@article {11845, title = {Changes in the Hierarchy of Functional Impairment from Middle Age to Older Age.}, journal = {The Journals of Gerontology, Series A }, volume = {77}, year = {2022}, pages = {1577-1584}, abstract = {

BACKGROUND: Understanding the hierarchy of functional impairment in older adults has helped illuminate mechanisms of impairment and inform interventions, but little is known about whether hierarchies vary by age. We compared the pattern of new-onset impairments in activities of daily living (ADLs) and instrumental ADLs (IADLs) from middle age through older age.

METHODS: We conducted a cohort study using nationally representative data from 32486 individuals enrolled in the Health and Retirement Study. The outcomes were new-onset impairment in each ADL and IADL, defined as self-reported difficulty performing each task, assessed yearly for 9 years. We used multi-state models and competing risks survival analysis to estimate the cumulative incidence of impairment in each task by age group (ages 50-64, 65-74, 75-84, and 85 or older).

RESULTS: The pattern of incident ADL impairments differed by age group. Among individuals ages 50-64 and 65-74 who were independent at baseline, over 9 years{\textquoteright} follow-up, difficulties dressing and transferring were the most common impairments to develop. In individuals ages 75-84 and 85 or older who were independent at baseline, difficulties bathing, dressing, and walking were most common. For IADLs, the pattern of impairments was similar across age groups; difficulty shopping was most common followed by difficulty managing money and preparing meals. Complementary analyses demonstrated a similar pattern.

CONCLUSIONS: These findings suggest that the hierarchy of ADL impairment differs by age. These findings have implications for the development of age-specific interventions to prevent or delay functional impairment.

}, keywords = {Activities of Daily Living, functional impairment}, issn = {1758-535X}, doi = {10.1093/gerona/glab250}, author = {Brown, Rebecca T and L Grisell Diaz-Ramirez and W John Boscardin and Anne Cappola and Lee, Sei J and Michael A Steinman} } @article {12231, title = {Incidence of potentially disruptive medical and social events in older adults with and without dementia.}, journal = {Journal of the American Geriatrics Society}, volume = {70}, year = {2022}, pages = {1461-1470}, abstract = {

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 (PWD). 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 and 2018 (n~=~9346), including a subset who were married-partnered at baseline (n~=~5105). 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: 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~=~8750). 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.

}, keywords = {Dementia, Hip fracture, Pneumonia, Widowhood}, issn = {1532-5415}, doi = {10.1111/jgs.17682}, author = {Hunt, Lauren J and R Sean Morrison and Gan, Siqi and Espejo, Edie and Katherine A Ornstein and W John Boscardin and Smith, Alexander K} } @article {13027, title = {WHICH NEIGHBORHOOD FEATURES MATTER MOST FOR MUSCLE STRENGTH? FINDINGS FROM THE HEALTH AND RETIREMENT STUDY}, journal = {Innovation in Aging}, volume = {6}, year = {2022}, pages = {254{\textendash}255}, abstract = {Linking data from the National Neighborhood Data Archive (NaNDA) to the 2006-2018 Health and Retirement Study (N=22,245), we fit linear mixed models to assess which of 22 built and social neighborhood environment variables predicted grip strength, a measure of total-body muscle strength. Among 22,245 respondents (mean age=63 years, SD=9.2) with up to 4 grip strength measures, neighborhood physical disorder (B= -0.25 kg, 95\% CI= -0.37,-0.13), number of parks (B= 0.05 kg, 95\% CI= 0.01, 0.10), number of gyms/fitness centers (B=-0.44 kg, 95\% CI= -0.82, -0.07), proportion of highly developed land (B=-2.06 kg, 95\% CI=-4.06, -0.07), and \% urban (B=-0.66 kg, 95\% CI=-1.27, -0.05) were associated with grip strength level after adjustment. No social neighborhood variables were associated with grip strength. Although preliminary, findings suggest that highly developed urbanized land may be a barrier to maintaining muscle strength in later life, but resources such as parks are associated with better outcomes.}, keywords = {Grip strength, Muscle Strength, Neighborhood characteristics}, doi = {10.1093/geroni/igac059.1010}, author = {Kate A Duchowny and L Grisell Diaz-Ramirez and W John Boscardin and Peggy Cawthon and Maria Glymour and Scarlett Lin Gomez} } @article {11622, title = {Association of Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention With Memory Decline in Older Adults Undergoing Coronary Revascularization}, journal = {JAMA}, volume = {325}, year = {2021}, pages = {1955-1964}, abstract = {It is uncertain whether coronary artery bypass grafting (CABG) is associated with cognitive decline in older adults compared with a nonsurgical method of coronary revascularization (percutaneous coronary intervention [PCI]).To compare the change in the rate of memory decline after CABG vs PCI.Retrospective cohort study of community-dwelling participants in the Health and Retirement Study, who underwent CABG or PCI between 1998 and 2015 at age 65 years or older. Data were modeled for up to 5 years preceding and 10 years following revascularization or until death, drop out, or the 2016-2017 interview wave. The date of final follow-up was November 2017.CABG (including on and off pump) or PCI, ascertained from Medicare fee-for-service billing records.The primary outcome was a summary measure of cognitive test scores and proxy cognition reports that were performed biennially in the Health and Retirement Study, referred to as memory score, normalized as a z score (ie, mean of 0, SD of 1 in a reference population of adults aged >=72 years). Memory score was analyzed using multivariable linear mixed-effects models, with a prespecified subgroup analysis of on-pump and off-pump CABG. The minimum clinically important difference was a change of 1 SD of the population-level rate of memory decline (0.048 memory units/y).Of 1680 participants (mean age at procedure, 75 years; 41\% female), 665 underwent CABG (168 off pump) and 1015 underwent PCI. In the PCI group, the mean rate of memory decline was 0.064 memory units/y (95\% CI, 0.052 to 0.078) before the procedure and 0.060 memory units/y (95\% CI, 0.048 to 0.071) after the procedure (within-group change, 0.004 memory units/y [95\% CI, -0.010 to 0.018]). In the CABG group, the mean rate of memory decline was 0.049 memory units/y (95\% CI, 0.033 to 0.065) before the procedure and 0.059 memory units/y (95\% CI, 0.047 to 0.072) after the procedure (within-group change, -0.011 memory units/y [95\% CI, -0.029 to 0.008]). The between-group difference-in-differences estimate for memory decline for PCI vs CABG was 0.015 memory units/y (95\% CI, -0.008 to 0.038; P = .21). There was statistically significant increase in the rate of memory decline after off-pump CABG compared with after PCI (difference-in-differences: mean increase in the rate of decline of 0.046 memory units/y [95\% CI, 0.008 to 0.084] after off-pump CABG), but not after on-pump CABG compared with PCI (difference-in-differences: mean slowing of decline of 0.003 memory units/y [95\% CI, -0.024 to 0.031] after on-pump CABG).Among older adults undergoing coronary revascularization with CABG or PCI, the type of revascularization procedure was not significantly associated with differences in the change of rate of memory decline.}, keywords = {cardiology, cardiothoracic surgery, ischemic heart disease}, isbn = {0098-7484}, doi = {10.1001/jama.2021.5150}, author = {Elizabeth L Whitlock and L Grisell Diaz-Ramirez and Alexander K Smith and W John Boscardin and Kenneth E Covinsky and Michael S. Avidan and M. Maria Glymour} } @article {11749, title = {The epidemiology of social isolation and loneliness among older adults during the last years of life.}, journal = {Journal of the American Geriatrics Society}, volume = {69}, year = {2021}, pages = {3081-3091}, abstract = {

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 4 years of life (n~=~3613).

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 4 years of life (correlation~=~0.11). The adjusted prevalence of social isolation was higher for individuals nearer to death (4 years: 18\% vs 0-3 months: 27\%, p~=~0.05) and there was no significant change in loneliness (4 years: 19\% vs 0-3 months: 23\%, p~=~0.13). Risk factors for both isolation and loneliness included (p < 0.01): low net-worth (Isolation: 34\% vs 14\%; Loneliness: 29\% vs 13\%), hearing impairment (Isolation: 26\% vs 20\%; Loneliness: 26\% vs 17\%), and difficulty preparing meals (Isolation: 27\% vs 19\%; Loneliness: 29\% vs 15\%). Factors associated with loneliness, but not social isolation, included being female, pain, incontinence, and cognitive impairment.

CONCLUSIONS: Social isolation and loneliness are common at the end of life, affecting 1 in 4 older adults, but few experience both. Rates were higher for older adults who were poor and experienced functional or sensory impairments. Results can inform clinical efforts to identify and address end-of-life psychosocial suffering and health policies which prioritize social needs at the end of life.

}, keywords = {Cognition, end of life, Loneliness, Palliative care, social isolation}, issn = {1532-5415}, doi = {10.1111/jgs.17366}, author = {Ashwin A Kotwal and Irena Cenzer and Linda J. Waite and Kenneth E Covinsky and Perissinotto, Carla M and W John Boscardin and Louise C Hawkley and Dale, William and Smith, Alexander K} } @article {11500, title = {Long-term individual and population functional outcomes in older adults with atrial fibrillation.}, journal = {Journal of the American Geriatrics Society}, volume = {69}, year = {2021}, pages = {1570-1578}, abstract = {

Background: Older adults with atrial fibrillation (AF) have multiple risk factors for disablement. Long-term function and the contribution of strokes to disability has not been previously characterized.

