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Background: Central nervous system (CNS) medication use is common among older adults, yet the impact of hospitalizations on use remains unclear. This study details CNS medication use, discontinuations, and user profiles during hospitalization periods. Methods: Retrospective cohort study using electronic health records on patients ≥65 years, from three hospitals (2018–2020), and prescribed a CNS medication around hospitalization (90 days prior to 90 days after). Latent class transitions analysis (LCTA) examined profiles of CNS medication class users across four time points (90 days prior, admission, discharge, 90 days after hospitalization). Results: Among 4666 patients (mean age 74.3 ± 9.3 years; 63% female; 70% White; mean length of stay 4.6 ± 5.6 days (median 3.0 [2.0, 6.0]), the most commonly prescribed CNS medications were antidepressants (56%) and opioids (49%). Overall, 74% (n = 3446) of patients were persistent users of a CNS medication across all four time points; 7% (n = 388) had discontinuations during hospitalization, but of these, 64% (216/388) had new starts or restarts within 90 days after hospitalization. LCTA identified three profile groups: (1) low CNS medication users, 54%–60% of patients; (2) mental health medication users, 30%–36%; and (3) acute/chronic pain medication users, 9%–10%. Probability of staying in same group across the four time points was high (0.88–1.00). Transitioning to the low CNS medication use group was highest from admission to discharge (probability of 9% for pain medication users, 5% for mental health medication users). Female gender increased (OR 2.4, 95% CI 1.3–4.3), while chronic kidney disease lowered (OR 0.5, 0.2–0.9) the odds of transitioning to the low CNS medication use profile between admission and discharge. Conclusions: CNS medication use stays consistent around hospitalization, with discontinuation more likely between admission and discharge, especially among pain medication users. Further research on patient outcomes is needed to understand the benefits and harms of hospital deprescribing, particularly for medications requiring gradual tapering. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To develop a prognostic model for hospital admissions over a 1‐year period among community‐dwelling older adults with self‐reported hearing and/or vision impairments based on readily obtainable clinical predictors. DESIGN: Retrospective cohort study. SETTING: Medicare Current Beneficiary Survey from 1999 to 2006. PARTICIPANTS: Community‐dwelling Medicare beneficiaries, aged 65 years and older, with self‐reported hearing and/or vision impairment (N = 15,999). MEASUREMENTS: The primary outcome was any hospital admission over a predefined 1‐year study period. Candidate predictors included demographic factors, prior healthcare utilization, comorbidities, functional impairment, and patient‐level factors. We analyzed the association of all candidate predictors with any hospital admission over the 1‐year study period using multivariable logistic regression. The final model was created using a penalized regression method known as the least absolute shrinkage and selection operator. Model performance was assessed by discrimination (concordance statistic (c‐statistic)) and calibration (evaluated graphically). Internal validation was performed via bootstrapping, and results were adjusted for overoptimism. RESULTS: Of the 15,999 participants, the mean age was 78 years and 55% were female. A total of 2,567 participants (16.0%) had at least one hospital admission in the 1‐year study period. The final model included seven variables independently associated with hospitalization: number of inpatient admissions in the previous year, number of emergency department visits in the previous year, activities of daily living difficulty score, poor self‐rated health, and self‐reported history of myocardial infarction, stroke, and nonskin cancer. The c‐statistic of the final model was 0.717. The optimism‐corrected c‐statistic after bootstrap internal validation was 0.716. A calibration plot suggested that the model tended to overestimate risk among patients at the highest risk for hospitalization. CONCLUSION: This prognostic model can help identify which community‐dwelling older adults with sensory impairments are at highest risk for hospitalization and may inform allocation of healthcare resources. [ABSTRACT FROM AUTHOR]

