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Although studies have shown posttraumatic stress disorder (PTSD) associated with risk of suicide, the relationship in later life, especially for overdose death, remains unclear. Thus, the aim of the current study was to determine associations between PTSD, suicide, and unintended overdose death in mid- to late-life.A nationwide cohort study integrating Department of Veterans Affairs' (VA) data, Centers for MedicareMedicaid Services data, and national cause-specific mortality data. Participants were US veterans aged ≥50 years with PTSD diagnoses at baseline (2012-2013) and were propensity-matched 1:1 with patients without PTSD based on sociodemographics, Charlson Comorbidity Index, and neuropsychiatric disorders (N = 951,018). Information on suicide attempts and unintended death by overdose through December 31, 2017 was provided by the VA's National Suicide Prevention Applications Network (non-fatal attempts) and Mortality Data Repository (death).Veterans with PTSD (N = 475,509) had increased risk of suicide attempt (Hazard Ratio [HR], 1.59; 95% CI, 1.54-1.65; p 0.001), non-fatal attempt (HR, 1.74; 95% CI, 1.67-1.81; p 0.001), drug overdose death overall (HR, 1.32; 95% CI, 1.22-1.42; p 0.001), and suicide overdose death (HR, 1.44; 95% CI, 1.15-1.80; p = 0.002), even after adjusting for sociodemographics, Charlson comorbidity index, and neuropsychiatric disorders. We found increased risk for overdose death by narcotics (HR, 1.30; 95% CI, 1.15-1.46; p 0.001), antiepileptic/sedative-hypnotics (HR, 1.29; 95% CI, 1.02-1.62; p = 0.032), and for other/unspecified drugs (HR, 1.35; 95% CI, 1.20-1.51; p 0.001), the last category indicative of polydrug. Results remained robust when examined for unintentional, suicide, and undetermined intent for cause-specific death by other/unspecified drugs.PTSD persists throughout mid- to late-life with considerable increased risk for non-fatal suicide attempts and suicide overdose death. These findings suggest the importance of drug-monitoring in preventing late-life suicide.

Hospitalizations among people with dementia (PWD) may precipitate behavioral changes, leading to the psychotropic medication use despite adverse outcomes and limited efficacy. We sought to determine the incidence of new psychotropic medication use among community-dwelling PWD after hospital discharge and, among new users, the proportion with prolonged use.This was a retrospective cohort study using a 20% random sample of Medicare claims in 2017, including hospitalized PWD with traditional and Part D Medicare who were 68 years or older. The primary outcome was incident prescribing at discharge of psychotropics including antipsychotics, sedative-hypnotics, antiepileptics, and antidepressants. This was defined as new prescription fills (i.e., from classes not used in 180 days preadmission) within 7 days of hospital or skilled nursing facility discharge. Prolonged use was defined as the proportion of new users who continued to fill newly prescribed medications beyond 90 days of discharge.The cohort included 117,022 hospitalized PWD with a mean age of 81 years; 63% were female. Preadmission, 63% were using at least 1 psychotropic medication; 10% were using medications from ≥3 psychotropic classes. These included antidepressants (44% preadmission), antiepileptics (29%), sedative-hypnotics (21%), and antipsychotics (11%). The proportion of PWD discharged from the hospital with new psychotropics ranged from 1.9% (antipsychotics) to 2.9% (antiepileptics); 6.6% had at least one new class started. Among new users, prolonged use ranged from 36% (sedative-hypnotics) to 63% (antidepressants); across drug classes, prolonged use occurred in 51%. Predictors of newly initiated psychotropics included length of stay (≥median vs.median; aOR 1.5, 95% CI: 1.4-1.6) and delirium (aOR 1.8, 95% CI: 1.7-1.9).Hospitalized PWD have a high prevalence of preadmission psychotropic medication use; against this baseline, discharge from the hospital with new psychotropics is relatively uncommon. Nevertheless, prolonged use of newly initiated psychotropics occurs in a substantial proportion of this population.

Claims-based measures of multimorbidity, which evaluate the presence of a defined list of diseases, are limited in their ability to predict future outcomes. We evaluated whether claims-based markers of disease severity could improve assessments of multimorbid burden.We developed 7 dichotomous markers of disease severity which could be applied to a range of diseases using claims data. These markers were based on the number of disease-associated outpatient visits, emergency department visits, and hospitalizations made by an individual over a defined interval; whether an individual with a given disease had outpatient visits to a specialist who typically treats that disease; and ICD-9 codes which connote more versus less advanced or symptomatic manifestations of a disease. Using Medicare claims linked with Health and Retirement Study data, we tested whether including these markers improved ability to predict ADL decline, IADL decline, hospitalization, and death compared to equivalent models which only included the presence or absence of diseases.Of 5012 subjects, median age was 76 years and 58% were female. For a majority of diseases tested individually, adding each of the 7 severity markers yielded minimal increase in c-statistic (≤0.002) for outcomes of ADL decline and mortality compared to models considering only the presence versus absence of disease. Gains in predictive power were more substantial for a small number of individual diseases. Inclusion of the most promising marker in multi-disease multimorbidity indices yielded minimal gains in c-statistics (0.001-0.007) for predicting ADL decline, IADL decline, hospitalization, and death compared to indices without these markers.Claims-based markers of disease severity did not contribute meaningfully to the ability of multimorbidity indices to predict ADL decline, mortality, and other important outcomes.

