Sacral neuromodulation in nursing home residents: Predictors of success and complications in a national cohort of older adults

AIMS

There is limited evidence to support the efficacy of sacral neuromodulation (SNM) for older adults with overactive bladder (OAB). This study aims to report outcomes following SNM among nursing home (NH) residents, a vulnerable population with high rates of frailty and comorbidity.

METHODS

This is a retrospective cohort study of long-stay NH residents who underwent a trial of percutaneous nerve evaluation (PNE) or Stage 1 permanent lead placement (Stage 1) between 2014 and 2016. Residents were identified using the Minimum Data Set linked to Medicare claims. The primary outcome of this study was successful progression from trial to implant. Rates of 1-year device explant/revisions were also investigated.

RESULTS

Trial of SNM was observed in 1089 residents (mean age: 77.9 years). PNE was performed in 66.9% of residents and 33.2% underwent Stage 1. Of Stage 1 procedures, 23.8% were performed with simultaneous device implant (single-stage). Overall, 53.1% of PNEs and 72.4% of Stage 1 progressed to device implant, which was associated with Stage 1 procedure versus PNE (adjusted relative risk [aRR]: 1.34; 95% confidence interval [95% CI]: 1.21-1.49) and female versus male sex (aRR: 1.26; 95% CI: 1.09-1.46). One-year explant/revision was observed in 9.3% of residents (6.3% for PNE, 10.5% for Stage 1, 20.3% single-stage). Single stage procedure versus PNE was significantly associated with device explant/revision (aRR: 3.4; 95% CI: 1.9-6.2).

CONCLUSIONS

In this large cohort of NH residents, outcomes following SNM were similar to previous reports of younger healthier cohorts. Surgeons managing older patients with OAB should use caution when selecting patients for single stage SNM procedures.

Associations of Lower Extremity Muscle Strength, Area, and Specific Force with Lower Urinary Tract Symptoms in Older Men: the Baltimore Longitudinal Study of Aging

BACKGROUND

Lower urinary tract symptoms (LUTS) in older men are associated with increased risk of mobility limitations. Lower extremity muscle quality may represent a novel shared mechanism of both LUTS and mobility limitations.

METHODS

We evaluated associations of thigh skeletal muscle measures (strength, area, and specific force) with total LUTS severity (American Urologic Association Symptom Index; AUASI) and voiding and storage subscores among 352 men aged ≥60 years enrolled in the Baltimore Longitudinal Study of Aging. Thigh muscle strength (Nm) was defined as maximum concentric 30°/s knee extensor torque, area (cm2), and specific force (Nm/cm2) defined as strength/area. Associations with AUASI score were estimated using multivariable linear regression and linear mixed models.

RESULTS

Mean thigh muscle strength at baseline was 139.7Nm. In cross-sectional multivariable models, each 39Nm increment in thigh muscle strength and 0.28Nm/cm2 increment in specific force was associated with -1.17 point (95%CI -1.93, -0.41) and -0.95 point (95%CI -1.63,-0.27) lower AUASI score, respectively. Similar associations were observed for voiding and storage subscores, although somewhat attenuated. In longitudinal analyses, baseline muscle measures were not associated with annual change in AUASI and current changes in muscle measures and AUASI were unrelated.

CONCLUSIONS

Cross-sectionally, higher thigh muscle strength and specific force were associated with decreased LUTS severity in older men. However, we did not observe concurrent worsening LUTS severity with declining thigh muscle strength, area, or specific force in longitudinal analyses.

Skeletal Muscle Health, Physical Performance, and Lower Urinary Tract Symptoms in Older Adults: the Study of Muscle, Mobility and Aging (SOMMA)

BACKGROUND

Lower urinary tract symptoms (LUTS) and mobility limitations are bidirectionally associated among older adults, but the role of skeletal muscle remains unknown. We evaluated cross-sectional associations of muscle health and physical performance with LUTS.

METHODS

We used data from 377 women and 264 men age>70 years in the Study of Muscle, Mobility and Aging (SOMMA). LUTS and urinary bother were assessed using the LURN Symptom Index-10 (SI-10;higher=worse symptoms). Muscle mass and volume were assessed using D3-creatine dilution (D3Cr) and magnetic resonance imaging. Grip strength and peak leg power assessed upper/lower extremity physical performance. 400m walk, Short Physical Performance Battery (SPPB), and Four Square Step Test (FSST) assessed global physical performance. Mobility Assessment Tool-short form (MAT-sf) assessed self-reported mobility. We calculated Spearman correlation coefficients adjusted for age, BMI, multimorbidity, and polypharmacy, chi-square tests, and Fisher's Z-test to compare correlations.

RESULTS

Among women, LURN SI-10 total scores were inversely correlated with FSST (rs=0.11,P=0.045), grip strength (rs=-0.15,P=0.006), and MAT-sf (rs=-0.18,P=0.001), but not other muscle and physical performance measures in multivariable models. LURN SI-10 was not associated with any of these measures among men. 44% of women in the lowest tertile of 400m walk speed versus 24% in the highest tertile reported they were at least "somewhat bothered" by urinary symptoms (P<0.001) whereas differences among men were not significant.

CONCLUSIONS

Balance and grip strength were associated with LUTS severity in older women but not men. Associations with other muscle and physical performance measures varied by LUTS subtype but remained strongest among women.

Lower urinary tract symptom severity, urinary bother, and incident life-space mobility restriction among older men

BACKGROUND

Life-space mobility represents the distance, frequency, and independence of mobility, ranging from one's bedroom to beyond their town. Older men with lower urinary tract symptoms (LUTS) may limit their life-space to stay close to a bathroom. However, it's unknown whether LUTS severity or urinary bother are associated with risk of life-space mobility restriction.

METHODS

We analyzed data from 3025 community-dwelling men age ≥71 years without life-space mobility restriction at analytic baseline (Year 7) of the Osteoporotic Fractures in Men (MrOS) study. The American Urologic Association Symptom Index (AUASI) was assessed at baseline and includes one question assessing urinary bother ("If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?"; score 0-1,2,3,4-6) and seven items to classify LUTS severity as none/mild (score 0-7), moderate (8-19), or severe (20-35). The University of Alabama Life-space Assessment was used to define life-space mobility restriction (≤60) at baseline and follow-up (Year 9). We used log-binomial regression with robust variance estimators to model adjusted risk ratios (ARR) for LUTS severity and urinary bother with incident life-space mobility restriction, controlling for age, site, health-related factors, and comorbidities. We then mutually adjusted for urinary bother and LUTS severity.

RESULTS

Overall, the 2-year risk of life-space mobility restrictions was 9.9%. Compared to men without urinary bother (scores 0-1), the risk of life-space mobility restriction was significantly higher among men with bother scores of 4-6 (ARR = 2.20, 95% CI: 1.52, 3.19), independent of LUTS severity and confounders. Conversely, LUTS severity was not independently associated with the risk of life-space mobility restriction.

CONCLUSIONS

Urinary bother, but not LUTS severity, is independently associated with incident life-space mobility restriction among older men. To maintain life-space mobility in older men with LUTS, future studies should identify shared mechanisms and interventions that minimize urinary bother.

The devil's in the details: Variation in estimates of late-life activity limitations across national cohort studies

BACKGROUND

Assessing activity limitations is central to aging research. However, assessments of activity limitations vary, and this may have implications for the populations identified. We aim to compare measures of activities of daily living (ADLs) and their resulting prevalence and mortality across three nationally-representative cohort studies: the National Health and Aging Trends Study (NHATS), the Health and Retirement Survey (HRS), and the Medicare Current Beneficiary Survey (MCBS).

METHODS

We compared the phrasing and context of questions around help and difficulty with six self-care activities: eating, bathing, toileting, dressing, walking inside, and transferring. We then compared the prevalence and 1-year mortality for difficulty and help with eating and dressing.