Methods: We performed a longitudinal, observational study in the nationally representative Health and Retirement Study (1992-2014). We included participants >=65 years with Medicare claims who met incident AF diagnosis claims criteria. We examined the association of incident stroke with three functional outcomes: independence with activities of daily living (ADL) and instrumental activities of daily living (IADL) and community-dwelling. We fit separate logistic regression models with repeated measures adjusting for comorbidities and demographics to estimate the effect of stroke on function. We estimate the contribution of strokes to the overall population burden of functional impairment using the method of recycled predictions.

Results: Among 3530 participants (median age 79 years, 53\% women, median CHA DS -VASc 5), 262 had a stroke over 17,396 person-years. Independent of stroke and accounting for population comorbidities, annually, ADL dependence increased by 4.4\%, IADL dependence increased by 3.9\%, and nursing home residence increased by 1.2\% (p<0.05 for all). Accounting for comorbidities, of those who experienced a stroke, 31.9\% developed new ADL dependence, 26.5\% developed new IADL dependence, and 8.6\% newly moved to a nursing home (p<0.05 for all). Considering all causes of function loss, 1.7\% of ADL disability-years, 1.2\% of IADL disability-years, and 7.3\% of nursing home years could be attributed to stroke over 7.4years.

Conclusion: Older adults lose substantial function over time following AF diagnosis, independent of stroke. Stroke was associated with a significant decline in function and an increase in the likelihood of nursing home move, but stroke did not accelerate subsequent disability accrual. Because of the high background rate of functional loss, stroke was not the dominant determinant of population-level disability in older adults with AF.

Impact statement: We certify that this work is novel. Little is known about long-term function (ADL, IADL, community-dwelling) among older adults with AF and the association with stroke. This nationally representative study finds a high rate of function loss independent of stroke, and among those who suffer a stroke, a dramatic and immediate decline in function. Because of the high rate of function loss independent of stroke and the relatively low rate of stroke, on a population level, stroke is not the dominant determinant of disability in older adults with AF.

}, keywords = {ADL disability, Atrial Fibrillation, community living, IADLS}, doi = {10.1101/2020.05.04.20091025}, author = {Anna L Parks and Sun Y Jeon and W John Boscardin and Michael A Steinman and Alexander K Smith and Margaret C Fang and Sachin J Shah} } @article {11579, title = {A Novel Method for Identifying a Parsimonious and Accurate Predictive Model for Multiple Clinical Outcomes.}, journal = {Computer Methods and Programs in Biomedicine}, volume = {204}, year = {2021}, pages = {106073}, abstract = {

BACKGROUND AND OBJECTIVE: Most methods for developing clinical prognostic models focus on identifying parsimonious and accurate models to predict a single outcome; however, patients and providers often want to predict multiple outcomes simultaneously. As an example, for older adults one is often interested in predicting nursing home admission as well as mortality. We propose and evaluate a novel predictor-selection computing method for multiple outcomes and provide the code for its implementation.

METHODS: Our proposed algorithm selected the best subset of common predictors based on the minimum average normalized Bayesian Information Criterion (BIC) across outcomes: the Best Average BIC (baBIC) method. We compared the predictive accuracy (Harrell{\textquoteright}s C-statistic) and parsimony (number of predictors) of the model obtained using the baBIC method with: 1) a subset of common predictors obtained from the union of optimal models for each outcome (Union method), 2) a subset obtained from the intersection of optimal models for each outcome (Intersection method), and 3) a model with no variable selection (Full method). We used a case-study data from the Health and Retirement Study (HRS) to demonstrate our method and conducted a simulation study to investigate performance.

RESULTS: In the case-study data and simulations, the average Harrell{\textquoteright}s C-statistics across outcomes of the models obtained with the baBIC and Union methods were comparable. Despite the similar discrimination, the baBIC method produced more parsimonious models than the Union method. In contrast, the models selected with the Intersection method were the most parsimonious, but with worst predictive accuracy, and the opposite was true in the Full method. In the simulations, the baBIC method performed well by identifying many of the predictors selected in the baBIC model of the case-study data most of the time and excluding those not selected in the majority of the simulations.

CONCLUSIONS: Our method identified a common subset of variables to predict multiple clinical outcomes with superior balance between parsimony and predictive accuracy to current methods.

}, keywords = {backward elimination, Bayesian Information Criterion, prognostic models, Survival Analysis, variable selection}, issn = {1872-7565}, doi = {10.1016/j.cmpb.2021.106073}, author = {L Grisell Diaz-Ramirez and Lee, Sei J and Alexander K Smith and Gan, Siqi and W John Boscardin} } @article {11523, title = {A Novel Metric for Developing Easy-to-Use and Accurate Clinical Prediction Models: The Time-cost Information Criterion.}, journal = {Medical Care}, volume = {59}, year = {2021}, pages = {418-424}, abstract = {

BACKGROUND: Guidelines recommend that clinicians use clinical prediction models to estimate future risk to guide decisions. For example, predicted fracture risk is a major factor in the decision to initiate bisphosphonate medications. However, current methods for developing prediction models often lead to models that are accurate but difficult to use in clinical settings.

OBJECTIVE: The objective of this study was to develop and test whether a new metric that explicitly balances model accuracy with clinical usability leads to accurate, easier-to-use prediction models.

METHODS: We propose a new metric called the Time-cost Information Criterion (TCIC) that will penalize potential predictor variables that take a long time to obtain in clinical settings. To demonstrate how the TCIC can be used to develop models that are easier-to-use in clinical settings, we use data from the 2000 wave of the Health and Retirement Study (n=6311) to develop and compare time to mortality prediction models using a traditional metric (Bayesian Information Criterion or BIC) and the TCIC.

RESULTS: We found that the TCIC models utilized predictors that could be obtained more quickly than BIC models while achieving similar discrimination. For example, the TCIC identified a 7-predictor model with a total time-cost of 44 seconds, while the BIC identified a 7-predictor model with a time-cost of 119 seconds. The Harrell C-statistic of the TCIC and BIC 7-predictor models did not differ (0.7065 vs. 0.7088, P=0.11).

CONCLUSION: Accounting for the time-costs of potential predictor variables through the use of the TCIC led to the development of an easier-to-use mortality prediction model with similar discrimination.