Older patients with poor prognosis cancers have complex needs that can benefit from geriatrics and palliative care principles. Because they are not routinely assessed, the prevalence of preexisting geriatric and palliative conditions in this population is unknown.We used the nationally representative Health and Retirement Study (HRS) linked with Medicare claims (1998-2016) to identify adults aged ≥65 years diagnosed with poor prognosis cancers (cancers with a median survival ≤1 year). Using the HRS interview before the first Medicare cancer claim, we used survey-weighted descriptive statistics and modified Poisson regression analysis to examine the prevalence of the following clinically significant conditions: functional impairment, difficulty with mobility, falls and injurious falls, social support, cognition, advance care planning, use of pain or sleep medications, and presence of pain or breathlessness.Of 2105 participants (mean age 76, 53% women, 34% lung cancer, 21% gastrointestinal cancer), the median survival was 9.6 months. Approximately 65% had difficulty climbing stairs (95% CI 63%-67%), 49% had no advance directive (95% CI 45%-54%), 35% lived alone (95% CI 33%-37%), 36% fell in the last 2 years (95% CI 34%-38%), and 32% rated their memory as poor (95% CI 29%-34%). After adjusting for gender, cancer type, and HRS survey time before the first Medicare claim for a poor prognosis cancer, functional impairment and falls were highest among adults aged 85+. Adults aged 65-74 years were less likely to have an advance directive. After adjusting for age, cancer type, and HRS survey time, women had a higher rate of pain and physical impairment. In exploratory analyses, race and socioeconomic status predicted difficulty with mobility and instrumental activities of daily living, living alone, and advance directive completion.Due to a high prevalence across multiple domains, all older adults with poor prognosis cancers should be assessed for geriatric and palliative care conditions.

People with dementia (PWD) are at high risk for hospice disenrollment, yet little is known about patterns of disenrollment among the growing number of hospice enrollees with dementia.Retrospective, observational cohort study of 100% Medicare beneficiaries with dementia aged 65 and older enrolled in the Medicare Hospice Benefit between July 2012 and December 2017. Outcome measures included hospice-initiated disenrollment for patients whose rate of decline ceased to meet the Medicare hospice eligibility guideline of "expected death within 6 months" (extended prognosis) and patient-initiated disenrollment (revocation). Hospice, regional, and patient risk factors and variation were assessed with multilevel mixed-effects logistic regression models.Among 867,695 hospice enrollees with dementia, 70,945 (8.2%) were disenrolled due to extended prognosis and 43,133 (5.0%) revoked within 1-year of their index admission. There was substantial variation in hospice provider disenrollment due to extended prognosis (10th-90th percentile 4.5%-14.6%, adjusted median odds ratio (MOR) 1.86, 95% confidence interval (CI) 1.82, 1.91) and revocation (10th-90th percentile 2.5%-10.1%, MOR 2.09, 95% CI 2.03, 2.14). Among hospital referral regions (HRR), there was more variation in revocation (10th-90th percentile 3.5%-7.6%, MOR 1.4, 95% CI 1.34, 1.47) than extended prognosis (10th-90th percentile 7.0%-9.5%, MOR 1.23, 95% CI 1.18, 1.27), with much higher revocation rates noted in HRRs located in the Southeast and Southern California. A number of patient and hospice characteristics were associated with higher odds of both types of disenrollment (younger age, female sex, minoritized race and ethnicity, Medicaid dual eligibility, Medicare Part C enrollment), while some were associated with revocation only (more comorbidities, newer, smaller, and for-profit hospices).In this nationally representative study of hospice enrollees with dementia, hospice disenrollment varied by type of hospice, geographic region, and patient characteristics including age, sex, race, and ethnicity. These findings raise important questions about whether and how the Medicare Hospice Benefit could be adapted to reduce disparities and better support PWD.

Many clinical and financial decisions for older adults depend on the future risk of disability and mortality. Prognostic tools for long-term disability risk in a general population are lacking. We aimed to create a comprehensive prognostic tool that predicts the risk of mortality, of activities of daily living (ADL) disability, and walking disability simultaneously using the same set of variables.We conducted a longitudinal analysis of the nationally-representative Health and Retirement Study (HRS). We included community-dwelling adults aged ≥70 years who completed a core interview in the 2000 wave of HRS, with follow-up through 2018. We evaluated 40 predictors encompassing demographics, diseases, physical functioning, and instrumental ADLs. We applied novel methods to optimize three models simultaneously while prioritizing variables that take less time to ascertain during backward stepwise elimination. The death prediction model used Cox regression and both the models for walking disability and for ADL disability used Fine and Gray competing-risk regression. We examined calibration plots and generated optimism-corrected statistics of discrimination using bootstrapping. To simulate unavailable patient data, we also evaluated models excluding one or two variables from the final model.In 6646 HRS participants, 2662 developed walking disability, 3570 developed ADL disability, and 5689 died during a median follow-up of 9.5 years. The final prognostic tool had 16 variables. The optimism-corrected integrated area under the curve (iAUC) was 0.799 for mortality, 0.685 for walking disability, and 0.703 for ADL disability. At each percentile of predicted mortality risk, there was a substantial spread in the predicted risks of walking disability and ADL disability. Discrimination and calibration remained good even when missing one or two predictors from the model. This model is now available on ePrognosis (https://eprognosis.ucsf.edu/alexlee.php) CONCLUSIONS: Given the variability in disability risk for people with similar mortality risks, using individualized risks of disabilities may inform clinical and financial decisions for older adults.

BACKGROUND/OBJECTIVES Prognostic indices rarely include cognition. We determined if a comprehensive cognitive screen or brief individual items were associated with improved mortality predictions of a widely used prognostic index. DESIGN, SETTING, AND PARTICIPANTS The National Social Life Health and Aging Project Wave 2, a nationally representative, cross-sectional, in-home survey conducted in 2010 to 2011 on 3,199 community-dwelling adults aged 60 to 99 years. MEASUREMENTS Cognition was measured using a Survey-Adapted Montreal Cognitive Assessment (MoCA-SA) grouped into three screened categories: screen normal (≥24 points), screen positive for mild cognitive impairment (18-23 points), and screen positive for dementia (

