Improving measurement of functional status among older adults in primary care: A pilot study

Despite its importance for clinical care and outcomes among older adults, functional status-the ability to perform basic activities of daily living (ADLs) and instrumental ADLs (IADLs)-is seldom routinely measured in primary care settings. The objective of this study was to pilot test a person-centered, interprofessional intervention to improve identification and management of functional impairment among older adults in Veterans Affairs (VA) primary care practices. The four-component intervention included (1) an interprofessional educational session; (2) routine, standardized functional status measurement among patients aged ≥75; (3) annual screening by nurses using a standardized instrument and follow-up assessment by primary care providers; and (4) electronic tools and templates to facilitate increased identification and improved management of functional impairment. Surveys, semi-structured interviews, and electronic health record data were used to measure implementation outcomes (appropriateness, acceptability and satisfaction, feasibility, fidelity, adoption/reach, sustainability). We analyzed qualitative interviews using rapid qualitative analysis. During the study period, all 959 eligible patients were screened (100% reach), of whom 7.3% (n = 58) reported difficulty or needing help with ≥1 ADL and 11.8% (n = 113) reported difficulty or needing help with ≥1 IADL. In a chart review among a subset of 50 patients with functional impairment, 78% percent of clinician notes for the visit when screening was completed had content related to function, and 48% of patients had referrals ordered to address impairments (e.g., physical therapy) within 1 week. Clinicians highly rated the quality of the educational session and reported increased ability to measure and communicate about function. Clinicians and patients reported that the intervention was appropriate, acceptable, and feasible to complete, even during the COVID pandemic. These findings suggest that this intervention is a promising approach to improve identification and management of functional impairment for older patients in primary care. Broader implementation and evaluation of this intervention is currently underway.

Mortality Among Older Medical Patients at Flagship Hospitals and Their Affiliates

BACKGROUND

We define a "flagship hospital" as the largest academic hospital within a hospital referral region and a "flagship system" as a system that contains a flagship hospital and its affiliates. It is not known if patients admitted to an affiliate hospital, and not to its main flagship hospital, have better outcomes than those admitted to a hospital outside the flagship system but within the same hospital referral region.

OBJECTIVE

To compare mortality at flagship hospitals and their affiliates to matched control patients not in the flagship system but within the same hospital referral region.

DESIGN

A matched cohort study PARTICIPANTS: The study used hospitalizations for common medical conditions between 2018-2019 among older patients age ≥ 66 years. We analyzed 118,321 matched pairs of Medicare patients admitted with pneumonia (N=57,775), heart failure (N=42,531), or acute myocardial infarction (N=18,015) in 35 flagship hospitals, 124 affiliates, and 793 control hospitals.

MAIN MEASURES

30-day (primary) and 90-day (secondary) all-cause mortality.

KEY RESULTS

30-day mortality was lower among patients in flagship systems versus control hospitals that are not part of the flagship system but within the same hospital referral region (difference= -0.62%, 95% CI [-0.88%, -0.37%], P<0.001). This difference was smaller in affiliates versus controls (-0.43%, [-0.75%, -0.11%], P=0.008) than in flagship hospitals versus controls (-1.02%, [-1.46%, -0.58%], P<0.001; difference-in-difference -0.59%, [-1.13%, -0.05%], P=0.033). Similar results were found for 90-day mortality.

LIMITATIONS

The study used claims-based data.

CONCLUSIONS

In aggregate, within a hospital referral region, patients treated at the flagship hospital, at affiliates of the flagship hospital, and in the flagship system as a whole, all had lower mortality rates than matched controls outside the flagship system. However, the mortality advantage was larger for flagship hospitals than for their affiliates.

"I'll fill in the gaps": perspectives of HHAs on promoting aging in place for older adults with low incomes

Older adults with low incomes experience disproportionate rates of cognitive and functional impairment and an elevated risk of nursing home admission. Home health aides (HHAs) may have insight into how to optimize aging in place for this population, yet little is known about HHAs' perspectives on this topic. We conducted 6 focus groups with 21 English-speaking and 10 Spanish-speaking HHAs in Pennsylvania and New Jersey. Transcripts were analyzed using qualitative thematic analysis, and three themes emerged. First, HHAs described the uniqueness of their role within multidisciplinary care teams. Second, HHAs shared concrete interventions they employ to help their clients improve their function at home. Third, HHAs discussed barriers they face when helping clients age in place. Our findings suggest that HHAs have important insights into improving aging in place for older adults with low incomes and that their perspectives should be incorporated into care planning and intervention delivery.

Caring for Patients with Functional Impairment in Middle Age: Perspectives from Primary Care Providers and Geriatricians

BACKGROUND

The prevalence of functional impairment is increasing among middle-aged adults and is associated with adverse health outcomes. Primary care providers (PCPs) and geriatricians may have important insights about optimal approaches to caring for these patients, but little is known about their perspectives.

OBJECTIVE

To examine PCPs' and geriatricians' perspectives on clinical needs and optimal approaches to care for middle-aged patients with functional impairment.

DESIGN

Qualitative study using semi-structured interviews.

PARTICIPANTS

PCPs and geriatricians from outpatient practices in the San Francisco Bay area.

APPROACH

Interviews focused on characteristics and care needs of middle-aged patients with functional impairment and models of care to address these needs. We analyzed interviews using hybrid deductive-inductive qualitative thematic analysis.

KEY RESULTS

Clinicians (14 PCPs, 15 geriatricians) described distinct characteristics of functional impairment in middle-aged versus older adults, such as different rates of onset, but similar clinical needs. Despite these similar needs, clinicians identified age-specific barriers to delivering optimal care to middle-aged patients. These included system-level challenges such as limited access to insurance and social services; practice- and clinician-level barriers including inadequate clinician training; and patient-level factors including less access to family caregivers and perceptions of stigma. To overcome these challenges, clinicians suggested clinical approaches including addressing health-related social needs within healthcare systems; implementing practice-based models that are multi-disciplinary, team-based, and coordinated; training clinicians to effectively manage functional impairment; and expanding community-based services and supports to help patients navigate the medical system. Identified needs, challenges, and solutions were generally similar across geriatricians and PCPs.

CONCLUSIONS

Clinicians face challenges in delivering optimal care to middle-aged patients who have functional impairments similar to their older counterparts but lack access to services and supports available to older people. These findings suggest the importance of increasing access to care models that address functional impairment regardless of age.

Reducing Falls in Older Women with Urinary Incontinence

Urinary incontinence is common in older women and doubles the risk of falls in this population. The association between urinary incontinence, especially urgency urinary incontinence, and falls is multifactorial and likely the result of a complex interaction between physical, mental, social, and environmental factors. As a result of this multifactorial etiology and based on existing evidence, the integration of different fall prevention strategies including strength and resistance exercises, bladder training, and home hazard reduction have the potential to decrease the risk of falls in older women with urinary incontinence. Given the prevalence of urinary incontinence and the significant morbidity associated with falls, effective interventions to reduce fall risk in older women with urinary incontinence is of high public health significance.

