The decision‐making process on behalf of unrepresented adults (ie, those who lack capacity to make medical decisions and have no identifiable surrogate) is at risk for not incorporating their ...interests, raising ethical concerns. We performed semistructured interviews with key stakeholders across multiple sectors in an urban county who participate in the care of or decision‐making process for unrepresented adults. This included a safety net healthcare system, social services, and legal services. Participants were healthcare, social service, and legal professionals who worked with unrepresented adults (n = 25). Our interview questions explored the current process for proxy decision making in cases of unrepresented adults and potential alternatives. We recorded, transcribed, and analyzed interviews using the constant comparative method to identify major themes related to ethical challenges if they were raised. Participants grappled with multiple ethical challenges around the care of unrepresented adults. Themes described by participants were: (1) prioritizing autonomy; (2) varying safety thresholds; (3) distributing resources fairly; and (4) taking a moral toll on stakeholders. In conclusion, all stakeholders identified ethical challenges in caring for unrepresented adults. An applied ethical framework that takes these dilemmas into account could improve ethical practice for unrepresented adults and lessen the emotional toll on stakeholders. J Am Geriatr Soc 67:1724–1729, 2019
Social isolation is common in the last years of life, especially among individuals with cognitive impairment (CI), but it is unknown if social isolation is related to end-of-life health care use.
We ...used nationally-representative 2006-2018 Health and Retirement Study (HRS) data linked to Medicare claims, including adults age ≥65 interviewed in the last 4 years of life (N = 2380). We used a validated social isolation scale and three social isolation subscales: (1) household contacts (marital status, household size, nearby children), (2) social network interaction (with children, family, and friends), and (3) community engagement. End-of-life health outcomes included 2+ emergency department (ED) visits in the last month of life, hospitalizations or ICU stays in the last 6 months of life, and any hospice use. CI was defined using the validated Langa-Weir methodology. We used logistic regression to test the association of each social isolation measure with each end-of-life outcome, adjusted for sociodemographic covariates, and tested for interaction terms with CI (p < 0.2).
The mean age of our sample of decedents was 81.2 (SD = 9.9), 53% were female, 8% Black, and 4% Hispanic. Overall, social isolation and the community engagement subscale were not associated with end-of-life health care use. Fewer household contacts were associated with lower hospice use (aOR = 0.74, p = 0.005). There were significant interaction terms between the social network interaction subscale and CI for ED use (p = 0.009) and hospitalizations (p = 0.04), and a trend for ICU stays (p = 0.15); individuals with both low social network interaction and CI had lower health care use across all three outcomes compared to other groups.
Individuals with fewer household contacts had lower hospice use, and cognitively impaired individuals with low social network interaction had fewer end-of-life ED visits, hospitalizations, and ICU stays. Clinicians should consider mobilizing external support services to ensure access to goal-concordant care for older adults with limited end-of-life social contact when needed.
OBJECTIVES
To identify participants living at home and to estimate the risk of their transition into an institutional setting.
DESIGN
Prospective cohort study from the National Health and Aging ...Trends Study (NHATS), a nationally representative survey of US adults aged 65 and older.
SETTING
US national sample.
PARTICIPANTS
A total of 4712 NHATS participants were living at home in 2011. Residential transitions were described every year through 2017.
MEASUREMENTS
The primary outcome was transition time into an institutional setting. Primary predictors were social support factors (living spouse, lives with others, presence of social network, and participation in social activities). Covariates included age, sex, race, cognitive status, functional disability, multimorbidity, and Medicaid enrollment. A Fine and Gray hazards model estimated the risk of transition into an institutional setting, with death before institutionalization considered a competing risk.
RESULTS
In 2011, 4712 NHATS participants were living at home (78 ± 8 y; 57% female; 80% white; 10% probable dementia; 7% with three or more activities of daily living disabilities). By 2017, 58% remained at home, 17% had either transitioned to an institution or died in an institution, and 25% died before institutionalization. In multivariable analyses that adjusted for age, sex, race, cognitive status, functional disability, multimorbidity, and Medicaid enrollment, participants were more likely to move out of the home into an institution if they had no social network (0 vs three or more people; subhazard ratio sHR = 1.8; 95% confidence interval CI = 1.2–2.5; P = .003) or lived alone (sHR = 1.9; 95% CI = 1.6–2.2; P < .0001). Older adults who enjoyed going to the movies, dinner, or the casino and visiting family or friends had a lower probability of institutionalization compared with participants who did not enjoy these activities or did not visit family or friends (adjusted sHR = .7; 95% CI = .6–.9; adjusted sHR = .7; 95% CI = .6–.9, respectively).