BACKGROUND: People with dementia (PWD) take medications that may be unnecessary or harmful. This problem can be addressed through deprescribing, but it is unclear if PWD would be willing to engage in deprescribing with their providers. Our goal was to investigate attitudes toward deprescribing among PWD. METHODS: This was a cross-sectional study of 422 PWD aged ≥65 years who completed the Medications Attitudes module of the National Health and Aging Trends Study (NHATS) in 2016. Proxies provided responses when a participant was unable to respond due to health or cognitive problems. Attitudinal outcomes comprised responses to 2 statements from the Patients’ Attitudes Towards Deprescribing questionnaire and its revised version (representing belief about the necessity of one’s medications and willingness to deprescribe); another elicited the maximum number of pills that a respondent would be comfortable taking. RESULTS: The weighted sample represented over 1.8 million PWD; 39% were 75 to 84 years old and 38% were 85 years or older, 60% were female, and 55% reported 6 or more regular medications. Proxies provided responses for 26% of PWD. Overall, 22% believed that they may be taking one or more medicines that they no longer needed, 87% were willing to stop one or more of their medications, and 50% were uncomfortable taking 5 or more medications. Attitudinal outcomes were similar across sociodemographic and clinical factors. PWD taking ≥6 medications were more likely to endorse a belief that at least one medication was no longer necessary compared to those taking

BACKGROUND: Understanding life expectancy can help persons with dementia, their care partners, and policymakers plan for what lies ahead. We sought to determine life expectancy and predictors of mortality for community-dwelling persons with dementia and severe disability. METHODS: Using the National Health and Aging Trends Study (NHATS) linked to Medicare claims, we identified community-dwelling respondents age 65+ who entered NHATS in 2011 with dementia and severe disability (defined as 3 impairments in activities of daily living), or who subsequently met criteria for dementia and then severe disability. We estimated time to death based on the timing of meeting severe disability criteria. We conducted parametric survival analyses using a Gompertz distribution to calculate risk of death and predicted median time to death. Predictors included demographic, functional, clinical characteristics, and behavioral symptoms (assessed among NHATS respondents with proxy interviews). RESULTS: Among 842 community-dwelling persons with dementia and severe disability, 80.5% died during the study period. After adjusting for age and gender, overall predicted median time to death was 1.7 years (25(th) percentile 0.6, 75(th) percentile 3.8 years). Six notable characteristics were associated with shorter life expectancy: 1) older age (90+), with a predicted median time to death of 1.0 year (0.4, 2.1); 2) being bedbound, 1.1 years (0.4, 2.3); 3) being homebound, 1.2 years (0.5, 2.6); 4) having comorbid cancer, 1.2 years (0.5, 2.6); 5) unintended weight loss, 1.4 years (0.5, 3.1); and 6) comorbid depression, 1.5 years (0.6, 3.3). CONCLUSIONS: Community-dwelling persons with dementia and severe disability lived a median of 1.7 years. Clinicians can use the study findings to provide anticipatory guidance to patients and care partners, and policymakers to inform design of longitudinal supportive services.

BACKGROUND: Potentially disruptive medical, surgical, and social events–such as pneumonia, hip fracture, and widowhood–may accelerate the trajectory of decline and impact caregiving needs in older adults, especially among people with dementia. Prior research has focused primarily on nursing home residents with dementia. We sought to assess the incidence of potentially disruptive events in community-dwelling people with and without dementia. METHODS: Retrospective cohort study of participants aged 65+ enrolled in the Health and Retirement Study between 2010–2018 (n=9,346), including a subset who were married/partnered at baseline (n=5,105). Dementia was defined with a previously validated algorithm. We calculated age-adjusted and gender-stratified incidence per 1000 person-years and incidence rate ratios of: 1) hospitalization for pneumonia; 2) hip fracture and; 3) widowhood in people with and without dementia. RESULTS: People with dementia (PWD) (n=596) were older (mean age 84 vs. 75) and a higher proportion were female (67% vs 57%) than people without dementia (PWoD) (n=8,750). Age-adjusted incidence rates (per 1000 person-years) of pneumonia were higher in PWD (113.1; 95% CI 94.3, 131.9) compared to PWoD (62.1; 95% CI 54.7, 69.5), as were hip fractures (12.3; 95% CI 9.1, 15.6 for PWD compared to 8.1; 95% CI 6.9, 9.2 in PWoD). Point estimates of widowhood incidence were slightly higher for PWD (25.3; 95% CI 20.1, 30.5) compared to PWoD (21.9; 95% CI 20.3, 23.5), but differences were not statistically significant. The association of dementia with hip fracture—but not pneumonia or widowhood—was modified by gender (male incidence rate ratio (IRR) 2.24, 95% CI 1.34, 3.75 versus female IRR 1.31 95% CI 0.92,1.86); interaction term p=0.02). CONCLUSIONS: Compared to PWoD, community-dwelling PWD had higher rates of pneumonia and hip fracture, but not widowhood. Knowing how often PWD experience these events can aid in anticipatory guidance and care planning for this growing population.

BACKGROUND: Males have worse outcomes after hip fracture than female counterparts. Cognitive impairment (CI) also increases the risk of poor recovery from hip fracture; however, CI is under-recognized. Patient sex may contribute to this under-recognition through differential misclassification. The objective of this study was to measure under-recognition and differential misclassification of CI by patient sex. METHODS: A cross-sectional analysis of baseline data from an observational cohort study of community-dwelling hip fracture patients aged 65 and older (n=339; females =171, males =168) recruited from eight hospitals in the greater Baltimore, MD area within 15 days of hospitalization for surgical repair with cognitive testing within 22 days of admission. Indication of Alzheimer’s Disease or related dementias and/or delirium as a post-operative complication in the medical record was considered evidence of documented CI. Observed CI was measured with the Modified Mini Mental State Examination (3MS, ≤78). Source of cognitive impairment identification (SCI) was defined as: ‘3MS Only’, ‘Hospital Record Only’, ‘Both’, ‘No CI’ was compared between males and females using logistic regression. RESULTS: Males had more comorbidities and worse physical status upon admission, but otherwise had similar hospital experiences. SCI distribution was 12.7% ‘3MS Only’ (n=42), 11.5% ‘Hospital Record Only’ (n=38), 9.4% ‘Both’ (n=31), and ‘No CI’ (n=219). Males were more likely to be identified with CI using the (‘3MS Only’ and ‘Both’) and females were more likely to have no indication of CI CONCLUSION: There were sex differences in the documentation of CI versus observed impairment. Males had more CI using direct testing. This may be contributing to sex differences in recovery outcomes post hip fracture. Results support the implementation of cognitive testing in hip fracture patients to reduce the impact of differential misclassification by patient sex.