"You Need to Keep It Going, Mind, Body, and Spirit": Older Adults' Perspectives on Aging in Place in Subsidized Housing

In the U.S., more than one million older adults with low incomes live in apartment buildings subsidized by the Low-Income Housing Tax Credit. Although this population experiences disproportionate rates of nursing home admission, little is known about residents' perspectives on factors that influence their ability to live independently in these settings. Fifty-eight residents aged 62 and older and eight study partners participated in qualitative interviews about their perspectives on living independently in subsidized housing, including barriers and facilitators. We analyzed transcripts using a hybrid inductive and deductive approach to qualitative thematic analysis. Barriers and facilitators for living independently in subsidized housing related to the influence of the social and physical environment on individuals' experiences of living independently, including factors unique to subsidized housing. Findings suggest how interventions to optimize functional status and promote independence among older adults living in subsidized housing can build on existing strengths of the subsidized housing environment to improve outcomes.

Epigenetic age and socioeconomic status contribute to racial disparities in cognitive and functional aging between Black and White older Americans

Epigenetic age, a biological aging marker measured by DNA methylation, is a potential mechanism by which social factors drive disparities in age-related health. Epigenetic age gap is the residual between epigenetic age measures and chronological age. Previous studies showed associations between epigenetic age gap and age-related outcomes including cognitive capacity and performance on some functional measures, but whether epigenetic age gap contributes to disparities in these outcomes is unknown. We use data from the Health and Retirement Study to examine the role of epigenetic age gap in racial disparities in cognitive and functional outcomes and consider the role of socioeconomic status (SES). Epigenetic age measures are GrimAge or Dunedin Pace of Aging methylation (DPoAm). Cognitive outcomes are cross-sectional score and two-year change in Telephone Interview for Cognitive Status (TICS). Functional outcomes are prevalence and incidence of limitations performing Instrumental Activities of Daily Living (IADLs). We find, relative to White participants, Black participants have lower scores and greater decline in TICS, higher prevalence and incidence rates of IADL limitations, and higher epigenetic age gap. Age- and gender-adjusted analyses reveal that higher GrimAge and DPoAm gap are both associated with worse cognitive and functional outcomes and mediate 6-11% of racial disparities in cognitive outcomes and 19-39% of disparities in functional outcomes. Adjusting for SES attenuates most DPoAm associations and most mediation effects. These results support that epigenetic age gap contributes to racial disparities in cognition and functioning and may be an important mechanism linking social factors to disparities in health outcomes.

Using multiple qualitative methods to inform intervention development: Improving functional status measurement for older veterans in primary care settings

Functional status, or the ability to perform activities of daily living, is central to older adults' health and quality of life. However, health systems have been slow to incorporate routine measurement of function into patient care. We used multiple qualitative methods to develop a patient-centered, interprofessional intervention to improve measurement of functional status for older veterans in primary care settings. We conducted semi-structured interviews with patients, clinicians, and operations staff (n = 123) from 7 Veterans Health Administration (VHA) Medical Centers. Interviews focused on barriers and facilitators to measuring function. We used concepts from the Consolidated Framework for Implementation Science and sociotechnical analysis to inform rapid qualitative analyses and a hybrid deductive/inductive approach to thematic analysis. We mapped qualitative findings to intervention components. Barriers to measurement included time pressures, cumbersome electronic tools, and the perception that measurement would not be used to improve patient care. Facilitators included a strong interprofessional environment and flexible workflows. Findings informed the development of five intervention components, including (1) an interprofessional educational session; (2) routine, standardized functional status measurement among older patients; (3) annual screening by nurses using a standardized instrument and follow-up assessment by primary care providers; (4) electronic tools and templates to facilitate increased identification and improved management of functional impairment; and (5) tailored reports on functional status for clinicians and operations leaders. These findings show how qualitative methods can be used to develop interventions that are more responsive to real-world contexts, increasing the chances of successful implementation. Using a conceptually-grounded approach to intervention development has the potential to improve patient and clinician experience with measuring function in primary care.

Contributions of neighborhood social environment and air pollution exposure to Black-White disparities in epigenetic aging

Racial disparities in many aging-related health outcomes are persistent and pervasive among older Americans, reflecting accelerated biological aging for Black Americans compared to White, known as weathering. Environmental determinants that contribute to weathering are poorly understood. Having a higher biological age, measured by DNA methylation (DNAm), than chronological age is robustly associated with worse age-related outcomes and higher social adversity. We hypothesize that individual socioeconomic status (SES), neighborhood social environment, and air pollution exposures contribute to racial disparities in DNAm aging according to GrimAge and Dunedin Pace of Aging methylation (DPoAm). We perform retrospective cross-sectional analyses among 2,960 non-Hispanic participants (82% White, 18% Black) in the Health and Retirement Study whose 2016 DNAm age is linked to survey responses and geographic data. DNAm aging is defined as the residual after regressing DNAm age on chronological age. We observe Black individuals have significantly accelerated DNAm aging on average compared to White individuals according to GrimAge (239%) and DPoAm (238%). We implement multivariable linear regression models and threefold decomposition to identify exposures that contribute to this disparity. Exposure measures include individual-level SES, census-tract-level socioeconomic deprivation and air pollution (fine particulate matter, nitrogen dioxide, and ozone), and perceived neighborhood social and physical disorder. Race and gender are included as covariates. Regression and decomposition results show that individual-level SES is strongly associated with and accounts for a large portion of the disparity in both GrimAge and DPoAm aging. Higher neighborhood deprivation for Black participants significantly contributes to the disparity in GrimAge aging. Black participants are more vulnerable to fine particulate matter exposure for DPoAm, perhaps due to individual- and neighborhood-level SES, which may contribute to the disparity in DPoAm aging. DNAm aging may play a role in the environment "getting under the skin", contributing to age-related health disparities between older Black and White Americans.

Study protocol: Type III hybrid effectiveness-implementation study implementing Age-Friendly evidence-based practices in the VA to improve outcomes in older adults

BACKGROUND

Unmet care needs among older adults accelerate cognitive and functional decline and increase medical harms, leading to poorer quality of life, more frequent hospitalizations, and premature nursing home admission. The Department of Veterans Affairs (VA) is invested in becoming an "Age-Friendly Health System" to better address four tenets associated with reduced harm and improved outcomes among the 4 million Veterans aged 65 and over receiving VA care. These four tenets focus on "4Ms" that are fundamental to the care of older adults, including (1) what Matters (ensuring that care is consistent with each person's goals and preferences); (2) Medications (only using necessary medications and ensuring that they do not interfere with what matters, mobility, or mentation); (3) Mentation (preventing, identifying, treating, and managing dementia, depression, and delirium); and (4) Mobility (promoting safe movement to maintain function and independence). The Safer Aging through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) seeks to implement four evidence-based practices (EBPs) that have shown efficacy in addressing these core tenets of an "Age-Friendly Health System," leading to reduced harm and improved outcomes in older adults.

METHODS

We will implement four EBPs in 9 VA medical centers and associated outpatient clinics using a type III hybrid effectiveness-implementation stepped-wedge trial design. We selected four EBPs that align with Age-Friendly Health System principles: Surgical Pause, EMPOWER (Eliminating Medications Through Patient Ownership of End Results), TAP (Tailored Activities Program), and CAPABLE (Community Aging in Place - Advancing Better Living for Elders). Guided by the Pragmatic Robust Implementation and Sustainability Model (PRISM), we are comparing implementation as usual vs. active facilitation. Reach is our primary implementation outcome, while "facility-free days" is our primary effectiveness outcome across evidence-based practice interventions.

