

The final study sample consisted of 35 755 patients. After accounting for cancer stage at diagnosis, the authors found that life expectancy was strongly related to both age and the burden of chronic illness. Among men who received a diagnosis of stage I cancer at 67 years of age, life expectancy decreased from 19.1 years (95% CI, 17.8 to 20.5 years) for patients with no chronic conditions to 12.4 years (CI, 11.4 to 13.5 years) for those with 1 or 2 conditions and 7.6 years (CI, 6.1 to 9.4 years) for those with 3 or more conditions. A similar trend was noted among female counterparts, with life expectancy decreasing from approximately 23 years to 16 years and 7 years for the 3 chronic condition groups, respectively. For men and women 81 years of age with no chronic illnesses, life expectancy after stage I cancer diagnosis was 10.3 years (CI, 9.2 to 11.9 years) and 13.8 years (CI, 12.3 to 15.3 years), respectively.

LIMITATIONS

Administrative claims may not identify all chronic conditions. Life expectancy estimates at the population level are averages and, therefore, may not accurately predict the life expectancy of individual patients.

CONCLUSIONS

Coexisting chronic illness is associated with a substantial reduction in life expectancy after diagnosis of early-stage colorectal cancer. Physicians should consider this when deciding whether to screen older persons.

Older Adults Discharged from the Hospital with Delirium: 1-Year Outcomes

OBJECTIVES

To compare 1-year institutionalization and mortality rates of patients who were delirious at discharge, patients whose delirium resolved by discharge, and patients who were never delirious in the hospital.

DESIGN

Secondary analysis of prospective cohort data from the Delirium Prevention Trial.

SETTING

General medicine service at Yale New Haven Hospital, March 25, 1995, through March 18, 1998, with follow-up interviews completed in 2000.

PARTICIPANTS

Four hundred thirty-three patients aged 70 and older who were not delirious at admission.

MEASUREMENTS

Patients underwent daily assessments of delirium from admission to discharge using the Confusion Assessment Method. Nursing home placement and mortality were determined at 1-year follow up.

RESULTS

Of the 433 study patients, 24 (5.5%) had delirium at discharge, 31 (7.2%) had delirium that resolved during hospitalization, and 378 (87.3%) were never delirious. After 1 year of follow-up, 20 of 24 (83.3%) patients discharged with delirium, 21 of 31 (67.7%) patients whose delirium resolved, and 157 of 378 (41.5%) patients who were never delirious were admitted to a nursing home or died. Compared with patients who were never delirious, patients with delirium at discharge had a multivariable adjusted hazard ratio (HR) of 2.64 (95% confidence interval (CI)=1.60-4.35) for nursing home placement or mortality, whereas resolved cases had a HR of 1.53 (95% CI=0.96-2.43).

CONCLUSION

Delirium at discharge is associated with a high rate of nursing home placement and mortality over a 1-year follow-up period. Interventions to increase detection of delirium and improvements in transitional care may help reduce these negative outcomes.

Symptoms of depression in older home-care patients: patient and informant reports

The purpose of this study was to examine the level of agreement and patterns of disagreement between home-care patient and informant reports of depressive symptoms. The authors interviewed a sample of 355 older home-care patients and their informants using the Structured Diagnostic Interview for DSM-IV (R. L. Spitzer, M. Gibbon, & J. B. Williams, 1995). Informants reported more psychological symptoms than patients, and this type of discrepancy was higher for patients with cognitive impairment and patients who had younger informants. Younger informants also reported more cognitive symptoms, whereas patients were more likely to report suicidal thoughts or ideation if they were not cognitively impaired. The patterns of these discrepancies may reflect age- and cohort-related response bias in the reports of depressive symptoms obtained from older adults.

Depression in elderly homecare patients: patient versus informant reports

BACKGROUND

This study compares patient and informant reports of depressive disorders in a community sample of elderly medical homecare patients. The associations between specific patterns of agreement/disagreement and other patient and informant characteristics are examined.

