Cover Ho, Vanessa S.; Cenzer, Irena S.; Nguyen, Brian T. ...
Journal of the American Geriatrics Society (JAGS),
05/2022, Letnik:
70, Številka:
5
Journal Article
Although nursing home (NH) residents make up a large and growing proportion of Americans with diabetes mellitus, little is known about how glucose-lowering medications are used in this population. We ...sought to examine glucose-lowering medication use in Veterans Affairs (VA) NH residents with diabetes between 2005 and 2011.
Retrospective cohort study, using linked laboratory, pharmacy, administrative, and NH Minimum Dataset (MDS) 2.0 databases in 123 VA NHs. A total of 9431 long-stay (>90 days) VA NH residents older than 65 followed for 52,313 person-quarters. We identified receipt of glucose-lowering medications, including insulin, metformin, sulfonylureas, thiazolidinediones, and others (alpha-glucosidase inhibitors, meglitinides, glucagonlike peptide-1 analogs, dipeptidyl peptidase-4 inhibitors and amylin analogs) per quarter.
The rates of sulfonylurea use in long-stay NH residents dropped dramatically from 24% in 2005 to 12% in 2011 (P < .001), driven in large part by the dramatic decrease in glyburide use (10% to 2%, P < .001). There was sharp drop in thiazolidinedione use in 2007 (4% to <1%, P < .001). Metformin use was stable, ranging between 7% and 9% (P = .24). Insulin use increased slightly from 30% to 32% (P < .001). Use of other classes of glucose-lowering medications was stable (P = .22) and low, remaining below 1.3%.
Between 2005 and 2011, there were dramatic declines in use of sulfonylureas and thiazolidinediones in VA NH residents, suggesting that prescribing practices can be quickly changed in this setting.
Medicare currently penalizes hospitals for high readmission rates for seniors but does not account for common age-related syndromes, such as functional impairment.
To assess the effects of functional ...impairment on Medicare hospital readmissions given the high prevalence of functional impairments in community-dwelling seniors.
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.
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.
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).
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.
Objectives
To determine prevalence of, and outcomes associated with, a positive screen for cognitive impairment in older adults in jail.
Design
Combined data from cross‐sectional (n=185 participants) ...and longitudinal (n=125 participants) studies.
Setting
Urban county jail.
Participants
Individuals in jail aged 55 and older (N = 310; mean age 59, range 55–80). Inclusion of individuals aged 55 and older is justified because the criminal justice system defines “geriatric prisoners” as those aged 55 and older.
Measurements
Baseline and follow‐up assessments of health, psychosocial factors, and cognitive status (using the Montreal Cognitive Assessment (MoCA)); 6‐month acute care use and repeat arrest assessed in those followed longitudinally.
Results
Participants were of low socioeconomic status (85% annual income < $15,000) and predominantly nonwhite (75%). Many (70%) scored less than 25 on the MoCA; those with a low MoCA score were more likely to be nonwhite (81% vs 62%, p<.001) and report fair or poor health (54% vs 41%, p=.04). Over 6 months, a MoCA score of less than 25 was associated with multiple emergency department visits (32% vs 13%, p=.02), hospitalization (35% vs 16%, p=.03), and repeat arrests (45% vs 21%, p=.01).
Conclusions
Cognitive impairment is prevalent in older adults in jail and is associated with adverse health and criminal justice outcomes. A geriatric approach to jail‐based and transitional health care should be developed to assess and address cognitive impairment. Additional research is needed to better assess cognitive impairment and its consequences in this population. J Am Geriatr Soc 66:2065–2071, 2018.
See related editorial by Lisa Barry
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.