CONCLUSION
Policy initiatives should target older adults with limited social support to reduce the risk of moving from home into an institution. J Am Geriatr Soc 67:2622–2627, 2019
Guidelines recommend targeting preventive interventions toward older adults whose life expectancy is greater than the intervention's time to benefit (TTB). The TTB for statin therapy is unknown.
To ...conduct a survival meta-analysis of randomized clinical trials of statins to determine the TTB for prevention of a first major adverse cardiovascular event (MACE) in adults aged 50 to 75 years.
Studies were identified from previously published systematic reviews (Cochrane Database of Systematic Reviews and US Preventive Services Task Force) and a search of MEDLINE and Google Scholar for subsequently published studies until February 1, 2020.
Randomized clinical trials of statins for primary prevention focusing on older adults (mean age >55 years).
Two authors independently abstracted survival data for the control and intervention groups. Weibull survival curves were fit, and a random-effects model was used to estimate pooled absolute risk reductions (ARRs) between control and intervention groups each year. Markov chain Monte Carlo methods were applied to determine time to ARR thresholds.
The primary outcome was time to ARR thresholds (0.002, 0.005, and 0.010) for a first MACE, as defined by each trial. There were broad similarities in the definition of MACE across trials, with all trials including myocardial infarction and cardiovascular mortality.
Eight trials randomizing 65 383 adults (66.3% men) were identified. The mean age ranged from 55 to 69 years old and the mean length of follow-up ranged from 2 to 6 years. Only 1 of 8 studies showed that statins decreased all-cause mortality. The meta-analysis results suggested that 2.5 (95% CI, 1.7-3.4) years were needed to avoid 1 MACE for 100 patients treated with a statin. To prevent 1 MACE for 200 patients treated (ARR = 0.005), the TTB was 1.3 (95% CI, 1.0-1.7) years, whereas the TTB to avoid 1 MACE for 500 patients treated (ARR = 0.002) was 0.8 (95% CI, 0.5-1.0) years.
These findings suggest that treating 100 adults (aged 50-75 years) without known cardiovascular disease with a statin for 2.5 years prevented 1 MACE in 1 adult. Statins may help to prevent a first MACE in adults aged 50 to 75 years old if they have a life expectancy of at least 2.5 years. There is no evidence of a mortality benefit.
ABSTRACT
BACKGROUND
As our society ages, improving medical care for an older population will be crucial. Discrimination in healthcare may contribute to substandard experiences with the healthcare ...system, increasing the burden of poor health in older adults. Few studies have focused on the presence of healthcare discrimination and its effects on older adults.
OBJECTIVE
We aimed to examine the relationship between healthcare discrimination and new or worsened disability.
DESIGN
This was a longitudinal analysis of data from the nationally representative Health and Retirement Study administered in 2008 with follow-up through 2012.
PARTICIPANTS
Six thousand and seventeen adults over the age of 50 years (mean age 67 years, 56.3 % female, 83.1 % white) were included in this study.
MAIN MEASURES
Healthcare discrimination assessed by a 2008 report of receiving poorer service or treatment than other people by doctors or hospitals (never, less than a year=infrequent; more than once a year=frequent). Outcome was self-report of new or worsened disability by 2012 (difficulty or dependence in any of six activities of daily living). We used a Cox proportional hazards model adjusting for age, race/ethnicity, gender, net worth, education, depression, high blood pressure, diabetes, cancer, lung disease, heart disease, stroke, and healthcare utilization in the past 2 years.
KEY RESULTS
In all, 12.6 % experienced discrimination infrequently and 5.9 % frequently. Almost one-third of participants (29 %) reporting frequent healthcare discrimination developed new or worsened disability over 4 years, compared to 16.8 % of those who infrequently and 14.7 % of those who never experienced healthcare discrimination (
p
< 0.001). In multivariate analyses, compared to no discrimination, frequent healthcare discrimination was associated with new or worsened disability over 4 years (aHR = 1.63, 95 % CI 1.16–2.27).
CONCLUSIONS
One out of five adults over the age of 50 years experiences discrimination in healthcare settings. One in 17 experience frequent healthcare discrimination, and this is associated with new or worsened disability by 4 years. Future research should focus on the mechanisms by which healthcare discrimination influences disability in older adults to promote better health outcomes for an aging population.
Rehabbed to Death: Breaking the Cycle Flint, Lynn A.; David, Daniel; Lynn, Joanne ...