METHOD

A random sample of 355 elderly medical homecare patients and their informants were interviewed using the current mood section of the Structured Clinical Interview for DSM-IV (SCID).

RESULTS

Thirty-seven patients (10.4 %) reported a depressive disorder (major or subsyndromal) that was also identified by their informant while 27 (7.6 %) patients self-reported depression that the informant did not identify. There were 250 patients (70.4 %) who were not depressed according to both patient and informant report and 41 patients (11.5%) were identified as depressed by informant report alone. Patients identified as depressed by informant report alone were similar to patients who self-reported depression on a number of the sociodemographic and clinical correlates of depression, but had significantly poorer performance on items assessing orientation and short-term recall. These patients also had poorer functioning in a number of domains (social, cognitive, and functional) when compared with patients who were not depressed according to both the patient and informant. Finally, patients with younger informants were more likely to be identified as depressed by their informant.

CONCLUSIONS

Obtaining informant reports of depression may be a useful method for detecting clinically significant cases of late-life depression that would otherwise be missed when relying only on patient report.

Recognition of late-life depression in home care: accuracy of the outcome and assessment information set

This study evaluated the accuracy of home care nurses' ratings of the Outcome and Assessment Information Set (OASIS) depression items. The accuracy of home care nurses' depression assessments was studied by comparing nurse ratings of OASIS depression items with a research diagnostic assessment based on the Structured Clinical Interview for Axis I Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID). The setting for this study was a nonprofit, Medicare-certified, voluntary home healthcare agency. Sixty-four home care nurses assessed 220 patients aged 65 and older with the OASIS upon admission. Of the 220 patients, using standard SCID criteria, 35 cases of major or minor depression were identified. The home care nurses accurately documented the presence of depression in 13 of 35 cases (sensitivity=37.1%; positive predictive value=0.56). Of the 220 patients, 185 had no SCID-identified major or minor depression. The nurses agreed on the absence of depression in 175 of 185 cases (specificity=94.6%; negative predictive value=88.8%). This study indicates that home care nurses often do not accurately rate OASIS depression items for older adult patients.

Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial

CONTEXT

Suicide rates are highest in late life; the majority of older adults who die by suicide have seen a primary care physician in preceding months. Depression is the strongest risk factor for late-life suicide and for suicide's precursor, suicidal ideation.

OBJECTIVE

To determine the effect of a primary care intervention on suicidal ideation and depression in older patients.

DESIGN AND SETTING

Randomized controlled trial known as PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) with patient recruitment from 20 primary care practices in New York City, Philadelphia, and Pittsburgh regions, May 1999 through August 2001.

PARTICIPANTS

Two-stage, age-stratified (60-74, > or =75 years) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of screened negative patients. This analysis included patients with a depression diagnosis (N = 598).

INTERVENTION

Treatment guidelines tailored for the elderly with care management compared with usual care.

MAIN OUTCOME MEASURES

Assessment of suicidal ideation and depression severity at baseline, 4 months, 8 months, and 12 months.

RESULTS

Rates of suicidal ideation declined faster (P =.01) in intervention patients compared with usual care patients; at 4 months, in the intervention group, raw rates of suicidal ideation declined 12.9% points (29.4% to 16.5%) compared with 3.0% points (20.1% to 17.1% in usual care [P =.01]). Among patients reporting suicidal ideation, resolution of ideation was faster among intervention patients (P =.03); differences peaked at 8 months (70.7% vs 43.9% resolution; P =.005). Intervention patients had a more favorable course of depression in both degree and speed of symptom reduction; group difference peaked at 4 months. The effects on depression were not significant among patients with minor depression unless suicidal ideation was present.

CONCLUSIONS

Evidence of the intervention's effectiveness in community-based primary care with a heterogeneous sample of depressed patients introduces new challenges related to its sustainability and dissemination. The intervention's effectiveness in reducing suicidal ideation, regardless of depression severity, reinforces its role as a prevention strategy to reduce risk factors for suicide in late life.