RESULTS

NHATS, HRS, and MCBS varied widely in phrasing and framing of questions around activity limitations, impacting the proportion of the population found to experience difficulty or receive help. For example, in NHATS 12.4% [95% confidence interval (CI) 11.5%-13.4%] of the cohort received help with dressing, while in HRS this figure was 6.4% [95% CI 5.7%-7.2%] and MCBS 5.3% [95% CI 4.7%-5.8%]. When combined with variation in sampling frame and survey approach of each survey, such differences resulted in large variation in estimates of the older population of older adults with ADL disability.

CONCLUSIONS

In order to take late-life activity limitations seriously, we must clearly define the measures we use. Further, researchers and clinicians seeking to understand the experience of older adults with activity limitations should be careful to interpret findings in light of the framing of the question asked.

Women with cirrhosis have lower self-rated health than men

BACKGROUND

Women systematically experience lower rates of liver transplantation (LT) and higher rates of waitlist mortality than men. Self-rated health has been associated with patient outcomes in the global population. We, therefore, assessed gender differences in self-rated and clinician-rated health among LT candidates.

METHODS

Ambulatory LT candidates without hepatocellular carcinoma were enrolled from 2012 to 2018. Participants and their hepatologists were asked separately to rate the participant's overall general health on a 6-point scale (0="excellent" to 5="very poor"). Logistic regression was used to assess the associations between covariates and superior self-assessment, defined as 1 SD above the mean self-assessment score.

RESULTS

Of 855 participants, the median (interquartile range) self-rated health score was 2 (1-3); 156 (18%) were categorized as superior self-rated health. The correlation between self-rated and clinician-rated health was positive (Spearman's rho 0.3, P<0.001). In univariate analysis, being a woman was associated with lower odds of superior self-rated health (OR 0.7, 95% CI 0.5-1.0, P=0.04), which persisted on multivariable analysis (aOR 0.7, 95% CI 0.4-1.0, P=0.05), controlling for race, frailty, work status, comorbidities, Model for End-Stage Liver Disease-Na, hepatic encephalopathy, and ascites.

CONCLUSION

These findings highlight the need for well-designed quality-based research to determine how our patients perceive health to highlight opportunities to offer more comprehensive, quality-based care.

Longitudinal Associations between Concurrent Changes in Phenotypic Frailty and Lower Urinary Tract Symptoms among Older Men

BACKGROUND

Lower urinary tract symptoms (LUTS) are associated with prevalent frailty and functional impairment, but longitudinal associations remain unexplored.

OBJECTIVES

To assess the association of change in phenotypic frailty with concurrent worsening LUTS severity among older men without clinically significant LUTS at baseline.

DESIGN

Multicenter, prospective cohort study.

SETTING

Population-based.

PARTICIPANTS

Participants included community-dwelling men age ≥65 years at enrollment in the Osteoporotic Fractures in Men study.

MEASUREMENTS

Data were collected at 4 visits over 7 years. Phenotypic frailty score (range: 0-5) was defined at each visit using adapted Fried criterion and men were categorized at baseline as robust (0), pre-frail (1-2), or frail (3-5). Within-person change in frailty was calculated at each visit as the absolute difference in number of criteria met compared to baseline. LUTS severity was defined using the American Urologic Association Symptom Index (AUASI; range: 0-35) and men with AUASI ≥8 at baseline were excluded. Linear mixed effects models were adjusted for demographics, health-behaviors, and comorbidities to quantify the association between within-person change in frailty and AUASI.

RESULTS

Among 3235 men included in analysis, 48% were robust, 45% were pre-frail, and 7% were frail. Whereas baseline frailty status was not associated with change in LUTS severity, within-person increases in frailty were associated with greater LUTS severity (quadratic P<0.001). Among robust men at baseline, mean predicted AUASI during follow-up was 4.2 (95% CI 3.9, 4.5) among those meeting 0 frailty criteria, 4.6 (95% CI 4.3, 4.9) among those meeting 1 criterion increasing non-linearly to 11.2 (95% CI 9.8, 12.6) among those meeting 5 criteria.

CONCLUSIONS

Greater phenotypic frailty was associated with non-linear increases in LUTS severity in older men over time, independent of age and comorbidities. Results suggest LUTS and frailty share an underlying mechanism that is not targeted by existing LUTS interventions.

SPECTRUM OF DEMENTIA IN OLDER HOSPICE RECIPIENTS

We know little about differences between hospice enrollees with dementia co-existing with another terminal illness (like cancer), those dying from dementia (as principal hospice diagnosis), and those dying with no dementia. We used the National Health Aging and Trends Study linked to Medicare claims to compare characteristics, hospice use patterns, and care quality ratings. Among 1,105 decedent hospice-enrollees age 70+, we found 39% were dying with coexisting dementia, 17% from dementia, and 44% without dementia. In adjusted analyses, those dying with dementia had similarly high rates of functional impairment, higher rates of clinical needs, and worse measures of care quality compared to elders dying from dementia. Hospice use patterns were different for elders dying with dementia compared to elders without dementia. In summary, 56% of older hospice enrollees have dementia, mostly in addition to another terminal illness. Their differing hospice experience implies changes are needed to hospice care and policy.

ASSOCIATION OF HBA1C WITH BEHAVIORAL SYMPTOMS OF DEMENTIA IN VA NURSING HOME RESIDENTS WITH DIABETES (2013–2019)

For people with dementia, behavioral symptoms of dementia are often signs of distress and may be caused by pain, confusion, agitation, or negative moods. In people with diabetes, pain, confusion, and agitation may result from aspects of diabetes management, including poor glycemic control, episodes of very low or high blood sugar (hypo- and hyper-glycemia), insulin injections, or fingerstick pricks to check blood glucose. Few studies have examined how diabetes control contributes to behavioral symptoms of dementia. We conducted a retrospective study in VA nursing home (NH) residents aged 65+ with both dementia and diabetes, and a NH stay&gt;45 days. We used the second assessment of the Minimum Dataset (MDS 3.0) to identify behavioral symptoms of verbal or physical outbursts during the prior 7 days. We conducted mixed-effects logistic regression, with clustering by NH facility. The 5060 residents were overwhelmingly male (99%), had an average age of 78, with mean HbA1c was 7.1 (standard deviation 1.6). The overall prevalence of any behavioral symptoms was 16.7%. Compared to residents with HbA1c &lt; 6%, behavioral symptoms were slightly more common among residents with HbA1c 6-7%, 7-8%, and &gt;9%, but not statistically significantly different. Behavioral symptoms were significantly more common in residents with HbA1c 8-9% (prevalence 19.6%) than in residents with HbA1c &lt; 6% (prevalence 15.5%; odd ratios adjusted for NH facility: 1.35, 95% confidence interval: 1.05-1.75). Additional research is needed to determine which aspects of diabetes management may be contributing to excess risk of behavioral symptoms of dementia.

SKELETAL MUSCLE HEALTH AND LOWER URINARY TRACT SYMPTOMS IN OLDER ADULTS

Lower urinary tract symptoms (LUTS) are associated with increased risk of mobility limitations among older adults. Our objective was to evaluate the association of muscle (D3Cr muscle mass, MRI total thigh muscle volume, Keiser extensor power, grip strength) and physical performance (400m walk, SPPB) measures with LUTS severity and bother among adults age &gt;70 years in the Study of Muscle, Mobility and Aging (SOMMA). We used data from the first 132 women and 103 men to complete their baseline visit where LUTS were assessed using the LURN Symptom Index-10 (SI-10) plus a global urinary bother question. We calculated Spearman correlation coefficients and chi-square tests as appropriate, stratified by sex. Among women, LURN SI-10 scores were inversely correlated with D3Cr muscle mass/body weight (ρ=-0.217, P=0.01), peak leg power/body weight (ρ=-0.179,P=0.04), and SPPB (ρ=-0.173,P=0.047), but not 400m walk, MRI thigh muscle volume, or grip strength (P&gt;0.1 for all). 46% of women in the lowest tertile of % muscle mass versus 38% in the highest tertile reported they were at least “somewhat bothered” by urinary symptoms (P=0.04). Among men, no muscle or physical performance measures were significantly associated with LURN SI-10 or urinary bother (P&gt;0.2 for all). In conclusion, older women with greater muscle mass, leg power, and SPPB scores had reduced LUTS severity whereas LURN SI-10 was not significantly correlated with muscle and physical performance measures in older men. Older women with higher D3Cr muscle mass were also less bothered by urinary symptoms, supporting muscle health as a novel female LUTS mechanism.