}, keywords = {Bayesian Information Criterion, Methodology}, issn = {1537-1948}, doi = {10.1097/MLR.0000000000001510}, author = {Lee, Sei J and Alexander K Smith and Ramirez-Diaz, Ledif G and Kenneth E Covinsky and Gan, Siqi and Chen, Catherine L and W John Boscardin} } @article {10.1001/jamasurg.2020.0091, title = {Association of Functional, Cognitive, and Psychological Measures With 1-Year Mortality in Patients Undergoing Major Surgery}, journal = {JAMA Surgery}, year = {2020}, type = {Journal}, abstract = {More older adults are undergoing major surgery despite the greater risk of postoperative mortality. Although measures, such as functional, cognitive, and psychological status, are known to be crucial components of health in older persons, they are not often used in assessing the risk of adverse postoperative outcomes in older adults.To determine the association between measures of physical, cognitive, and psychological function and 1-year mortality in older adults after major surgery.Retrospective analysis of a prospective cohort study of participants 66 years or older who were enrolled in the nationally representative Health and Retirement Study and underwent 1 of 3 types of major surgery.Major surgery, including abdominal aortic aneurysm repair, coronary artery bypass graft, and colectomy.Our outcome was mortality within 1 year of major surgery. Our primary associated factors included functional, cognitive, and psychological factors: dependence in activities of daily living (ADL), dependence in instrumental ADL, inability to walk several blocks, cognitive status, and presence of depression. We adjusted for other demographic and clinical predictors.Of 1341 participants, the mean (SD) participant age was 76 (6) years, 737 (55\%) were women, 99 (7\%) underwent abdominal aortic aneurysm repair, 686 (51\%) coronary artery bypass graft, and 556 (42\%) colectomy; 223 (17\%) died within 1 year of their operation. After adjusting for age, comorbidity burden, surgical type, sex, race/ethnicity, wealth, income, and education, the following measures were significantly associated with 1-year mortality: more than 1 ADL dependence (29\% vs 13\%; adjusted hazard ratio [aHR], 2.76; P = .001), more than 1 instrumental ADL dependence (21\% vs 14\%; aHR, 1.32; P = .05), the inability to walk several blocks (17\% vs 11\%; aHR, 1.64; P = .01), dementia (21\% vs 12\%; aHR, 1.91; P = .03), and depression (19\% vs 12\%; aHR, 1.72; P = .01). The risk of 1-year mortality increased within the increasing risk factors present (0 factors: 10.0\%; 1 factor: 16.2\%; 2 factors: 27.8\%).In this older adult cohort, 223 participants (17\%) who underwent major surgery died within 1 year and poor function, cognition, and psychological well-being were significantly associated with mortality. Measures in function, cognition, and psychological well-being need to be incorporated into the preoperative assessment to enhance surgical decision-making and patient counseling.}, keywords = {Cognition, Mortality, Surgery}, issn = {2168-6254}, doi = {10.1001/jamasurg.2020.0091}, url = {https://jamanetwork.com/journals/jamasurgery/article-abstract/2762522}, author = {Victoria L. Tang and Jing, Bocheng and W John Boscardin and Ngo, Sarah and Silvestrini, Molly and Finlayson, Emily and Kenneth E Covinsky} } @article {10028, title = {Association of functional impairment in middle age with hospitalization, nursing home admission, and death}, journal = {JAMA Internal Medicine}, year = {2019}, month = {Aug-04-2019}, abstract = {Importance Difficulty performing daily activities such as bathing and dressing ({\textquotedblleft}functional impairment{\textquotedblright}) affects nearly 15\% of middle-aged adults. Older adults who develop such difficulties, often because of frailty and other age-related conditions, are at increased risk of acute care use, nursing home admission, and death. However, it is unknown if functional impairments that develop among middle-aged people, which may have different antecedents, have similar prognostic significance. Objective To determine whether middle-aged individuals who develop functional impairment are at increased risk for hospitalization, nursing home admission, and death. Design, Setting, and Participants This matched cohort study analyzed longitudinal data from the Health and Retirement Study, a nationally representative prospective cohort study of US adults. The study population included 5540 adults aged 50 to 56 years who did not have functional impairment at study entry in 1992, 1998, or 2004. Participants were followed biennially through 2014. Individuals who developed functional impairment between 50 and 64 years were matched by age, sex, and survey wave with individuals without impairment as of that age and survey wave. Statistical analysis was conducted from March 15, 2017, to December 11, 2018. Exposures Impairment in activities of daily living (ADLs), defined as self-reported difficulty performing 1 or more ADLs, and impairment in instrumental ADLs (IADLs), defined similarly. Main Outcomes and Measures The 3 primary outcomes were time from the first episode of functional impairment (or matched survey wave, in controls) to hospitalization, nursing home admission, and death. Follow-up assessments occurred every 2 years until 2014. Competing risks survival analysis was used to assess the association of functional impairment with hospitalization and nursing home admission and Cox proportional hazards regression analysis was used to assess the association with death. Results Of the 5540 study participants (2739 women and 2801 men; median age, 53.7 years [interquartile range, 52.3-55.2 years]), 1097 (19.8\%) developed ADL impairment between 50 and 64 years, and 857 (15.5\%) developed IADL impairment. Individuals with ADL impairment had an increased risk of each adverse outcome compared with those without impairment, including hospitalization (subhazard ratio, 1.97; 95\% CI, 1.77-2.19), nursing home admission (subhazard ratio, 2.62; 95\% CI, 1.99-3.45), and death (hazard ratio, 2.06; 95\% CI, 1.74-2.45). After multivariable adjustment, the risks of hospitalization (subhazard ratio, 1.54; 95\% CI, 1.36-1.75) and nursing home admission (subhazard ratio, 1.73; 95\% CI, 1.24-2.43) remained significantly higher among individuals with ADL impairment, but the risk of death was not statistically significant (hazard ratio, 1.06; 95\% CI, 0.85-1.32). Individuals with IADL impairment had an increased risk of all 3 outcomes in adjusted and unadjusted analyses. Conclusions and Relevance Similar to older adults, middle-aged adults who develop functional impairment appear to be at increased risk for adverse outcomes. Even among relatively young people, functional impairment has important clinical implications.}, keywords = {Functional limitations, Hospitalization, Mortality, Nursing homes}, issn = {2168-6106}, doi = {10.1001/jamainternmed.2019.0008}, url = {http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2019.0008http:///jamainternalmedicine/article-pdf/doi/10.1001/jamainternmed.2019.0008/17440339/jamainternal_brown_2019_oi_190001.pdf}, author = {Rebecca T Brown and L Grisell Diaz-Ramirez and W John Boscardin and Sei J. Lee and Brie A Williams and Michael A Steinman} } @article {9916, title = {Cognitive Change After Cardiac Surgery Versus Cardiac Catheterization: A Population-Based Study.}, journal = {The Annals of Thoracic Surgergy}, volume = {107}, year = {2019}, pages = {1119-1125}, abstract = {

BACKGROUND: Despite concern that cardiac surgery may adversely affect cognition, little evidence is available from population-based studies using presurgery data. With the use of the Health and Retirement Study, we compared memory change after participant-reported cardiac catheterization or cardiac surgery.

METHODS: Participants were community-dwelling adults aged 65 years and older who self-reported cardiac catheterization or "heart surgery" at any biennial Health and Retirement Study interview between 2000 and 2014. Participants may have undergone the index procedure any time in the preceding 2 years. We modeled preprocedure to postprocedure change in composite memory score, derived from objective memory testing, using linear mixed effects models. We modeled postprocedure subjective memory decline with logistic regression. To quantify clinical relevance, we used the predicted memory change to estimate impact on ability to manage medications and finances independently.

RESULTS: Of 3,105 participants, 1,921 (62\%) underwent catheterization and 1,184 (38\%) underwent operation. In adjusted analyses, surgery participants had little difference in preprocedure to postprocedure memory change compared with participants undergoing cardiac catheterization (-0.021 memory units; 95\% confidence interval:~-0.046 to 0.005 memory units, p~= 0.12). If the relationship were causal, the point estimate for memory decline would confer an absolute 0.26\% or 0.19\% decrease in ability to manage finances or medications, respectively, corresponding to 4.6 additional months of cognitive aging. Cardiac surgery was not associated with subjective memory decline (adjusted odds ratio 0.93, 95\% confidence interval: 0.74 to 1.18).

CONCLUSIONS: In this large, population-based cohort, memory declines after heart surgery and cardiac catheterization were similar. These findings suggest intermediate-term population-level adverse cognitive effects of cardiac surgery, if any, are likely subtle.

}, keywords = {Cardiac surgery, Cardiovascular disease, Cognition \& Reasoning, Memory}, issn = {1552-6259}, doi = {10.1016/j.athoracsur.2018.10.021}, author = {Elizabeth L Whitlock and L Grisell Diaz-Ramirez and Alexander K Smith and W John Boscardin and Michael S. Avidan and M. Maria Glymour} } @article {9512, title = {Chronic disease burden predicts food insecurity among older adults.}, journal = {Public Health Nutrition}, volume = {21}, year = {2018}, pages = {1737-1742}, abstract = {

OBJECTIVE: Increased out-of-pocket health-care expenditures may exert budget pressure on low-income households that leads to food insecurity. The objective of the present study was to examine whether older adults with higher chronic disease burden are at increased risk of food insecurity.

DESIGN: Secondary analysis of the 2013 Health and Retirement Study (HRS) Health Care and Nutrition Study (HCNS) linked to the 2012 nationally representative HRS.

SETTING: USA.

SUBJECTS: Respondents of the 2013 HRS HCNS with household incomes <300 \% of the federal poverty line (n 3552). Chronic disease burden was categorized by number of concurrent chronic conditions (0-1, 2-4, >=5 conditions), with multiple chronic conditions (MCC) defined as >=2 conditions.

RESULTS: The prevalence of food insecurity was 27{\textperiodcentered}8 \%. Compared with those having 0-1 conditions, respondents with MCC were significantly more likely to report food insecurity, with the adjusted odds ratio for those with 2-4 conditions being 2{\textperiodcentered}12 (95 \% CI 1{\textperiodcentered}45, 3{\textperiodcentered}09) and for those with >=5 conditions being 3{\textperiodcentered}64 (95 \% CI 2{\textperiodcentered}47, 5{\textperiodcentered}37).

CONCLUSIONS: A heavy chronic disease burden likely exerts substantial pressure on the household budgets of older adults, creating an increased risk for food insecurity. Given the high prevalence of food insecurity among older adults, screening those with MCC for food insecurity in the clinical setting may be warranted in order to refer to community food resources.

