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.
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.
To determine the population-level association between persistent pain, which may reflect chronic pain, and subsequent cognitive decline.
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.
"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.
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.
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.
Persistent pain was associated with accelerated memory decline and increased probability of dementia.
Objectives
To determine whether advance care planning influences quality of end‐of‐life care.
Design
In this observational cohort study, Medicare data and survey data from the Health and Retirement ...Study (HRS) were combined to determine whether advance care planning was associated with quality metrics.
Setting
The nationally representative HRS.
Participants
Four thousand three hundred ninety‐nine decedent subjects (mean age 82.6 at death, 55% women).
Measurements
Advance care planning (ACP) was defined as having an advance directive (AD), durable power of attorney (DPOA) or having discussed preferences for end‐of‐life care with a next of kin. Outcomes included previously reported quality metrics observed during the last month of life (rates of hospital admission, in‐hospital death, >14 days in the hospital, intensive care unit admission, >1 emergency department visit, hospice admission, and length of hospice ≤3 days).
Results
Seventy‐six percent of subjects engaged in ACP. Ninety‐two percent of ADs stated a preference to prioritize comfort. After adjustment, subjects who engaged in ACP were less likely to die in a hospital (adjusted relative risk (aRR) = 0.87, 95% confidence interval (CI) = 0.80–0.94), more likely to be enrolled in hospice (aRR = 1.68, 95% CI = 1.43–1.97), and less likely to receive hospice for 3 days or less before death (aRR = 0.88, 95% CI = 0.85–0.91). Having an AD, a DPOA or an ACP discussion were each independently associated with a significant increase in hospice use (P < .01 for all).
Conclusion
ACP was associated with improved quality of care at the end of life, including less in‐hospital death and increased use of hospice. Having an AD, assigning a DPOA and conducting ACP discussions are all important elements of ACP.
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.
ABSTRACT
We present and analyse a new tidal disruption event (TDE), AT2017eqx at redshift z = 0.1089, discovered by Pan-STARRS and ATLAS. The position of the transient is consistent with the nucleus ...of its host galaxy; the spectrum shows a persistent blackbody temperature T ≳ 20 000 K with broad H i and He ii emission; and it peaks at a blackbody luminosity of L ≈ 1044 erg s−1. The lines are initially centred at zero velocity, but by 100 d, the H i lines disappear while the He ii develops a blueshift of ≳ 5000 km s−1. Both the early- and late-time morphologies have been seen in other TDEs, but the complete transition between them is unprecedented. The evolution can be explained by combining an extended atmosphere, undergoing slow contraction, with a wind in the polar direction becoming visible at late times. Our observations confirm that a lack of hydrogen a TDE spectrum does not indicate a stripped star, while the proposed model implies that much of the diversity in TDEs may be due to the observer viewing angle. Modelling the light curve suggests AT2017eqx resulted from the complete disruption of a solar-mass star by a black hole of ∼106.3 M⊙. The host is another Balmer-strong absorption galaxy, though fainter and less centrally concentrated than most TDE hosts. Radio limits rule out a relativistic jet, while X-ray limits at 500 d are among the deepest for a TDE at this phase.
Serious illness impairs function and threatens survival. Patients facing serious illness value shared decision making, yet few decision aids address the needs of this population.
To perform a ...systematic review of evidence about decision aids and other exportable tools that promote shared decision making in serious illness, thereby (1) identifying tools relevant to the treatment decisions of seriously ill patients and their caregivers, (2) evaluating the quality of evidence for these tools, and (3) summarizing their effect on outcomes and accessibility for clinicians.
We searched PubMed, CINAHL, and PsychInfo from January 1, 1995, through October 31, 2014, and identified additional studies from reference lists and other systematic reviews. Clinical trials with random or nonrandom controls were included if they tested print, video, or web-based tools for advance care planning (ACP) or decision aids for serious illness. We extracted data on the study population, design, results, and risk for bias using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Each tool was evaluated for its effect on patient outcomes and accessibility.
Seventeen randomized clinical trials tested decision tools in serious illness. Nearly all the trials were of moderate or high quality and showed that decision tools improve patient knowledge and awareness of treatment choices. The available tools address ACP, palliative care and goals of care communication, feeding options in dementia, lung transplant in cystic fibrosis, and truth telling in terminal cancer. Five randomized clinical trials provided further evidence that decision tools improve ACP documentation, clinical decisions, and treatment received.
Clinicians can access and use evidence-based tools to engage seriously ill patients in shared decision making. This field of research is in an early stage; future research is needed to develop novel decision aids for other serious diagnoses and key decisions. Health care delivery organizations should prioritize the use of currently available tools that are evidence based and effective.
BACKGROUND
Physical frailty is a powerful tool for identifying nondisabled individuals at high risk of adverse outcomes. The extent to which cognitive impairment in those without dementia adds value ...to physical frailty in detecting high‐risk individuals remains unclear.
OBJECTIVES
To estimate the effects of combining physical frailty and cognitive impairment without dementia (CIND) on the risk of basic activities of daily living (ADL) dependence and death over 8 years.
DESIGN
Prospective cohort study.
SETTING
The Health and Retirement Study (HRS).
PARTICIPANTS
A total of 7338 community‐dwelling people, 65 years or older, without dementia and ADL dependence at baseline (2006‐2008). Follow‐up assessments occurred every 2 years until 2014.
MEASUREMENTS
The five components of the Cardiovascular Health Study defined physical frailty. A well‐validated HRS method, including verbal recall, series of subtractions, and backward count task, assessed cognition. Primary outcomes were time to ADL dependence and death. Hazard models, considering death as a competing risk, associated physical frailty and CIND with outcomes after adjusting for sociodemographics, comorbidities, depression, and smoking status.
RESULTS
The prevalence of physical frailty was 15%; CIND, 19%; and both deficits, 5%. In unadjusted and adjusted analyses, combining these factors identified older adults at an escalating risk for ADL dependence (no deficit = 14% reference group; only CIND = 26%, sub–hazard ratio sHR = 1.5, 95% confidence interval CI = 1.3–1.8; only frail = 33%, sHR = 1.7, 95% CI = 1.4–2.0; both deficits = 46%, sHR = 2.0, 95%CI = 1.6–2.6) and death (no deficit = 21%; only CIND = 41%, HR = 1.6, 95% CI = 1.4–1.9; only frail = 56%, HR = 2.2, 95% CI = 1.7–2.7; both deficits = 66%, HR = 2.6, 95% CI = 2.0–3.3) over 8‐year follow‐up. Adding the cognitive measure to models that already included physical frailty alone increased accuracy in identifying those at higher risk of ADL dependence (Harrell's concordance C, 0.74 vs 0.71; P < .001) and death (Harrell's C, 0.70 vs 0.67; P < .001).
CONCLUSION
Physical frailty and CIND are independent predictors of incident disability and death. Because together physical frailty and CIND identify vulnerable older adults better, optimal risk assessment should supplement measures of physical frailty with measures of cognitive function. J Am Geriatr Soc 67:477–483, 2019.
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