BACKGROUND: Hospital‐acquired disability (HAD) is common and often related to low physical activity while in the hospital. OBJECTIVE: To examine whether wearable hospital activity trackers can be used to predict HAD. DESIGN: A prospective observational study between January 2016 and March 2017. SETTING: An academic medical center. PARTICIPANTS: Community‐dwelling older adults, aged 60 years or older, enrolled within 24 hours of admission to general medicine (n = 46). MAIN MEASURES: Primary outcome was HAD, defined as having one or more new activity of daily living deficits, decline of four or greater on the Late‐Life Function and Disability Instrument (calculated between baseline and discharge), or discharge to a skilled nursing facility. Hospital activity (mean active time, mean sedentary time, and mean step counts per day) was measured using ankle‐mounted accelerometers. The association of the literature‐based threshold of 900 steps/day with HAD was also evaluated. RESULTS: Mean age was 73.2 years (SD = 9.5 years), 48% were male, and 76% were white. Median length of stay was 4 days (interquartile range [IQR] = 2.0‐6.0 days); 61% (n = 28) reported being able to walk without assistance of another person or walking aid at baseline. Median daily activity time and step counts were 1.1 h/d (IQR = 0.7‐1.7 h/d) and 1455.7 steps/day (IQR = 908.5‐2643 steps/day), respectively. Those with HAD (41%; n = 19) had lower activity time (0.8 vs 1.4 h/d; P =.04) and fewer step counts (1186 vs 1808 steps/day; P =.04), but no difference in sedentary time, compared to those without HAD. The 900 steps/day threshold had poor sensitivity (40%) and high specificity (85%) for detecting HAD. CONCLUSIONS: Low hospital physical activity, as measured by wearable accelerometers, is associated with HAD. Clinicians can utilize wearable technology data to refer patients to physical/occupational therapy services or other mobility interventions, like walking programs. J Am Geriatr Soc 68:261–265, 2020 [ABSTRACT FROM AUTHOR]

Objectives To perform an economic evaluation of a primary care-based physical activity counseling intervention that improved physical activity levels and rapid gait speed in older veterans. Design Secondary objective of randomized trial that assessed the effect of exercise counseling (relative to usual care) on physical performance, physical activity, function, disability, and medical resource use and cost. Setting Veterans Affairs Medical Center, Durham, North Carolina. Participants Male veterans aged ≥70 years (n = 398). Intervention An experienced health counselor provided baseline in-person exercise counseling, followed by telephone counseling at 2, 4, and 6 weeks, and monthly thereafter through one year. Each participant's primary care physician provided initial endorsement of the intervention, followed by monthly automated telephone messages tailored to the patient. Individualized progress reports were mailed quarterly. Measurements Intervention costs were assessed. Health care resource use and costs were estimated from enrollment through one year follow-up. The incremental cost of achieving clinically significant changes in major trial endpoints was calculated. Results The total direct cost of the intervention per participant was $459, 85% of which was counselor effort. With overhead, program cost totaled $696 per participant. Medical costs during follow-up reached $10,418 with the intervention, versus $12,052 with usual care (difference = −$1,634 (95% confidence interval = −$4,683 to $1,416; P = .29)). Expressed in terms of short-term clinical outcomes, the intervention cost $4,971 per additional patient reaching target exercise levels, or $4,640 per patient achieving a clinically significant change in rapid gait speed. Conclusion Improvements in physical activity and rapid gait speed in the physical activity counseling group were obtained at a cost that represents a small fraction of patients' annual health care costs. [ABSTRACT FROM AUTHOR]