}, keywords = {Chronic conditions, Comorbidity, Food insecurity}, issn = {1475-2727}, doi = {10.1017/S1368980017004062}, author = {Jih, Jane and Stijacic-Cenzer, Irena and Hilary K Seligman and W John Boscardin and Thu T Nguyen and Christine S Ritchie} } @article {9857, title = {{\textquoteleft}Til Death Do Us Part: End-of-Life Experiences of Married Couples in a Nationally Representative Survey}, journal = {Journal of the American Geriatrics Society}, year = {2018}, month = {Jan-09-2020}, abstract = {Objectives: To determine whether end-of-life (EOL) experiences in the first spouse in a marriage are associated with EOL experiences in the other spouse. Design: Nationally representative, longitudinal survey. Setting: Health and Retirement Study, Waves 1992{\textendash}2012 linked to Medicare claims. Participants: Community-dwelling older adults who died (N=4,558), representing 2,279 married heterosexual couples. Measurements: We examined 3 EOL experiences: enrollment in hospice for >3 days before death, lack of advance care planning (ACP) before death, and intensive care unit (ICU) use during the last 30 days of life. We used multiple logistic regression to determine whether the EOL experience of the first spouse was a significant predictor of the EOL experience of the second spouse after adjusting for demographic characteristics, socioeconomic status, health status, and time between the first and second spouses{\textquoteright} deaths. Results: First spouses who died were on average 80 years old, and 62\% were male; second spouses were on average 85 years old, and 62\% were female. After adjustment, second spouses were more likely to use hospice if the first spouse used hospice (odds ratio (OR)=1.68, 95\% confidence interval (CI)=1.29{\textendash}2.20). Second spouses were less likely to have ACP when the first spouse did not have ACP (OR=2.91, 95\% CI=2.02{\textendash}4.21). Hospice and ACP associations were stronger when deaths were closer in time to one another (p-value for interaction <.05). Second spouses were more likely to use ICU services if the first spouse did (OR=1.80, 95\% CI=1.27{\textendash}2.55). Conclusions: The EOL experiences of older spouses are strongly associated, which may be relevant when framing ACP discussions. {\textcopyright} 2018, Copyright the Author Journal compilation {\textcopyright} 2018, The American Geriatrics Society }, keywords = {End of life decisions, End-of-life care, Hospice, Marriage}, doi = {10.1111/jgs.15573}, url = {http://doi.wiley.com/10.1111/jgs.15573http://onlinelibrary.wiley.com/wol1/doi/10.1111/jgs.15573/fullpdfhttps://api.wiley.com/onlinelibrary/tdm/v1/articles/10.1111\%2Fjgs.15573}, author = {Ashwin A Kotwal and Abdoler, Emily and L Grisell Diaz-Ramirez and Amy Kelley and Katherine A Ornstein and W John Boscardin and Alexander K Smith} } @article {9116, title = {Association between persistent pain and memory decline and dementia in a longitudinal cohort of elders}, journal = {JAMA Internal Medicine}, volume = {177}, year = {2017}, chapter = {1146-1153}, abstract = {Importance: Chronic pain is common among the elderly and is associated with cognitive deficits in cross-sectional studies; the population-level association between chronic pain and longitudinal cognition is unknown. Objective: To determine the population-level association between persistent pain, which may reflect chronic pain, and subsequent cognitive decline. Design, Setting, and Participants: Cohort study with biennial interviews of 10 065 community-dwelling older adults in the nationally representative Health and Retirement Study who were 62 years or older in 2000 and answered pain and cognition questions in both 1998 and 2000. Data analysis was conducted between June 24 and October 31, 2016. Exposures: {\textquotedblleft}Persistent pain,{\textquotedblright} defined as a participant reporting that he or she was often troubled with moderate or severe pain in both the 1998 and 2000 interviews. Main Outcomes and Measures: Coprimary outcomes were composite memory score and dementia probability, estimated by combining neuropsychological test results and informant and proxy interviews, which were tracked from 2000 through 2012. Linear mixed-effects models, with random slope and intercept for each participant, were used to estimate the association of persistent pain with slope of the subsequent cognitive trajectory, adjusting for demographic characteristics and comorbidities measures in 2000 and applying sampling weights to represent the 2000 US population. We hypothesized that persistent pain would predict accelerated memory decline and increased probability of dementia. To quantify the impact of persistent pain on functional independence, we combined our primary results with information on the association between memory and ability to manage medications and finances independently. Results: Of the 10,065 eligible HRS sample members, 60\% were female, and median baseline age was 73 years (interquartile range, 67-78 years). At baseline, persistent pain affected 10.9\% of participants and was associated with worse depressive symptoms and more limitations in activities of daily living. After covariate adjustment, persistent pain was associated with 9.2\% (95\% CI, 2.8\%-15.0\%) more rapid memory decline compared with those without persistent pain. After 10 years, this accelerated memory decline implied a 15.9\% higher relative risk of inability to manage medications and an 11.8\% higher relative risk of inability to manage finances independently. Adjusted dementia probability increased 7.7\% faster (95\% CI, 0.55\%-14.2\%); after 10 years, this translates to an absolute 2.2\% increase in dementia probability for those with persistent pain. Conclusions and Relevance: Persistent pain was associated with accelerated memory decline and increased probability of dementia.}, keywords = {Chronic pain, Cognitive Ability, Memory}, doi = {10.1001/jamainternmed.2017.1622}, url = {https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2629448}, author = {Elizabeth L Whitlock and L Grisell Diaz-Ramirez and M. Maria Glymour and W John Boscardin and Kenneth E Covinsky} } @article {9113, title = {Bringing functional status into a big data world: Validation of national Veterans Affairs functional status data}, journal = {PLoS One}, volume = {12}, year = {2017}, month = {Jan-06-2017}, pages = {e0178726}, abstract = {Background The ability to perform basic daily activities ({\textquotedblleft}functional status{\textquotedblright}) is key to older adults{\textquoteright} quality of life and strongly predicts health outcomes. However, data on functional status are seldom collected during routine clinical care in a way that makes them available for clinical use and research. Objectives To validate functional status data that Veterans Affairs (VA) medical centers recently started collecting during routine clinical care, compared to the same data collected in a structured research setting. Design Prospective validation study. Setting Seven VA medical centers that collected complete data on 5 activities of daily living (ADLs) and 8 instrumental activities of daily living (IADLs) from older patients attending primary care appointments. Participants Randomly selected patients aged 75 and older who had new ADL and IADL data collected during a primary care appointment (N = 252). We oversampled patients with ADL dependence and applied these sampling weights to our analyses. Measurements Telephone-based interviews using a validated measure to assess the same 5 ADLs and 8 IADLs. Results Mean age was 83 years, 96\% were male, and 75\% were white. Of 85 participants whom VA data identified as dependent in 1 or more ADLs, 74 (87\%) reported being dependent by interview; of 167 whom VA data identified as independent in ADLs, 149 (89\%) reported being independent. The sample-weighted sensitivity of the VA data for identifying ADL dependence was 45\% (95\% CI, 29\%, 62\%) compared to the reference standard, the specificity was 99\% (95\% CI, 99\%, >99\%), and the positive predictive value was 87\% (95\% CI, 79\%, 93\%). The weighted kappa statistic was 0.55 (95\% CI, 0.41, 0.68) for the agreement between VA data and research-collected data in identifying ADL dependence. Conclusion Overall agreement of VA functional status data with a reference standard was moderate, with fair sensitivity but high specificity and positive predictive value.}, keywords = {Daily activities, Functional status, Veterans}, doi = {10.1371/journal.pone.0178726 Free full text}, url = {http://dx.plos.org/10.1371/journal.pone.0178726}, author = {Rebecca T Brown and Kiya D Komaiko and Shi, Ying and Kathy Z Fung and W John Boscardin and Au-Yeung, Alvin and Tarasovsky, Gary and Jacob, Riya and Michael A Steinman}, editor = {Hernandez-Boussard, Tina} } @article {9005, title = {Difficulty managing medications and finances in older adults: A 10-year cohort study.}, journal = {Journal of the American Geriatrics Society}, volume = {65}, year = {2017}, pages = {1455-1461}, abstract = {

BACKGROUND: Difficulty managing medicines and finances becomes increasingly common with advanced age, and compromises the ability to live safely and independently. Remarkably little is known how often this occurs.

OBJECTIVES: To provide population-based estimates of the risk of developing incident difficulty managing medications and finances in older adults.

DESIGN: A prospective cohort study.

SETTING: The Health and Retirement Study (HRS), a nationally representative study of older adults.

PARTICIPANTS: 9,434 participants aged 65 and older who did not need help in managing medications or managing finances in 2002. Follow-up assessments occurred every 2 years until 2012.

MEASUREMENTS: The primary outcomes were time to difficulty managing medications and time to difficulty managing finances. Risk factors such as demographics, comorbidities, functional status, and cognitive status were assessed at baseline. Hazard models that considered the competing risk of death were used to estimate both the cumulative incidence of developing difficulty managing medications and finances and to identify potential risk factors. Analyses were adjusted for age, gender, race, marital status, wealth and education.

RESULTS: The 10 years incidence of difficulty increased markedly with age, ranging from 10.3\% (95\% CI 9.3-11.6) for managing medications and 23.1\% (95\% CI 21.6-24.7) for managing finances in those aged 65-69, to 38.2\% (95\% CI 33.4-43.5) for medicines and 69\% (95\% CI 63.7-74.3) for finances in those over age 85. Women had a higher probability of developing difficulty managing medications and managing finances than men.

CONCLUSION: This study highlights the importance of preparing older adults for the likelihood they will need assistance with managing their medicines and finances as the risk for having difficulty with these activities over time is substantial.

}, keywords = {Financial literacy, Older Adults, Prescription Medication, Risk Factors}, issn = {1532-5415}, doi = {10.1111/jgs.14819}, author = {Bleijenberg, Nienke and Sei J. Lee and Irena Cenzer and W John Boscardin and Kenneth E Covinsky} } @article {9154, title = {Functional impairment: An unmeasured marker of Medicare costs for postacute care of older adults.}, journal = {Journal of the American Geriatrics Society}, volume = {65}, year = {2017}, month = {09/2017}, pages = {1996-2002}, abstract = {

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.