BACKGROUND: Social isolation and loneliness are critical to the health of older adults, but they have not been well-described at the end of life. OBJECTIVES: To determine the prevalence and correlates of social isolation and loneliness among older adults in the last years of life. DESIGN: Nationally-representative, cross-sectional survey. SETTING: Health and Retirement Study, 2006–2016 data. PARTICIPANTS: Adults age >50 interviewed once in the last four years of life (n=3,613). MEASUREMENTS: 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. RESULTS: Approximately 19% experienced social isolation, 18% loneliness, and 5% both in the last four 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

BACKGROUND/OBJECTIVES: Among married couples, the death of one’s spouse can influence perceptions of health services available at the end-of-life (EOL). However, it is unknown if one spouse’s EOL experience is associated with the widowed spouse’s uptake of health services or advance care planning (ACP). We determine if EOL experiences in the first spouse are associated with EOL experiences in the second spouse. DESIGN: Nationally-representative, longitudinal survey. SETTING: Health and Retirement Study, Waves 1992–2012 linked to Medicare claims PARTICIPANTS: 4,558 community-dwelling older adults who died, representing 2,279 male-female married couples. MEASUREMENTS: We examined three EOL experiences: 1) enrollment in hospice for >3 days before death; 2) lack of ACP prior to death; and 3) Intensive care unit (ICU) use during the last 30 days of life. We used multiple logistic regression to determine if the EOL experience of the first spouse was a significant predictor of the EOL experience in the second spouse after adjusting for demographics, socioeconomic status, health status, and time between the first and second spouses’ death. RESULTS: First spouses who died were on average 80 years old and 62% male, and second spouses were on average 85 years old and 62% female. After adjustment, second spouses were more likely to use hospice if the first spouse used hospice services (OR=1.68, 95% CI: 1.29–2.20). Second spouses were less likely to have ACP when the first spouse did not have ACP prior to death (OR=2.91, 95% CI: 2.02–4.21). Hospice and ACP associations were stronger when deaths were closer in time to one another (p-value for interaction

Author(s): Barnes, Deborah E; Zhou, Jing; Walker, Rod L; Larson, Eric B; Lee, Sei J; Boscardin, W John; Marcum, Zachary A; Dublin, Sascha | Abstract: ObjectivesEarly recognition of dementia would allow patients and their families to receive care earlier in the disease process, potentially improving care management and patient outcomes, yet nearly half of patients with dementia are undiagnosed. Our aim was to develop and validate an electronic health record (EHR)-based tool to help detect patients with unrecognized dementia (EHR Risk of Alzheimer's and Dementia Assessment Rule [eRADAR]).DesignRetrospective cohort study.SettingKaiser Permanente Washington (KPWA), an integrated healthcare delivery system.ParticipantsA total of 16 665 visits among 4330 participants in the Adult Changes in Thought (ACT) study, who undergo a comprehensive process to detect and diagnose dementia every 2 years and have linked KPWA EHR data, divided into development (70%) and validation (30%) samples.MeasurementsEHR predictors included demographics, medical diagnoses, vital signs, healthcare utilization, and medications within the previous 2 years. Unrecognized dementia was defined as detection in ACT before documentation in the KPWA EHR (ie, lack of dementia or memory loss diagnosis codes or dementia medication fills).ResultsOverall, 1015 ACT visits resulted in a diagnosis of incident dementia, of which 498 (49%) were unrecognized in the KPWA EHR. The final 31-predictor model included markers of dementia-related symptoms (eg, psychosis diagnoses, antidepressant fills), healthcare utilization pattern (eg, emergency department visits), and dementia risk factors (eg, cerebrovascular disease, diabetes). Discrimination was good in the development (C statistic = .78; 95% confidence interval [CI] = .76-.81) and validation (C statistic = .81; 95% CI = .78-.84) samples, and calibration was good based on plots of predicted vs observed risk. If patients with scores in the top 5% were flagged for additional evaluation, we estimate that 1 in 6 would have dementia.ConclusionThe eRADAR tool uses existing EHR data to detect patients with good accuracy who may have unrecognized dementia. J Am Geriatr Soc 68:103-111, 2019.

Objectives To evaluate how often beta-blockers were started after acute myocardial infarction (AMI) in nursing home (NH) residents who previously did not use these drugs and to evaluate which factors were associated with post-AMI use of beta-blockers. Design Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims. Setting U.S. NHs. Participants National cohort of 15,720 residents aged 65 and older who were hospitalized for AMI between May 2007 and March 2010, had not taken beta-blockers for at least 4 months before their AMI, and survived 14 days or longer after NH readmission. Measurements The outcome was beta-blocker initiation within 30 days of NH readmission. Results Fifty-seven percent (n = 8,953) of residents initiated a beta-blocker after AMI. After covariate adjustment, use of beta-blockers was less in older residents (ranging from odds ratio (OR) = 0.89, 95% confidence interval (CI) = 0.79–1.00 for aged 75–84 to OR = 0.65, 95% CI = 0.54–0.79 for ≥95 vs 65–74) and less in residents with higher levels of functional impairment (dependent or totally dependent vs independent to limited assistance: OR = 0.84, 95% CI = 0.75–0.94) and medication use (≥15 vs ≤10 medications: OR = 0.89, 95% CI = 0.80–0.99). A wide variety of resident and NH characteristics were not associated with beta-blocker use, including sex, cognitive function, comorbidity burden, and NH ownership. Conclusion Almost half of older NH residents in the United States do not initiate a beta-blocker after AMI. The absence of observed factors that strongly predict beta-blocker use may indicate a lack of consensus on how to manage older NH residents, suggesting the need to develop and disseminate thoughtful practice standards.

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.