Distressing symptoms are associated with poor function, acute care use, and mortality in older adults. The number of older jail inmates is increasing rapidly, prompting calls to develop systems of ...care to meet their healthcare needs, yet little is known about multidimensional symptom burden in this population. This cross‐sectional study describes the prevalence and factors associated with distressing symptoms and the overlap between different forms of symptom distress in 125 older jail inmates in an urban county jail. Physical distress was assessed using the Memorial Symptom Assessment Scale. Several other forms of symptom distress were also examined, including psychological (Generalized Anxiety Disorder Scale, Patient Health Questionnaire), existential (Patient Dignity Inventory), and social (Three Item Loneliness Scale). Information was collected on participant sociodemographic characteristics, multimorbidity, serious mental illness (SMI), functional impairment, and behavioral health risk factors through self‐report and chart review. Chi‐square tests were used to identify factors associated with physical distress. Overlap between forms of distress was evaluated using set theory analysis. Overall, many participants (74%) reported distressing symptoms, including having one or more physical (44%), psychological (37%), existential (54%), or social (45%) symptoms. Physical distress was associated with poor health (multimorbidity, functional impairment, SMI) and low income. Of the 93 participants with any symptom, 49% reported three or more forms of distress. These findings suggest that an optimal model of care for this population would include a geriatrics–palliative care approach that integrates the management of all forms of symptom distress into a comprehensive treatment paradigm stretching from jail to the community.
Objectives
To assess the effects of preadmission functional impairment on Medicare costs of postacute care up to 365 days after hospital discharge.
Design
Longitudinal cohort study.
Setting
Health ...and Retirement Study (HRS).
Participants
Nationally representative sample of 16,673 Medicare hospitalizations of 8,559 community‐dwelling older adults from 2000 to 2012.
Measurements
The main outcome was total Medicare costs in the year after hospital discharge, assessed according to Medicare claims data. The main predictor was functional impairment (level of difficulty or dependence in activities of daily living (ADLs)), determined from HRS interview preceding hospitalization. Multivariable linear regression was performed, adjusted for age, race, sex, income, net worth, and comorbidities, with clustering at the individual level to characterize the association between functional impairment and costs of postacute care.
Results
Unadjusted mean Medicare costs for 1 year after discharge increased with severity of impairment in a dose‐response fashion (P < .001 for trend); 68% had no functional impairment ($25,931), 17% had difficulty with one ADL ($32,501), 7% had dependency in one ADL ($39,928), and 8% had dependency in two or more ADLs ($45,895). The most severely impaired participants cost 77% more than those with no impairment; adjusted analyses showed attenuated effect size (33% more) but no change in trend. Considering costs attributable to comorbidities, only three conditions were more expensive than severe functional impairment (lymphoma, metastatic cancer, paralysis).
Conclusion
Functional impairment is associated with greater Medicare costs for postacute care and may be an unmeasured but important marker of long‐term costs that cuts across conditions.
Mild cognitive impairment is often a precursor to dementia due to Alzheimer's disease, but many patients with mild cognitive impairment never develop dementia. New diagnostic criteria may lead to ...more patients receiving a diagnosis of mild cognitive impairment.
To develop a prediction index for the 3-year risk of progression from mild cognitive impairment to dementia relying only on information that can be readily obtained in most clinical settings.
382 participants diagnosed with amnestic mild cognitive impairment enrolled in the Alzheimer's Disease Neuroimaging Initiative (ADNI), a multi-site, longitudinal, observational study.
Demographics, comorbid conditions, caregiver report of participant symptoms and function, and participant performance on individual items from basic neuropsychological scales.
Progression to probable Alzheimer's disease.
Subjects had a mean (SD) age of 75 (7) years and 43% progressed to probable Alzheimer's disease within 3 years. Important independent predictors of progression included being female, resisting help, becoming upset when separated from caregiver, difficulty shopping alone, forgetting appointments, number of words recalled from a 10-word list, orientation and difficulty drawing a clock. The final point score could range from 0 to 16 (mean SD: 4.2 2.9). The optimism-corrected Harrell's c-statistic was 0.71(95% CI: 0.68-0.75). Fourteen percent of subjects with low risk scores (0-2 points, n = 124) converted to probable Alzheimer's disease over 3 years, compared to 51% of those with moderate risk scores (3-8 points, n = 223) and 91% of those with high risk scores (9-16 points, n = 35).
An index using factors that can be obtained in most clinical settings can predict progression from amnestic mild cognitive impairment to probable Alzheimer's disease and may help clinicians differentiate between mild cognitive impairment patients at low vs. high risk of progression.
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