}, keywords = {Functional limitations, Medicare linkage, Medicare/Medicaid/Health Insurance}, issn = {1532-5415}, doi = {10.1111/jgs.14955}, author = {S. Ryan Greysen and Irena Cenzer and W John Boscardin and Kenneth E Covinsky} } @article {9471, title = {Functional Impairment and Decline in Middle Age: A Cohort Study.}, journal = {Annals of Internal Medicine}, volume = {167}, year = {2017}, pages = {761-768}, abstract = {

Background: Difficulties with daily functioning are common in middle-aged adults. However, little is known about the epidemiology or clinical course of these problems, including the extent to which they share common features with functional impairment in older adults.

Objective: To determine the epidemiology and clinical course of functional impairment and decline in middle age.

Design: Cohort study.

Setting: The Health and Retirement Study.

Participants: 6874 community-dwelling adults aged 50 to 56 years who did not have functional impairment at enrollment.

Measurements: Impairment in activities of daily living (ADLs), defined as self-reported difficulty performing 1 or more ADLs, assessed every 2 years for a maximum follow-up of 20 years, and impairment in instrumental ADLs (IADLs), defined similarly. Data were analyzed by using multistate models that estimate probabilities of different outcomes.

Results: Impairment in ADLs developed in 22\% of participants aged 50 to 64 years, in whom further functional transitions were common. Two years after the initial impairment, 4\% (95\% CI, 3\% to 5\%) of participants had died, 9\% (CI, 8\% to 11\%) had further ADL decline, 50\% (CI, 48\% to 52\%) had persistent impairment, and 37\% (CI, 35\% to 39\%) had recovered independence. In the 10 years after the initial impairment, 16\% (CI, 14\% to 18\%) had 1 or more episodes of functional decline and 28\% (CI, 26\% to 30\%) recovered from their initial impairment and remained independent throughout this period. The pattern of findings was similar for IADLs.

Limitation: Functional status was self-reported.

Conclusion: Functional impairment and decline are common in middle age, as are transitions from impairment to independence and back again. Because functional decline in older adults has similar features, current interventions used for prevention in older adults may hold promise for those in middle age.

Primary Funding Source: National Institute on Aging and National Center for Advancing Translational Sciences through the University of California, San Francisco, Clinical and Translational Sciences Institute.

}, keywords = {Activities of Daily Living, Functional limitations, Memory, Older Adults}, issn = {1539-3704}, doi = {10.7326/M17-0496}, author = {Rebecca T Brown and L Grisell Diaz-Ramirez and W John Boscardin and Sei J. Lee and Michael A Steinman} } @article {8678, title = {Rates of Recovery to Pre-Fracture Function in Older Persons with Hip Fracture: an Observational Study.}, journal = {J Gen Intern Med}, volume = {32}, year = {2017}, month = {2017 Feb}, pages = {153-158}, abstract = {

BACKGROUND: Knowledge about expected recovery after hip fracture is essential to help patients and families set realistic expectations and plan for the future.

OBJECTIVES: To determine rates of functional recovery in older adults who sustained a hip fracture based on one{\textquoteright}s previous function.

DESIGN: Observational study.

PARTICIPANTS: We identified subjects who sustained a hip fracture while enrolled in the nationally representative Health and Retirement Study (HRS) using linked Medicare claims. HRS interviews subjects every 2~years. Using information from interviews collected during the interview preceding the fracture and the first interview 6 or more months after the fracture, we determined the proportion of subjects who returned to pre-fracture function.

MAIN MEASURES: Functional outcomes of interest were: (1) ADL dependency, (2) mobility, and (3) stair-climbing ability. We examined baseline characteristics associated with a return to: (1) ADL independence, (2) walking one block, and (3) climbing a flight of stairs.

KEY RESULTS: A total of 733 HRS subjects >=65~years of age sustained a hip fracture (mean age 84 {\textpm} 7~years, 77~\% female). Thirty-one percent returned to pre-fracture ADL function, 34~\% to pre-fracture mobility function, and 41~\% to pre-fracture climbing function. Among those who were ADL independent prior to fracture, 36~\% returned to independence, 27~\% survived but needed ADL assistance, and 37~\% died. Return to ADL independence was less likely for those >=85~years old (26~\% vs. 44~\%), with dementia (8~\% vs. 39~\%), and with a Charlson comorbidity score >2 (23~\% vs. 44~\%). Results were similar for those able to walk a block and for those able to climb a flight of stairs prior to fracture.

CONCLUSIONS: Recovery rates are low, even among those with higher levels of pre-fracture functional status, and are worse for patients who are older, cognitively impaired, and who have multiple comorbidities.

}, keywords = {Activities of Daily Living, Age Factors, Aged, Aged, 80 and over, Comorbidity, Dementia, Female, Geriatric Assessment, Hip Fractures, Humans, Longitudinal Studies, Male, Mobility Limitation, Recovery of Function, Walking}, issn = {1525-1497}, doi = {10.1007/s11606-016-3848-2}, author = {Victoria L. Tang and Rebecca L. Sudore and Irena Cenzer and W John Boscardin and Alexander K Smith and Christine S Ritchie and Margaret Wallhagen and Finlayson, Emily and Petrillo, Laura and Kenneth E Covinsky} } @article {9081, title = {Survival, functional status, and eating ability after percutaneous endoscopic gastrostomy tube placement for acute stroke}, journal = {Journal of the American Geriatrics Society}, volume = {65}, year = {2017}, pages = {1848-1852}, abstract = {

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.

}, keywords = {Gastrostomy, Palliative care, Stroke}, issn = {1532-5415}, doi = {10.1111/jgs.14908}, author = {Meisel, Karl and Robert M. Arnold and Irena Cenzer and W John Boscardin} } @article {9344, title = {Wealth-Associated Disparities in Death and Disability in the United States and England.}, journal = {JAMA Internal Medicine}, volume = {177}, year = {2017}, pages = {1745-1753}, abstract = {

Importance: Low income has been associated with poor health outcomes. Owing to retirement, wealth may be a better marker of financial resources among older adults.

Objective: To determine the association of wealth with mortality and disability among older adults in the United States and England.

Design, Setting, and Participants: The US Health and Retirement Study (HRS) and English Longitudinal Study of Aging (ELSA) are nationally representative cohorts of community-dwelling older adults. We examined 12 173 participants enrolled in HRS and 7599 enrolled in ELSA in 2002. Analyses were stratified by age (54-64 years vs 66-76 years) because many safety-net programs commence around age 65 years. Participants were followed until 2012 for mortality and disability.

Exposures: Wealth quintile, based on total net worth in 2002.

Main Outcomes and Measures: Mortality and disability, defined as difficulty performing an activity of daily living.

Results: A total of 6233 US respondents and 4325 English respondents aged 54 to 64 years (younger cohort) and 5940 US respondents and 3274 English respondents aged 66 to 76 years (older cohort) were analyzed for the mortality outcome. Slightly over half of respondents were women (HRS: 6570, 54\%; ELSA: 3974, 52\%). A higher proportion of respondents from HRS were nonwhite compared with ELSA in both the younger (14\% vs 3\%) and the older (13\% vs 3\%) age cohorts. We found increased risk of death and disability as wealth decreased. In the United States, participants aged 54 to 64 years in the lowest wealth quintile (Q1) (<=$39 000) had a 17\% mortality risk and 48\% disability risk over 10 years, whereas in the highest wealth quintile (Q5) (>$560 000) participants had a 5\% mortality risk and 15\% disability risk (mortality hazard ratio [HR], 3.3; 95\% CI, 2.0-5.6; P < .001; disability subhazard ratio [sHR], 4.0; 95\% CI, 2.9-5.6; P < .001). In England, participants aged 54 to 64 years in Q1 (<={\textsterling}34,000) had a 16\% mortality risk and 42\% disability risk over 10 years, whereas Q5 participants (>{\textsterling}310,550) had a 4\% mortality risk and 17\% disability risk (mortality HR, 4.4; 95\% CI, 2.7-7.0; P < .001; disability sHR, 3.0; 95\% CI, 2.1-4.2; P < .001). In 66- to 76-year-old participants, the absolute risks of mortality and disability were higher, but risk gradients across wealth quintiles were similar. When adjusted for sex, age, race, income, and education, HR for mortality and sHR for disability were attenuated but remained statistically significant.

Conclusions and Relevance: Low wealth was associated with death and disability in both the United States and England. This relationship was apparent from age 54 years and continued into later life. Access to health care may not attenuate wealth-associated disparities in older adults.