ASSOCIATION OF LOWER URINARY TRACT SYMPTOMS WITH INCIDENT FRAILTY AND MORTALITY AMONG OLDER COMMUNITY-DWELLING MEN

Lower urinary tract symptoms (LUTS) are associated with increased risk of new mobility and functional limitations among older men. Our objective was to evaluate the longitudinal relationship between baseline LUTS severity and incident frailty or all-cause mortality among 3667 community-dwelling non-frail men age >70 years from the Osteoporotic Fractures in Men (MrOS) study. LUTS severity at analytic baseline was defined using the American Urologic Association Symptom Index (AUASI). Phenotypic frailty was defined at baseline and 2-year follow-up visits using modified Fried criteria and classified as robust (0), intermediate stage (1-2), or frail (3-5); men classified as frail at analytic baseline were excluded. Vital status was assessed every 4 months. Since the proportional odds assumption was not met, we used multivariable multinomial logistic regression to estimate odds ratios (OR) for the association between baseline LUTS severity and incident frailty or death at follow-up compared to robust. OR were adjusted for demographics, health-behaviors, comorbidities, and cognition. After a mean follow-up of 2.3 years, 37% of men were categorized as robust, 46% were intermediate stage, 9.2% developed incident frailty, and 7.9% had died. Per 4 point higher AUASI, the adjusted odds incident frailty versus robust was 1.23 (95% CI 1.12, 1.34). Odds of death versus robust was not statistically significant (OR=1.05, 95% CI 0.94, 1.18). In conclusion, non-frail men with greater LUTS severity at baseline have slightly greater odds of incident frailty within 2 years. Clinicians should be aware that LUTS severity is a prognostic marker for developing frailty in older men.

Functional and cognitive outcomes after suprapubic catheter placement in nursing home residents: A national cohort study

BACKGROUND

Long-term functional and cognitive outcomes in nursing home residents after procedures are poorly understood. Our objective was to evaluate these outcomes after suprapubic tube (SPT) placement.

METHODS

We performed a retrospective, cohort study in the nursing home setting. Participants were long-term nursing home residents who underwent SPT placement from 2014 to 2016 in the United States. SPT placements were identified in Medicare Inpatient, Outpatient, and Carrier files using International Classification of Diseases and Current Procedural Terminology codes. Residents were identified through the Minimum Data Set (MDS) 3.0 for Nursing Home Residents. MDS Activities of Daily Living (MDS-ADL) and Brief Interview for Mental Status (BIMS) scores were used to assess function and cognition, respectively. Outcomes of interest were worsening MDS-ADL and BIMS scores at 1 year postoperatively, 30-day postoperative complications, and 1-year mortality. Functional and cognitive trajectories were modeled to 1 year postoperatively using mixed-effect spline models.

RESULTS

From 2014 to 2016, 9647 residents with a mean age of 80.9 (SD 8.1) years underwent SPT placement. At 1 year postoperatively, 37.6% of residents died, while of survivors, 33.7% had worsening MDS-ADL and 36.2% worsened BIMS. Residents had steeper postoperative rates of functional decline compared to relatively stable preoperative trends that never recovered to baseline status. However, robustly characterizing an association between SPT placement and functional decline would require a propensity score matched cohort without SPT placement. Decline in cognitive status was not clearly associated with SPT placement, suggesting either the natural course of a vulnerable population or limitations of BIMS scores.

CONCLUSIONS

Outcomes important to older adults, such as functional ability and cognitive status, do not show improvement after SPT placement. These findings emphasize that this "minor" procedure should be considered with caution in this population and primarily for palliation.

Geriatric conditions and healthcare utilisation in older adults living with HIV

BACKGROUND

older HIV-positive adults experience a significant burden of geriatric conditions. However, little is known about the association between geriatric conditions and healthcare utilisation in this population.

SETTING

outpatient safety-net HIV clinic in San Francisco.

METHODS

in 2013, HIV-positive adults ≥50 years of age underwent geriatric assessment including functional impairment, fall(s)in past year, cognitive impairment (MOCA <26) and low social support (Lubben social network scale ≤12). We reviewed medical records from 2013 through 2017 to capture healthcare utilisation (emergency room (ER) visits and hospitalisations) and used Poisson models to examine the association between geriatric conditions and utilisation events over 4 years.

RESULTS

among 192 participants, 81% were male, 51% were white, the median age was 56 (range 50-74), and the median CD4 count was 508 (IQR 338-688) cells/mm3. Sixteen percent of participants had ≥1 activities of daily living (ADL) dependency, 58% had ≥1 instrumental activities of daily living IADL dependency, 43% reported ≥1 falls, 31% had cognitive impairment, and 58% had low social support. Over 4 years, 90 participants (46%) had ≥1 ER visit (total of 289 ER visits), 39 (20%) had ≥1 hospitalisation (total of 68 hospitalisations), and 15 (8%) died. In unadjusted and adjusted analyses, IADL dependency and falls were associated with healthcare utilisation (adjusted incidence rate ratios IADL (95%CI): 1.73 (1.33-2.25); falls: 1.51 (1.21-1.87)).

CONCLUSION

IADL dependency and history of falls were associated with healthcare utilisation among older HIV-positive adults. Although our results are limited by sample size, improved understanding of the association between geriatric conditions and healthcare utilisation could build support for geriatric HIV care models.

Lower urinary tract symptoms and incident functional limitations among older community-dwelling men

BACKGROUND

Lower urinary tract symptoms (LUTS) are associated with frailty phenotype, a risk factor for functional decline. Our objective was to determine the association between baseline LUTS and 2-year risk of new functional limitation among older men.

METHODS

We analyzed data from the Osteoporotic Fractures in Men (MrOS) study with baseline at Year 7 and follow-up through Year 9. Participants included 2716 community-dwelling men age ≥ 71 years without any baseline self-reported functional limitation. LUTS severity (American Urologic Association Symptom Index) was classified as none/mild (score 0-7), moderate (8-19), and severe (20-35). At baseline and follow-up, men reported their ability to complete several mobility, activities of daily living (ADLs), and cognition-dependent tasks. Risk was estimated for 3 incident functional limitation outcomes: (1) mobility (any difficulty walking 2-3 blocks or climbing 10 steps), (2) ADL (any difficulty bathing, showering, or transferring), and (3) cognition-dependent (any difficulty managing money or medications). We used Poisson regression with a robust variance estimator to model adjusted risk ratios (ARR) and 95% CIs controlling for age, site, and comorbidities; other demographic/lifestyle factors did not meet criteria for inclusion.

RESULTS

Overall, the 2-year risk was 15% for mobility, 10% for ADLs, and 4% for cognition-dependent task limitations. Compared to none/mild LUTS, risk of incident mobility limitations was increased for moderate (ARR = 1.35, 95% CI: 1.12, 1.63) and severe LUTS (ARR = 1.98, 95% CI: 1.48, 2.64). Men were also at higher risk for incident ADL limitations if they reported moderate (ARR = 1.32, 95% CI: 1.05, 1.67) and severe LUTS (ARR = 1.62, 95% CI: 1.07,2.43). Results were somewhat attenuated after adjusting for the frailty phenotype but remained statistically significant. LUTS were not associated with incident cognition-dependent task limitations.

CONCLUSIONS

LUTS severity is associated with incident mobility and ADL limitations among older men. Increased clinical attention to risk of functional limitations among older men with LUTS is likely warranted.

