1. Understand how social isolation is defined and should be considered among older adults with cognitive impairment.
2. Understand how social isolation and cognitive impairment can lead to reduced ...healthcare use at the end of life and the role of clinicians in addressing social needs
At the end of life, older adults may rely on others to access healthcare, particularly if they have impaired cognition.
To determine whether socially isolated older adults with and without cognitive impairment have different patterns of end-of-life healthcare use.
We used nationally representative 2006-2016 Health and Retirement Study data linked to Medicare claims to examine adults age >50 interviewed once in the last 4 years of life (N = 2,073). We measured three self-report subscales of social relationships: household contacts, social network interaction, and community engagement. The three subscales were combined to create an overall social isolation measure. End-of-life health outcomes included emergency department (ED) visits, hospitalizations, ICU stays, and hospice use in the last months of life. Cognitive impairment (CI) included CIND or dementia. We used logistic regression to test the adjusted association of each social measure with each end-of-life outcome and tested for significant interactions with CI (p < 0.1).
Our sample had a mean age of 82 (52% female, 9% Black, 5% Hispanic, 47% had CI). There were significant interactions between social isolation or network interaction and CI for all end-of-life outcomes; social isolation was associated with lower hospice use (aOR = 0.61, p = 0.05), ED use (aOR = 0.55, p = 0.03), ICU use (aOR = 0.62, p = 0.05), and hospitalizations (aOR = 0.63, p = 0.04) for patients with CI, whereas there was no association for those with no CI (hospice, aOR = 1.1; ED, aOR = 1.1; ICU, aOR = 1.0; hospitalizations, aOR = 1.1).
Cognitively impaired older adults who were socially isolated or had reduced social network interaction had fewer ED visits, hospitalizations, ICU stays, and hospice use at the end of life.
Cognitively impaired, isolated older adults may struggle to access end-of-life healthcare. Further research is needed to determine whether low rates of acute care and hospice are concordant with their wishes or are due to a lack of support in accessing health services.
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.
The clinical decision to initiate bisphosphonate therapy for the treatment of osteoporosis requires balancing shorter-term harms and burdens (eg, gastroesophageal irritation or severe musculoskeletal ...pain) with longer-term benefits in reducing potential fractures.
To assess the time to benefit (TTB) of bisphosphonate therapy for the prevention of nonvertebral and other fractures among postmenopausal women with osteoporosis.
Randomized clinical trials (RCTs) were identified from systematic reviews commissioned by the US Preventive Services Task Force (1 review), the Agency for Healthcare Research and Quality (1 review), the Cochrane Library (2 reviews), and the Endocrine Society (1 review).
Studies selected were RCTs involving postmenopausal women with a diagnosis of osteoporosis based on existing vertebral fractures or bone mineral density T scores of -2.5 or lower. The selection process was focused on studies of alendronate, risedronate, and zoledronic acid because they are guideline-recommended first-line agents for reducing nonvertebral fractures. Studies were excluded if they did not focus on women with a primary diagnosis of osteoporosis, had no placebo arm, or had a lack of data on time to fracture.
Random-effects Weibull survival curves were fitted and Markov chain Monte Carlo methods were used to estimate the absolute risk reduction (ARR) and TTB for each study. These estimates were pooled using a random-effects meta-analysis model.
The primary outcome was the time to 3 different ARR thresholds (0.002, 0.005, and 0.010) for the first nonvertebral fracture. Secondary outcomes included the time to 4 ARR thresholds (0.001, 0.002, 0.005, and 0.010) for hip fracture, any clinical fracture, and clinical vertebral fracture.
Of 67 full-text articles identified, 10 RCTs comprising 23 384 postmenopausal women with osteoporosis were included either as the original RCT or part of subsequently published pooled analyses. Among the studies, the number of participants ranged from 994 to 7765, with mean (SD) age ranging from 63 (7) years to 74 (3) years and follow-up duration ranging from 12 to 48 months. The pooled meta-analysis found that 12.4 months (95% CI, 6.3-18.4 months) were needed to avoid 1 nonvertebral fracture per 100 postmenopausal women receiving bisphosphonate therapy at an ARR of 0.010. To prevent 1 hip fracture, 200 postmenopausal women with osteoporosis would need to receive bisphosphonate therapy for 20.3 months (95% CI, 11.0-29.7 months) at an ARR of 0.005. In addition, 200 postmenopausal women with osteoporosis would need to receive bisphosphonate therapy for 12.1 months (95% CI, 6.4-17.8 months) to avoid 1 clinical vertebral fracture at an ARR of 0.005.
This meta-analysis found that the TTB of bisphosphonate therapy was 12.4 months to prevent 1 nonvertebral fracture per 100 postmenopausal women with osteoporosis. These results suggest that bisphosphonate therapy is most likely to benefit postmenopausal women with osteoporosis who have a life expectancy greater than 12.4 months.