}, keywords = {Cross-National, Disabilities, Mortality, Wealth Inequality}, issn = {2168-6114}, doi = {10.1001/jamainternmed.2017.3903}, author = {Lena K Makaroun and Rebecca T Brown and L Grisell Diaz-Ramirez and Cyrus Ahalt and W John Boscardin and Lang-Brown, Sean and Sei J. Lee} } @article {8501, title = {One-Year Mortality After Hip Fracture: Development and Validation of a Prognostic Index.}, journal = {J Am Geriatr Soc}, volume = {64}, year = {2016}, month = {2016 09}, pages = {1863-8}, abstract = {

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.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Cause of Death, Cohort Studies, Comorbidity, Disability Evaluation, Female, Hip Fractures, Humans, Incidence, Longitudinal Studies, Male, Prognosis, Retrospective Studies, Risk Assessment, Survival Analysis, United States}, issn = {1532-5415}, doi = {10.1111/jgs.14237}, url = {http://www.ncbi.nlm.nih.gov/pubmed/27295578}, author = {Irena Cenzer and Victoria L. Tang and W John Boscardin and Christine S Ritchie and Margaret Wallhagen and Espaldon, Roxanne and Kenneth E Covinsky} } @article {8679, title = {Prevalence and Outcomes of Breathlessness in Older Adults: A National Population Study.}, journal = {J Am Geriatr Soc}, volume = {64}, year = {2016}, month = {2016 10}, pages = {2035-2041}, abstract = {

OBJECTIVES: To determine the prevalence and outcomes of breathlessness in older Americans.

SETTING: Community-dwelling older adults.

PARTICIPANTS: Individuals aged 70 and older in the nationally representative Health and Retirement Study (2008, follow-up through 2012) (N = 3,671; mean age 78).

MEASUREMENTS: Breathlessness was assessed by asking the question, "How often do you become short of breath while awake?" Responses of often or sometimes were considered to represent a level of breathlessness sufficient to warrant clinical attention. The prevalence of breathlessness is described overall and in subpopulations, then rates of associated symptoms, well-being, and health services use of participants who were breathless are compared with rates of those who were not. The risk of decline in activities of daily living (ADLs) and death through 2012 was estimated by creating a multivariable Cox proportional hazards model, adjusting for age, sex, race and ethnicity, and education.

RESULTS: Twenty-five percent of participants reported breathlessness. The prevalence of breathlessness was higher in certain subpopulations: chronic lung disease (63\%), multimorbidity (>=2 chronic conditions) (45\%), current smokers (38\%), heart disease (36\%), obesity (body mass index >=30.0 kg/m ) (33\%), and education less than high school (32\%). Breathlessness was associated with higher rates of depression, anxiety, and severe fatigue; lower ratings of well-being; and higher rates of clinic and emergency department visits and hospitalizations (all P < .001). Breathlessness predicted ADL decline over 5 years (adjusted hazard ratio (aHR) = 1.43, 95\% confidence interval (CI) = 1.22-1.68) and death (aHR 1.62, 95\% CI = 1.32-2.02).

CONCLUSION: One in four adults aged 70 and older in the United States experiences breathlessness, which is associated with lack of well-being, greater health services use, and a 40\% greater risk of worsened function and 60\% greater risk of death over the next 5 years.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Anxiety, Chronic disease, Comorbidity, depression, Dyspnea, Female, Geriatric Assessment, Hospitalization, Humans, Male, Prevalence, Proportional Hazards Models, Risk Assessment, Risk Factors, Symptom Assessment, United States}, issn = {1532-5415}, doi = {10.1111/jgs.14313}, author = {David C. Currow and Amy P Abernethy and Miriam J Johnson and Yinghui Miao and W John Boscardin and Christine S Ritchie} } @article {8506, title = {Self-Reported Hearing in the Last 2 Years of Life in Older Adults.}, journal = {J Am Geriatr Soc}, volume = {64}, year = {2016}, month = {2016 07}, pages = {1486-91}, abstract = {

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.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, California, Demography, Female, Hearing aids, Hearing loss, Humans, Longitudinal Studies, Male, Middle Aged, Prevalence, Quality of Life, Risk Factors, Self Report, Vulnerable Populations}, issn = {1532-5415}, doi = {10.1111/jgs.14145}, url = {http://www.ncbi.nlm.nih.gov/pubmed/27341383}, author = {Christine S Ritchie and Yinghui Miao and W John Boscardin and Margaret Wallhagen} } @article {8224, title = {Discrimination in Healthcare Settings is Associated with Disability in Older Adults: Health and Retirement Study, 2008-2012.}, journal = {J Gen Intern Med}, volume = {30}, year = {2015}, note = {Export Date: 29 May 2015 Article in Press}, month = {2015 Oct}, pages = {1413-20}, publisher = {30}, abstract = {

BACKGROUND: As our society ages, improving medical care for an older population will be crucial. Discrimination in healthcare may contribute to substandard experiences with the healthcare system, increasing the burden of poor health in older adults. Few studies have focused on the presence of healthcare discrimination and its effects on older adults.

OBJECTIVE: We aimed to examine the relationship between healthcare discrimination and new or worsened disability.

DESIGN: This was a longitudinal analysis of data from the nationally representative Health and Retirement Study administered in 2008 with follow-up through 2012.

PARTICIPANTS: Six thousand and seventeen adults over the age of 50 years (mean age 67 years, 56.3 \% female, 83.1 \% white) were included in this study.

MAIN MEASURES: Healthcare discrimination assessed by a 2008 report of receiving poorer service or treatment than other people by doctors or hospitals (never, less than a year=infrequent; more than once a year=frequent). Outcome was self-report of new or worsened disability by 2012 (difficulty or dependence in any of six activities of daily living). We used a Cox proportional hazards model adjusting for age, race/ethnicity, gender, net worth, education, depression, high blood pressure, diabetes, cancer, lung disease, heart disease, stroke, and healthcare utilization in the past 2 years.

KEY RESULTS: In all, 12.6 \% experienced discrimination infrequently and 5.9 \% frequently. Almost one-third of participants (29 \%) reporting frequent healthcare discrimination developed new or worsened disability over 4 years, compared to 16.8 \% of those who infrequently and 14.7 \% of those who never experienced healthcare discrimination (p < 0.001). In multivariate analyses, compared to no discrimination, frequent healthcare discrimination was associated with new or worsened disability over 4 years (aHR = 1.63, 95 \% CI 1.16-2.27).

CONCLUSIONS: One out of five adults over the age of 50 years experiences discrimination in healthcare settings. One in 17 experience frequent healthcare discrimination, and this is associated with new or worsened disability by 4 years. Future research should focus on the mechanisms by which healthcare discrimination influences disability in older adults to promote better health outcomes for an aging population.

}, keywords = {Activities of Daily Living, Aged, Ageism, Aging, Disabled Persons, Female, Follow-Up Studies, Health Status, Humans, Longitudinal Studies, Male, Middle Aged, Retirement, Surveys and Questionnaires}, issn = {1525-1497}, doi = {10.1007/s11606-015-3233-6}, url = {http://www.scopus.com/inward/record.url?eid=2-s2.0-84924662760andpartnerID=40andmd5=4aaf0227e962a58fb0e6670d3d3c6bff}, author = {Stephanie E Rogers and Angela D Thrasher and Yinghui Miao and W John Boscardin} } @article {8229, title = {Increase in Disability Prevalence Before Hip Fracture.}, journal = {J Am Geriatr Soc}, volume = {63}, year = {2015}, note = {Times Cited: 0 0}, month = {2015 Oct}, pages = {2029-35}, publisher = {63}, abstract = {

OBJECTIVES: To establish the prevalence and correlates of disability during the 2 years before hip fracture.

DESIGN: 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.

SETTING: The HRS is a nationally representative longitudinal study (1992-2010).

PARTICIPANTS: HRS participants aged >=65 with hip fracture (mean age at fracture 84, 77\% female).

RESULTS: 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\%).

CONCLUSION: 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.

