@article {11981, title = {Association of Social Support With Functional Outcomes in Older Adults Who Live Alone.}, journal = {JAMA Internal Medicine}, volume = {182}, year = {2022}, pages = {26-32}, abstract = {

Importance: Older adults who live alone are at risk for poor health outcomes. Whether social support mitigates the risk of living alone, particularly when facing a sudden change in health, has not been adequately reported.

Objective: To assess if identifiable support buffers the vulnerability of a health shock while living alone.

Design, Setting, and Participants: In this longitudinal, prospective, nationally representative cohort study from the Health and Retirement Study (enrollment March 2006 to April 2015), 4772 community-dwelling older adults 65 years or older who lived alone in the community and could complete activities of daily living (ADLs) and instrumental ADLs independently were followed up biennially through April 2018. Statistical analysis was completed from May 2020 to March 2021.

Exposures: Identifiable support (ie, can the participant identify a relative/friend who could help with personal care if needed), health shock (ie, hospitalization, new diagnosis of cancer, stroke, heart attack), and interaction (multiplicative and additive) between the 2 exposures.

Main Outcomes and Measures: The primary outcomes were incident ADL dependency, prolonged nursing home stay (>=30 days), and death.

Results: Of 4772 older adults (median [IQR] age, 73 [68-81] years; 3398 [71\%] women) who lived alone, at baseline, 1813 (38\%) could not identify support, and 3013 (63\%) experienced a health shock during the study. Support was associated with a lower risk of a prolonged nursing home stay at 2 years (predicted probability, 6.7\% vs 5.2\%; P = .002). Absent a health shock, support was not associated with a prolonged nursing home stay (predicted probability over 2 years, 1.9\% vs 1.4\%; P = .21). However, in the presence of a health shock, support was associated with a lower risk of a prolonged nursing home stay (predicted probability over 2 years, 14.2\% vs 10.9\%; P = .002). Support was not associated with incident ADL dependence or death.

Conclusions and Relevance: In this longitudinal cohort study among older adults who live alone, identifiable support was associated with a lower risk of a prolonged nursing home stay in the setting of a health shock.

}, keywords = {health outcomes, Social Support}, issn = {2168-6114}, doi = {10.1001/jamainternmed.2021.6588}, author = {Sachin J Shah and Margaret C Fang and Wannier, S Rae and Michael A Steinman and Kenneth E Covinsky} } @article {11117, title = {Geriatric Syndromes and Atrial Fibrillation: Prevalence and Association with Anticoagulant Use in a National Cohort of Older Americans.}, journal = {Journal of the American Geriatrics Society}, volume = {69}, year = {2021}, pages = {349-356}, abstract = {

BACKGROUND: Although guidelines recommend focusing primarily on stroke risk to recommend anticoagulants in atrial fibrillation (AF), physicians report that geriatric syndromes (e.g., falls and disability) are important when considering anticoagulants. Little is known about the prevalence of geriatric syndromes in older adults with AF or the association with anticoagulant use.

METHODS: We performed a cross-sectional analysis of the 2014 Health and Retirement Study, a nationally representative study of older Americans. Participants were asked questions to assess domains of aging, including function, cognition, and medical conditions. We included participants 65 years and older with 2 years of continuous Medicare enrollment who met AF diagnosis criteria by claims codes. We examined five geriatric syndromes: one or more falls within the last 2 years, receiving help with activities of daily living (ADLs) or instrumental ADLs (IADL), experienced incontinence, and cognitive impairment. We determined the prevalence of geriatric syndromes and their association with anticoagulant use, adjusting for ischemic stroke risk (i.e., CHA DS -VASc score [congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, and sex]).

RESULTS: In this study of 779 participants with AF (median age = 80 years; median CHA DS -VASc score = 4), 82\% had one or more geriatric syndromes. Geriatric syndromes were common: 49\% reported falls, 38\% had ADL impairments, 42\% had IADL impairments, 37\% had cognitive impairments, and 43\% reported incontinence. Overall, 65\% reported anticoagulant use; guidelines recommend anticoagulant use for 97\% of participants. Anticoagulant use rate decreased for each additional geriatric syndrome (average marginal effect = -3.7\%; 95\% confidence interval = -1.4\% to -5.9\%). Lower rates of anticoagulant use were reported in participants with ADL dependency, IADL dependency, and dementia.

CONCLUSION: Most older adults with AF had at least one geriatric syndrome, and geriatric syndromes were associated with reduced anticoagulant use. The high prevalence of geriatric syndromes may explain the lower than expected anticoagulant use in older adults.

}, keywords = {anticoagulants, Atrial Fibrillation, Epidemiology, geriatric syndromes}, issn = {1532-5415}, doi = {10.1111/jgs.16822}, author = {Sachin J Shah and Margaret C Fang and Sun Y Jeon and Gregorich, Steven E and Kenneth E Covinsky} } @article {11992, title = {Long-Term Functional Outcomes in Older Adults After Hospitalization for Extracranial Hemorrhage}, journal = {Circulation}, volume = {144}, year = {2021}, pages = {A10778}, abstract = {Introduction: Antiplatelet and anticoagulant medications often used to manage cardiovascular disease increase the risk of extracranial hemorrhage (ECH), such as gastrointestinal bleeding. There are few long-term data on the loss of function following ECH. This study{\textquoteright}s goal was to measure the acute and persistent loss of independence in activities of daily living (ADLs) after ECH hospitalization. Methods: We used data from 1995-2015 from the Health and Retirement Study, a longitudinal, nationally representative survey of older Americans. We included subjects over age 65 who consented to Medicare linkage. We examined the association of ECH hospitalization with ability to perform all ADLs independently (walk across a room, dress, bathe, eat, toilet, get out of bed). To compare rates of ADL independence over time between those with ECH and a control group without ECH, we fit a logistic regression model that included an interaction term between ECH hospitalization and time and adjusted for comorbidities and sociodemographics. Results: In a cohort of 8950 with an average follow-up time of 7.3 years (65,335 person-years), 882 (10\%) participants were hospitalized for ECH. Mean age was 78, and 59\% were women. In the control group without ECH, the baseline rate of ADL independence declined by an average of 3.1\% per year (average marginal effect [AME], 95\% CI -3.1\% to -3.3\%). Assuming hospitalization for ECH at 5.2 years, the median time to ECH in this cohort, ECH was associated with an immediate decrease in ADL independence from 68\% to 53\% (AME -15\%, 95\% CI -11\% to -18\%). Following ECH, the average annual baseline rate of function loss did not change. Conclusions: In this nationally representative cohort, ECH hospitalization was associated with an immediate and pronounced decline in function that was equivalent to accelerating ADL disability by 5 years. After ECH, ADL independence continued to decline and did not recover to pre-ECH levels of independence over time.}, keywords = {anticoagulation, antiplatelet drugs, hemorrhage}, doi = {10.1161/circ.144.suppl_1.10778}, author = {Anna L Parks and Sun Y Jeon and John J Boscardin and Michael A Steinman and Alexander K Smith and Margaret C Fang and Kenneth E Covinsky and Sachin J Shah} } @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} }