In clinical practice and training, estimating prognosis--the probability of an individual developing a particular outcome over a specific period of time--typically receives less attention than ...diagnosing and treating disease. Yet many clinical decisions are not fully informed unless the patient's prognosis is considered. Because of competing chronic conditions and diminished life expectancy, careful consideration of prognosis is particularly important for clinical decision making in older adults. Here, Gill discusses the central role of prognosis in clinical decision making.
Chronic diseases associated with aging, such as arthritis, frequently cause reduced mobility, pain and diminished quality of life. To date, research on the association between mobility and quality of ...life has primarily focused in the elderly; hence, much less is known about this association in the near elderly. This cross-sectional study aimed to assess the association between mobility and quality of life measures in the near elderly.
A prospective observational study of persons aged 50-69 years was conducted. The primary endpoint was quality of life measured by EQ-5D-5L, and the primary explanatory variable was observed mobility assessed using the 6-minute walk distance (6MWD). We applied regression models controlling for demographic, health status and other factors to evaluate the association between 6MWD and EQ-5D-5L.
Of the 183 participants analyzed in the study, 37% were male and the average age was 59.8 years. After adjusting for differences in demographic characteristics and health status, EQ-5D-5L-based utility values were 0.046 points (p<0.001), or 5.2% (95% CI: 2.7% to 7.8%), higher on average for individuals with 100 meters longer 6MWD. Holding constant the mobility-specific component of EQ-5D-5L, we still found that walking an additional 100 meters was associated with an EQ-5D-5L utility value that was 0.029 points (p<0.001), or 3.5% (95% CI: 1.7% to 5.5%), higher than the average participant. Among persons with arthritis, the association between 6MWD and EQ-5D-5L was slightly stronger.
Near elderly persons with better mobility had higher quality of life. Diseases that decrease mobility, such as arthritis, are likely to have a significant impact on quality of life.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Frailty can be measured in relation to the accumulation of deficits using a frailty index. A frailty index can be developed from most ageing databases. Our objective is to systematically describe a ...standard procedure for constructing a frailty index.
This is a secondary analysis of the Yale Precipitating Events Project cohort study, based in New Haven CT. Non-disabled people aged 70 years or older (n = 754) were enrolled and re-contacted every 18 months. The database includes variables on function, cognition, co-morbidity, health attitudes and practices and physical performance measures. Data came from the baseline cohort and those available at the first 18-month follow-up assessment.
Procedures for selecting health variables as candidate deficits were applied to yield 40 deficits. Recoding procedures were applied for categorical, ordinal and interval variables such that they could be mapped to the interval 0-1, where 0 = absence of a deficit, and 1= full expression of the deficit. These individual deficit scores were combined in an index, where 0= no deficit present, and 1= all 40 deficits present. The values of the index were well fit by a gamma distribution. Between the baseline and follow-up cohorts, the age-related slope of deficit accumulation increased from 0.020 (95% confidence interval, 0.014-0.026) to 0.026 (0.020-0.032). The 99% limit to deficit accumulation was 0.6 in the baseline cohort and 0.7 in the follow-up cohort. Multivariate Cox analysis showed the frailty index, age and sex to be significant predictors of mortality.
A systematic process for creating a frailty index, which relates deficit accumulation to the individual risk of death, showed reproducible properties in the Yale Precipitating Events Project cohort study. This method of quantifying frailty can aid our understanding of frailty-related health characteristics in older adults.
Over the past 2 decades, there has been considerable progress in the assessment of function and disability in older persons. Tests of physical performance are now routinely included in longitudinal ...studies to measure functional limitations, which are considered the building blocks of functioning. In addition, new strategies have been developed to assess the presence and onset of disability and to expand the scope of disability assessments beyond traditional indicators of difficulty and dependence. Contemporary measurement technologies, such as item response theory and computer adaptive testing, show great promise in the assessment of functional status and disability, but prospective studies are needed to demonstrate their true value, particularly to identify the circumstances in which their use will improve the assessment of functional outcomes in older persons. Another high priority for future research is to validate and further refine strategies to more completely and accurately ascertain the occurrence of disability in older persons.
