To examine concurrent prevalence trends of chronic disease, impairment and disability among older adults.
We analyzed the 1998, 2004 and 2008 waves of the Health and Retirement Study, a nationally ...representative survey of older adults in the United States, and included 31,568 community dwelling adults aged 65 and over. Measurements include: prevalence of chronic diseases including hypertension, heart disease, stroke, diabetes, cancer, chronic lung disease and arthritis; prevalence of impairments, including impairments of cognition, vision, hearing, mobility, and urinary incontinence; prevalence of disability, including activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
The proportion of older adults reporting no chronic disease decreased from 13.1% (95% Confidence Interval CI, 12.4%-13.8%) in 1998 to 7.8% (95% CI, 7.2%-8.4%) in 2008, whereas the proportion reporting 1 or more chronic diseases increased from 86.9% (95% CI, 86.2%-89.6%) in 1998 to 92.2% (95% CI, 91.6%-92.8%) in 2008. In addition, the proportion reporting 4 or more diseases increased from 11.7% (95% CI, 11.0%-12.4%) in 1998 to 17.4% (95% CI, 16.6%-18.2%) in 2008. The proportion of older adults reporting no impairments was 47.3% (95% CI, 46.3%-48.4%) in 1998 and 44.4% (95% CI, 43.3%-45.5%) in 2008, whereas the proportion of respondents reporting 3 or more was 7.2% (95% CI, 6.7%-7.7%) in 1998 and 7.3% (95% CI, 6.8%-7.9%) in 2008. The proportion of older adults reporting any ADL or IADL disability was 26.3% (95% CI, 25.4%-27.2%) in 1998 and 25.4% (95% CI, 24.5%-26.3%) in 2008.
Multiple chronic disease is increasingly prevalent among older U.S. adults, whereas the prevalence of impairment and disability, while substantial, remain stable.
Distress behaviors in dementia (DBD) likely increase sympathetic nervous system activity. The aim of this study was to examine the associations among DBD, blood pressure (BP), and intensity of ...antihypertensive treatment, in nursing home (NH) residents with dementia.
We identified long-stay Veterans Affairs NH residents with dementia in 2019-20 electronic health data. Each individual with a BP reading and a DBD incident according to a structured behavior note on a calendar day (DBD group) was compared with an individual with a BP reading but without a DBD incident on that same day (comparison group). In each group we calculated daily mean BP from 14 days before to 7 days after the DBD incident day. We then calculated the change in BP between the DBD incident day and, as baseline, the 7-day average of BP 1 week prior, and tested for differences between DBD and comparison groups in a generalized estimating equations multivariate model.
The DBD and comparison groups consisted of 707 and 2328 individuals, respectively. The DBD group was older (74 vs. 72 y), was more likely to have severe cognitive impairment (13% vs. 8%), and had worse physical function scores (15 vs. 13 on 28-point scale). In the DBD group, mean systolic BP on the DBD incident day was 1.6 mmHg higher than baseline (p < .001), a change that was not observed in the comparison group. After adjusting for covariates, residents in the DBD group, but not the comparison group, had increased likelihood of having systolic BP > = 160 mmHg on DBD incident days (OR 1.02; 95%CI 1.00-1.03). Systolic BP in the DBD group began to rise 7 days before the DBD incident day and this rise persisted 1 week after. There were no significant changes in mean number of antihypertensive medications over this time period in either group.
NH residents with dementia have higher BP when they experience DBD, and BP rises 7 days before the DBD incident. Clinicians should be aware of these findings when deciding intensity of BP treatment.
OBJECTIVES
To describe patterns of antihypertensive medication treatment in hypertensive nursing home (NH) residents with and without dementia and determine the association between antihypertensive ...treatment and outcomes important to individuals with dementia.
DESIGN
Observational cohort study.
SETTING
All US NHs.
PARTICIPANTS
Long‐term NH residents treated for hypertension in the second quarter of 2013, with and without moderate or severe cognitive impairment, as defined by the NH Minimum Data Set (MDS) Cognitive Function Scale.
MEASUREMENTS
The primary exposure was intensity of antihypertensive treatment, as defined as number of first‐line antihypertensive medications in Medicare Part D dispensing data. The outcome measures were hospitalization, hospitalization for cardiovascular diseases using Medicare Hierarchical Condition Categories, decline in physical function using the MDS Activities of Daily Living (ADLs) scale, and death during a 180‐day follow‐up period.