DISCUSSION

To our knowledge, this is the first large-scale randomized effort to implement "Age-Friendly" aligned evidence-based practices. Understanding the barriers and facilitators to implementing these evidence-based practices is essential to successfully help shift current healthcare systems to become Age-Friendly. Effective implementation of this project will improve the care and outcomes of older Veterans and help them age safely within their communities.

TRIAL REGISTRATION

Registered 05 May 2021, at ISRCTN #60,657,985.

REPORTING GUIDELINES

Standards for Reporting Implementation Studies (see attached).

Defining Multimorbidity in Older Patients Hospitalized with Medical Conditions

BACKGROUND

The term "multimorbidity" identifies high-risk, complex patients and is conventionally defined as ≥2 comorbidities. However, this labels almost all older patients as multimorbid, making this definition less useful for physicians, hospitals, and policymakers.

OBJECTIVE

Develop new medical condition-specific multimorbidity definitions for patients admitted with acute myocardial infarction (AMI), heart failure (HF), and pneumonia patients. We developed three medical condition-specific multimorbidity definitions as the presence of single, double, or triple combinations of comorbidities - called Qualifying Comorbidity Sets (QCSs) - associated with at least doubling the risk of 30-day mortality for AMI and pneumonia, or one-and-a-half times for HF patients, compared to typical patients with these conditions.

DESIGN

Cohort-based matching study PARTICIPANTS: One hundred percent Medicare Fee-for-Service beneficiaries with inpatient admissions between 2016 and 2019 for AMI, HF, and pneumonia.

MAIN MEASURES

Thirty-day all-location mortality KEY RESULTS: We defined multimorbidity as the presence of ≥1 QCS. The new definitions labeled fewer patients as multimorbid with a much higher risk of death compared to the conventional definition (≥2 comorbidities). The proportions of patients labeled as multimorbid using the new definition versus the conventional definition were: for AMI 47% versus 87% (p value<0.0001), HF 53% versus 98% (p value<0.0001), and pneumonia 57% versus 91% (p value<0.0001). Thirty-day mortality was higher among patients with ≥1 QCS compared to ≥2 comorbidities: for AMI 15.0% versus 9.5% (p<0.0001), HF 9.9% versus 7.0% (p <0.0001), and pneumonia 18.4% versus 13.2% (p <0.0001).

CONCLUSION

The presence of ≥2 comorbidities identified almost all patients as multimorbid. In contrast, our new QCS-based definitions selected more specific combinations of comorbidities associated with substantial excess risk in older patients admitted for AMI, HF, and pneumonia. Thus, our new definitions offer a better approach to identifying multimorbid patients, allowing physicians, hospitals, and policymakers to more effectively use such information to consider focused interventions for these vulnerable patients.

When Functional Impairment Develops Early: Perspectives from Middle-Aged Adults

BACKGROUND

Difficulty performing basic daily activities such as bathing and dressing ("functional impairment") affects more than 15% of middle-aged people, and this proportion is increasing. Little is known about the experiences and needs of individuals who develop functional impairment in middle age.

OBJECTIVE

To examine the experiences and needs of adults who developed functional impairment in middle age.

DESIGN

Qualitative study using semi-structured interviews.

PARTICIPANTS

Forty patients aged 50-64 years who developed functional impairment in middle age, recruited from four primary care clinics in San Francisco.

APPROACH

Interviews included open-ended questions about participants' daily life, ability to perform activities of daily living (ADLs), and needs related to functional impairment. We analyzed interviews using qualitative thematic analysis.

KEY RESULTS

Interviews revealed several themes related to the psychosocial and physical impacts of developing functional impairment in middle age. Participants noted that losses associated with functional impairment, such as loss of independence, control, and social roles, caused conflict in their sense of identity. To cope with these losses, participants used strategies including acceptance, social comparison, adjusting standards, and engaging in valued life activities. Participants reflected on the intersection of their functional impairment with the aging process, noting that their impairments seemed premature compared to the more "natural" aging process in older adults. In terms of physical impacts, participants described how a lack of accommodations in the built environment exacerbated their impairments. While participants used behavioral strategies to overcome these challenges, unmet needs remained, resulting in downstream physical and psychological impacts including safety risks, falls, frustration, and fear.

CONCLUSIONS

Unmet psychosocial and physical needs were common among middle-aged adults with functional impairment and led to negative downstream effects. Eliciting and addressing unmet needs may help mitigate downstream health consequences for this growing population, optimizing function and quality of life.

Achieving and sustaining behavior change for older adults: A Research Centers Collaborative Network workshop report

Modifying unhealthy behaviors and/or environments may improve or maintain an older adult's health. However, achieving and sustaining behavior change is challenging and depends upon clinical, social, psychological, and political domains. In an effort to highlight the multidisciplinary nature of behavior change, the NIA Research Centers Collaborative Network (RCCN) held a two-day workshop, Achieving and sustaining behavior change for older adults. The workshop was informed by the socioecological model and designed to initiate dialogue around individual, community, and systems-level determinants of behavior change. This paper summarizes key topics presented during the workshop, discusses opportunities for future research, education, and training, and recommends how each of the six NIA research centers may pursue work in behavior change for older adults.

Benzodiazepine and antipsychotic use among hospitalized older adults before versus after restricting visitation: March to May 2020

BACKGROUND

Hospital visitation restrictions during the COVID-19 pandemic prompted concerns about unintended consequences for older patients, including an increased incidence of delirium and agitation. While first-line interventions for these conditions are non-pharmacologic, a lack of family support could result in increased use of benzodiazepines and antipsychotics, which are associated with poor outcomes in older adults. Little is known about the association of visitation policies with use of these medications among older adults.

METHODS

We conducted a retrospective cross-sectional study among adults aged ≥65 hospitalized from March 1 through May 31, 2020 at four hospitals in the Mid-Atlantic. The dates of onset of visitation restrictions (i.e., hospital-wide guidelines barring visitors) were collected from hospital administrators. Outcomes were use of benzodiazepines and antipsychotics, assessed using patient-level electronic health record data. Using multivariable logistic regression with hospital and study-day fixed effects, the quasi-experimental study design leveraged the staggered onset of visitation restrictions across the hospitals to measure the odds of receiving each medication when visitors were versus were not allowed.

RESULTS

Among 2931 patients, mean age was 76.6 years (SD, 8.3), 51.6% were female, 58.6% white, 32.5% black, and 2.6% Hispanic. Overall, 924 (31.5%) patients received a benzodiazepine and 298 (10.2%) an antipsychotic. The adjusted odds of benzodiazepine use was lower on days when visitors were versus were not allowed (adjusted odds ratio [AOR], 0.62; 95% CI, 0.39, 0.99). Antipsychotic use did not significantly differ between days when visitors were versus were not allowed (AOR, 0.98; 95% CI, 0.43, 2.21).

CONCLUSIONS

Among older patients hospitalized during the first wave of the pandemic, benzodiazepine use was lower on days when visitors were allowed. These findings suggest that the presence of caregivers impacts use of potentially inappropriate medications among hospitalized older adults, supporting efforts to recognize caregivers as essential members of the care team.

Factors Associated With Mortality Among Homeless Older Adults in California: The HOPE HOME Study

Importance

The population of homeless older adults is growing and experiences premature mortality. Little is known about factors associated with mortality among homeless older adults.

