BACKGROUND/OBJECTIVES
Physical distancing during the COVID‐19 pandemic may have unintended, detrimental effects on social isolation and loneliness among older adults. Our objectives were to ...investigate (1) experiences of social isolation and loneliness during shelter‐in‐place orders, and (2) unmet health needs related to changes in social interactions.
DESIGN
Mixed‐methods longitudinal phone‐based survey administered every 2 weeks.
SETTING
Two community sites and an academic geriatrics outpatient clinical practice.
PARTICIPANTS
A total of 151 community‐dwelling older adults.
MEASUREMENTS
We measured social isolation using a six‐item modified Duke Social Support Index, social interaction subscale, that included assessments of video‐based and Internet‐based socializing. Measures of loneliness included self‐reported worsened loneliness due to the COVID‐19 pandemic and loneliness severity based on the three‐item University of California, Los Angeles (UCLA) Loneliness Scale. Participants were invited to share open‐ended comments about their social experiences.
RESULTS
Participants were on average aged 75 years (standard deviation = 10), 50% had hearing or vision impairment, 64% lived alone, and 26% had difficulty bathing. Participants reported social isolation in 40% of interviews, 76% reported minimal video‐based socializing, and 42% minimal Internet‐based socializing. Socially isolated participants reported difficulty finding help with functional needs including bathing (20% vs 55%; P = .04). More than half (54%) of the participants reported worsened loneliness due to COVID‐19 that was associated with worsened depression (62% vs 9%; P < .001) and anxiety (57% vs 9%; P < .001). Rates of loneliness improved on average by time since shelter‐in‐place orders (4–6 weeks: 46% vs 13–15 weeks: 27%; P = .009), however, loneliness persisted or worsened for a subgroup of participants. Open‐ended responses revealed challenges faced by the subgroup experiencing persistent loneliness including poor emotional coping and discomfort with new technologies.
CONCLUSION
Many older adults are adjusting to COVID‐19 restrictions since the start of shelter‐in‐place orders. Additional steps are critically needed to address the psychological suffering and unmet medical needs of those with persistent loneliness or barriers to technology‐based social interaction.
In older patients, acute medical illness that requires hospitalization is a sentinel event that often precipitates disability. This results in the subsequent inability to live independently and ...complete basic activities of daily living (ADLs). This hospitalization-associated disability occurs in approximately one-third of patients older than 70 years of age and may be triggered even when the illness that necessitated the hospitalization is successfully treated. In this article, we describe risk factors and risk stratification tools that identify older adults at highest risk of hospitalization-associated disability. We describe hospital processes that may promote hospitalization-associated disability and models of care that have been developed to prevent it. Since recognition of functional status problems is an essential prerequisite to preventing and managing disability, we also describe a pragmatic approach toward functional status assessment in the hospital focused on evaluation of ADLs, mobility, and cognition. Based on studies of acute geriatric units, we describe interventions hospitals and clinicians can consider to prevent hospitalization-associated disability in patients. Finally, we describe approaches clinicians can implement to improve the quality of life of older adults who develop hospitalization-associated disability and that of their caregivers.
IMPORTANCE: Medicare currently penalizes hospitals for high readmission rates for seniors but does not account for common age-related syndromes, such as functional impairment. OBJECTIVE: To assess ...the effects of functional impairment on Medicare hospital readmissions given the high prevalence of functional impairments in community-dwelling seniors. DESIGN, SETTING, AND PARTICIPANTS: We created a nationally representative cohort of 7854 community-dwelling seniors in the Health and Retirement Study, with 22 289 Medicare hospitalizations from January 1, 2000, through December 31, 2010. MAIN OUTCOMES AND MEASURES: Outcome was 30-day readmission assessed by Medicare claims. The main predictor was functional impairment determined from the Health and Retirement Study interview preceding hospitalization, stratified into the following 5 levels: no functional impairments, difficulty with 1 or more instrumental activities of daily living, difficulty with 1 or more activities of daily living (ADL), dependency (need for help) in 1 to 2 ADLs, and dependency in 3 or more ADLs. Adjustment variables included age, race/ethnicity, sex, annual income, net worth, comorbid conditions (Elixhauser score from Medicare claims), and prior admission. We performed multivariable logistic regression to adjust for clustering at the patient level to characterize