Objectives To determine the long-term survival and independence of individuals with stroke and percutaneous endoscopic gastrostomy (PEG) tube placement. Design Retrospective cohort study. Setting A longitudinal nationally representative community-based sample of older adults. Participants Individuals with stroke who had a PEG tube placed (N = 174, mean age 79, 51% female, 29% African American). Measurements Functional status before incident stroke was determined based on data from the Health and Retirement Study (HRS), a national longitudinal survey of community-dwelling older adults, from 1993 to 2012. Hospitalizations for stroke and PEG placement were determined according to Medicare claims. HRS participants were interviewed, and outcomes of survivors interviewed in the 2 years after hospitalization are described. Survival and functional and eating ability of the cohort were examined. Groups were compared according to age and prestroke functional disability in activities of daily living (ADLs) because it was hypothesized that ADL disability would predict worse outcomes. Results In the 2 years after hospitalization, overall mortality was 66%. Fifteen participants survived and regained independent ADL function (9%). Of those who survived to a follow-up interview, 33 (56%) could not eat independently, and 31 (53%) required assistance to walk across the room. Age of 85 and older was associated with worse outcomes (10% vs 29% at 2 years, P < .001), but baseline ADL disability was not. Conclusion In this community-based sample, individuals who had had a stroke and a PEG tube placed had high mortality, and survivors were unlikely to be functional or mobile or to recover eating ability after hospitalization. A palliative care discussion including goals of care should occur before PEG tube placement is considered.

Objectives To assess the prevalence and correlates of self-reported hearing loss during the last 2 years of life. Design Observational cohort study. Setting The Health and Retirement Study (HRS), a longitudinal nationally representative cohort of adults aged 50 and older (2000–13). Participants Older adults (N = 5,895, mean age at death 78, 53% female, 20% nonwhite). Measurements The HRS interview closest to death was used (mean 12.2 months before death). Participants rated their hearing (excellent, very good, good, fair, poor) and indicated whether they used hearing aids. The prevalence and correlates of fair and poor ratings are described, adjusted for age and sex. Results Thirty-two percent (95% confidence interval (CI) = 31–34%) of all participants and 60% (95% CI = 57–64%) of the 7% of participants who used hearing aids rated their hearing as fair or poor. The prevalence of fair or poor hearing was highest in participants interviewed closest to death (29% 19–24 months before death, 36% 1–6 months before death, P for trend = .01). Correlates of fair or poor hearing during the last 2 years of life included age at death (50–59, 22%; 60–69, 21%; 70–79, 26%; 80–89, 38%; ≥90, 50%), sex (men 35%, women 30%), race and ethnicity (Hispanic 42%, white 33%), wealth (lowest quartile 38%, highest quartile 27%), history of heart disease (yes 38%, no 27%), activity of daily living dependence (yes 42%, no 26%), difficulty taking medications (yes 46%, no 29%), and probable dementia (yes 44%, no 24%). Conclusion Self-reported hearing loss increases during the last 2 years of life and is associated with physical and social vulnerability.

Objectives To develop a prediction index for 1-year mortality after hip fracture in older adults that includes predictors from a wide range of domains. Design Retrospective cohort study. Settings Health and Retirement Study (HRS). Participants HRS participants who experienced hip fracture between 1992 and 2010 as identified according to Medicare claims data (N = 857). Measurements Outcome measure was death within 1 year of hip fracture. Predictor measures were participant demographic characteristics, socioeconomic status, social support, health, geriatric symptoms, and function. Variables independently associated with 1-year mortality were identified, and best-subsets regression was used to identify the final model. The selected variables were weighted to create a risk index. The index was internally validated using bootstrapping to estimate model optimism. Results Mean age at time of hip fracture was 84, and 76% of the participants were women. There were 235 deaths (27%) during the 1-year follow up. Five predictors of mortality were included in the final model: aged 90 and older (2 points), male sex (2 points), congestive heart failure (2 points), difficulty preparing meals (2 points), and not being able to drive (1 point). The point scores of the index were associated with 1-year mortality, with 0 points predicting 10% risk and 7 to 9 points predicting 66% risk. The c-statistic for the final model was 0.73, with an estimated optimism penalty of 0.01, indicating very little evidence of overfitting. Conclusion The prognostic index combines demographic, comorbidity, and function variables and can be used to differentiate between individuals at low and high risk of 1-year mortality after hip fracture.

Objectives: To determine the relationship between depressive symptoms after hospitalization and survival and functional outcomes. Design: Secondary analysis of a prospective cohort study. Setting: General medical service of two urban, teaching hospitals in Ohio. Participants: Hospitalized individuals aged 70 and older. Measurements: Ten depressive symptoms, instrumental activities of daily living (IADLs), and basic activities of daily living (ADLs) were measured at hospital discharge and 1, 3, 6, and 12 months later. Participant-specific changes in depressive symptoms (slopes) were determined using all data points. Four groups were also defined according to number of depressive symptoms (?3 symptoms, low; 4�10 symptoms, high) at discharge and follow-up: low�low, low�high, high�low, and high�high. Mortality was measured 3, 6, and 12 months after hospital discharge. Results: Participant-specific discharge depressive symptoms and change in depressive symptoms over time (slopes) were associated (P < .05) with functional and mortality outcomes. At 1 year, more participants in the low�low depressive symptom group (49%) were alive and independent in IADLs and ADLs than in the low�high group (37%, P = .02), and more participants in the high�low group (39%) were alive and independent in IADLs and ADLs than in the high�high group (19%, P < .001). Conclusion: Number of depressive symptoms and change in number of depressive symptoms during the year after discharge were associated with functional and mortality outcomes in hospitalized older adults. Fewer participants with persistently high or increasing depressive symptoms after hospitalization were alive and functionally independent 1 year later than participants with decreasing or persistently low symptoms, respectively.