Association of Frailty and Suicide in Adults 65 Years and Older

Nearly 10,000 adults aged 65 years and older die by suicide in US annually. Although prior studies have linked individual diagnostic factors to late-life suicide risk, to our knowledge none have examined how accumulated health burden affects suicide risk. Such a metric could be studied utilizing a frailty index (FI). Our primary study objective was to determine the relationship of FI to risk of suicide. We examined a longitudinal cohort of 2,858,876 veterans 65 years and older from fiscal year 2012-2013 (baseline) through 12/31/2017, linking the VA’s suicide and mortality databases with medical record data. FI was defined by 31 variables, including morbidity, function, cognition, mood, sensory loss, chronic pain, and failure to thrive. We used Fine-Gray proportional hazards regression to examine time to suicide attempt (fatal and non-fatal). Our sample’s average age was 75 (SD 8), 88% White, 9% Black, and 98% male. Thirty-seven percent of veterans were non-frail, 30% were pre-frail, 17% mildly frail, 9% moderately frail, and 7% severely frail. Over the course of the study, 9,043 veterans had a documented suicide attempt with &gt;60% fatal. After adjusting for race, gender, region, substance use disorder, and PTSD, risk of suicide attempt increased across frailty categories: Hazard ratios increased from 1.37 (95%CI: 1.30-1.45) for pre-frail individuals to 1.57 (1.43-1.72) for severely frail individuals. We found similar results after further adjustment for the Charlson Comorbidity Index, suggesting cumulative deficit FI may be a strong prognostic marker for risk of suicide in adults over 65; informing late-life suicide prevention efforts.

Association of Frailty Index with Clinical BPH Progression and Serious Adverse Events: the MTOPS Trial

Lower urinary tract symptoms due to suspected benign prostatic hyperplasia (BPH) are increasingly treated with medications targeting obstruction among older men, but frailty may represent a novel risk factor for this condition. Our objective was to assess the associations between frailty and clinical BPH progression or serious adverse events (SAE) among 3047 men, age 50-89 years, enrolled in the Medical Therapy of Prostatic Symptoms Study, a placebo-controlled RCT of doxazosin, finasteride, or combination therapy on clinical BPH progression. We created a frailty index using 69 items collected at baseline and categorized men as fit (0-0.1), less fit (0.1-&lt;0.25), or frail (0.25-1.0). The primary outcomes were time to 1) first composite event of clinical BPH progression, and 2) SAE requiring hospitalization. Cox proportional hazards models were adjusted for demographics, intervention, BPH surrogates, and comorbidities. At baseline, 28% men were fit, 58% were less fit, and 14% were frail. During follow-up (mean 4.5 years), the incidence rate of clinical BPH progression was 2.2/100p-y among fit, 3.0/100p-y among less fit (HR =1.28, 95% CI 0.98, 1.67), and 4.1/100p-y among frail men (HR=1.60, 95% CI 1.13, 2.26). Among men randomized to combination therapy, the SAE incidence rate was 3.4/100p-y for fit men versus 12.7/100p-y for frail men (HR=5.98, 95% CI 3.76, 9.52). In conclusion, frailty is independently associated with greater risk of both clinical BPH progression and SAE. The decision to initiate medical therapy for BPH among frail men should therefore include a discussion of both benefits and risks via shared decision making.

Assessment of Frailty and Association With Progression of Benign Prostatic Hyperplasia Symptoms and Serious Adverse Events Among Men Using Drug Therapy

IMPORTANCE

Benign prostatic hyperplasia (BPH) in older men can cause lower urinary tract symptoms (LUTS), which are increasingly managed with medications. Frailty may contribute to both symptom progression and serious adverse events (SAEs), shifting the balance of benefits and harms of drug therapy.

OBJECTIVE

To assess the association between a deficit accumulation frailty index and clinical BPH progression or SAE.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the Medical Therapy of Prostatic Symptoms trial, which compared placebo, doxazosin, finasteride, and combination therapy in men with moderate-to-severe LUTS, reduced urinary flow rate, and no prior BPH interventions, hypotension, or elevated prostate-specific antigen. Enrollment was from 1995 to 1998, and follow-up was through 2001. Data were assessed in February 2021.

EXPOSURES

A frailty index (score range, 0-1) using 68 potential deficits collected at baseline was used to categorized men as robust (score ≤0.1), prefrail (score 0.1 to <0.25), or frail (score ≥0.25).

MAIN OUTCOMES AND MEASURES

Primary outcomes were time to clinical BPH progression and time to SAE, as defined in the parent trial. Adjusted hazard ratios (AHRs) were estimated using Cox proportional hazards regressions adjusted for demographic variables, treatment group, measures of obstruction, and comorbidities.

RESULTS

Among 3047 men (mean [SD] age, 62.6 [7.3] years; range, 50-89 years) in this analysis, 745 (24%) were robust, 1824 (60%) were prefrail, and 478 (16%) were frail at baseline. Compared with robust men, frail men were older (age ≥75 years, 12 men [2%] vs 62 men [13%]), less likely to be White (646 men [87%] vs 344 men [72%]), less likely to be married (599 men [80%] vs 342 men [72%]), and less likely to have 16 years or more of education (471 men [63%] vs 150 men [31%]). During mean (SD) follow-up of 4.0 (1.5) years, the incidence rate of clinical BPH progression was 2.2 events per 100 person-years among robust men, 2.9 events per 100 person-years among prefrail men (AHR, 1.36; 95% CI, 1.02-1.83), and 4.0 events per 100 person-years among frail men (AHR, 1.82; 95% CI, 1.24-2.67; linear P = .005). Larger point estimates were seen among men who received doxazosin or combination therapy, although the test for interaction between frailty index and treatment group did not reach statistical significance (P for interaction = .06). Risk of SAE was higher among prefrail and frail men (prefrail vs robust AHR, 1.81; 95% CI, 1.48-2.23; frail vs robust AHR, 2.86; 95% CI, 2.21-3.69; linear P < .001); this association was similar across treatment groups (P for interaction = .76).

CONCLUSIONS AND RELEVANCE

These findings suggest that frailty is independently associated with greater risk of both clinical BPH progression and SAEs. Older frail men with BPH considering initiation of drug therapy should be counseled regarding their higher risk of progression despite combination therapy and their likelihood of experiencing SAEs regardless of treatment choice.

Longitudinal Changes in Adiposity and Lower Urinary Tract Symptoms Among Older Men

BACKGROUND

Adiposity increases risk for male lower urinary tract symptoms (LUTS), although longitudinal studies have produced conflicting results. No prior studies have evaluated longitudinal associations of changes in adiposity with concurrent LUTS severity among older men.

METHODS

We used repeated adiposity measurements from dual-energy x-ray absorptiometry (DXA), body mass index (BMI), and American Urological Association Symptom Index (AUASI) measured at four study visits over a 9-year period among 5949 men enrolled in the Osteoporotic Fractures in Men (MrOS) study. Linear mixed effect models adjusted for age, health-related behaviors, and comorbidities were created to evaluate the association between baseline and change in visceral adipose tissue (VAT) area, total fat mass, and BMI with change in LUTS severity measured by the AUASI.

RESULTS

A non-linear association was observed between baseline VAT area and change in AUASI: men in baseline VAT tertile (T) 2 had a lower annual increase in AUASI score compared to men in T1 and T3 (T2 versus T1: β=-0.07; 95% CI -0.12, -0.03; P= 0.008; T3 versus T1: NS) but differences were small. No significant associations were observed between change in VAT area and change in AUASI score. Neither baseline tertiles nor change in total fat mass or BMI were associated with change in AUASI score.

CONCLUSIONS

Changes in VAT area, total fat mass, and BMI were not associated with change in LUTS severity in this cohort. Thus, despite other health benefits, interventions targeting adiposity alone are unlikely to be effective for preventing or treating LUTS among older men.

Comparative outcomes for older adults undergoing surgery for bladder and bowel dysfunction

BACKGROUND/OBJECTIVES

To compare surgical outcomes between vulnerable nursing home (NH) residents and matched community-dwelling older adults undergoing surgery for bladder and bowel dysfunction.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A total of 55,389 NH residents and propensity matched (based on procedure, age, sex, race, comorbidity, and year) community-dwelling older adults undergoing surgery for bladder and bowel dysfunction [female pelvic surgery, transurethral resection of the prostate, suprapubic tube placement, hemorrhoid surgery, rectal prolapse surgery]. Individuals were identified using Medicare claims and the Minimum Data Set (MDS) for NH residents between 2014 and 2016.