One-month stability of depression among elderly home-care patients

OBJECTIVE

Studies in primary care settings have shown that depression is often chronic and associated with negative outcomes among patients with medical illness. The stability of depression among home care recipients has not been investigated. The authors examined the 1-month stability of major depression in a representative sample of elderly adults shortly after their admission to home care.

METHODS

A group of 539 subjects over age 65, newly admitted to home care for skilled nursing, were interviewed with the Structured Clinical Interview for DSM-IV (SCID-IV). Depression severity, medical comorbidity, pain, functional status, cognitive status, and recent life events were also assessed. Of 84 subjects who met criteria for major depression (MDD) at baseline, 74 were available for 1-month follow-up interview.

RESULTS

At 1-month follow-up, 31 subjects (42%) continued to meet MDD criteria; 20 (27%) achieved partial remission; and 23 (31%) were in full remission. Fewer instrumental activity limitations at baseline, experiencing "a great deal" of pain, and absence of a recent stressful life event were associated with full remission at 1-month follow-up.

CONCLUSION

Nearly one-half of newly admitted elderly home care patients who meet criteria for MDD continue to meet full criteria 1 month later. Functional and psychosocial factors affect the short-term course.

Major depression in elderly home health care patients

OBJECTIVE

Despite the growth of geriatric home health services, little is known about the mental health needs of geriatric patients seen in their homes. The authors report the distribution, correlates, and treatment status of DSM-IV major depression in a random sample of elderly patients receiving home health care for medical or surgical problems.

METHOD

Geriatric patients newly admitted to a large, traditional visiting nurse agency were sampled on a weekly basis over a period of 2 years. The 539 patients ranged in age from 65 to 102 years; 351 (65%) were women, and 81 (15%) were nonwhite. The Structured Clinical Interview for DSM-IV Axis I Disorders was used to interview patients and informants. The authors reviewed the results of these interviews plus the patients' medical charts to generate a best-estimate DSM-IV psychiatric diagnosis.

RESULTS

The patients had substantial medical burden and disability. According to DSM-IV criteria, 73 (13.5%) of the 539 patients were diagnosed with major depression. Most of these patients (N=52, 71%) were experiencing their first episode of depression, and the episode had lasted for more than 2 months in most patients (N=57, 78%). Major depression was significantly associated with medical morbidity, instrumental activities of daily living disability, reported pain, and a past history of depression but not with cognitive function or sociodemographic factors. Only 16 (22%) of the depressed patients were receiving antidepressant treatment, and none was receiving psychotherapy. Five (31%) of the 16 patients receiving antidepressants were prescribed subtherapeutic doses, and two (18%) of the 11 who were prescribed appropriate doses reported not complying with their antidepressant treatment.

CONCLUSIONS

Geriatric major depression is twice as common in patients receiving home care as in those receiving primary care. Most depressions in patients receiving home care are untreated. The poor medical and functional status of these patients and the complex organizational structure of home health care pose a challenge for determining safe and effective strategies for treating depressed elderly home care patients.

Maternal life history--versus gestation-focused assessment of prenatal exposure to substances of abuse

PURPOSE

Substance use by pregnant women is socially stigmatized and may be legally punishable. This societal condemnation raises concerns about underascertainment of prenatal substance exposure of offspring if mothers are asked specifically about their behavior during gestation, versus their life histories without reference to gestational dates. This study assessed agreement between life history-focused and pregnancy-focused assessments of prenatal exposure, and percentages of offspring classified as exposed to a range of substances by each measure, in a sample of school-aged children of methadone-maintained, opioid-dependent parents.

METHODS

Prenatal exposure was assessed in 172 offspring of 109 mothers by: (a) questionnaires administered to mothers about substance use during pregnancy; and (b) best-estimate (BE) diagnoses of substance use disorders in mothers overlapping with pregnancy dates. BE diagnoses were based on interviews with the Schedule for Affective Disorders and Schizophrenia-Lifetime Version, conducted by trained mental health professionals with mothers about their life histories of psychiatric and substance use disorders, as well as mothers' medical records. Chance-corrected agreement between the measures was examined using kappa statistics. Percentages of offspring classified as exposed by each method were compared using McNemar chi 2 tests.