To determine functional status and mortality rates after colon cancer surgery in older nursing home residents.Retrospective cohort study.Nursing homes in the United States.Six thousand eight hundred twenty-two nursing home residents aged 65 and older who underwent surgery for colon cancer in the United States between 1999 and 2005.Changes in functional status were assessed before and after surgery using the Minimum Data Set Activity of Daily Living (MDS-ADL) summary scale, a 28-point scale in which score increases as functional dependence increases. Regression techniques were used to identify patient characteristics associated with mortality and functional decline 1 year after surgery.On average, residents who underwent colectomy had a 3.9-point worsening in MDS-ADL score at 1 year. One year after surgery, rates of mortality and sustained functional decline were 53% and 24%, respectively. In multivariate analysis, older age (≥ 80 vs 65-69, adjusted relative risk (ARR) = 1.53, 95% confidence interval (CI) = 1.15-2.04, P.001), readmission after surgical hospitalization (ARR = 1.15, 95% CI = 1.03-1.29, P = .02), surgical complications (ARR = 1.11, 95% CI = 1.02-1.21, P = .01), and functional decline before surgery (ARR = 1.21, 95% CI = 1.11-1.32, P.001) were associated with functional decline at 1 year.Mortality and sustained functional decline are common after colon cancer surgery in nursing home residents. Initiatives aimed at improving surgical outcomes are needed in this vulnerable population.

Many older adults who are independent prior to hospitalization develop a new disability by hospital discharge. Early risk stratification for new-onset disability may improve care. Thus, this study's objective was to develop and validate a clinical index to determine, at admission, risk for new-onset disability among older, hospitalized adults at discharge. DESIGN: Data analyses derived from two prospective studies. SETTING: Two teaching hospitals in Ohio. PARTICIPANTS: Eight hundred eighty-five patients aged 70 years and older were discharged from a general medical service at a tertiary care hospital (mean age 78, 59% female) and 753 patients discharged from a separate community teaching hospital (mean age 79, 63% female). All participants reported being independent in five activities of daily living (ADLs: bathing, dressing, transferring, toileting, and eating) 2 weeks before admission. MEASUREMENTS: New-onset disability, defined as a new need for personal assistance in one or more ADLs at discharge in participants who were independent 2 weeks before hospital admission. RESULTS: Seven independent risk factors known on admission were identified and weighted using logistic regression: age (80�89, 1 point; ?90, 2 points); dependence in three or more instrumental ADLs at baseline (2 points); impaired mobility at baseline (unable to run, 1 point; unable to climb stairs, 2 points); dependence in ADLs at admission (2�3 ADLs, 1 point; 4�5 ADLs, 3 points); acute stroke or metastatic cancer (2 points); severe cognitive impairment (1 point); and albumin less than 3.0 g/dL (2 points). New-onset disability occurred in 6%, 13%, 18%, 34%, 35%, 45%, 50%, and 87% of participants with 0, 1, 2, 3, 4, 5, 6, and 7 or more points, respectively, in the derivation cohort (area under the receiver operating characteristic curve (AUC)=0.784), and in 8%, 10%, 27%, 38%, 44%, 45%, 58%, and 83%, respectively, in the validation cohort (AUC=0.784). The risk score also predicted (P

OBJECTIVES: To determine the hypo- and hyperglycemic outcomes associated with implementing the American Geriatrics Society (AGS) guideline for a glycosylated hemoglobin (HbA1c) level of less than 8% in frail older adults with diabetes mellitus (DM). DESIGN: Guideline implementation. SETTING: Program of All-Inclusive Care for the Elderly. PARTICIPANTS: All participants in the before (October 2002�December 2004, n=338), early (January 2005�June 2006, n=289) and late (July 2006�December 2008, n=385) periods of guideline implementation with a diagnosis of DM and at least one HbA1c measurement. INTERVENTION: Clinician education in 2005 with annual monitoring of the proportion of each clinician's patients with DM with HbA1c less than 8%. MEASUREMENTS: Hypoglycemia (blood glucose 400 mg/dL), and severe hypoglycemia (emergency department (ED) visit for hypoglycemia). RESULTS: Participants in the before, early, and late periods were similar in age, race and ethnicity, comorbidities, and functional dependence. Antihyperglycemic medication use was greater in the late period, with more participants using metformin (28% before, 42% late, P

OBJECTIVES: To determine whether geriatric conditions and functional impairment are independent risk factors for adverse drug events (ADEs). DESIGN: Prospective cohort study. SETTING: Veterans Affairs Medical Center. PARTICIPANTS: Three hundred seventy-seven veterans aged 65 and older and taking five or more medications. MEASUREMENTS: Geriatric conditions and functional status were assessed using participant interviews and structured assessments at study baseline. ADEs were elicited during participant interviews 3 and 12 months after study enrollment using validated methods. RESULTS: The strong majority (97%) of participants were male, with a mean age of 74±5; 123 (33%) had one or more dependencies in instrumental activities of daily living (IADLs). Over the 1-year study period, 126 participants (33%) developed 167 ADEs. Upon multivariable analysis, risk of ADEs was not associated with any of the geriatric conditions that there was sufficient power to evaluate, including IADL function, cognitive impairment, depression, visual impairment, incontinence, constipation, and a summative measure of geriatric burden comprising the above and history of falls or gait instability. In exploratory analyses, the strongest factor associated with ADEs was the number of drugs added to a participant's medication regimen during the 1-year study period (incidence rate ratio 1.11 per each added drug, 95% confidence interval=1.03�1.19). CONCLUSION: Common geriatric conditions and IADL function were not associated with ADEs in a predominantly male, older veteran population. Although it is important to consider the unique circumstances of each participant, excessive caution in prescribing to older adults with these geriatric conditions may not be warranted.