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.
To assess the usability of German hospital administrative claims data (GHACD) to determine inpatient management patterns, healthcare resource utilization, and quality-of-care in patients with ...multiple myeloma (PwMM). Based on German tertiary hospital's claims data (2015-2017), PwMM aged >18 years were included if they had an International Classification of Diseases, Tenth Revision, code of C90.0 or received anti-MM therapy. Subgroup analysis was performed on stem cell transplantation (SCT) patients. Of 230 PwMM, 59.1% were men; 56.1% were aged greater than or equal to65 years. Hypertension and infections were present in 50% and 67.0%, respectively. Seventy percent of PwMM received combination therapy. Innovative drugs such as bortezomib and lenalidomide were given to 36.1% and 10.9% of the patients, respectively. Mean number of admissions and mean hospitalization length/patient were 3.69 (standard deviation (SD) 2.71 (1-16)) and 12.52 (SD 9.55 (1-68.5)) days, respectively. In-hospital mortality was recorded in 12.2%. Seventy-two percent of SCT patients (n = 88) were aged less than or equal to65 years, 22.7% required second transplantation, and 89.8% received platelet transfusion at a mean of 1.42(SD 0.63 (1-3)). GHACD provided relevant information essential for healthcare studies about PwMM from routine care settings. Data fundamental for quality-of-care assessment were also captured.
Predicting 10-year mortality for older adults Cruz, Marisa; Covinsky, Kenneth; Widera, Eric W ...
JAMA : the journal of the American Medical Association,
2013-Mar-06, Letnik:
309, Številka:
9
Journal Article
1. Appreciate the high prevalence of loneliness and social isolation in people with COPD and COPD on oxygen supplementation.
2. Evaluate risk factors for loneliness and social isolation in people ...with COPD.
Loneliness and social isolation are distinct social risk factors critical to health, quality of life, and healthcare use among persons with COPD. However, their prevalence is not well-described in this population, especially those with COPD requiring oxygen.
We used the nationally representative Health Retirement Study (2016-2018), which includes adults ≥50 years (N=10,225). COPD and oxygen use are self-reported. We categorized participants into three groups: (1) no COPD, (2) COPD, and (3) COPD on oxygen. Loneliness was measured using the 3-item UCLA Loneliness Scale. Social isolation was defined using a 15-item scale measuring household contacts, social network interaction, and community engagement. We used multivariable logistic regression adjusting for sociodemographic and comorbidities to determine their adjusted prevalence and identify independent risk factors.
The average age was 68 years (range 50-102), 9% reported COPD, 2% COPD on oxygen, 54% female, 10% African American, 10% Latino, 66% married/partnered. After adjustment, persons with COPD were more likely to experience loneliness (no COPD: 10%, COPD: 22%, COPD on oxygen: 30%, p<0.001), social isolation (no COPD: 11%, COPD: 19%, COPD on oxygen: 26%, p<0.001), or both (no COPD: 3%, COPD: 7%, COPD on oxygen: 16%, p<0.001). Among those with COPD, risk factors for loneliness (p<0.001) included younger age (50-65 years: 18%, 86-102 years: 11%), being single (single: 26%, married: 10%), depression (depression: 35%, no depression 13%) and low net worth ($<81,000: 21%, $>239,000: 14%). Risk factors for social isolation (p<0.001) included male gender (men: 21%, women: 12%), race (White: 19%, Latino 14%, African American 6%), low net worth ($<81,000: 26%, $>239,000: 12%), and depression (depression: 25%, no depression 15%).
People with COPD are three times more likely to experience loneliness and social isolation than people without COPD. Social interventions may be needed to improve the quality of life of persons experiencing COPD, particularly those with identified risk factors.
Loneliness is a common source of distress, suffering, and impaired quality of life in older persons. We examined the relationship between loneliness, functional decline, and death in adults older ...than 60 years in the United States.
This is a longitudinal cohort study of 1604 participants in the psychosocial module of the Health and Retirement Study, a nationally representative study of older persons. Baseline assessment was in 2002 and follow-up assessments occurred every 2 years until 2008. Subjects were asked if they (1) feel left out, (2) feel isolated, or (3) lack companionship. Subjects were categorized as not lonely if they responded hardly ever to all 3 questions and lonely if they responded some of the time or often to any of the 3 questions. The primary outcomes were time to death over 6 years and functional decline over 6 years on the following 4 measures: difficulty on an increased number of activities of daily living (ADL), difficulty in an increased number of upper extremity tasks, decline in mobility, or increased difficulty in stair climbing. Multivariate analyses adjusted for demographic variables, socioeconomic status, living situation, depression, and various medical conditions.