RESULTS
Of 255 670 NH residents treated for hypertension, 117 732 (46.0%) had moderate or severe cognitive impairment. At baseline, 54.4%, 34.3%, and 11.4% received one, two, and three or more antihypertensive medications, respectively. Moderate or severe cognitive impairment (odds ratio OR = 0.80 vs no or mild impairment; P < .0001), worse physical function (OR = 0.64 worst vs best tertile; P < .0001), and hospice or less than a 6‐month life expectancy (OR = 0.80; P < .0001) were associated with receipt of fewer antihypertensive medications. Increased intensity of antihypertensive treatment was associated with small increases in hospitalization (difference per additional medication = 0.24%; 95% confidence interval = 0.03%‐0.45%) and cardiovascular hospitalization (difference per additional medication = 0.30%; 95% confidence interval = 0.21%‐0.39%) and a small decrease in ADL decline (difference per additional medication = −0.46%; 95% confidence interval = −0.67% to −0.25%). There was no significant difference in mortality (difference per additional medication = −0.05%; 95% confidence interval = −0.23% to 0.13%).
CONCLUSION
Long‐term NH residents with hypertension do not experience significant benefits from more intensive antihypertensive treatment. Antihypertensive medications are reasonable targets for deintensification in residents in whom this is consistent with goals of care. J Am Geriatr Soc 67:2058–2064, 2019
Postoperative cognitive dysfunction (POCD) and delirium are the most common perioperative cognitive complications in older adults undergoing surgery. A recent study of cardiac surgery patients ...suggests that physical frailty is a risk factor for both complications. We sought to examine the relationship between preoperative frailty and postoperative delirium and preoperative frailty and POCD after major noncardiac surgery.
We performed a prospective cohort study of patients >65 years old having major elective noncardiac surgery with general anesthesia. Exclusion criteria were preexisting dementia, inability to consent, cardiac, intracranial, or emergency surgery. Preoperative frailty was determined using the FRAIL scale, a simple questionnaire that categorizes patients as robust, prefrail, or frail. Delirium was assessed with the Confusion Assessment Method for the intensive care unit (CAM-ICU) twice daily, starting in the recovery room until hospital discharge. All patients were assessed with neuropsychological tests (California Verbal Learning Test II, Trail Making Test, subtests from the Wechsler Adult Intelligence Scale, Logical Memory Story A, Immediate and Delayed Recall, Animal and Vegetable verbal fluency, Boston Naming Test, and the Mini-Mental Status Examination) before surgery and at 3 months afterward.
A total of 178 patients met inclusion criteria; 167 underwent major surgery and 150 were available for follow-up 3 months after surgery. The median age was 70 years old. Thirty-one patients (18.6%) tested as frail, and 72 (43.1%) prefrail before surgery. After adjustment for baseline cognitive score, age, education, surgery duration, American Society of Anesthesiologists (ASA) physical status, type of surgery, and sex, patients who tested frail or prefrail had an estimated 2.7 times the odds of delirium (97.5% confidence interval, 1.0-7.3) when compared to patients who were robust. There was no significant difference between the proportion of POCD between patients who tested as frail, prefrail, or robust.
After adjustment for baseline cognition, testing as frail or prefrail with the FRAIL scale is associated with increased odds of postoperative delirium, but not POCD after noncardiac surgery.
Hypertension occurs in >50% of US nursing home (NH) residents, but it is unclear which antihypertensive classes offer the best balance of benefits and risks in this population. The objectives of this ...study were to describe the patterns of antihypertensive medication treatment in this population, focusing on thiazide diuretics, and to determine the association between thiazide diuretics (DIURs) and outcomes important to NH patients.
This observational cohort study was conducted in long-term NH residents treated for hypertension in the second quarter (Q2) of 2013, from all US NHs. The primary exposure was the frequency of use of antihypertensive treatment class (DIURs, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers ARBs, calcium channel blockers, and β-blockers) according to Medicare Part D dispensing data. Because DIUR-related urinary symptoms were a focus, residents receiving nonthiazide diuretics were excluded. We ascertained continued medication use by class from Q2 to Q4 of 2013, and ascertained 6-month incontinence and hospitalization using data from Medicare claims and the Minimum Data Set.