BACKGROUND Few studies to date have used the cancer diagnosis as a teachable moment to promote healthy behavior changes in survivors of cancer and their family members. Given the role of obesity in the primary and tertiary prevention of breast cancer, the authors explored the feasibility of a mother-daughter weight loss intervention. METHODS A randomized controlled trial of a mailed weight loss intervention was undertaken among 68 mother-daughter dyads (n = 136), each comprised of a survivor of breast cancer (AJCC stage 0-III) and her adult biological daughter. All women had body mass indices ≥ 25 kg/m2 and underwent in-person assessments at baseline, 6 months, and 12 months, with accelerometry and exercise capacity performed on a subset of individuals. All women received a personalized workbook and 6 newsletters over a 1-year period that promoted weight loss; exercise; and a nutrient-rich, low-energy density diet. A total of 25 dyads received individually tailored instruction (INDIVIDUAL), 25 dyads received team-tailored instruction (TEAM), and 18 dyads received standardized brochures (CONTROL). RESULTS The trial met its accrual target, experienced 90% retention, and caused no serious adverse events. Significant differences in baseline to 12-month changes were observed between INDIVIDUAL versus CONTROL mothers for body mass index, weight, and waist circumference (WC); significant differences also were observed in the WC of corresponding daughters ( P < .05). Significant differences were found between INDIVIDUAL versus CONTROL and TEAM versus CONTROL dyads for WC ( P = .0002 and .018, respectively), minutes per week of physical activity ( P = .031 and .036, respectively), and exercise capacity ( P = .047 for both). CONCLUSIONS Significant improvements in lifestyle behaviors and health outcomes are possible with tailored print interventions directed toward survivors of cancer and their family members. For greater impact, more research is needed to expand this work beyond the mother-daughter dyad. Cancer 2014;120:2522-2534. © 2014 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine the relationship between the reason for an emergency department (ED) visit and subsequent risk of adverse health outcomes in older adults discharged from the ED. DESIGN: Secondary analysis of data from the Medicare Current Beneficiary Survey. SETTING: ED. PARTICIPANTS: One thousand eight hundred fifty-one community-dwelling Medicare fee-for-service enrollees aged 65 and older discharged from the ED between January 2000 and September 2002. MEASUREMENTS: Independent variables were ED discharge diagnosis groups: injury or musculoskeletal (MSK) (e.g., fracture, open wound), chronic condition (e.g., chronic obstructive pulmonary disorder, heart failure), infection, non-MSK symptom (e.g., chest pain, abdominal pain), and unclassified. Adverse health outcomes were hospitalization or death within 30 days of the index ED visit. RESULTS: Injury or MSK was the largest ED diagnosis group (31.4%), followed by non-MSK symptom (22.2%), chronic condition (20.9%), and infection (7.8%); 338 (17.8%) had ED discharge diagnoses that were unclassified. In adjusted analyses, a discharge diagnosis of injury or MSK condition was associated with lower risk of subsequent adverse health outcomes (hazard ratio (HR)=0.69, 95% confidence interval (CI)=0.50–0.96) than for all other diagnosis groups. Patients seen in the ED for chronic conditions were at greater risk of adverse outcomes (HR=1.86, 95% CI=1.37–2.52) than all others. There were no significant differences in risk between patients with infections, those with non-MSK symptoms, and the unclassified group. CONCLUSION: Adverse health outcomes were common in older patients with an ED discharge diagnosis classified as a chronic condition. ED discharge diagnosis may improve risk assessment and inform the development of targeted interventions to reduce adverse health outcomes in older adults discharged from the ED. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether frail older adults, based on a deficit accumulation index (DAI), are at greater risk of adverse outcomes after discharge from the emergency department (ED). DESIGN AND SETTING: Secondary analysis of data from the Medicare Current Beneficiary Survey. PARTICIPANTS: One thousand eight hundred fifty-one community-dwelling Medicare fee-for-service enrollees, aged 65 and older who were discharged from the ED between January 2000 and September 2002. MEASUREMENTS: The primary dependent variable was time to first adverse outcome, defined as repeat outpatient ED visit, hospital admission, nursing home admission, or death, within 30 days of the index ED visit. RESULTS: Time to first adverse outcome was shortest in individuals with the highest number of accumulated deficits. The frailest participants were at greater risk of adverse outcomes after ED discharge than those who were least frail (hazard ratio (HR)=1.44, 95% confidence interval (CI)=1.06–1.96). The frailest individuals were also at higher risk of serious adverse outcomes, defined as hospitalization, nursing home admission, or death (HR=1.98, 95% CI=1.29–3.05). In contrast, no association was detected between degree of frailty and repeat outpatient ED visits within 30 days (HR=1.06, 95% CI=0.73–1.54). CONCLUSION: The DAI as a construct of frailty was a robust predictor of serious adverse outcomes in the first 30 days after ED discharge. Frailty was not found to be a major determinant of repeat outpatient ED visits; therefore, additional study is needed to investigate this particular type of health service use by older adults. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether suboptimal pharmacotherapy increases the risk of adverse outcomes in older adults discharged from the emergency department (ED). DESIGN: Retrospective, cohort study. SETTING: Academically affiliated Veterans Affairs Medical Center. PARTICIPANTS: Nine hundred forty-two veterans aged 65 and older discharged from the ED. MEASUREMENTS: The primary independent variable, suboptimal pharmacotherapy, was based on drugs-to-avoid criteria, drug–drug interactions, drug–disease interactions, or failure to satisfy explicit quality indicators (QIs). An adverse outcome was defined as one or more repeat ED visits or hospitalizations or death within 90 days of ED discharge. RESULTS: Four hundred twenty-one patients were prescribed a new medication at ED discharge. Of these, 134 (31.8%) had suboptimal pharmacotherapy; 49 (11.6%) were prescribed a drug to avoid, 53 (12.6%) received a drug that introduced a new drug–drug interaction, 24 (5.7%) were given a drug that introduced a drug–disease interaction, and 74 (17.6%) did not have a QI satisfied. Overall, 320 patients (34.0%) experienced an adverse outcome within 90 days. Multivariable analyses suggested a trend toward greater risk of adverse outcomes in patients with suboptimal pharmacotherapy (hazard ratio=1.32, 95% confidence interval=0.95, 1.84). CONCLUSION: A substantial number of older male veterans discharged from the ED may be at risk for adverse events due to suboptimal prescribing and inadequate medication monitoring. Efforts to improve the quality of pharmacotherapy in this vulnerable population are warranted. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine the prevalence and type of suboptimal pharmacotherapy that older veterans discharged from the emergency department (ED) or urgent care clinic (UCC) receive and to examine factors associated with suboptimal pharmacotherapy in this population. DESIGN: Retrospective, cohort study. SETTING: An academically affiliated Department of Veterans' Affairs (VA) Medical Center. PARTICIPANTS: Four hundred twenty-one veterans aged 65 and older who were prescribed a new medication at the time of discharge from the ED or UCC. MEASUREMENTS: The primary dependent variable, suboptimal pharmacotherapy, was a composite measure defined as one or more drug-related problems, based on drugs-to-avoid criteria, drug–drug interactions, drug–disease interactions, and failure to satisfy an explicit quality indicator for prescribing or medication monitoring. RESULTS: A total of 757 drugs were prescribed to the 421 patients at the time of discharge from the ED or UCC (mean number±standard deviation per patient 1.65±1.1). The most frequently prescribed medications were nonsteroidal antiinflammatory drugs (n=59), opioid analgesics (n=47), and fluoroquinolone antibiotics (n=46). Overall, 134 (31.8%) subjects were found to have suboptimal pharmacotherapy with regard to their discharge medications; 49 (11.6%) were prescribed a drug to avoid, 53 (12.6%) received a drug that introduced a new drug–drug interaction, 24 (5.7%) were given a drug that introduced a drug–disease interaction, and 74 (17.6%) did not have a quality indicator satisfied (61% of these evaluated prescribing and 39% evaluated medication monitoring). No consistent associations between patient or visit characteristics and suboptimal pharmacotherapy were identified in multivariable models. CONCLUSION: A substantial number of older adults discharged from the ED or UCC may be at risk for adverse events due to suboptimal prescribing and inadequate medication monitoring. Further study is needed to examine the relationship between suboptimal pharmacotherapy and adverse clinical outcomes. [ABSTRACT FROM AUTHOR]