The mean age of subjects was 71 years. Fifty-nine percent were women; 81% were white, 11%, black, and 6%, Hispanic; and 18% lived alone. Among the elderly participants, 43% reported feeling lonely. Loneliness was associated with all outcome measures. Lonely subjects were more likely to experience decline in ADL (24.8% vs 12.5%; adjusted risk ratio RR, 1.59; 95% CI, 1.23-2.07); develop difficulties with upper extremity tasks (41.5% vs 28.3%; adjusted RR, 1.28; 95% CI, 1.08-1.52); experience decline in mobility (38.1% vs 29.4%; adjusted RR, 1.18; 95% CI, 0.99-1.41); or experience difficulty in climbing (40.8% vs 27.9%; adjusted RR, 1.31; 95% CI, 1.10-1.57). Loneliness was associated with an increased risk of death (22.8% vs 14.2%; adjusted HR, 1.45; 95% CI, 1.11-1.88).
Among participants who were older than 60 years, loneliness was a predictor of functional decline and death.
Objectives
To examine whether life expectancy influences treatment pattern of nonmelanoma skin cancer, or keratinocyte carcinoma (KC), the most common malignancy and the fifth most costly cancer to ...Medicare.
Design
Nationally representative cross‐sectional study.
Setting
Nationally representative Health and Retirement Study linked to Medicare claims.
Participants
Treatments (N = 9,653) from individuals aged 65 and older treated for basal or squamous cell carcinoma between 1992 and 2012 (N = 2,702) were included.
Measurements
Limited life expectancy defined according to aged 85 and older, medical comorbidities, Charlson Comorbidity Index score of 3 or greater, difficulty in at least one activity of daily living (ADL), and a Lee index of 13 or greater. Treatment type (Mohs micrographic surgery (MMS) (most intensive, highest cost), excision, or electrodesiccation and curettage (ED&C) (least intensive, lowest cost)), according to procedure code.
Results
Most KCs (61%) were treated surgically. Rates of MMS (19%), excision (42%), and ED&C (39%) were no different in participants with limited life expectancy and those with normal life expectancy. For example, 19% of participants with difficulty or dependence in ADLs, 20% of those with a Charlson comorbidity score greater than 3, and 15% of those in their last year of life underwent MMS; participants who died within 1 year of diagnosis were treated in the same way as those who lived longer.
Conclusion
A one‐size‐fits‐all approach in which advanced age, health status, functional status, and prognosis are not associated with intensiveness of treatment appears to guide treatment for KC, a generally nonfatal condition. Although intensive treatment of skin cancer when it causes symptoms may be indicated regardless of life expectancy, persons with limited life expectancy should be given choices to ensure that the treatment matches their goals and preferences.
1. Analyze the role of marriage in serious illness and dementia
2. Discuss interactive biopsychosocial model underlying marriage and health among older adults with serious illness, and key social ...measures
3. Describe the prevalence of loneliness, depression, or both among spouses married to persons with dementia
4. Discuss how one's partner's cognitive decline is associated with higher levels of loneliness and depression
Older adults married to persons with dementia (PWD) may be at risk for loneliness and depression. However, it is unclear how often each occur and the extent to which they are distinct.
To determine the prevalence of loneliness and depression among older adults married to PWD or mild cognitive impairment (MCI) and the role of marital closeness in mediating these outcomes
We used a nationally representative sample of 3,666 married couples enrolled in the Health and Retirement Study (2014 and 2016). We included older adults married to PWD (N=201), married to persons with MCI (N=778), or married to persons with normal cognition (N=2,687). We determined the prevalence of loneliness using multivariable logistic regression adjusting for socio-demographic characteristics, then tested for interaction between marital closeness and degree of spousal cognitive impairment. We assessed the prevalence of depression, and both loneliness and depression, using the same method.
The sample was 54% women and on average 67 years old (Range: 50–97). After adjustment, older adults married to PWD were more likely to be lonely (Normal: 20%, MCI: 21%, PWD: 30%; p=0.02), depressed (Normal: 7%, MCI: 14%, PWD: 16%; p< 0.01), and both (Normal: 4%, MCI: 8%, PWD: 9%; p< 0.01). The association between spousal cognition and loneliness differed by marital closeness (interaction p-value=0.01); among “close” couples, spousal cognitive impairment was associated with higher likelihood of loneliness (p=0.01). In contrast, no association existed between spousal cognitive impairment and loneliness among “not close” couples (p=0.24).
Nearly 1 in 3 spouses of PWD experienced loneliness and 1 in 6 experienced depression. The association between spousal cognition and loneliness was stronger among those with close marital bonds.
Findings highlight substantial opportunity to identify and address loneliness and depression among spouses of PWD with close relational bonds to improve quality of life.
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