Of 152,902 NH residents treated for hypertension, 52.2% were treated with β-blockers (22% as a single agent), 39.7% with calcium channel blockers (14% as a single agent), 38.8% with angiotensin-converting enzyme inhibitors (14% as a single agent), 14.2% with DIURs (2% as a single agent), and 13.2% with ARBs (4% as a single agent). Overall, 55.1% were treated with 1 drug; 33.2%, with 2 drugs; and 11.8%, with 3 or more drugs. From Q2 to Q4, DIURs were more likely to have been discontinued than any other class (19.4% vs 14.1%–16.1% for each of the other 4 classes; all, p < 0.05) and less likely to have been started than any other class except ARBs (1.4% vs 3.8%–5.3% for each of the other 3 classes). Urinary incontinence occurred in 76.6% of the sample. In a multivariate logistic regression model, new DIUR use from Q2 to Q4 of 2013 was not significantly associated with urinary incontinence in Q4, and none of the antihypertensive drug classes were associated with 6-month hospitalization.
In 2013, long-term NH residents treated for hypertension were least likely to receive, more likely to discontinue, and less likely to start a new DIUR than any other first-line antihypertensive medication. DIURs were not associated with increased incontinence or hospitalization, so in the absence of indications for other drugs, DIURs may be a reasonable first-line choice for hypertension treatment in this population.
•Among long-term nursing home residents treated for hypertension, 55% are treated with 1 drug and 45% are treated with 2 or more drugs.•The most commonly prescribed classes are beta-blockers, calcium channel blockers, and angiotensin converting enzyme inhibitors.•Long-term nursing home residents treated for hypertension are less likely to receive, more likely to discontinue, and less likely to start a new thiazide diuretic than any other first-line antihypertensive medication.•However, thiazide diuretics are not associated with new incontinence or hospitalization in this population, and in the absence of chronic conditions that are indications for other antihypertensive classes, they may be reasonable first-line choices for hypertension treatment.
Transitions across acute and post-acute settings are complex processes that became more challenging during the COVID-19 pandemic. Prolonged hospital stays may result in deconditioning, necessitating ...patient discharge to skilled nursing facilities (SNFs)1 for rehabilitation when discharge home is deemed unsafe. Although return home from SNF is the goal for these patients, a safe SNF discharge often requires additional support from home health care (HHC) or from patients' families.2 Prior work has examined hospital discharge practices for COVID-19 patients,3 but has not investigated post-acute SNF discharge patterns. Understanding the challenges to safe discharge at every healthcare transition is necessary for systems planning. To understand how post-acute SNF discharge was affected by the COVID-19 pandemic, we studied discharge processes for SNF patients with COVID-19.
A second article reports results of a national survey of patients' treatment preferences in which respondents chose nonpharmacological treatment for insomnia as more acceptable than pharmacological ...treatment.3 This finding, along with evidence that nonpharmacological treatment (eg, cognitive-behavioral therapy) has a longer beneficial impact on sleep than drugs and may also benefit concomitant mood and anxiety disorders,4 reinforces the recommendation that nonpharmacological approaches be the first line of treatment and access to them increased.
Nursing home (NH) residents have a high prevalence of delirium risk factors, experience two to four acute medical conditions (e.g., infections) each year, and have an incidence of delirium during ...these conditions similar to that of hospitalized older adults. Many NH residents with delirium do not return to their prior level of cognitive function. They are more likely to die, be hospitalized, and less likely to be discharged home than those without delirium. Research on the prevention or treatment of delirium in NHs is limited. This article describes the development and pilot testing of a multicomponent delirium prevention intervention in the NH setting adapted from the Hospital Elder Life Program (HELP‐LTC). Activities to reduce the risk of delirium that were appropriate for functionally impaired NH residents were developed and delivered during treatment for and recovery from acute illness, a novel resident‐targeting approach. Expertly trained certified nursing assistants (CNAs — a total of 1.4 full‐time equivalent (FTE) positions—) visited residents throughout the facility and delivered the activities. The current study reports on incident delirium, delirium remission, cognitive and physical function change, hospitalization, and death associated with acute medical conditions as ascertained by a program coordinator. The integration and acceptance of the CNAs' activities by residents and staff are also reported on. Hospitalization and death were ascertained in a nonintervention comparison group. Findings support a test of the intervention in a controlled trial. The potential effect is great; there are approximately 1.4 million NH residents in the United States and an estimated 1 million with dementia or cognitive impairment, an important delirium risk factor. An intervention would be broadly adoptable if a reduction in healthcare costs through prevention of hospitalization offset the cost of the program's CNAs.
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