Objective

To identify the prevalence and factors associated with mortality in a cohort of homeless adults 50 years and older.

Design, Setting, and Participants

In this prospective cohort study (Health Outcomes in People Experiencing Homelessness in Older Middle Age [HOPE HOME]), 450 adults 50 years and older who were homeless at baseline were recruited via venue-based sampling in Oakland, California. Enrollment occurred in 2 phases, from July 2013 to June 2014 and from August 2017 to July 2018, and participants were interviewed at 6-month intervals.

Exposures

Baseline and time-varying characteristics, including sociodemographic factors, social support, housing status, incarceration history, chronic medical conditions, substance use, and mental health problems.

Main Outcomes and Measures

Mortality through December 31, 2021, based on state and local vital records information from contacts and death certificates. All-cause mortality rates were compared with those in the general population from 2014 to 2019 using age-specific standardized mortality ratios with 95% CIs.

Results

Of the 450 included participants, median (IQR) age at baseline was 58.1 (54.5-61.6) years, 107 (24%) were women, and 360 (80%) were Black. Over a median (IQR) follow-up of 55 (38-93) months, 117 (26%) participants died. Median (IQR) age at death was 64.6 (60.3-67.5) years. In multivariable analyses, characteristics associated with mortality included a first episode of homelessness at 50 years and older (adjusted hazard ratio [aHR], 1.62; 95% CI, 1.13-2.32), homelessness (aHR, 1.82; 95% CI, 1.23-2.68) or institutionalization (aHR, 6.36; 95% CI, 3.42-11.82) at any follow-up compared with being housed, fair or poor self-rated health (aHR, 1.64; 95% CI, 1.13-2.40), and diabetes (aHR, 1.55; 95% CI, 1.06-2.26). Demographic characteristics, substance use problems, and mental health problems were not independently associated. All-cause standardized mortality was 3.5 times higher (95% CI, 2.5-4.4) compared with adults in Oakland. The most common causes of death were heart disease (n = 17 [14.5%]), cancer (n = 17 [14.5%]), and drug overdose (n = 14 [12.0%]).

Conclusions and Relevance

The cohort study found that premature mortality was common among homeless older adults and associated factors included late-life homelessness and ongoing homelessness. There is an urgent need for policy approaches to prevent and end homelessness among older adults in the US.

Changes in the Hierarchy of Functional Impairment from Middle Age to Older Age

BACKGROUND

Understanding the hierarchy of functional impairment in older adults has helped illuminate mechanisms of impairment and inform interventions, but little is known about whether hierarchies vary by age. We compared the pattern of new-onset impairments in activities of daily living (ADLs) and instrumental ADLs (IADLs) from middle age through older age.

METHODS

We conducted a cohort study using nationally representative data from 32486 individuals enrolled in the Health and Retirement Study. The outcomes were new-onset impairment in each ADL and IADL, defined as self-reported difficulty performing each task, assessed yearly for 9 years. We used multi-state models and competing risks survival analysis to estimate the cumulative incidence of impairment in each task by age group (ages 50-64, 65-74, 75-84, and 85 or older).

RESULTS

The pattern of incident ADL impairments differed by age group. Among individuals ages 50-64 and 65-74 who were independent at baseline, over 9 years' follow-up, difficulties dressing and transferring were the most common impairments to develop. In individuals ages 75-84 and 85 or older who were independent at baseline, difficulties bathing, dressing, and walking were most common. For IADLs, the pattern of impairments was similar across age groups; difficulty shopping was most common followed by difficulty managing money and preparing meals. Complementary analyses demonstrated a similar pattern.

CONCLUSIONS

These findings suggest that the hierarchy of ADL impairment differs by age. These findings have implications for the development of age-specific interventions to prevent or delay functional impairment.

Association of hospitalization with driving reduction and cessation in older adults

BACKGROUND

Driving has not been considered as part of the social cost of acute illness and may go unnoticed in the post-hospital care of older adults. Decreases in driving after hospitalization and at-risk populations have not been investigated.

OBJECTIVE

To determine the association between driving reduction and cessation and hospitalization in older adults by using nationally representative data.

DESIGN

Retrospective cohort analysis.

SETTING

Health and Retirement Study survey from 2004 to 2014.

PARTICIPANTS

Adults aged 65 years and older who were able to drive and had an available car (n = 12,110; 40,364 interviews).

MEASUREMENTS

Self-report of a hospitalization requiring an overnight stay, changes in driving patterns including driving cessation or limitations over a 2-year period, comorbid conditions, health utilization, and behaviors.

RESULTS

Of hospitalizations in adults aged 65 years and older, 22% were associated with a decrease in driving patterns within 2 years. The relative risk of a reduction or cessation in driving was 1.62 (95% CI: 1.54, 1.70, p < 0.001) when there was a hospitalization compared with when a hospitalization did not occur. Baseline functional, cognitive, and visual impairment, fair or poor self-rated health, and diabetes were identified as independent risk factors for decreased driving patterns after hospitalization.

CONCLUSIONS

Changes in driving patterns are common after a hospitalization in older adults. The findings suggest that driving, although not a current goal of post-hospital care, is important to the continued autonomy and community mobility of older adults and needs to be addressed as part of discharge planning and their recovery.

A Community Partnership to House and Care for Complex Patients with Unstable Housing

Rising homelessness, especially among older adults, has significant ramifications for our health care system. People experiencing homelessness tend to experience worse health and poorer access to needed health care than people with stable housing. Commonwealth Care Alliance (CCA), a not-for-profit payer and provider that offers health plans to people dually eligible for Medicare and Medicaid, sought to address homelessness among its beneficiaries through a partnership with a local community-based housing organization, Hearth. This partnership led to many CCA members gaining access to permanent supportive housing in a setting in which CCA and Hearth could monitor and address their medical, social, and behavioral needs. It also provided an opportunity to examine health care utilization and cost trends associated with permanent supportive housing. Our experience demonstrates that a community-based partnership can effectively address homelessness among older adults with significant medical needs and may be associated with reduced health care expenditures.

Older adults' access to primary care: Gender, racial, and ethnic disparities in telemedicine

BACKGROUND

In 2020, primary care practices adopted telemedicine as an alternative to in-person visits. Little is known about whether access to telemedicine was equitable, especially among older patients. Our objectives were to (1) examine older adults' use of telemedicine versus in-person primary care visits and (2) compare hospitalization for ambulatory care sensitive conditions (ACSCs) between the groups.

METHODS

In this retrospective cross-sectional study of 17,103 patients aged ≥65 years seen at 32 clinics in the Mid-Atlantic, primary care patients were classified into two groups-telemedicine versus in person-based on the first visit between March and May 2020 and followed up for 14 days. Using multivariable logistic regression, we measured the odds of being seen via telemedicine versus in person as a function of patient demographics, comorbidities, and week of study period. We then measured the odds of ACSC hospitalization by visit modality.