Abstract
Background
Monitoring trajectories of intrinsic capacity (IC) in older adults has been suggested by the World Health Organization as a means to inform prevention to avoid or delay negative ...health outcomes. Due to a lack of longitudinal studies, it is currently unclear how IC changes over time and whether repeatedly measured IC predicts negative health outcomes.
Methods
Based on 4 751 repeated observations of IC (range = 0–100) during 21 years of follow-up among 754 older adults 70 and older, we assessed longitudinal trajectories of IC, and whether time-varying IC predicted the risk of chronic activities of daily living disability, long-term nursing home stay, and mortality using joint models.
Results
Average IC declined progressively from 77 to 11 points during follow-up, with substantial heterogeneity between older adults. Adjusted for sociodemographics and chronic diseases, a 1-point lower IC value was associated with a 7% increase in the risk of activities of daily living disability, a 6% increase in the risk of a nursing home stay, and a 5% increase in mortality. Accuracy for 5- and 10-year predictions based on up to 3 repeated measurements of IC ranged between moderate and good (area under the receiver operating characteristic curve = 0.76–0.82).
Conclusions
Our study indicates that IC declines progressively and that it predicts negative health outcomes among older adults. Therefore, regular monitoring of IC could work as an early warning system informing preventive efforts.
To examine temporal trends in utilization of glucose-lowering medications, glycemic control, and rate of severe hypoglycemia among patients with type 2 diabetes (T2DM).
Using claims data from 1.66 ...million privately insured and Medicare Advantage patients with T2DM from 2006 to 2013, we estimated the annual
) age- and sex-standardized proportion of patients who filled each class of agents;
) age-, sex-, race-, and region-standardized proportion with hemoglobin A
(HbA
) <6%, 6 to <7%, 7 to <8%, 8 to <9%, ≥9%; and
) age- and sex-standardized rate of severe hypoglycemia among those using medications. Proportions were calculated overall and stratified by age-group (18-44, 45-64, 65-74, and ≥75 years) and number of chronic comorbidities (zero, one, and two or more).
From 2006 to 2013, use increased for metformin (from 47.6 to 53.5%), dipeptidyl peptidase 4 inhibitors (0.5 to 14.9%), and insulin (17.1 to 23.0%) but declined for sulfonylureas (38.8 to 30.8%) and thiazolidinediones (28.5 to 5.6%; all
< 0.001). The proportion of patients with HbA
<7% declined (from 56.4 to 54.2%;
< 0.001) and with HbA
≥9% increased (9.9 to 12.2%;
< 0.001). Glycemic control varied by age and was poor among 23.3% of the youngest and 6.3% of the oldest patients in 2013. The overall rate of severe hypoglycemia remained the same (1.3 per 100 person-years;
= 0.72), declined modestly among the oldest patients (from 2.9 to 2.3;
< 0.001), and remained high among those with two or more comorbidities (3.2 to 3.5;
= 0.36).
During the recent 8-year period, the use of glucose-lowering drugs has changed dramatically among patients with T2DM. Overall glycemic control has not improved and remains poor among nearly a quarter of the youngest patients. The overall rate of severe hypoglycemia remains largely unchanged.
This longitudinal study involving older adults identified five trajectories during the last year of life: no disability, catastrophic disability, accelerated disability, progressive disability, and ...persistently severe disability. Most of the subjects who died suddenly had no disability, and most of those who died from advanced dementia had persistently severe disability; however, the course of disability was not predictable for the majority of the subjects, who died from other causes.
This longitudinal study involving older adults identified five trajectories during the last year of life: no disability, catastrophic disability, accelerated disability, progressive disability, and persistently severe disability. The course of disability was not predictable for the majority of the subjects.
According to the hypothesis of a compression of morbidity, if the onset of disability could be postponed, then lifetime disability could be compressed into a shorter average period before death.
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Supporting this hypothesis, data from several large national surveys have shown a decline in disability rates that exceeds the observed decline in mortality.
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,
3
Although informative at the population level, these results may not be directly relevant to individual patients, their families, or their physicians, who may be more interested in knowing the likelihood and course of disability at the end of life. Previous research has shown that the majority . . .
National and global recommendations for BMI cutoffs to trigger action to prevent obesity-related complications like type 2 diabetes among non-White populations are questionable. We aimed to ...prospectively identify ethnicity-specific BMI cutoffs for obesity based on the risk of type 2 diabetes that are risk-equivalent to the BMI cutoff for obesity among White populations (≥30 kg/m2).