the association of functional impairments and readmission. RESULTS: Patients had a mean (SD) age of 78.5 (7.7) years (range, 65-105 years); 58.4% were female, 84.9% were white, 89.6% reported 3 or more comorbidities, and 86.0% had 1 or more hospitalizations in the previous year. Overall, 48.3% had some level of functional impairment before admission, and 15.5% of hospitalizations were followed by readmission within 30 days. We found a progressive increase in the adjusted risk of readmission as the degree of functional impairment increased: 13.5% with no functional impairment, 14.3% with difficulty with 1 or more instrumental activities of daily living (odds ratio OR, 1.06; 95% CI, 0.94-1.20), 14.4% with difficulty with 1 or more ADL (OR, 1.08; 95% CI, 0.96-1.21), 16.5% with dependency in 1 to 2 ADLs (OR, 1.26; 95% CI, 1.11-1.44), and 18.2% with dependency in 3 or more ADLs (OR, 1.42; 95% CI, 1.20-1.69). Subanalysis restricted to patients admitted with conditions targeted by Medicare (ie, heart failure, myocardial infarction, and pneumonia) revealed a parallel trend with larger effects for the most impaired (16.9% readmission rate for no impairment vs 25.7% for dependency in 3 or more ADLs OR, 1.70; 95% CI, 1.04-2.78). CONCLUSIONS AND RELEVANCE: Functional impairment is associated with increased risk of 30-day all-cause hospital readmission in Medicare seniors, especially those admitted for heart failure, myocardial infarction, or pneumonia. Functional impairment may be an important but underaddressed factor in preventing readmissions for Medicare seniors.
IMPORTANCE: Chronic pain is common among the elderly and is associated with cognitive deficits in cross-sectional studies; the population-level association between chronic pain and longitudinal ...cognition is unknown. OBJECTIVE: To determine the population-level association between persistent pain, which may reflect chronic pain, and subsequent cognitive decline. DESIGN, SETTING, AND PARTICIPANTS: Cohort study with biennial interviews of 10 065 community-dwelling older adults in the nationally representative Health and Retirement Study who were 62 years or older in 2000 and answered pain and cognition questions in both 1998 and 2000. Data analysis was conducted between June 24 and October 31, 2016. EXPOSURES: “Persistent pain,” defined as a participant reporting that he or she was often troubled with moderate or severe pain in both the 1998 and 2000 interviews. MAIN OUTCOMES AND MEASURES: Coprimary outcomes were composite memory score and dementia probability, estimated by combining neuropsychological test results and informant and proxy interviews, which were tracked from 2000 through 2012. Linear mixed-effects models, with random slope and intercept for each participant, were used to estimate the association of persistent pain with slope of the subsequent cognitive trajectory, adjusting for demographic characteristics and comorbidities measures in 2000 and applying sampling weights to represent the 2000 US population. We hypothesized that persistent pain would predict accelerated memory decline and increased probability of dementia. To quantify the impact of persistent pain on functional independence, we combined our primary results with information on the association between memory and ability to manage medications and finances independently. RESULTS: Of the 10 065 eligible HRS sample members, 60% were female, and median baseline age was 73 years (interquartile range, 67-78 years). At baseline, persistent pain affected 10.9% of participants and was associated with worse depressive symptoms and more limitations in activities of daily living. After covariate adjustment, persistent pain was associated with 9.2% (95% CI, 2.8%-15.0%) more rapid memory decline compared with those without persistent pain. After 10 years, this accelerated memory decline implied a 15.9% higher relative risk of inability to manage medications and an 11.8% higher relative risk of inability to manage finances independently. Adjusted dementia probability increased 7.7% faster (95% CI, 0.55%-14.2%); after 10 years, this translates to an absolute 2.2% increase in dementia probability for those with persistent pain. CONCLUSIONS AND RELEVANCE: Persistent pain was associated with accelerated memory decline and increased probability of dementia.
Social isolation and loneliness are critical to the health of older adults, but they have not been well-described at the end of life.
To determine the prevalence and correlates of social isolation ...and loneliness among older adults in the last years of life.
Nationally representative, cross-sectional survey.
Health and Retirement Study, 2006-2016 data.
Adults age > 50 interviewed once in the last 4 years of life (n = 3613).
We defined social isolation using a 15-item scale measuring household contacts, social network interaction, and community engagement, and frequent loneliness using the 3-item UCLA Loneliness Scale. We used multivariable logistic regression to determine their adjusted prevalence by time prior-to-death and by subgroups of interest.