RESULTS

Mean age was 75.1 years (SD, 7.5), 60.6% of patients were female, 64.6% white, 28.1% black, and 2.0% Hispanic. Overall, 60.3% of patients accessed primary care via telemedicine. Black (vs. white) patients had higher odds of using telemedicine (adjusted odds ratio [aOR], 1.30; 95% CI, 1.14-1.47) and Hispanic (vs. not Hispanic) patients had lower odds (aOR, 0.63; 95% CI, 0.42-0.92). Compared with the in-person group, patients in the telemedicine group had lower odds of ACSC hospitalization (aOR, 0.78; 95% CI, 0.61-1.00). Among patients who used telemedicine, black patients had 1.43 higher odds of ACSC hospitalization (95% CI, 1.02-2.01) compared with white patients. Patients aged 85 or older seen via telemedicine had higher odds of an ACSC hospitalization (aOR, 1.60; 95% CI, 1.03-2.47) compared with patients aged 65-74.

CONCLUSIONS

These findings support the use of telemedicine for primary care access for older adults. However, the observed disparities highlight the need to improve care quality and equity regardless of visit modality.

Investigating Sleep Disturbance and Its Correlates Among Formerly Homeless Adults in Permanent Supportive Housing

BACKGROUND

Adults experiencing homelessness have a high burden of sleep disturbance, which may be reduced by accessing permanent supportive housing.

OBJECTIVES

To assess sleep disturbances and their correlates, including demographics, activity level, health status, age-related health issues (eg, functionality and cognitive impairment), substance use, and homelessness history in a sample of permanent supportive housing (PSH) tenants.

RESEARCH DESIGN

Cross-sectional survey design.

SUBJECTS

A total of 237 formerly homeless adults between 45 and 80 years old.

MEASURES

The Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance short form was used to measure sleep disturbance.

RESULTS

Twenty-eight percent of our sample had PROMIS scores indicative of a moderate or severe sleep disturbance. Functional impairment, pain, and mental health comorbidities were associated with increased sleep disturbance in multivariable linear regression analyses. The number of years a person experienced homelessness was inversely associated with sleep disturbance.

CONCLUSIONS

This study supports the need to screen for sleep disturbances among PSH tenants. The findings suggest that supportive services in PSH may need to include integrated physical and behavioral health care, pain management, and interventions designed to address activities of daily livings to improve tenant sleep. They also suggest that improved sleep may help reduce PSH tenant pain, impairment, and mental health symptoms among PSH tenants.

Moving prevention of functional impairment upstream: is middle age an ideal time for intervention?

To live independently, individuals must be able to perform basic activities of daily living (ADLs), including bathing, dressing, and transferring out of a bed or chair. When older adults develop difficulty or the need for help performing ADLs, they experience decreased quality of life and an increased risk of acute care utilization, nursing home admission, and death. For these reasons, slowing or preventing the progression to functional problems is a key focus of the care of older adults. While preventive efforts currently focus mainly on older people, difficulty performing basic ADLs (“functional impairment”) affects nearly 15% of middle-aged adults, and this prevalence is increasing. People who develop functional impairment in middle age are at increased risk for adverse outcomes similar to those experienced by older adults. Developing ADL impairment in middle age also impacts work force participation and health expenditures, not just in middle age but also older age. Middle-aged adults have a high capacity for recovery from functional impairment, and many risk factors for developing functional impairment in middle and older age have their roots in mid-life. Taken together, these findings suggest that middle age may be an ideal period to intervene to prevent or delay functional impairment. To address the rising prevalence of functional impairment in middle age, we will need to work on several fronts. These include developing improved prognostic tools to identify middle-aged people at highest risk for functional impairment and developing interventions to prevent or delay impairment among middle-aged people. More broadly, we need to recognize functional impairment in middle age as a problem that is as prevalent and central to health outcomes as many chronic medical conditions.

"We Have a Long Way to Go:" A Case Study Examination of Older Women Veterans' Experiences in VA Primary Care

Women Veterans are a growing population with complex care needs. While previous research has examined the experiences of women Veterans, little attention has been paid to the specific experiences of older women Veterans. These case studies present the experiences of 2 older women Veterans who have been enrolled in Veterans Affairs (VA) health care for several decades. Results suggest that these older women Veterans have faced gender-specific challenges and barriers throughout their time accessing VA care. The experiences of these participants suggest that they have gender-sensitive needs that are not always addressed by VA primary care and that women’s groups are important mechanisms by which they have gained psychological support in a gender-sensitive environment. These cases suggest that access to gender-sensitive services and women-centered spaces are important for these 2 older women Veterans and should be explored in future research.

Examining fall risk among formerly homeless older adults living in permanent supportive housing

Although permanent supportive housing (PSH) has been credited with a decline in the number of chronically homeless adults in the United States since 2007, the extent to which PSH can accommodate the needs of a prematurely aging population, including reducing the likelihood of falls, is unclear. The objective of this study is to examine the prevalence and correlates of falls with a sample of 237 tenants (45- to 80-year olds) from two PSH programmes in Los Angeles from 1 January 2017 to 10 August 2017. We also explore the location and severity of fall-related injury using a subsample of 66 tenants. Standard surveys queried demographics, health status, history of homelessness and falls. Multivariable logistic regression assessed the correlates of falling in the past year. More than half of the sample had fallen and more than 40% had multiple falls in the past year. Functional impairment, frailty and persistent pain were all associated with increased fall risk. For the 66 tenants who provided more detailed fall information, more than 40% fell at home and of those nearly half fell in their bathroom. Fall-related injuries were common, with more than one-third of the subsample experiencing serious injury. These findings suggest that fall prevention is needed in PSH but that more research is needed to understand the degree to which individual and environmental risk factors are contributing to falls.

OLDER VETERANS’ PERSPECTIVES ON MEASURING FUNCTIONAL STATUS IN VA PRIMARY CARE CLINICS

Little is known about older adults’ perspectives on measuring functional status (i.e., ability to perform basic and instrumental activities of daily living). This study used a qualitative design to understand older Veterans’ perspectives on measuring function in primary care settings. Thematic analysis of interviews conducted with 28 Veterans ≥65 years and 5 caregivers from one VA Medical Center identified several themes including: 1) importance and relevance of discussing function; 2) preferences for assessment method (e.g., provider- or self-assessment;) and 3) wording of questions (i.e., needing help vs. having difficultly). These findings suggest that effective approaches to measuring function must consider patient preferences on content and format and ensure that measurement is used to inform care. We applied these findings to develop an interprofessional intervention to improve functional status measurement for older Veterans in primary care.

Trajectories of functional impairment in homeless older adults: Results from the HOPE HOME study

Difficulty performing activities of daily living ("functional impairment") is common in homeless adults aged 50 and older. However, little is known about the trajectory of these impairments, nor the extent to which these trajectories are similar to those of older adults in the general population. We identified trajectories of functional impairment in homeless adults aged 50 and older, and risk factors for differing trajectories. We conducted a prospective cohort study of 350 homeless adults, aged 50 and older, recruited via population-based sampling in Oakland, California and interviewed at 6-month intervals for up to 3 years. We assessed functional trajectories based on self-reported difficulty performing 5 activities of daily living. We used multivariable multinomial logistic regression to identify baseline risk factors for each trajectory. At baseline, participants' mean age was 58 years (SD, 5.3), 24.1% were women, 80.9% were African American, and 38.6% had difficulty performing 1 or more activities of daily living. We identified 4 distinct functional trajectories: minimal impairment in 136 participants (41.1%); persistent impairment in 81 (25.4%); partial improvement in 74 (23.5%); and decline in 28 (10.0%). Risk factors for persistent impairment included falls in the 6 months before baseline, depressive symptoms, and low physical performance. Although functional impairment improved in some homeless adults, it persisted or worsened in many others. These findings suggest that, similar to older adults in the general population, functional impairment among older homeless persons is not a transient phenomenon, but instead a chronic issue requiring long-term solutions.