}, keywords = {Activities of Daily Living, Age Factors, Aged, Aged, 80 and over, Dementia, Disability Evaluation, Disabled Persons, Educational Status, Female, Health Surveys, Hip Fractures, Humans, Income, Male, Mobility Limitation, Prevalence, United States}, issn = {1532-5415}, doi = {10.1111/jgs.13658}, author = {Irena Cenzer and W John Boscardin and Christine S Ritchie and Margaret Wallhagen and Kenneth E Covinsky} } @article {8746, title = {Subjective, Objective, and Observed Long-term Survival}, journal = {JAMA Internal Medicine}, volume = {175}, year = {2015}, month = {Jan-12-2015}, pages = {1986}, abstract = {Many professional guidelines recommend using life expectancy when considering diagnostic or treatment interventions in which the time to benefit may exceed patients{\textquoteright} survival.1 When subjected to such tests and treatments, these patients are put at risk for up-front harms with little chance of reaping benefits.2 Patients{\textquoteright} perceptions of prognosis are important. Clinicians who follow recommended guidelines may urge patients to change health routines to which they have become accustomed. Patients who underestimate their survival may choose to forego interventions that are likely to help them, while those who overestimate may choose to undergo interventions that are more likely to cause harm. However, little is known about how well older adults estimate their survival, the aim of this analysis. Methods We drew a sample of 64-, 69-, 74-, 79-, 84-, and 89-year-old participants in the 2000 wave of the Health and Retirement Study (HRS), a nationally representative, longitudinal, prospective cohort study of adults in the United States.3 Institutional review board approval for HRS was received from the University of California, San Francisco, Committee on Human Research. Informed consent was obtained by HRS at the time of the interview. Our variable of interest was participants{\textquoteright} subjective estimate of long-term survival, assessed by the question, {\textquotedblleft}What is the percent chance you will live to be x or more?{\textquotedblright} where x was 75, 80, 85, 90, 95, or 100 years old. Our sampling strategy ensured that all participants predicted survival across the same period. We calculated an objective estimate of life expectancy using the Lee life expectancy calculator.4 Observed survival was determined using mortality through 2010 (confirmed using the National Death Index). We compared participants{\textquoteright} subjective estimates to observed survival (using the C statistic) and the objective estimates (using a best-fit analysis). Participants were classified as underestimating or overestimating their survival if their estimate was more than 25 percentage points less or greater than the calculated prediction, respectively. Results A total of 2018 respondents of the specified ages were interviewed directly in the 2000 wave of the HRS, and our final sample included 1722 participants who had complete responses necessary for the calculator (56\% female, 88\% white). We combined the 84- and 89-year-olds because of the small number of respondents in each group. Overall, discrimination was moderate for participants{\textquoteright} subjective estimates of survival compared with observed survival (C statistic = 0.62; P < .001). The 64- and 69-year-olds were moderately able to estimate their survival (C statistic = 0.62 and 0.58, respectively; P < .001 for both), but older participants fared no better than chance (Table). Substantial dissimilarity was seen between participants{\textquoteright} subjective and the objective estimates of survival (Figure). Overall, 54.7\% of participants had estimates similar to the objective calculation; however, 32.7\% underestimated and 11.5\% overestimated. Underestimation was relatively similar across age groups, but overestimation increased significantly with age (Table) (P < .001). Discussion Our findings have important implications for clinicians. First, approximately half the time, participants accurately estimated survival compared with an objective clinical estimate, and when in error, they were more likely to underestimate than overestimate. Consequently, disclosing prognosis is not necessarily bad news. Second, because of the substantial dissimilarity between the subjective and objective estimates, patients may be hesitant to follow guideline recommendations to change long-standing regimens. Third, our findings make a case for using prognostic calculators, which were more accurate than participants{\textquoteright} subjective estimates and have been shown to be superior to clinician estimates.5 Fourth, participants in the HRS were willing to make an estimate of their survival and report it. Previous research suggests that older adults are generally willing to discuss long-term prognosis.6 Clinicians should solicit patients{\textquoteright} individual perception of prognosis and use this information as a starting point for further discussion, particularly among older patients who may be more prone to errors. Then, in conjunction with prognostic tools, they can begin to bridge the gap between subjective and objective estimates of survival.}, keywords = {Health Conditions and Status, Mortality, Older Adults, Self-reported health}, issn = {2168-6106}, doi = {10.1001/jamainternmed.2015.5542}, url = {http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2015.5542}, author = {Rafael D Romo and Sei J. Lee and Yinghui Miao and W John Boscardin} } @article {8119, title = {Individualizing life expectancy estimates for older adults using the Gompertz Law of Human Mortality.}, journal = {PLoS One}, volume = {9}, year = {2014}, note = {Times Cited: 0 0}, month = {2014}, pages = {e108540}, publisher = {9}, abstract = {

BACKGROUND: Guidelines recommend incorporating life expectancy (LE) into clinical decision-making for preventive interventions such as cancer screening. Previous research focused on mortality risk (e.g. 28\% at 4 years) which is more difficult to interpret than LE (e.g. 7.3 years) for both patients and clinicians. Our objective was to utilize the Gompertz Law of Human Mortality which states that mortality risk doubles in a fixed time interval to transform the Lee mortality index into a LE calculator.

METHODS: We examined community-dwelling older adults age 50 and over enrolled in the nationally representative 1998 wave of the Health and Retirement Study or HRS (response rate 81\%), dividing study respondents into development (n = 11701) and validation (n = 8009) cohorts. In the development cohort, we fit proportional hazards Gompertz survival functions for each of the risk groups defined by the Lee mortality index. We validated our LE estimates by comparing our predicted LE with observed survival in the HRS validation cohort and an external validation cohort from the 2004 wave of the English Longitudinal Study on Ageing or ELSA (n = 7042).

RESULTS: The ELSA cohort had a lower 8-year mortality risk (14\%) compared to our HRS development (23\%) and validation cohorts (25\%). Our model had good discrimination in the validation cohorts (Harrell{\textquoteright}s c 0.78 in HRS and 0.80 in the ELSA). Our predicted LE{\textquoteright}s were similar to observed survival in the HRS validation cohort without evidence of miscalibration (Hosmer-Lemeshow, p = 0.2 at 8 years). However, our predicted LE{\textquoteright}s were longer than observed survival in the ELSA cohort with evidence of miscalibration (Hosmer-Lemeshow, p<0.001 at 8 years) reflecting the lower mortality rate in ELSA.

CONCLUSION: We transformed a previously validated mortality index into a LE calculator that incorporated patient-level risk factors. Our LE calculator may help clinicians determine which preventive interventions are most appropriate for older US adults.

}, keywords = {Age Factors, Aged, Aged, 80 and over, Aging, Female, Humans, Life Expectancy, Longevity, Longitudinal Studies, Male, Middle Aged, Mortality, Proportional Hazards Models, Risk Factors}, issn = {1932-6203}, doi = {10.1371/journal.pone.0108540}, author = {Sei J. Lee and W John Boscardin and Katharine A Kirby and Kenneth E Covinsky} } @article {7821, title = {Advance care planning and the quality of end-of-life care in older adults.}, journal = {J Am Geriatr Soc}, volume = {61}, year = {2013}, note = {Times Cited: 0}, month = {2013 Feb}, pages = {209-14}, publisher = {61}, abstract = {

OBJECTIVES: To determine whether advance care planning influences quality of end-of-life care.

DESIGN: In this observational cohort study, Medicare data and survey data from the Health and Retirement Study (HRS) were combined to determine whether advance care planning was associated with quality metrics.

SETTING: The nationally representative HRS.

PARTICIPANTS: Four thousand three hundred ninety-nine decedent subjects (mean age 82.6 at death, 55\% women).

MEASUREMENTS: Advance care planning (ACP) was defined as having an advance directive (AD), durable power of attorney (DPOA) or having discussed preferences for end-of-life care with a next of kin. Outcomes included previously reported quality metrics observed during the last month of life (rates of hospital admission, in-hospital death, >14 days in the hospital, intensive care unit admission, >1 emergency department visit, hospice admission, and length of hospice <= 3 days).

RESULTS: Seventy-six percent of subjects engaged in ACP. Ninety-two percent of ADs stated a preference to prioritize comfort. After adjustment, subjects who engaged in ACP were less likely to die in a hospital (adjusted relative risk (aRR) = 0.87, 95\% confidence interval (CI) = 0.80-0.94), more likely to be enrolled in hospice (aRR = 1.68, 95\% CI = 1.43-1.97), and less likely to receive hospice for 3 days or less before death (aRR = 0.88, 95\% CI = 0.85-0.91). Having an AD, a DPOA or an ACP discussion were each independently associated with a significant increase in hospice use (P < .01 for all).

CONCLUSION: ACP was associated with improved quality of care at the end of life, including less in-hospital death and increased use of hospice. Having an AD, assigning a DPOA and conducting ACP discussions are all important elements of ACP.

}, keywords = {Adaptation, Psychological, Advance care planning, Aged, 80 and over, Female, Humans, Male, Quality of Life, Terminal Care, United States}, issn = {1532-5415}, doi = {10.1111/jgs.12105}, author = {Bischoff, Kara E and Rebecca L. Sudore and Yinghui Miao and W John Boscardin and Alexander K Smith} } @article {7789, title = {Disability during the last two years of life.}, journal = {JAMA Intern Med}, volume = {173}, year = {2013}, note = {Copyright - Copyright American Medical Association Sep 9, 2013 Last updated - 2013-09-18 SubjectsTermNotLitGenreText - United States--US}, month = {2013 Sep 09}, pages = {1506-13}, publisher = {173}, abstract = {

IMPORTANCE: Whereas many persons at advanced ages live independently and are free of disability, we know little about how likely older people are to be disabled in the basic activities of daily living that are necessary for independent living as they enter the last years of life.

OBJECTIVE: To determine national estimates of disability during the last 2 years of life.

DESIGN: Prospective cohort study.

SETTING: A nationally representative study of older adults in the United States.

PARTICIPANTS: Participants 50 years and older who died while enrolled in the Health and Retirement Study between 1995 and 2010. Each participant was interviewed once at a varying time point in the last 24 months of life. We used these interviews to calculate national estimates of the prevalence of disability across the 2 years prior to death. We modeled the prevalence of disability in the 2 years prior to death for groups defined by age at death and sex.

MAIN OUTCOMES AND MEASURES: Disability was defined as need for help with at least 1 of the following activities of daily living: dressing, bathing, eating, transferring, walking across the room, and using the toilet.

RESULTS: There were 8232 decedents (mean [SD] age at death, 79 [11] years; 52\% women). The prevalence of disability increased from 28\% (95\% CI, 24\%-31\%) 2 years before death to 56\% (95\% CI, 52\%-60\%) in the last month of life. Those who died at the oldest ages were much more likely to have disability 2 years before death (ages 50-69 years, 14\%; 70-79 years, 21\%; 80-89 years, 32\%; 90 years or more, 50\%; P for trend, <.001). Disability was more common in women 2 years before death (32\% [95\% CI, 28\%-36\%]) than men (21\% [95\% CI, 18\%-25\%]; P < .001), even after adjustment for older age at death.