Journal of the American Geriatrics Society (JAGS),
November 2019, 2019-11-00, 20191101, Letnik:
67, Številka:
11
Journal Article
Recenzirano
Many older adults transfer from the hospital to a post‐acute care (PAC) facility and back to the hospital in the final phase of life. This phenomenon, which we have dubbed “Rehabbing to death,” is ...emblematic of how our healthcare system does not meet the needs of older adults and their families. Policy has driven practice in this area including seemingly benign habits such as calling PAC facilities “rehab.” We advocate for practice changes: (1) calling PAC “after‐hospital transitional care,” rather than “rehab”; (2) adopting a serious illness communication model when discussing new care needs at the end of a hospitalization; and (3) policies that incentivize comprehensive care planning for older adults across all settings and provide broad support and training for caregivers. In realigning health and social policies to meet the needs of older adults and their caregivers, fewer patients will be rehabbed to death, and more will receive care consistent with their preferences and priorities. J Am Geriatr Soc 67:2398–2401, 2019
See related editorial by Ouslander and Grabowski
It is uncertain whether coronary artery bypass grafting (CABG) is associated with cognitive decline in older adults compared with a nonsurgical method of coronary revascularization (percutaneous ...coronary intervention PCI).
To compare the change in the rate of memory decline after CABG vs PCI.
Retrospective cohort study of community-dwelling participants in the Health and Retirement Study, who underwent CABG or PCI between 1998 and 2015 at age 65 years or older. Data were modeled for up to 5 years preceding and 10 years following revascularization or until death, drop out, or the 2016-2017 interview wave. The date of final follow-up was November 2017.
CABG (including on and off pump) or PCI, ascertained from Medicare fee-for-service billing records.
The primary outcome was a summary measure of cognitive test scores and proxy cognition reports that were performed biennially in the Health and Retirement Study, referred to as memory score, normalized as a z score (ie, mean of 0, SD of 1 in a reference population of adults aged ≥72 years). Memory score was analyzed using multivariable linear mixed-effects models, with a prespecified subgroup analysis of on-pump and off-pump CABG. The minimum clinically important difference was a change of 1 SD of the population-level rate of memory decline (0.048 memory units/y).
Of 1680 participants (mean age at procedure, 75 years; 41% female), 665 underwent CABG (168 off pump) and 1015 underwent PCI. In the PCI group, the mean rate of memory decline was 0.064 memory units/y (95% CI, 0.052 to 0.078) before the procedure and 0.060 memory units/y (95% CI, 0.048 to 0.071) after the procedure (within-group change, 0.004 memory units/y 95% CI, -0.010 to 0.018). In the CABG group, the mean rate of memory decline was 0.049 memory units/y (95% CI, 0.033 to 0.065) before the procedure and 0.059 memory units/y (95% CI, 0.047 to 0.072) after the procedure (within-group change, -0.011 memory units/y 95% CI, -0.029 to 0.008). The between-group difference-in-differences estimate for memory decline for PCI vs CABG was 0.015 memory units/y (95% CI, -0.008 to 0.038; P = .21). There was statistically significant increase in the rate of memory decline after off-pump CABG compared with after PCI (difference-in-differences: mean increase in the rate of decline of 0.046 memory units/y 95% CI, 0.008 to 0.084 after off-pump CABG), but not after on-pump CABG compared with PCI (difference-in-differences: mean slowing of decline of 0.003 memory units/y 95% CI, -0.024 to 0.031 after on-pump CABG).
Among older adults undergoing coronary revascularization with CABG or PCI, the type of revascularization procedure was not significantly associated with differences in the change of rate of memory decline.
Background
Difficulty managing medicines and finances becomes increasingly common with advanced age, and compromises the ability to live safely and independently. Remarkably little is known how often ...this occurs.
Objectives
To provide population‐based estimates of the risk of developing incident difficulty managing medications and finances in older adults.
Design
A prospective cohort study.
Setting
The Health and Retirement Study (HRS), a nationally representative study of older adults.
Participants
9,434 participants aged 65 and older who did not need help in managing medications or managing finances in 2002. Follow‐up assessments occurred every 2 years until 2012.
Measurements
The primary outcomes were time to difficulty managing medications and time to difficulty managing finances. Risk factors such as demographics, comorbidities, functional status, and cognitive status were assessed at baseline. Hazard models that considered the competing risk of death were used to estimate both the cumulative incidence of developing difficulty managing medications and finances and to identify potential risk factors. Analyses were adjusted for age, gender, race, marital status, wealth and education.
Results
The 10 years incidence of difficulty increased markedly with age, ranging from 10.3% (95% CI 9.3–11.6) for managing medications and 23.1% (95% CI 21.6–24.7) for managing finances in those aged 65–69, to 38.2% (95% CI 33.4–43.5) for medicines and 69% (95% CI 63.7–74.3) for finances in those over age 85. Women had a higher probability of developing difficulty managing medications and managing finances than men.
Conclusion
This study highlights the importance of preparing older adults for the likelihood they will need assistance with managing their medicines and finances as the risk for having difficulty with these activities over time is substantial.
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