In this population-based cohort study, we used electronic health records across primary care (Clinical Practice Research Datalink) linked to secondary care records (Hospital Episodes Statistics) from a network of general practitioner practices in England. Eligible participants were aged 18 years or older, without any past or current diagnosis of type 2 diabetes, had a BMI of 15·0–50·0 kg/m2 and complete ethnicity data, were registered with a general practitioner practice in England at any point between Sept 1, 1990, and Dec 1, 2018, and had at least 1 year of follow-up data. Patients with type 2 diabetes were identified by use of a CALIBER phenotyping algorithm. Self-reported ethnicity was collapsed into five main categories. Age-adjusted and sex-adjusted negative binomial regression models, with fractional polynomials for BMI, were fitted with incident type 2 diabetes and ethnicity data.
1 472 819 people were included in our study, of whom 1 333 816 (90·6%) were White, 75 956 (5·2%) were south Asian, 49 349 (3·4%) were Black, 10 934 (0·7%) were Chinese, and 2764 (0·2%) were Arab. After a median follow-up of 6·5 years (IQR 3·2–11·2), 97 823 (6·6%) of 1 472 819 individuals were diagnosed with type 2 diabetes. For the equivalent age-adjusted and sex-adjusted incidence of type 2 diabetes at a BMI of 30·0 kg/m2 in White populations, the BMI cutoffs were 23·9 kg/m2 (95% CI 23·6–24·0) in south Asian populations, 28·1 kg/m2 (28·0–28·4) in Black populations, 26·9 kg/m2 (26·7–27·2) in Chinese populations, and 26·6 kg/m2 (26·5–27·0) in Arab populations.
Revisions of ethnicity-specific BMI cutoffs are needed to ensure that minority ethnic populations are provided with appropriate clinical surveillance to optimise the prevention, early diagnosis, and timely management of type 2 diabetes.
National Institute for Health Research.
IMPORTANCE: Little is known about functional trajectories of older persons in the year before and after admission to the intensive care unit (ICU) or how pre-ICU functional trajectories affect ...post-ICU functional trajectories and death. OBJECTIVES: To characterize functional trajectories in the year before and after ICU admission and to evaluate the associations among pre-ICU functional trajectories and post-ICU functional trajectories, short-term mortality, and long-term mortality. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of 754 community-dwelling persons 70 years or older, conducted between March 23, 1998, and December 31, 2012, in greater New Haven, Connecticut. The analytic sample included 291 participants who had at least 1 admission to an ICU through December 2011. MAIN OUTCOMES AND MEASURES: Functional trajectories in the year before and after an ICU admission based on 13 basic, instrumental, and mobility activities. Additional outcomes included short-term (30 day) and long-term (1 year) mortality. RESULTS: The mean (SD) age of participants was 83.7 (5.5) years. Three distinct pre-ICU functional trajectories identified were minimal disability (29.6%), mild to moderate disability (44.0%), and severe disability (26.5%). Seventy participants (24.1%) experienced early death, defined as death in the hospital (50 participants 17.2%) or death after hospital discharge but within 30 days of admission (20 participants 6.9%). Among the remaining 221 participants, 3 distinct post-ICU functional trajectories identified were minimal disability (20.8%), mild to moderate disability (28.1%), and severe disability (51.1%). More than half of the participants (53.4%) experienced functional decline or early death after critical illness. The pre-ICU functional trajectories of mild to moderate disability and severe disability were associated with more than double (adjusted hazard ratio HR, 2.41; 95% CI, 1.29-4.50) and triple (adjusted HR, 3.84; 95% CI, 1.84-8.03) the risk of death within 1 year of ICU admission, respectively. Other factors associated with 1-year mortality included ICU length of stay (adjusted HR, 1.03; 95% CI, 1.00-1.05), mechanical ventilation (adjusted HR, 2.89; 95% CI, 1.91-4.37), and shock (adjusted HR, 2.68; 95% CI, 1.63-4.38). CONCLUSIONS AND RELEVANCE: Among older persons with critical illness, more than half died within 1 month or experienced significant functional decline over the following year, with particularly poor outcomes in those who had high levels of premorbid disability. These results may help to inform discussions about prognosis and goals of care before and during critical illness.
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