Association of Functional Impairment in Middle Age With Hospitalization, Nursing Home Admission, and Death

IMPORTANCE

Difficulty performing daily activities such as bathing and dressing ("functional impairment") affects nearly 15% of middle-aged adults. Older adults who develop such difficulties, often because of frailty and other age-related conditions, are at increased risk of acute care use, nursing home admission, and death. However, it is unknown if functional impairments that develop among middle-aged people, which may have different antecedents, have similar prognostic significance.

OBJECTIVE

To determine whether middle-aged individuals who develop functional impairment are at increased risk for hospitalization, nursing home admission, and death.

DESIGN, SETTING, AND PARTICIPANTS

This matched cohort study analyzed longitudinal data from the Health and Retirement Study, a nationally representative prospective cohort study of US adults. The study population included 5540 adults aged 50 to 56 years who did not have functional impairment at study entry in 1992, 1998, or 2004. Participants were followed biennially through 2014. Individuals who developed functional impairment between 50 and 64 years were matched by age, sex, and survey wave with individuals without impairment as of that age and survey wave. Statistical analysis was conducted from March 15, 2017, to December 11, 2018.

EXPOSURES

Impairment in activities of daily living (ADLs), defined as self-reported difficulty performing 1 or more ADLs, and impairment in instrumental ADLs (IADLs), defined similarly.

MAIN OUTCOMES AND MEASURES

The 3 primary outcomes were time from the first episode of functional impairment (or matched survey wave, in controls) to hospitalization, nursing home admission, and death. Follow-up assessments occurred every 2 years until 2014. Competing risks survival analysis was used to assess the association of functional impairment with hospitalization and nursing home admission and Cox proportional hazards regression analysis was used to assess the association with death.

RESULTS

Of the 5540 study participants (2739 women and 2801 men; median age, 53.7 years [interquartile range, 52.3-55.2 years]), 1097 (19.8%) developed ADL impairment between 50 and 64 years, and 857 (15.5%) developed IADL impairment. Individuals with ADL impairment had an increased risk of each adverse outcome compared with those without impairment, including hospitalization (subhazard ratio, 1.97; 95% CI, 1.77-2.19), nursing home admission (subhazard ratio, 2.62; 95% CI, 1.99-3.45), and death (hazard ratio, 2.06; 95% CI, 1.74-2.45). After multivariable adjustment, the risks of hospitalization (subhazard ratio, 1.54; 95% CI, 1.36-1.75) and nursing home admission (subhazard ratio, 1.73; 95% CI, 1.24-2.43) remained significantly higher among individuals with ADL impairment, but the risk of death was not statistically significant (hazard ratio, 1.06; 95% CI, 0.85-1.32). Individuals with IADL impairment had an increased risk of all 3 outcomes in adjusted and unadjusted analyses.

CONCLUSIONS AND RELEVANCE

Similar to older adults, middle-aged adults who develop functional impairment appear to be at increased risk for adverse outcomes. Even among relatively young people, functional impairment has important clinical implications.

Making Function Part of the Conversation: Clinician Perspectives on Measuring Functional Status in Primary Care

OBJECTIVES

Although there is increasing interest in using functional status to guide clinical decision making, function is seldom routinely assessed in primary care. We explored clinician perspectives on barriers and facilitators to routine measurement of older adults' functional status in primary care settings.

DESIGN

Qualitative study using semistructured interviews.

SETTING

Primary care and geriatrics clinics at six Veterans Affairs Medical Centers.

PARTICIPANTS

Twenty-four primary care providers, including 17 from primary care clinics and 7 from geriatrics clinics.

MEASUREMENTS

We conducted interviews to elicit clinician perspectives about functional status measurement, including barriers and facilitators to routine assessment. We analyzed transcripts iteratively using a hybrid inductive and deductive thematic approach.

RESULTS

Interviews revealed three distinct aspects to measuring function: screening and assessment, documentation, and use of data to inform care. Barriers and facilitators to screening and assessment included time availability, clinic processes, and degree of interdisciplinary environment. Barriers and facilitators to documentation included the usability and integration of electronic instruments into workflows and the availability of a standardized location to document function in the electronic medical record. Barriers and facilitators to use of data included the availability of a standardized location to retrieve data on function, the availability of appropriate referrals and services, and provider knowledge of available resources to address functional impairments. To address these barriers, providers emphasized the critical importance of connecting measurement of function directly to improved patient care.

CONCLUSION

Although clinicians emphasized the importance of measuring function, they also cautioned against additional workload burdens, cumbersome electronic documentation, and measurement of function without ensuring that these data are used to improve care. Approaches to functional status measurement must address these barriers to improve care and outcomes for older adults. J Am Geriatr Soc 67:493-502, 2019.

Geriatric Conditions in a Population-Based Sample of Older Homeless Adults

Purpose of the Study

Older homeless adults living in shelters have high rates of geriatric conditions, which may increase their risk for acute care use and nursing home placement. However, a minority of homeless adults stay in shelters and the prevalence of geriatric conditions among homeless adults living in other environments is unknown. We determined the prevalence of common geriatric conditions in a cohort of older homeless adults, and whether the prevalence of these conditions differs across living environments.

Design and Methods

We interviewed 350 homeless adults, aged 50 and older, recruited via population-based sampling in Oakland, CA. We evaluated participants for common geriatric conditions. We assessed living environment using a 6-month follow-back residential calendar, and used cluster analysis to identify participants' primary living environment over the prior 6 months.

Results

Participants stayed in 4 primary environments: unsheltered locations (n = 162), multiple locations including shelters and hotels (n = 88), intermittently with family/friends (n = 57), and, in a recently homeless group, rental housing (n = 43). Overall, 38.9% of participants reported difficulty performing 1 or more activities of daily living, 33.7% reported any falls in the past 6 months, 25.8% had cognitive impairment, 45.1% had vision impairment, and 48.0% screened positive for urinary incontinence. The prevalence of geriatric conditions did not differ significantly across living environments.

Implications

Geriatric conditions were common among older homeless adults living in diverse environments, and the prevalence of these conditions was higher than that seen in housed adults 20 years older. Services that address geriatric conditions are needed for older homeless adults living across varied environments.

Functional Impairment and Decline in Middle Age: A Cohort Study

BACKGROUND

Difficulties with daily functioning are common in middle-aged adults. However, little is known about the epidemiology or clinical course of these problems, including the extent to which they share common features with functional impairment in older adults.

OBJECTIVE

To determine the epidemiology and clinical course of functional impairment and decline in middle age.

DESIGN

Cohort study.

SETTING

The Health and Retirement Study.

PARTICIPANTS

6874 community-dwelling adults aged 50 to 56 years who did not have functional impairment at enrollment.

MEASUREMENTS

Impairment in activities of daily living (ADLs), defined as self-reported difficulty performing 1 or more ADLs, assessed every 2 years for a maximum follow-up of 20 years, and impairment in instrumental ADLs (IADLs), defined similarly. Data were analyzed by using multistate models that estimate probabilities of different outcomes.