MEASUREMENTS

Thirty-day complications, 1-year mortality, and weighted changes in healthcare resource utilization (hospital admissions, emergency room visits, office visits) in the year before and after surgery.

RESULTS

NH residents demonstrated statistically significant increased risk of 30-day complications [60.1% v. 47.2%; RR 1.3 (95% CI 1.3-1.3)] and 1-year mortality [28.9% vs. 21.3%; RR 1.4 (95% CI 1.3-1.4)], compared to community-dwelling older adults. NH residents also demonstrated decreased healthcare resource utilization, compared to community-dwelling older adults, changing from 3.9 to 1.9 (vs.1.1 to 1.0) hospital admissions, 11 to 10.1 (vs. 9 to 9.7) office visits, and 3.4 to 2.2 (vs. 1.9 to 1.9) emergency room visits from the year before to after surgery.

CONCLUSION

Despite matching on several important clinical characteristics, NH residents demonstrated increased rates of 30-day complications and 1-year mortality after surgery for bowel and bladder dysfunction, while demonstrating decreased healthcare resource utilization. These mixed findings suggest that outcomes may be more varied among vulnerable older adults and warrant further investigation.

Prevalence of psychotropic and opioid prescribing among hospice beneficiaries in the United States, 2014-2016

BACKGROUND/OBJECTIVES

Psychotropic and opioid medications are routinely prescribed for symptom management in hospice, but national estimates of prescribing are lacking. Changes in Medicare hospice payment in 2014 provide the first opportunity to examine psychotropic and opioid prescribing among hospice beneficiaries, and the factors associated with use of specific medication classes.

DESIGN

Cross-sectional analysis of a 20% sample of traditional and managed Medicare with Part D enrolled in hospice, 2014-2016.

SETTING

Beneficiaries enrolled in the Medicare hospice benefit.

PARTICIPANTS

Medicare beneficiaries ≥65 newly enrolled in hospice between July 1, 2014 and December 31, 2016 (N = 554,022).

MAIN OUTCOME

Prevalence of psychotropic and opioid medication prescribing by class and factors associated with prescribing.

RESULTS

70.3% of hospice beneficiaries were prescribed a psychotropic and 63.3% were prescribed an opioid. The most common psychotropic classes prescribed were: benzodiazepines (60.6%), antipsychotics (38.3%), antidepressants (18.4%), and antiepileptics (10.2%). Lorazepam (56.4%), morphine (52.8%), and haloperidol (28.6%) were received by the most beneficiaries. Prevalence of any psychotropic and opioid prescription was highest among beneficiaries who were female (76.7%), non-Hispanic white (76.6%), and those with cancer (78.9%). Compared to white beneficiaries, non-Hispanic black beneficiaries were less likely to receive nearly every class of medication, with significantly lower odds of receiving opioids (64.1% vs 57.9%; AOR 0.75, 95% CI 0.72-0.77) and benzodiazepines (61.6% vs 52.2%; AOR 0.66, 95% CI 0.64-0.68). Differences were seen across hospice diagnosis; those with cancer were more likely to receive opioids, benzodiazepines, and antipsychotics but less likely to receive antidepressants and antiepileptics.

CONCLUSIONS

Psychotropic and opioid medications are frequently prescribed in hospice. Observed variations in prescribing across race and ethnicity may reflect disparities in prescribing as well as patient preferences for care. Further work is important to understand factors driving prescribing given limited studies surrounding medication prescribing in hospice.

Effects of COVID-19 Pandemic on the Lived Experience of Diverse Older Adults Living Alone With Cognitive Impairment

Background and Objectives: Even before the COVID-19 pandemic, older adults with cognitive impairment living alone (an estimated 4,3 million individuals in the United States) were at high risk for negative health outcomes. There is an urgent need to learn how this population is managing during the pandemic. Research Design and Methods: This is a qualitative study of 24 adults aged 55 and over living alone with cognitive impairment from diverse racial/ethnic backgrounds. Participants’ lived experiences during the pandemic were elicited via 59 ethnographic interviews conducted over the phone either in English, Spanish, or Cantonese. Using a qualitative content analysis approach, interview transcripts and fieldnotes were analyzed to identify codes and themes. Results: Qualitative analysis of transcripts revealed five themes: 1) fear generated by the pandemic; 2) distress stemming from feeling extremely isolated; 3) belief in misinformation, 4) strategies for coping during the pandemic; and 5) the importance of access to essential services. Discussion and Implications: This pandemic put a spotlight on the precarity and unmet needs of older adults living alone with cognitive impairment living. Findings underscore the need to expand access to home care aides and mental health services for this population.

Substance Use Disorder–Related Hospitalizations and ED Use in Those Returning to Community From Prison in Later Life

High rates of substance use disorders (SUDs) in persons age 50 and older are concerning. Those reentering the community in later life after incarceration are especially at risk. We determined if later-life prison release increases risk of SUD-related hospitalizations and ED visits in a national sample of veterans (N=7,671) released from prison between 2012 to 2014 and matched never-incarcerated controls (N=7,671). Later-life prison release was associated with increased risk of any SUD-related hospitalization/ED visit (2907.1 vs. 465.0 per 100,000/year; adjusted HR=2.67; 95% CI, 2.11-3.36) and 3-fold risk of hospitalizations/ED visits due to alcohol use disorder (1955.4.1 vs. 282.6 per 100,000/year; adjusted HR=3.04; 95% CI, 2.24-4.13) and drug use disorder (1586.1 vs. 252.0 per 100,000/year; adjusted HR=3.09; 95% CI, 2.23-4.30). Those reentering the community in later life after prison are at higher risk of experiencing SUD-related hospitalizations or ED visits. Prevention and intervention efforts targeting later-life prison-to-community care transitions are needed. Part of a symposium sponsored by the Aging, Alcohol and Addictions Interest Group.

Social Incentives to Improve Mobility Among Elderly Patients After Radical Cystectomy

Radical cystectomy is a complex surgery that disproportionately affects elderly patients and is associated with high morbidity and mortality rates. We proposed a randomized control trial to improve mobility using gamification and social incentives while hospitalized, and immediately after surgery at home. Social incentives may be particularly useful in this population as the majority of cystectomy patients rely on a primary caregiver. There have been multiple challenges in this interdisciplinary work to utilize innovative technologies. This would represent one of the first use of gamification and behavioral economic principles in postoperative patients, so there are questions about how patients would respond to gamification while recovering postoperatively. There were challenges in patient selection and interdisciplinary collaboration to consider, especially in an elderly population that may not have ready mobile access. By collaborating across disciplines, we hope to make significant improvements in postoperative outcomes for elderly patients by utilizing innovative interventions.

Co-Occurrence of Lower Urinary Tract Symptoms and Frailty among Community-Dwelling Older Men

BACKGROUND/OBJECTIVES

To estimate associations between lower urinary tract symptoms (LUTS) and phenotypic frailty in older men.

DESIGN

Cross-sectional study.

SETTING

Community-dwelling men recruited from 2000 to 2002 from six U.S. academic centers for the Osteoporotic Fractures in Men Study.

PARTICIPANTS

A total of 5,979 men aged 65 and older.

MEASUREMENTS

The independent variable was LUTS severity (none/mild, moderate, or severe) assessed with the American Urologic Association Symptom Index. Participants were categorized as frail, intermediate stage, or robust using an adapted Cardiovascular Health Study index (components: low lean mass, weakness, exhaustion, slowness, and low physical activity). Associations were estimated with odds ratios and 95% confidence intervals (CIs) from multivariable multinomial logistic regression models adjusted for potential confounders of age, other demographics, health-related behaviors, and comorbidities.