Many investigators have embraced a model in which frailty represents a state of decreased physiological reserves and dysregulation of multiple physiological systems.1 In 2001, Fried et al.2 used data from the Cardiovascular Health Study (CHS) and defined a phenotype of frailty that included three or more of the following: weight loss, weak grip, exhaustion, slow gait, and low physical activity level. A subsequent study used latent class analyses in the Women’s Health and Aging Study to demonstrate that the selected dichotomized CHS criteria occur together across individuals.3 At the 2004 National Institute on Aging/American Geriatrics Society Research Conference on Frailty, identifying frailty subdimensions was identified as a research priority.4 Identifying subdimensions with different prognostic profiles could offer insights into the varied pathways by which older adults become frail and proceed from frailty to bad outcomes. Ultimately, identifying different pathways could lead to the development of different or adjusted interventions to prevent and treat frailty. Scientists at the second International Frailty Conference in 2006 concurred that identification of subdimensions was a research priority and stated that a “broader definition of frailty may be useful, and even crucial, in research to understand the causes and consequences of the variety of traits subsumed under the general idea of frailty.”5 For example, many geriatricians believe that cognitive impairment is intrinsic to geriatric frailty.6–10 It has also been hypothesized that inflammation characterizes frailty,11 and high interleukin-6 (IL-6) levels are associated with the CHS frailty phenotype.12 This team hypothesized that the construct of frailty would subsume two or more subdimensions—one or more of which would include the CHS criteria, as well as cognitive impairment, subclinical inflammation, and subjective weakness and anorexia. The specific aims of this study were to use the MacArthur Study of Successful Aging to test empirically for the existence of subdimensions of frailty, using the CHS and an expanded set of criteria from vulnerability-based models, and to test the predictive and discriminant validity of identified subdimensions.

To establish the prevalence and correlates of disability during the 2 years before hip fracture.Data from participants who experienced hip fracture in the Health and Retirement Study (HRS) with hip fracture identified using linked Medicare claims. Each participant was interviewed at varying time points in the 2 years before hip fracture. Disability was defined as self-report of the need for assistance in any activity of daily living (walking across the room, eating, bathing, dressing, using the toilet, transferring). Based on the timing between interview and hip fracture, prevalence of disability was calculated in the cohort as a whole over the 2 years before hip fracture and in subgroups defined according to demographic and clinical characteristics.The HRS is a nationally representative longitudinal study (1992-2010).HRS participants aged ≥65 with hip fracture (mean age at fracture 84, 77% female).The adjusted prevalence of disability was 20% (95% confidence interval (CI) = 14-25%) 2 years before hip fracture, with little change until approximately 10 months before fracture, when it started to rise, reaching 44% (95% CI = 33-55%) in the month before hip fracture. The prevalence of disability was highest in the last month before fracture for persons aged 85 and older (53%) and for those with dementia (60%).Care models for hip fracture need to consider not only the acute medical and surgical needs, but also the high level of need for supportive care and caregiver assistance that chronically disabled individuals require.

Older adults often have multiple concurrent diseases, and the number and cumulative burden of individual conditions often increases with advancing age. Nevertheless, much remains unknown about patterns of multimorbidity in older adults. The lack of attention to this topic has created substantial difficulties for clinical practice guidelines, because the standard recommendations for a single disease may not be applicable to individuals whose other conditions interact with that disease, both at the level of pathophysiology and with the medications used to treat an individual’s ailments.1–5 Identifying the most common disease clusters in older adults may help the next generation of clinical practice guidelines explicitly account for common co-occurring conditions so that they can help clinicians avoid drug–drug and drug–disease interactions. Previous work has shed important light on this question by quantifying the number of co-occurring diseases within populations, examining linkages between common conditions, and determining the healthcare outcomes and costs associated with different patterns of multimorbidity,6–20 but the existing literature has certain limitations. Most of studies in this area have evaluated a limited number of conditions or limited populations, ranked conditions based on costs and outcomes rather than prevalence, focused on two-way disease combinations (and not more-complex patterns of disease co-occurrence), and provide little information on how patterns of multimorbidity may vary between the young-old (e.g., 65–74) and the “old-old” (e.g., ≥85).8,10–12,16–21 Thus, important knowledge gaps remain, particularly in identifying the specific patterns of multimorbidity that are most common in older adults and how these patterns differ between young-old and old-old people. This study was designed to identify common patterns of multimorbidity in a nationwide sample of community-dwelling older adults receiving care in the Department of Veterans Affairs (VA) healthcare system. First, this study aimed to identify the prevalence of common diseases in older male and female veterans and how the prevalence of these conditions varies according to age and sex. Second, the study sought to determine the most common combinations of diseases in older veterans and the extent to which the prevalence of these disease clusters varies between young-old and old-old individuals. In doing so, this study focused on diseases and conditions typically identifiable using large data sources and not on geriatric syndromes, which are critically important to the health of older adults but are more difficult to ascertain using administrative data.

To investigate patterns in prevalences of chronic medical conditions over the age span of long-term stay nursing home residents and between the sexes with data from the 2004 National Nursing Home Survey (NNHS).Retrospective, cross-sectional study.U.S. nursing homes.Nationally representative sample comprising 11,788 long-term stay residents (3,003 (25%) men, 8,785 (75%) women) aged 65 and older.Clinical Classifications Software was used to group International Classification of Diseases, Ninth Revision, codes to identify the 20 most-prevalent chronic medical conditions. SAS survey procedures were used to account for design effects of stratification and clustering to generate nationally representative estimates of prevalences of medical conditions.Average age was 84, with women older than men (85 vs 81, P = .02) and 67% of women aged 80 to 95. Women required more assistance with activities of daily living. The most frequent chronic medical conditions were hypertension (men 53%, women 56%), dementia (men 45%, women 52%), depression (men 31%, women 37%), arthritis (men 26%, women 35%), diabetes mellitus (men 26%, women 23%), gastroesophageal reflux disease (GERD) (men 23%, women 23%), atherosclerosis (men 24%, women 20%), congestive heart failure (CHF) (men 18%, women 21%), cerebrovascular disease (CVD) (men 24%, women 19%), and anemia (men 17%, women 20%). Sex differences in prevalences existed for all but constipation, GERD, and hypertension. Diabetes mellitus, CVD, and lipid disorders decreased with age in men and women. Atrial fibrillation, anemia, arthritis, CHF, dementia, and thyroid disease increased with age in men and women. Age-related patterns differed between the sexes for diabetes mellitus, hypertension, and Parkinson's disease.The profile of chronic medical conditions varies over the age span of nursing home residents and differs between men and women. This knowledge should guide educational and care efforts in long-term care.