RESULTS

Impairment in ADLs developed in 22% of participants aged 50 to 64 years, in whom further functional transitions were common. Two years after the initial impairment, 4% (95% CI, 3% to 5%) of participants had died, 9% (CI, 8% to 11%) had further ADL decline, 50% (CI, 48% to 52%) had persistent impairment, and 37% (CI, 35% to 39%) had recovered independence. In the 10 years after the initial impairment, 16% (CI, 14% to 18%) had 1 or more episodes of functional decline and 28% (CI, 26% to 30%) recovered from their initial impairment and remained independent throughout this period. The pattern of findings was similar for IADLs.

LIMITATION

Functional status was self-reported.

CONCLUSION

Functional impairment and decline are common in middle age, as are transitions from impairment to independence and back again. Because functional decline in older adults has similar features, current interventions used for prevention in older adults may hold promise for those in middle age.

PRIMARY FUNDING SOURCE

National Institute on Aging and National Center for Advancing Translational Sciences through the University of California, San Francisco, Clinical and Translational Sciences Institute.

Wealth-Associated Disparities in Death and Disability in the United States and England

Importance

Low income has been associated with poor health outcomes. Owing to retirement, wealth may be a better marker of financial resources among older adults.

Objective

To determine the association of wealth with mortality and disability among older adults in the United States and England.

Design, Setting, and Participants

The US Health and Retirement Study (HRS) and English Longitudinal Study of Aging (ELSA) are nationally representative cohorts of community-dwelling older adults. We examined 12 173 participants enrolled in HRS and 7599 enrolled in ELSA in 2002. Analyses were stratified by age (54-64 years vs 66-76 years) because many safety-net programs commence around age 65 years. Participants were followed until 2012 for mortality and disability.

Exposures

Wealth quintile, based on total net worth in 2002.

Main Outcomes and Measures

Mortality and disability, defined as difficulty performing an activity of daily living.

Results

A total of 6233 US respondents and 4325 English respondents aged 54 to 64 years (younger cohort) and 5940 US respondents and 3274 English respondents aged 66 to 76 years (older cohort) were analyzed for the mortality outcome. Slightly over half of respondents were women (HRS: 6570, 54%; ELSA: 3974, 52%). A higher proportion of respondents from HRS were nonwhite compared with ELSA in both the younger (14% vs 3%) and the older (13% vs 3%) age cohorts. We found increased risk of death and disability as wealth decreased. In the United States, participants aged 54 to 64 years in the lowest wealth quintile (Q1) (≤$39 000) had a 17% mortality risk and 48% disability risk over 10 years, whereas in the highest wealth quintile (Q5) (>$560 000) participants had a 5% mortality risk and 15% disability risk (mortality hazard ratio [HR], 3.3; 95% CI, 2.0-5.6; P < .001; disability subhazard ratio [sHR], 4.0; 95% CI, 2.9-5.6; P < .001). In England, participants aged 54 to 64 years in Q1 (≤£34,000) had a 16% mortality risk and 42% disability risk over 10 years, whereas Q5 participants (>£310,550) had a 4% mortality risk and 17% disability risk (mortality HR, 4.4; 95% CI, 2.7-7.0; P < .001; disability sHR, 3.0; 95% CI, 2.1-4.2; P < .001). In 66- to 76-year-old participants, the absolute risks of mortality and disability were higher, but risk gradients across wealth quintiles were similar. When adjusted for sex, age, race, income, and education, HR for mortality and sHR for disability were attenuated but remained statistically significant.

Conclusions and Relevance

Low wealth was associated with death and disability in both the United States and England. This relationship was apparent from age 54 years and continued into later life. Access to health care may not attenuate wealth-associated disparities in older adults.

Current approaches to measuring functional status among older adults in VA primary care clinics

VA primary care clinics had widely varying approaches for assessing and documenting the functional status of geriatric patients.

Good Cop, Better Cop: Evaluation of a Geriatrics Training Program for Police

OBJECTIVES

To develop, implement, and evaluate a training program in aging-related health for police officers.

DESIGN

Cross-sectional.

SETTING

Crisis intervention training program for police officers in San Francisco.

PARTICIPANTS

Police officers attending one of five 2-hour trainings (N = 143).

INTERVENTION

A lecture on aging-related health conditions pertinent to police work followed by three experiential trainings on how it feels to be "old."

MEASUREMENTS

Participants evaluated the quality of the training and the likelihood that they would apply new knowledge to their work and rated their knowledge using a retrospective pre-post evaluation. In open-ended responses, participants reported work-related changes they anticipated making in response to the training.

RESULTS

All 143 participants completed the evaluation. Eighty-four percent reported interacting with older adults at least monthly; 45% reported daily interactions. Participants rated the training quality at 4.6/5 and the likelihood they would apply new knowledge to their work at 4.4/5. Retrospective pre-post knowledge scores increased for all domains, including how to identify aging-related health conditions that can affect safety during police interactions (2.9/5 to 4.2/5; P < .001). In open-ended responses, participants anticipated having more empathy for and awareness of aging-related conditions and greater ability to provide older adults with appropriate community referrals.

CONCLUSION

A brief training in aging-related health significantly increased police officers' self-reported knowledge and skills. Clinicians have an important opportunity to help enhance safe and effective community policing for older adults.

Bringing functional status into a big data world: Validation of national Veterans Affairs functional status data

BACKGROUND

The ability to perform basic daily activities ("functional status") is key to older adults' quality of life and strongly predicts health outcomes. However, data on functional status are seldom collected during routine clinical care in a way that makes them available for clinical use and research.

OBJECTIVES

To validate functional status data that Veterans Affairs (VA) medical centers recently started collecting during routine clinical care, compared to the same data collected in a structured research setting.

DESIGN

Prospective validation study.

SETTING

Seven VA medical centers that collected complete data on 5 activities of daily living (ADLs) and 8 instrumental activities of daily living (IADLs) from older patients attending primary care appointments.

PARTICIPANTS

Randomly selected patients aged 75 and older who had new ADL and IADL data collected during a primary care appointment (N = 252). We oversampled patients with ADL dependence and applied these sampling weights to our analyses.

MEASUREMENTS

Telephone-based interviews using a validated measure to assess the same 5 ADLs and 8 IADLs.

RESULTS

Mean age was 83 years, 96% were male, and 75% were white. Of 85 participants whom VA data identified as dependent in 1 or more ADLs, 74 (87%) reported being dependent by interview; of 167 whom VA data identified as independent in ADLs, 149 (89%) reported being independent. The sample-weighted sensitivity of the VA data for identifying ADL dependence was 45% (95% CI, 29%, 62%) compared to the reference standard, the specificity was 99% (95% CI, 99%, >99%), and the positive predictive value was 87% (95% CI, 79%, 93%). The weighted kappa statistic was 0.55 (95% CI, 0.41, 0.68) for the agreement between VA data and research-collected data in identifying ADL dependence.

CONCLUSION

Overall agreement of VA functional status data with a reference standard was moderate, with fair sensitivity but high specificity and positive predictive value.