RESULTS

The prevalence of frailty was 7%, 11%, and 18% among men with none/mild, moderate, and severe LUTS, respectively. Moderate and severe LUTS, overall and by storage and voiding subscores, were associated with higher odds of both intermediate stage and frailty in all models. After adjustment for confounders, the odds of frailty was 1.41 times higher among men with moderate LUTS (95% CI = 1.14-1.74) and 2.51 times higher among men with severe LUTS (95% CI = 1.76-3.55), compared with none/mild LUTS. Severe LUTS was associated with a greater odds of individual frailty components exhaustion and low physical activity.

CONCLUSION

The prevalence of phenotypic frailty is higher among older community-dwelling men with moderate or severe LUTS compared with those with mild or no LUTS. The positive association between LUTS severity and frailty among older men appears independent of age and known frailty risk factors. Although the temporal direction of this association and the utility of LUTS or frailty interventions in this population remain unclear, the high co-occurrence of these conditions could lead to earlier identification of frailty when clinically appropriate.

Frailty after lung transplantation is associated with impaired health-related quality of life and mortality

BACKGROUND

Lung transplantation and related medications are associated with pathobiological changes that can induce frailty, a state of decreased physiological reserve. Causes of persistent or emergent frailty after lung transplantation, and whether such transplant-related frailty is associated with key outcomes, are unknown.

METHODS

Frailty and health-related quality of life (HRQL) were prospectively measured repeatedly for up to 3 years after lung transplantation. Frailty, quantified by the Short Physical Performance Battery (SPPB), was tested as a time-dependent binary and continuous predictor. The association of transplant-related frailty with HRQL and mortality was evaluated using mixed effects and Cox regression models, respectively, adjusting for age, sex, ethnicity, diagnosis, and for body mass index and lung function as time-dependent covariates. We tested the association between measures of body composition, malnutrition, renal dysfunction and immunosuppressants on the development of frailty using mixed effects models with time-dependent predictors and lagged frailty outcomes.

RESULTS

Among 259 adults (56% male; mean age 55.9±12.3 years), transplant-related frailty was associated with lower HRQL. Frailty was also associated with a 2.5-fold higher mortality risk (HR 2.51; 95% CI 1.21 to 5.23). Further, each 1-point worsening in SPPB was associated, on average, with a 13% higher mortality risk (HR 1.13; 95% CI 1.04 to 1.23). Secondarily, we found that sarcopenia, underweight and obesity, malnutrition, and renal dysfunction were associated with the development of frailty after transplant.

CONCLUSIONS

Transplant-related frailty is associated with lower HRQL and higher mortality in lung recipients. Abnormal body composition, malnutrition and renal dysfunction may contribute to the development of frailty after transplant. Confirming the role of these potential contributors and developing interventions to mitigate frailty may improve lung transplant success.

Abstract 251: Geriatric Syndromes Associated With Reduced Anticoagulant Use in Older Adults With Atrial Fibrillation

Background: While guidelines recommend focusing primarily on stroke risk when considering anticoagulants in atrial fibrillation (AF), physicians report that geriatric syndromes (e.g., falls, disability) are important when considering anticoagulants. However, little is known about the prevalence of geriatric syndromes in older adults with AF or the association with anticoagulant use.

Methods: We performed a cross-sectional analysis of the 2014 Health and Retirement Study, a nationally representative study of older adults. We included patients ≥67 years with 2 years of continuous Medicare fee-for-service enrollment and 1 inpatient or 2 outpatient AF diagnosis claims. We evaluated five geriatric syndromes: falls, activities of daily living impairment (ADL), instrumental activities of daily living impairment (IADL), cognitive impairment, and incontinence. We measured their prevalence and associations with anticoagulant use via log-binomial regression models adjusting for CHA2DS2-VASc score.

Results: In this study of 779 patients with AF (median age 80 years, median CHA2DS2-VASc score 4), 83% (CI 79-86%) had ≥1 geriatric syndrome. Adjusting for stroke risk, lower rates of anticoagulant use were reported in those with ADL dependency (RR 0.87, CI 0.79-99), IADL dependency (RR 0.86, CI 0.77-0.98), and dementia (RR 0.72, CI 0.60-0.86).

Conclusion: Most older patients with AF have at least one geriatric syndrome, and geriatrics syndromes are associated with less anticoagulant use. The high prevalence of geriatric syndromes may explain the lower than expected anticoagulants use in older adults. Since the benefits and harms of anticoagulants in this group are ill-defined, it is unclear if lower anticoagulant use is appropriate.

Heterogeneous Exposure Associations in Observational Cohort Studies: The Example of Blood Pressure in Older Adults

Heterogeneous exposure associations (HEAs) can be defined as differences in the association of an exposure with an outcome among subgroups that differ by a set of characteristics. In this article, we intend to foster discussion of HEAs in the epidemiologic literature and present a variant of the random forest algorithm that can be used to identify HEAs. We demonstrate the use of this algorithm in the setting of the association between systolic blood pressure and death in older adults. The training set included pooled data from the baseline examination of the Cardiovascular Health Study (1989-1993), the Health, Aging, and Body Composition Study (1997-1998), and the Sacramento Area Latino Study on Aging (1998-1999). The test set included data from the National Health and Nutrition Examination Survey (1999-2002). The hazard ratios ranged from 1.25 (95% confidence interval: 1.13, 1.37) per 10-mm Hg increase in systolic blood pressure among men aged ≤67 years with diastolic blood pressure greater than 80 mm Hg to 1.00 (95% confidence interval: 0.96, 1.03) among women with creatinine concentration ≤0.7 mg/dL and a history of hypertension. HEAs have the potential to improve our understanding of disease mechanisms in diverse populations and guide the design of randomized controlled trials to control exposures in heterogeneous populations.

FAMILY CAREGIVER FACTORS AND SUBSEQUENT EMERGENCY DEPARTMENT UTILIZATION AMONG OLDER ADULTS WITH DISABILITY

Community-living older adults with disability are frequent Emergency Department (ED) users and most rely on family caregiver support. However, no prior research has examined associations between caregiver characteristics and subsequent ED utilization among older adults. We draw on a sample of 2,521 community-living older adults with mobility/self-care disability and their primary family caregivers to identify caregiver characteristics associated with all-cause or potentially preventable ED use. We use Cox proportional hazards regression to separately model the likelihood of all-cause and potentially preventable ED use as a function of caregiver characteristics. Models account for competing risk of mortality and adjust for measures of older adults’ socio-demographic characteristics, health status, and survey wave. About half (52.5%) of older adults incurred 1+ ED visit and 26.8% incurred 1+ potentially preventable ED visit within 12 months of interview. Adjusting for survey wave and older adult sociodemographic characteristics and health status, older adults were at greater risk of all-cause ED use if their primary caregiver provided greater than 40 hours of care per week (HR: 1.22, 95% CI: 1.04-1.43; p=0.02), helped with health care tasks (HR: 1.26; 95% CI: 1.08-1.46; p<0.01), or experienced physical strain (HR: 1.18; 95% CI: 1.03-1.36; p=0.02). Older adults were at greater risk of potentially preventable ED use if their primary caregiver helped with health care tasks (HR: 1.25; 95% CI: 1.02-1.54; p=0.03). Findings highlight the relevance of caregiver factors to older adults’ ED use and suggest the need for assessment and support of family caregivers in the care delivery setting.

FAMILY CAREGIVER FACTORS AND HOSPITALIZATION IN DISABLED OLDER ADULTS WITH AND WITHOUT DEMENTIA

Older adults with disabilities commonly rely on family caregivers’ help, yet effects of caregiver factors on patient outcomes are poorly understood. Within this population, dementia is common. Our objective was to evaluate the association between caregiver factors and risk of hospitalization in disabled older adults with and without dementia. We examined 2,589 community-living older adults with mobility/self-care disability and their primary family caregiver in four waves of the National Long-Term Care Survey and National Health and Aging Trends Study. We used Cox proportional hazards models to examine risk of one-year, Medicare claims-derived, all-cause hospitalization as a function of caregiver factors, adjusting for older adult characteristics (sociodemographics, comorbidities, healthcare utilization) and survey year, considering dementia a characteristic of interest. Among disabled older adults, 38% were hospitalized over one year, and 31% had probable dementia. Hospitalization rates were similar for older adults with and without dementia (39.5% and 37.3% respectively); dementia was not associated with hospitalization risk (HR 1.09, 95% CI 0.95-1.26). Older adults demonstrated greater risk of hospitalization if their caregiver was male (HR 1.31, 95% CI 1.10-1.56), new to caregiving (HR 1.61, 95% CI 1.27-2.04 for &lt; 1 year versus ≥ 4 years), or helped with healthcare tasks (HR 1.21, 95% CI 1.04-1.41). The association between most caregiving factors and hospitalization risk did not differ by dementia status. Results suggest that strategies to reduce hospitalization in older adults with disabilities could target select caregivers using similar strategies in populations with and without dementia.