RESULTS

Except for cigarettes, agreement between the measures was poor. Except for alcohol, diagnosed episodes of substance use disorders in mothers with dates overlapping pregnancy classified more offspring as exposed than mothers' responses to the questionnaire focusing on behavior while pregnant, though the differences in proportions identified as exposed were not always large or statistically significant.

IMPLICATIONS

When retrospective ascertainment of prenatal exposure is necessary, asking mothers for their own life histories, without reference to pregnancy dates, may be the preferred approach.

Factors related to current and subsequent psychotropic drug use in an elderly cohort

AIMS OF THE STUDY

The purpose of this study was to estimate the prevalence of psychotropic drug use in a cohort of elderly persons and to examine factors related to current and subsequent drug use.

POPULATION

A representative cohort of non-institutionalized subjects aged 65 and over living in New Haven, Connecticut, was interviewed in 1982, and again in 1985 and 1988. Psychotropic drug use during the prior two weeks was assessed at each home interview.

RESULTS

At the baseline interview in 1982, 12.3% of the subjects reported using psychotropic drugs, half of them (6.25%) benzodiazepines. In multivariate analyses, psychotropic drug use was significantly associated with female gender and white ethnicity but not with older age. Psychotropic drug use and depressive symptomatology were strongly correlated in both genders. However, less than 5% of the subjects reporting high depressive symptomatology were using antidepressants. Psychotropic drug use was also associated with sleep problems in men and medical conditions in women. Psychotropic drug consumption increased slightly to 15.1% in 1988. Continuous use (use reported in 1982, 1985 and 1988) was found in 4.5% of the sample; it was strongly related to both depressive symptomatology and sleep problems reported at baseline. New use, beginning either in 1985 or in 1988, was observed in 12.6% of the sample; it was related to female gender, older age, and, among baseline health variables, to depressive symptomatology.

CONCLUSIONS

Prevalence of psychotropic drug use in this cohort of elderly people was lower than in other studies conducted in the U.S. The reasons for this variation are discussed. Continuous use was not higher for benzodiazepines than for other psychotropic drugs.

A longitudinal study of change in domain-specific self-efficacy among older adults

Predictors of change in domain-specific self-efficacy were examined in a sample of community-residing men and women aged 62 and older. Self-efficacy perceptions were assessed for eight domains of living: productivity, health, transportation, family relationships, relationships with friends, finances, safety, and living arrangements. Using pooled logistic regression models, both baseline and time-varying predictors of decline and improvement in self-efficacy were examined. The results indicated that while demographic and health factors were predictive of decline in self-efficacy for some domains of living, the most consistent predictors of decline were psychosocial characteristics. Specifically, prior levels of depression were associated with decline in the transportation, family relationships, relationships with friends, financial, safety, and living arrangements domains of living. The presence of a domain-specific hassle was associated with a decline in self-efficacy for the transportation, family relationships, finances, and living arrangements domains. In addition, lower levels of social network contact were predictive of decline in the health and safety domains, and the absence of instrumental support was also associated with decline in the productivity, health, and transportation domains of living. Improvements in self-efficacy perceptions were associated with fewer of the health and psychosocial characteristics and were primarily influenced by the availability of financial and emotional support resources.

Social network characteristics and onset of ADL disability: MacArthur studies of successful aging

The relationship between social network structural and support characteristics and onset of new or recurrent activities of daily living (ADL) disability was examined in a cohort of older men and women. No significant protective effects were found for network structural or support characteristics. However, greater frequency of instrumental support was associated with significantly increased risk of ADL disability among men; a similar though nonsignificant pattern was seen among women. These findings indicate that receipt of more instrumental support may not have uniformly beneficial effects on functional status. They serve to underscore the need for more comprehensive research, examining both the positive and negative effects of social interactions on health and functioning.