CONCLUSIONS AND RELEVANCE: Those who live to an older age are likely to be disabled, and thus in need of caregiving assistance, many months or years prior to death. Women have a substantially longer period of end-of-life disability than men.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Disability Evaluation, Disabled Persons, Educational Status, Female, Frail Elderly, Humans, Income, Longitudinal Studies, Male, Marital Status, Middle Aged, Prospective Studies, Sex Distribution, Socioeconomic factors, United States}, issn = {2168-6114}, doi = {10.1001/jamainternmed.2013.8738}, author = {Alexander K Smith and Louise C Walter and Yinghui Miao and W John Boscardin and Kenneth E Covinsky} } @article {7722, title = {Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there.}, journal = {Health Aff (Millwood)}, volume = {31}, year = {2012}, month = {2012 Jun}, pages = {1277-85}, publisher = {31}, abstract = {

Emergency department use contributes to high end-of-life costs and is potentially burdensome for patients and family members. We examined emergency department use in the last months of life for patients age sixty-five or older who died while enrolled in a longitudinal study of older adults in the period 1992-2006. We found that 51 percent of the 4,158 [corrected] decedents visited the emergency department in the last month of life, and 75 percent in the last six months of life. Repeat visits were common. A total of 77 percent of the patients seen in the emergency department in the last month of life were admitted to the hospital, and 68 percent of those who were admitted died there. In contrast, patients who enrolled in hospice at least one month before death rarely visited the emergency department in the last month of life. Policies that encourage the preparation of patients and families for death and early enrollment in hospice may prevent emergency department visits at the end of life.

}, keywords = {Aged, Aged, 80 and over, Emergency Service, Hospital, Female, Hospital Mortality, Hospitalization, Humans, Insurance Claim Review, Male, Terminal Care, Terminally Ill, United States}, issn = {1544-5208}, doi = {10.1377/hlthaff.2011.0922}, author = {Alexander K Smith and Ellen P McCarthy and Ellen Weber and Irena Cenzer and W John Boscardin and Jonathan Fisher and Kenneth E Covinsky} } @article {7782, title = {Use of the Medicare Posthospitalization Skilled Nursing Benefit in the Last 6 Months of Life}, journal = {Archives of Internal Medicine}, volume = {172}, year = {2012}, note = {Copyright - Copyright American Medical Association Nov 12, 2012 Language of summary - English ProQuest ID - 1152162690 Last updated - 2012-11-16 Place of publication - Chicago Corporate institution author - Aragon, Katherine; Covinsky, Kenneth; Miao, Yinghui; Boscardin, W John, PhD; Flint, Lynn; Smith, Alexander K, MD, MS, MPH DOI - 2817091601; 73733012; 29256; AINM; INODAINM0000634121}, pages = {1573}, publisher = {172}, abstract = {In the last 6 months of life, many older adults will experience a hospitalization, followed by a transfer to a skilled nursing facility (SNF) for additional care. We sought to examine patterns of Medicare posthospitalization SNF use in the last 6 months of life. We used data from the Health and Retirement Study, a longitudinal survey of older adults, linked to Medicare claims (January 1994 through December 2007). We determined the number of individuals 65 years or older at death who had used the SNF benefit in the last 6 months of life. We report demographic, social, and clinical correlates of SNF use. We examined the relationship between place of death and hospice use for those residing in nursing homes and the community before the last 6 months of life. The mean age at death among 5163 individuals was 82.8 years; 54.5 of the cohort were female, and 23.2 had resided in a nursing home. In total, 30.5 had used the SNF benefit in the last 6 months of life, and 9.2 had died while enrolled in the SNF benefit. The use of the SNF benefit was greater among patients who were 85 years or older, had at least a high school education, did not have cancer, resided in a nursing home, used home health services, and were expected to die soon (P .01 for all). Of community dwellers who had used the SNF benefit, 42.5 died in a nursing home, 10.7 died at home, 38.8 died in the hospital, and 8.0 died elsewhere. In contrast, of community dwellers who did not use the SNF benefit, 5.3 died in a nursing home, 40.6 died at home, 44.3 died in the hospital, and 9.8 died elsewhere. Almost one-third of older adults receive care in a SNF in the last 6 months of life under the Medicare posthospitalization benefit, and 1 in 11 elders will die while enrolled in the SNF benefit. Palliative care services should be incorporated into SNF-level care.}, keywords = {Healthcare, Medicare/Medicaid/Health Insurance}, doi = {10.1001/archinternmed.2012.4451}, author = {Aragon, Katherine and Kenneth E Covinsky and Yinghui Miao and W John Boscardin and Flint, Lynn} } @article {7501, title = {The epidemiology of pain during the last 2 years of life.}, journal = {Ann Intern Med}, volume = {153}, year = {2010}, month = {2010 Nov 02}, pages = {563-9}, publisher = {153}, abstract = {

BACKGROUND: The epidemiology of pain during the last years of life has not been well described.

OBJECTIVE: To describe the prevalence and correlates of pain during the last 2 years of life.

DESIGN: Observational study. Data from participants who died while enrolled in the Health and Retirement Study were analyzed. The survey interview closest to death was used. Each participant or proxy was interviewed once in the last 24 months of life and was classified into 1 of 24 cohorts on the basis of the number of months between the interview and death. The relationship between time before death and pain was modeled and was adjusted for age, sex, race or ethnicity, education level, net worth, income, terminal diagnosis category, presence of arthritis, and proxy status.

SETTING: The Health and Retirement Study, a nationally representative survey of community-living older adults (1994 to 2006).

PARTICIPANTS: Older adult decedents.

MEASUREMENTS: Clinically significant pain, as indicated by a report that the participant was "often troubled" by pain of at least moderate severity.

RESULTS: The sample included 4703 decedents. Mean age (SD) of participants was 75.7 years (SD, 10.8); 83.1\% were white, 10.7\% were black, 4.7\% were Hispanic; and 52.3\% were men. The adjusted prevalence of pain 24 months before death was 26\% (95\% CI, 23\% to 30\%). The prevalence remained flat until 4 months before death (28\% [CI, 25\% to 32\%]), then it increased, reaching 46\% (CI, 38\% to 55\%) in the last month of life. The prevalence of pain in the last month of life was 60\% among patients with arthritis versus 26\% among patients without arthritis (P < 0.001) and did not differ by terminal diagnosis category (cancer [45\%], heart disease [48\%], frailty [50\%], sudden death [42\%], or other causes [47\%]; P = 0.195).

LIMITATION: Data are cross-sectional; 19\% of responses were from proxies; and information about cause, location, and treatment of pain was not available.

CONCLUSION: Although the prevalence of pain increases in the last 4 months of life, pain is present in more than one quarter of elderly persons during the last 2 years of life. Arthritis is strongly associated with pain at the end of life.

PRIMARY FUNDING SOURCE: National Institute on Aging, National Center for Research Resources, National Institute on Musculoskeletal and Skin Diseases, and National Palliative Care Research Center.

}, keywords = {Aged, Aged, 80 and over, Arthritis, Chronic disease, Cross-Sectional Studies, Death, Female, Humans, Male, pain, Palliative care, Prevalence, Quality of Life, Socioeconomic factors, Terminally Ill, Time Factors}, issn = {1539-3704}, doi = {10.7326/0003-4819-153-9-201011020-00005}, author = {Alexander K Smith and Irena Cenzer and Sara J Knight and Kathleen A Puntillo and Eric W Widera and Brie A Williams and W John Boscardin and Kenneth E Covinsky} } @article {7499, title = {Length of stay for older adults residing in nursing homes at the end of life.}, journal = {J Am Geriatr Soc}, volume = {58}, year = {2010}, month = {2010 Sep}, pages = {1701-6}, publisher = {58}, abstract = {

OBJECTIVES: To describe lengths of stay of nursing home decedents.

DESIGN: Retrospective cohort study.

SETTING: The Health and Retirement Study (HRS), a nationally representative survey of U.S. adults aged 50 and older.

PARTICIPANTS: One thousand eight hundred seventeen nursing home residents who died between 1992 and 2006.

MEASUREMENTS: 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.

RESULTS: The mean age of decedents was 83.3 {\textpm} 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 {\textpm} 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).

CONCLUSION: Nursing home lengths of stay are brief for the majority of decedents. Lengths of stay varied markedly according to factors related to social support.

}, keywords = {Advance care planning, Aged, Aged, 80 and over, Female, Follow-Up Studies, Humans, Length of Stay, Male, Middle Aged, Nursing homes, Palliative care, Retrospective Studies, United States}, issn = {1532-5415}, doi = {10.1111/j.1532-5415.2010.03005.x}, author = {Kelly, Anne and Conell-Price, Jessamyn and Kenneth E Covinsky and Irena Cenzer and Chang, Anna and W John Boscardin and Alexander K Smith} }