Elderly minorities are more likely to die in inpatient settings than their Caucasian counterparts. It is not known whether this difference is due to cultural preferences for place of death or decreased access to hospice. This analysis examines ethnic differences in the place of death of elderly hospice patients. Using data from a large, national hospice provider, elderly (≥65) African-American, Hispanic, and Caucasian decedents admitted to hospice between January 1, 2000, and December 31, 2003, were identified. Of the 115,854 eligible decedents, 78.3% were Caucasian, 10.7% African American, and 11% Hispanic. Hispanics and African Americans were more likely to die in inpatient hospice settings than Caucasians (38.5%, 38.5%, and 32%, respectively). After adjustment for demographic and hospice use variables, older African Americans had higher odds than older Caucasians of dying in an inpatient hospice setting than a nursing home (odds ratio (OR)=1.12, 95% confidence interval (CI)=1.07–1.19). However, African-American ethnicity was not a significant predictor of death in an inpatient setting versus home (OR=1.03, 95% CI=0.97–1.08)). Hispanics had lower odds than Caucasians of death in an inpatient hospice setting than at home (OR=0.88, 95% CI=0.84, 0.93) and higher odds of death in an inpatient setting than a nursing home (OR=1.45, 95% CI=1.37–1.53). Admission to hospice reduces but does not eliminate ethnic differences in place of death. Further research should examine the effect of individual and cultural preferences for place of death on decisions to enroll in hospice. [ABSTRACT FROM AUTHOR]

To determine the prevalence and predictors of unnecessary drug use at hospital discharge in frail elderly patients. Cross-sectional. Eleven Veterans Affairs Medical Centers. Three hundred eighty-four frail older patients from the Geriatric Evaluation and Management Drug Study. Assessment of unnecessary drug use was determined by the consensus of a clinical pharmacist and physician pair applying the Medication Appropriateness Index to each regularly scheduled medication at hospital discharge. Those drugs that received an inappropriate rating for indication, efficacy, or therapeutic duplication were defined as unnecessary. Forty-four percent of patients had at least one unnecessary drug, with the most common reason being lack of indication. The most commonly prescribed unnecessary drug classes were gastrointestinal, central nervous system, and therapeutic nutrients/minerals. Factors associated ( P<.05) with unnecessary drug use included hypertension (adjusted odds ratio (AOR)=0.61, 95% confidence interval (CI)=0.38–0.96), multiple prescribers (AOR=3.35, 95% CI=1.16–9.68), and nine or more medications (AOR=2.24, 95% CI=1.25–3.99). A high prevalence of unnecessary drug use at discharge was found in frail hospitalized elderly patients. Additional studies are needed to identify predictors and prevalence of unnecessary drug use in nonveteran populations so that interventions can be designed to reduce the problem. [ABSTRACT FROM AUTHOR]

Objective: To ascertain whether use of mechanical ventilation on admission to the hospital is a proxy indicator of coma (i.e., very severe stroke) among acute stroke patients.Methods: A secondary analysis of data from a medical record review on a nationally representative sample of 2,824 Medicare patients, ages 65 years or older, who were hospitalized for stroke in 1982-1983 or 1985-1986 in 297 acute care hospitals in 30 areas within five geographically dispersed states.Results: Use of mechanical ventilation on the first day of hospitalization was significantly associated with level of consciousness on admission: < 2 percent of noncomatose patients versus 17.5 percent of comatose (p < .001). With a high specificity and high likelihood ratio for a positive test, use of mechanical ventilation on the first day of hospitalization ruled-in coma. It was also significantly associated with severity of illness, prognostic indicators (i.e., admission through the emergency room, admission to intensive care, and having a "do-not-resuscitate" order written during the hospital stay), and with in-hospital death. Adjusting for patient demographics, stroke type, comorbidity, and process of care, early initiation of mechanical ventilation remained significantly associated with both coma and in-hospital death.Conclusions: A stroke patient's use of mechanical ventilation on the first day of hospitalization is a valid proxy indicator of level of consciousness. [ABSTRACT FROM AUTHOR]