Many older adults who are independent prior to hospitalization develop a new disability by hospital discharge. Early risk stratification for new-onset disability may improve care. Thus, this study's objective was to develop and validate a clinical index to determine, at admission, risk for new-onset disability among older, hospitalized adults at discharge.Data analyses derived from two prospective studies.Two teaching hospitals in Ohio.Eight hundred eighty-five patients aged 70 years and older were discharged from a general medical service at a tertiary care hospital (mean age 78, 59% female) and 753 patients discharged from a separate community teaching hospital (mean age 79, 63% female). All participants reported being independent in five activities of daily living (ADLs: bathing, dressing, transferring, toileting, and eating) 2 weeks before admission.New-onset disability, defined as a new need for personal assistance in one or more ADLs at discharge in participants who were independent 2 weeks before hospital admission.Seven independent risk factors known on admission were identified and weighted using logistic regression: age (80-89, 1 point; ≥90, 2 points); dependence in three or more instrumental ADLs at baseline (2 points); impaired mobility at baseline (unable to run, 1 point; unable to climb stairs, 2 points); dependence in ADLs at admission (2-3 ADLs, 1 point; 4-5 ADLs, 3 points); acute stroke or metastatic cancer (2 points); severe cognitive impairment (1 point); and albumin less than 3.0 g/dL (2 points). New-onset disability occurred in 6%, 13%, 18%, 34%, 35%, 45%, 50%, and 87% of participants with 0, 1, 2, 3, 4, 5, 6, and 7 or more points, respectively, in the derivation cohort (area under the receiver operating characteristic curve (AUC)=0.784), and in 8%, 10%, 27%, 38%, 44%, 45%, 58%, and 83%, respectively, in the validation cohort (AUC=0.784). The risk score also predicted (P.001) disability severity, nursing home placement, and long-term survival.This clinical index determines risk for new-onset disability in hospitalized older adults and may inform clinical care.

To determine whether geriatric conditions and functional impairment are independent risk factors for adverse drug events (ADEs).Prospective cohort study.Veterans Affairs Medical Center.Three hundred seventy-seven veterans aged 65 and older and taking five or more medications.Geriatric conditions and functional status were assessed using participant interviews and structured assessments at study baseline. ADEs were elicited during participant interviews 3 and 12 months after study enrollment using validated methods.The strong majority (97%) of participants were male, with a mean age of 74 ± 5; 123 (33%) had one or more dependencies in instrumental activities of daily living (IADLs). Over the 1-year study period, 126 participants (33%) developed 167 ADEs. Upon multivariable analysis, risk of ADEs was not associated with any of the geriatric conditions that there was sufficient power to evaluate, including IADL function, cognitive impairment, depression, visual impairment, incontinence, constipation, and a summative measure of geriatric burden comprising the above and history of falls or gait instability. In exploratory analyses, the strongest factor associated with ADEs was the number of drugs added to a participant's medication regimen during the 1-year study period (incidence rate ratio 1.11 per each added drug, 95% confidence interval=1.03-1.19).Common geriatric conditions and IADL function were not associated with ADEs in a predominantly male, older veteran population. Although it is important to consider the unique circumstances of each participant, excessive caution in prescribing to older adults with these geriatric conditions may not be warranted.

To describe lengths of stay of nursing home decedents.Retrospective cohort study.The Health and Retirement Study (HRS), a nationally representative survey of U.S. adults aged 50 and older.One thousand eight hundred seventeen nursing home residents who died between 1992 and 2006.The primary outcome was length of stay, defined as the number of months between nursing home admission and date of death. Covariates were demographic, social, and clinical factors drawn from the HRS interview conducted closest to the date of nursing home admission.The mean age of decedents was 83.3 ± 9.0; 59.1% were female, and 81.5% were white. Median and mean length of stay before death were 5 months (interquartile range 1-20) and 13.7 ± 18.4 months, respectively. Fifty-three percent died within 6 months of placement. Large differences in median length of stay were observed according to sex (men, 3 months vs women, 8 months) and net worth (highest quartile, 3 months vs lowest quartile, 9 months) (all P.001). These differences persisted after adjustment for age, sex, marital status, net worth, geographic region, and diagnosed chronic conditions (cancer, hypertension, diabetes mellitus, lung disease, heart disease, and stroke).Nursing home lengths of stay are brief for the majority of decedents. Lengths of stay varied markedly according to factors related to social support.

To identify frailty subdimensions.Longitudinal cohort (MacArthur Study).Three U.S. urban centers.One thousand one hundred eighteen high-functioning subjects aged 70 to 79 in 1988.Participants with three or more of five Cardiovascular Health Study (CHS) frailty criteria (weight loss, weak grip, exhaustion, slow gait, and low physical activity) in 1991 were classified as having the CHS frailty phenotype. To identify frailty subdimensions, factor analysis was conducted using the CHS variables and an expanded set including the CHS variables, cognitive impairment, interleukin-6 (IL-6), C-reactive protein (CRP), subjective weakness, and anorexia. Participants with four or more of 10 criteria were classified as having an expanded frailty phenotype. Predictive validity of each identified frailty subdimension was assessed using regression models for 4-year disability and 9-year mortality.Two subdimensions of the CHS phenotype and four subdimensions of the expanded frailty phenotype were identified. Cognitive function was consistently part of a subdimension including slower gait, weaker grip, and lower physical activity. The CHS subdimension of slower gait, weaker grip, and lower physical activity predicted disability (adjusted odds ratio (AOR)=1.7, 95% confidence interval (CI)=1.3-2.2) and mortality (AOR=1.5, 95% CI=1.3-1.8). Subdimensions of the expanded model with predictive validity were higher IL-6 and CRP (AOR=1.2 for mortality); slower gait, weaker grip, lower physical activity, and lower cognitive function (AOR=1.8 for disability; AOR=1.5 for mortality), and anorexia and weight loss (AOR=1.2 for disability).This study provides preliminary empirical support for subdimensions of geriatric frailty, suggesting that pathways to frailty differ and that subdimension-adapted care might enhance care of frail seniors.