GERIATRIC MEASURES AS PREDICTORS OF 1-YEAR MORTALITY IN MAJOR SURGERY PATIENTS

A growing proportion of older adults are undergoing major surgery despite the higher risk of post-operative mortality. Geriatric measures (i.e. physical, cognitive, and psychosocial function) are often not included in studies evaluating post-operative outcomes in older adults. Our goal was to determine the association of geriatric measures and 1-year mortality in older adults after major surgery. We analyzed longitudinal data from the Health and Retirement Study linked to Medicare claims (N=1364 participants), age ≥ 65 and who underwent abdominal aortic aneurysm [AAA] repair, coronary artery bypass graft [CABG], or colectomy. Our outcome was mortality within 1 year of the major operation. Predictors included the following geriatric measures: dependence in activities of daily living (ADL), dependence in independent activities of daily living (IADL), mobility ability, and dementia, and depression. We analyzed using multivariate cox proportional hazard models. Mean participant age was 76±6 years, 56% were women, 11% underwent a AAA repair, 50% CABG, 40% colectomy; 18% died within 1 year of their major operation. After adjusting for age, comorbidity burden, surgical type, gender, race, wealth, income, and education, the following measures were significantly associated with 1-year mortality: depression (adjusted HR (aHR): 1.53, p=0.03), dementia (aHR: 1.90, p=0.03), >1 ADL dependence (aHR: 2.35, p<0.01), >1 IADL dependence (aHR: 1.95, p<0.01), and inability to walk several blocks (aHR: 1.69, p<0.01). In this cohort, 18% of participants who underwent major surgery died within 1 year and function, cognition, and psychological well-being were significantly associated with mortality. These measures should be incorporated into pre-operative assessment.

INTRODUCING ARTIFICIAL COMPANIONS TO USERS WITH DEMENTIA IN UNREGULATED MARKETS: OPPORTUNITIES VS. ETHICAL ISSUES

Because of the high costs of providing long-term care, artificial companions are increasingly considered an opportunity to provide support to older adults with cognitive impairment while saving costs. Artificial companion can comfort and inform, thus inducing a sense of being in a relationship. Sensors and algorithms usually allow these applications to exude a life-like feel. The explosion of these technologies has created a “cultural lag” between their rapid commercial introduction and the slower evolution of regulations. An outcome of this cultural lag is a tension between the potential of artificial companions to support users and a series of unresolved ethical issues related to the fact that users might lack the capacity to fully understand the implications of using these technologies. Specific challenges of deception, surveillance, consent and social isolation are raised by the introduction of these technologies in users with cognitive impairment. The case study of a sophisticated artificial companion commercially available in the United States lends the opportunity to examine the tension between the potential of this technologies vs. unresolved ethical issues. This companion is an avatar on an electronic tablet that is displayed as a dog or a cat. Whereas artificial intelligence guides most artificial companions, this application is a hybrid of robots and human beings because it also relies on technicians “behind” the on-screen avatar, who via surveillance, interact with users. We conclude with a call to develop regulations promoting artificial companions as “human-driven technologies,” i.e. technologies focused on truly empowering users according to their cognitive abilities.

Functional Status and Survival After Breast Cancer Surgery in Nursing Home Residents

Importance

Breast cancer surgery, the most common cancer operation performed in nursing home residents, is viewed as a low-risk surgical intervention. However, outcomes in patients with high functional dependence and limited life expectancy are poorly understood.

Objective

To assess the overall survival and functional status changes after breast cancer surgery in female nursing home residents stratified by surgery type.

Design, Setting, and Participants

This study used Medicare claims from 2003 to 2013 to identify 5969 US nursing home residents who underwent inpatient breast cancer surgery. Using the Minimum Data Set Activities of Daily Living (MDS-ADL) summary score, this study examined preoperative and postoperative function and identified patient characteristics associated with 30-day and 1-year mortality and 1-year functional decline after surgery. Cox proportional hazards regression was used to estimate unadjusted and adjusted hazard ratios (HRs) of mortality. Fine-Gray competing risks regression was used to estimate unadjusted and adjusted subhazard ratios (sHRs) of functional decline. Statistical analysis was performed from January 2016 to January 2018.

Main Outcomes and Measures

Functional status and death.

Results

From 2003 to 2013, a total of 5969 female nursing home residents (mean [SD] age, 82 [7] years; 4960 [83.1%] white) underwent breast cancer surgery: 666 (11.2%) underwent lumpectomy, 1642 (27.5%) underwent mastectomy, and 3661 (61.3%) underwent lumpectomy or mastectomy with axillary lymph node dissection (ALND). The 30-day mortality rates were 8% after lumpectomy, 4% after mastectomy, and 2% after ALND. The 1-year mortality rates were 41% after lumpectomy, 30% after mastectomy, and 29% after ALND. Among 1-year survivors, the functional decline rate was 56% to 60%. The mean MDS-ADL score increased (signifying greater dependency) by 3 points for lumpectomy, 4 points for mastectomy, and 5 points for ALND. In multivariate analysis, poor baseline MDS-ADL score (range, 20-28) was associated with a higher 1-year mortality risk (lumpectomy: HR, 1.92 [95% CI, 1.23-3.00], P = .004; mastectomy: HR, 1.80 [95% CI, 1.35-2.39], P < .001; and ALND: HR, 1.77 [95% CI, 1.46-2.15], P < .001). After multivariate adjustment, preoperative decline in MDS-ADL score (lumpectomy: sHR, 1.59 [95% CI, 1.25-2.03], P < .001; mastectomy: sHR, 1.79; [95% CI, 1.52-2.09], P < .001; and ALND: sHR, 1.72 [95% CI, 1.56-1.91], P < .001) and cognitive impairment (lumpectomy: sHR, 1.27 [95% CI, 1.03-1.56], P = .02; mastectomy: sHR, 1.26 [95% CI, 1.09-1.45], P = .002; and ALND: sHR, 1.14 [95% CI, 1.04-1.24], P = .003) were significantly associated with 1-year functional decline across all breast cancer surgery groups.

Conclusions and Relevance

For female nursing home residents who underwent breast cancer surgery, 30-day mortality and survival as well as 1-year mortality and functional decline were high. The 1-year survivors had significant functional decline. This study's findings suggest that this information should be incorporated into collaborative surgical decision-making processes.

A multiyear cross-sectional study of U.S. national prescribing patterns of first-generation sedating antihistamines in older adults with skin disease

BACKGROUND

First-generation antihistamines (FGAs) are classified as 'potentially inappropriate' for use in older patients (patients aged ≥ 65 years). However, the prevalence of and factors associated with FGA prescription have not been studied.

OBJECTIVES

To examine FGA prescription rates for older patients who visited dermatology offices, and compare them to those for younger patients (patients aged 18-65 years) who visited dermatology offices and those for older patients who visited primary-care physicians (PCPs).

METHODS

This was a multiyear cross-sectional observational study using data from the U.S. National Ambulatory Medical Care Survey (2006-2015). Visits by patients aged 18 years or older were included in the study; the data comprised 15 243 dermatology office visits and 66 036 PCP office visits. The main outcome was FGA prescription. Other variables included physician specialty (dermatologist or PCP), patient's age, diagnosis of dermatological conditions and reason for visit.