Pathways to Homelessness among Older Homeless Adults: Results from the HOPE HOME Study

Little is known about pathways to homelessness among older adults. We identified life course experiences associated with earlier versus later onset of homelessness in older homeless adults and examined current health and functional status by age at first homelessness. We interviewed 350 homeless adults, aged 50 and older, recruited via population-based sampling. Participants reported age at first episode of adult homelessness and their life experiences during 3 time periods: childhood (<18 years), young adulthood (ages 18–25), and middle adulthood (ages 26–49). We used a structured modeling approach to identify experiences associated with first adult homelessness before age 50 versus at age 50 or older. Participants reported current health and functional status, including recent mental health and substance use problems. Older homeless adults who first became homeless before 50 had more adverse life experiences (i.e., mental health and substance use problems, imprisonment) and lower attainment of adult milestones (i.e., marriage, full-time employment) compared to individuals with later onset. After multivariable adjustment, adverse experiences were independently associated with experiencing a first episode of homelessness before age 50. Individuals who first became homeless before age 50 had higher prevalence of recent mental health and substance use problems and more difficulty performing instrumental activities of daily living. Life course experiences and current vulnerabilities of older homeless adults with first homelessness before age 50 differed from those with later onset of homelessness. Prevention and service interventions should be adapted to meet different needs.

Health Outcomes of Obtaining Housing Among Older Homeless Adults

OBJECTIVES

We determined the impact of obtaining housing on geriatric conditions and acute care utilization among older homeless adults.

METHODS

We conducted a 12-month prospective cohort study of 250 older homeless adults recruited from shelters in Boston, Massachusetts, between January and June 2010. We determined housing status at follow-up, determined number of emergency department visits and hospitalizations over 12 months, and examined 4 measures of geriatric conditions at baseline and 12 months. Using multivariable regression models, we evaluated the association between obtaining housing and our outcomes of interest.

RESULTS

At 12-month follow-up, 41% of participants had obtained housing. Compared with participants who remained homeless, those with housing had fewer depressive symptoms. Other measures of health status did not differ by housing status. Participants who obtained housing had a lower rate of acute care use, with an adjusted annualized rate of acute care visits of 2.5 per year among participants who obtained housing and 5.3 per year among participants who remained homeless.

CONCLUSIONS

Older homeless adults who obtained housing experienced improved depressive symptoms and reduced acute care utilization compared with those who remained homeless.

Police on the front line of community geriatric health care: challenges and opportunities

As the population ages, police increasingly serve as first responders to incidents involving older adults in which aging-related health plays a critical role. The goals of this study were to assess police officers' knowledge of aging-related health, to identify challenges police experience in their encounters with older adults, and to describe their recommendations for how to address those challenges. This was a mixed-methods study of 141 San Francisco police officers recruited from mandatory police trainings between 2011 and 2013. Descriptive statistics were used to analyze 141 self-administered questionnaires, and principles of grounded theory were used to analyze open-ended questionnaire responses and 11 additional qualitative interviews. Eighty-nine percent of officers reported interacting with older adults at least monthly. Although 84% of police reported prior training in working with older adults, only 32% rated themselves as knowledgeable about aging-related health. Participants described themselves as first responders to medical and social emergencies involving older adults and identified several challenges, including identifying and responding to aging-related conditions and ensuring appropriate medical and social service handoffs. To address these challenges, officers recommended developing trainings focused on recognizing and responding to aging-related conditions and improving police knowledge of community resources for older adults. They also called for enhanced communication and collaboration between police and clinicians. These findings suggest that, because they assume a front-line role in responding to older adults with complex medical and social needs, many police may benefit from additional knowledge about aging-related health and community resources. Collaboration between police and healthcare providers presents an important opportunity to develop geriatrics training and interprofessional systems of care to support police work with a rapidly aging population.

Functional disability in late-middle-aged and older adults admitted to a safety-net hospital

OBJECTIVES

To determine the prevalence of preadmission functional disability in late-middle-aged and older safety-net inpatients and to identify characteristics associated with functional disability by age.

DESIGN

Cross-sectional analysis.

SETTING

Safety-net hospital in San Francisco, California.

PARTICIPANTS

English-, Spanish-, and Chinese-speaking community-dwelling individuals aged 55 and older admitted to a safety-net hospital with anticipated return to the community (N = 699).

MEASUREMENTS

At hospital admission, participants reported their need for help performing five activities of daily living (ADLs) and seven instrumental activities of daily living (IADLs) 2 weeks before admission. ADL disability was defined as needing help performing one or more ADLs and IADL disability as needing help performing two or more IADLs. Participant characteristics were assessed, including sociodemographic characteristics, health status, health-related behaviors, and health-seeking behaviors.

RESULTS

Overall, 28.3% of participants reported that they had an ADL disability 2 weeks before admission, and 40.4% reported an IADL disability. The prevalence of preadmission ADL disability was 28.9% of those aged 55 to 59, 20.7% of those aged 60 to 69, and 41.2% of those aged 70 and older (P < .001). The prevalence of IADL disability had a similar distribution. The characteristics associated with functional disability differed according to age; in participants aged 55 to 59, African Americans had a higher odds of ADL and IADL disability, whereas in participants aged 60 to 69 and aged 70 and older, inadequate health literacy was associated with functional disability.

CONCLUSION

Preadmission functional disability is common in individuals aged 55 and older admitted to a safety-net hospital. Late-middle-aged individuals admitted to safety-net hospitals may benefit from models of acute care currently used for older adults that prevent adverse outcomes associated with functional disability.

Factors associated with geriatric syndromes in older homeless adults

Although older homeless adults have high rates of geriatric syndromes, risk factors for these syndromes are not known. We used multivariable regression models to estimate the association of subject characteristics with the total number of geriatric syndromes in 250 homeless adults aged 50 years and older. Geriatric syndromes included falls, cognitive impairment, frailty, major depression, sensory impairment, and urinary incontinence. A higher total number of geriatric syndromes was associated with having less than a high school education, medical comorbidities (diabetes and arthritis), alcohol and drug use problems, and difficulty performing one or more activities of daily living. Clinicians who care for older homeless patients with these characteristics should consider screening them for geriatric syndromes. Moreover, this study identifies potentially modifiable risk factors associated with the total number of geriatric syndromes in older homeless adults. This knowledge may provide targets for clinical interventions to improve the health of older homeless patients.

Characteristics of emergency department visits by older versus younger homeless adults in the United States

OBJECTIVES

We compared the characteristics of emergency department (ED) visits of older versus younger homeless adults.

METHODS

We analyzed 2005-2009 data from the National Hospital Ambulatory Medical Care Survey, a nationally representative survey of visits to hospitals and EDs, and used sampling weights, strata, and clustering variables to obtain nationally representative estimates.

RESULTS

The ED visits of homeless adults aged 50 years and older accounted for 36% of annual visits by homeless patients. Although demographic characteristics of ED visits were similar in older and younger homeless adults, clinical and health services characteristics differed. Older homeless adults had fewer discharge diagnoses related to psychiatric conditions (10% vs 20%; P = .002) and drug abuse (7% vs 15%; P = .003) but more diagnoses related to alcohol abuse (31% vs 23%; P = .03) and were more likely to arrive by ambulance (48% vs 36%; P = .02) and to be admitted to the hospital (20% vs 11%; P = .003). Conclusions. Older homeless adults' patterns of ED care differ from those of younger homeless adults. Health care systems need to account for these differences to meet the needs of the aging homeless population.