Approximately 19% experienced social isolation, 18% loneliness, and 5% both in the last 4 years of life (correlation = 0.11). The adjusted prevalence of social isolation was higher for individuals nearer to death (4 years: 18% vs 0-3 months: 27%, p = 0.05) and there was no significant change in loneliness (4 years: 19% vs 0-3 months: 23%, p = 0.13). Risk factors for both isolation and loneliness included (p < 0.01): low net-worth (Isolation: 34% vs 14%; Loneliness: 29% vs 13%), hearing impairment (Isolation: 26% vs 20%; Loneliness: 26% vs 17%), and difficulty preparing meals (Isolation: 27% vs 19%; Loneliness: 29% vs 15%). Factors associated with loneliness, but not social isolation, included being female, pain, incontinence, and cognitive impairment.
Social isolation and loneliness are common at the end of life, affecting 1 in 4 older adults, but few experience both. Rates were higher for older adults who were poor and experienced functional or sensory impairments. Results can inform clinical efforts to identify and address end-of-life psychosocial suffering and health policies which prioritize social needs at the end of life.
Recent long-term care facility (LTCF) policy has focused on transitioning nursing home (NH) residents back to community settings, yet we lack recent descriptions of this phenomenon and how it ...compares in assisted living (AL).
Using the National Health and Aging Trends Study, we studied adults over age 65 who had moved from community living into an LTCF between 2011 and 2018. Persons or their proxies reported residence in annual interviews. NH was defined by facility staff. ALs were multi-unit buildings helping with activities of daily living. We excluded temporary short-stay NH patients and independent AL residents. Our primary outcome was cumulative incidence of return to community living, with death as co-primary outcome and modeled as a competing risk, stratified by NH versus AL entry. We identified covariates (age, gender, race/ethnicity, dementia, activity limitations, and prior living arrangement) associated with return to community living through bivariate and multivariable logistic regression.
Among 739 participants, weighted mean age was 84 years (SD 7.5), 66% were women, 13% were non-White, 57% had dementia, and 41% entered NH. At 1, 2, and 4 years, the cumulative incidence of return to community living was 2.9% (95% CIs: 1.9%-4.3%), 6.4% (4.7%-8.4%), and 7.4% (5.5%-9.8%); the cumulative incidence of death was 28% (95% CIs: 24%-31%), 44% (40%-48%) and 66% (61%-70%). Outcomes were similar in persons entering NH versus AL. Older persons (aOR 0.88, 95% CI 0.83-0.94), those with dementia (aOR 0.33, 95% CI 0.12-0.88), and those previously living alone (aOR 0.39, 95% CI 0.17-0.89) were less likely to return.
Few returned to community living after entering either NH or AL. Mortality was similar. Results highlight limits in transitioning persons out of LTCFs and the need to observe AL use to ensure policies do not merely displace persons between institutional care sectors.
Frailty, a critical determinant of health outcomes, is most commonly assessed in patients with cirrhosis by general clinician assessment that is limited by its subjectivity. We aimed to compare the ...objective Liver Frailty Index (LFI), consisting of three performance-based tests (grip, chair stands, balance), with a subjective hepatologist assessment.
Outpatients with cirrhosis awaiting liver transplantation (LT) underwent: (1) objective measurement using the LFI and (2) subjective clinician assessment. Spearman's correlation assessed associations between the LFI and clinician assessment; Cox regression with waitlist mortality (death/delisting for sickness); discriminative ability with Concordance(C) statistics. The net reclassification index evaluated the percentage of patients correctly reclassified by adding the LFI to the clinician assessment.
Of the 529 patients with cirrhosis, median LFI was 3.8 (range 1.0-7.0) and clinician assessment was 3 (range 0-5). Correlation between LFI and the clinician assessment was modest (ρ=0.38) with high variability by hepatologist (ρ=0.26-0.70). At a median of 11 months, 102 (19%) died/were delisted. Both the LFI (hazard ratio (HR) 2.2, 95% confidence interval (CI) 1.7-2.9) and clinician assessment (HR 1.6, 95% CI 1.3-1.9) were associated with adjusted waitlist mortality risk (P<0.01). The addition of the LFI to the clinician assessment significantly improved mortality prediction over the clinician assessment alone (0.74 vs. 0.68; P=0.02). Compared with the clinician assessment alone, the addition of the LFI correctly reclassified 34% (95% CI 8-53%) of patients to their correct survival status.
The subjective clinician assessment can predict waitlist mortality in patients with cirrhosis but is subjective and variable by hepatologist. The addition of the LFI to the subjective clinician assessment significantly improved mortality risk prediction, reclassifying 34% of patients. Our data strongly support the incorporation of the objective LFI to anchor our assessments of patients with cirrhosis to enhance our decision-making.
PDF