RESULTS

For dermatology visits, the overall FGA prescription rate for older patients was similar to that for younger patients (1·5% vs. 1·2%; P = 0·19), even when the diagnosis was dermatitis or pruritus (3·7% vs. 4·8%; P = 0·21) or when itch was a complaint (7·6% vs. 6·7%; P = 0·64). However, the rate of FGA prescription for dermatology visits was lower than that for PCP visits, in analyses matched for patient and visit characteristics (3·9% vs. 7·4%; P = 0·02).

CONCLUSIONS

Our findings suggest that FGAs are overprescribed to older patients but that dermatologists are less likely to prescribe FGAs than PCPs. What's already known about this topic? First-generation antihistamines (FGAs) have been shown to pose substantial risks to older adults, including cognitive impairment, falls, confusion, dry mouth and constipation. Therefore, FGAs have been classified as 'potentially inappropriate' for use in older patients by the American Geriatrics Society. It has also been shown that dermatologists do not always take patient characteristics (e.g. age or life expectancy) into account when deciding on a treatment, instead following a 'one-size-fits-all' approach. What does this study add? FGAs are often prescribed during dermatology visits, and prescription rates do not differ between older and younger patients. There were no significant differences in prescription rates when comparing younger and older adults with the same diagnosis or symptom (e.g. dermatitis, pruritus or itch). FGAs are prescribed at higher rates in primary-care offices than in dermatology offices.

Family Caregivers of Older Adults, 1999-2015: Trends in Characteristics, Circumstances, and Role-Related Appraisal

Purpose of Study

To assess trends in family caregiving between 1999 and 2015.

Design and Methods

We construct nationally representative profiles of community-dwelling older adults receiving help with self-care or indoor mobility and their "primary" family or unpaid caregiver using the 1999 and 2004 National Long Term Care Survey, 2011 and 2015 National Health and Aging Trends Study, and linked caregiver surveys. Trends are examined.

Results

Older adults receiving help were incrementally younger, more racially diverse, and better educated in 2015. Primary caregivers overwhelmingly continued to be spouses and adult children. Arrangements were increasingly 4 years or longer in duration (shifting from 44.8% in 1999 to 60.5% by 2015). On average, primary caregivers provided about or in excess of 30 hr per week at all four time points. Spouses provided fewer hours of care, were twice as likely to work, and half as likely to report substantial emotional, physical, and financial difficulty due to caregiving in 2015 than 1999. Adult children provided comparable hours of care to a more impaired population; a similar proportion reported substantial caregiving-related difficulty at each time. Use of respite care nearly doubled from 8.5% in 1999 to 15.7% in 2015. Dementia caregivers were less likely to report substantial physical and financial difficulty and more likely to use respite care in 2015 than 1999.

Implications

Family caregivers' circumstances generally improved during the 16-year period. Results diverge from prevailing concerns regarding the state of family caregiving and demonstrate the importance of longitudinally monitoring trends in late-life family caregiving.

Frailty trajectories in adult lung transplantation: A cohort study

BACKGROUND

Frailty is common in adults with advanced lung disease and is associated with death before and after lung transplantation. We aimed to determine whether frailty changes from before to after the lung transplant.

METHODS

In a single-center, prospective cohort study among adults undergoing lung transplantation from 2010 to 2017, we assessed frailty by the Short Physical Performance Battery (SPPB; higher scores reflect less frailty) and Fried Frailty Phenotype (FFP; higher scores reflect greater frailty) before and repeatedly up to 36 months after transplant. We tested for changes in frailty scores over time using segmented mixed effects models, adjusting for age, sex, and diagnosis. We quantified the proportion of subjects transitioning between frailty states (frail vs not frail) from before to after the transplant.

RESULTS

In 246 subjects, changes in frailty occurred within the first 6 post-operative months and remained stable thereafter. The overall change in frailty was attributable to improvements among those subjects who were frail before transplant. They experienced a 5.1-point improvement in SPPB (95% confidence interval [CI] 4.6-5.7) and a 1.8-point improvement in FFP (95% CI -2.1 to -1.6) during the early period. Frailty by SPPB and FFP did not change in those who were not frail before transplant. Approximately 84% of survivors who were frail before transplant became not frail after transplant.

CONCLUSIONS

Pre-operative frailty resolves in many patients after lung transplantation. Because a large proportion of frailty may be attributable to advanced lung disease, frailty alone should not be an absolute contraindication to transplantation.

Who Take Naps? Self-Reported and Objectively Measured Napping in Very Old Women

Background

Despite the widespread belief that napping is common among older adults, little is known about the correlates of napping. We examined the prevalence and correlates of self-reported and objectively measured napping among very old women.

Methods

We studied 2,675 community-dwelling women (mean age 84.5 ± 3.7 years; range 79-96). Self-reported napping was defined as a report of regular napping for ≥1 hour per day. Individual objective naps were defined as ≥5 consecutive minutes of inactivity as measured by actigraphy and women were characterized as "objective nappers" if they had at least 60 minutes of naps per day.

Results

Seven percent of the women only had self-reported napping, 29% only had objective napping, and 14% met the criteria for both. Multinomial logistic regression showed that the independent correlates of "both subjective and objective napping" were age (per 5 year odds ratio [OR] = 1.59; 95% CI: 1.31-1.93), depressive symptoms (per SD of score, OR = 1.53; 1.32-1.77), obesity (OR =1.93; 1.42-2.61), current smoking (OR = 3.37; 1.56-7.30), heavier alcohol drinking (OR = 0.49; 0.34-0.71), history of stroke (OR = 1.56; 1.08-2.26), diabetes (OR = 2.40; 1.61-3.57), dementia (OR = 3.31; 1.27-8.62), and Parkinson's disease (OR = 7.43; 1.87-29.50). Besides, having objective napping alone was associated with age and diabetes, whereas subjective napping was associated with stroke and myocardial infarction. These associations were independent of nighttime sleep duration and fragmentation.

Conclusions

Daytime napping is very common in women living in their ninth decade and both subjective and objective napping were significantly related to age and comorbidities. Future studies are needed to better understand napping and its health implications.

Family Caregiver Factors Associated With Emergency Department Utilization Among Community-Living Older Adults With Disabilities

Background: Older adults with disability are frequent users of the emergency department (ED) and often rely on family caregiver support. We identify whether and which caregiver characteristics are associated with older adults' ED use. Methods: We use Cox proportional hazards regression to model the likelihood of all-cause ED use (defined as 1 or more visits within 12 months of survey) as a function of caregiver characteristics after adjusting for older adult sociodemographic and health characteristics. We draw from linked older adult and caregiver surveys and administrative claims, creating a sample of 2521 community-living older adults with mobility/self-care disability receiving care from a family or unpaid caregiver. Results: About half (52.5%) of older adults receiving mobility or self-care help incurred 1 or more ED visits within 12 months of interview. Adjusting for year of data collection, sociodemographic characteristics, and health status, these older adults were at greater risk of all-cause ED use if their primary caregiver provided greater than 40 hours of care per week (hazard ratio [HR] 1.22, 95% CI 1.04-1.43; P = .02), helped with health care tasks (HR 1.26; 95% CI 1.08-1.46; P < .01), or experienced physical strain (HR 1.18; 95% CI 1.03-1.36; P = .02). Conclusion: Caregiver strain, helping with health care tasks, and greater hours of help per week are associated with heightened risk of ED use among older adults receiving mobility or self-care help. Study findings suggest the potential benefit of caregiver assessment and support.

Geriatrics Literature 2017 Year in Review

We present 11 of the most effective articles from 2017 in geriatric medicine. Studies address topics including self-driven advance care planning, unnecessary emergency department transfers from assisted living, effect of transcatheter aortic valve implantation on cognition, a modified Hospital Elder Life Program to reduce delirium after surgery, patient experience and provider understanding of nursing home placement, patient perspectives on recommendations to stop cancer screening, management of subclinical hypothyroidism, reduction of inappropriate medications in nursing homes, effect of lorazepam on end-of-life agitated delirium, and benefits of a novel exercise program on walking.