TY - JOUR T1 - Spousal Loneliness, Depression, and Closeness Among Older Adults Married to Persons with Dementia: A Nationally Representative Study (SA314B) JF - Journal of Pain and Symptom Management Y1 - 2023 A1 - Kristie Hsu A1 - Irena Cenzer A1 - Krista Harrison A1 - Christine Ritchie A1 - Linda Waite A1 - Linda Waite KW - closeness KW - depression KW - Loneliness KW - Older Adults AB - Outcomes 1. Analyze the role of marriage in serious illness and dementia 2. Discuss interactive biopsychosocial model underlying marriage and health among older adults with serious illness, and key social measures 3. Describe the prevalence of loneliness, depression, or both among spouses married to persons with dementia 4. Discuss how one's partner's cognitive decline is associated with higher levels of loneliness and depression Background Older adults married to persons with dementia (PWD) may be at risk for loneliness and depression. However, it is unclear how often each occur and the extent to which they are distinct. Research objectives To determine the prevalence of loneliness and depression among older adults married to PWD or mild cognitive impairment (MCI) and the role of marital closeness in mediating these outcomes Methods We used a nationally representative sample of 3,666 married couples enrolled in the Health and Retirement Study (2014 and 2016). We included older adults married to PWD (N=201), married to persons with MCI (N=778), or married to persons with normal cognition (N=2,687). We determined the prevalence of loneliness using multivariable logistic regression adjusting for socio-demographic characteristics, then tested for interaction between marital closeness and degree of spousal cognitive impairment. We assessed the prevalence of depression, and both loneliness and depression, using the same method. Results The sample was 54% women and on average 67 years old (Range: 50–97). After adjustment, older adults married to PWD were more likely to be lonely (Normal: 20%, MCI: 21%, PWD: 30%; p=0.02), depressed (Normal: 7%, MCI: 14%, PWD: 16%; p< 0.01), and both (Normal: 4%, MCI: 8%, PWD: 9%; p< 0.01). The association between spousal cognition and loneliness differed by marital closeness (interaction p-value=0.01); among “close” couples, spousal cognitive impairment was associated with higher likelihood of loneliness (p=0.01). In contrast, no association existed between spousal cognitive impairment and loneliness among “not close” couples (p=0.24). Conclusion Nearly 1 in 3 spouses of PWD experienced loneliness and 1 in 6 experienced depression. The association between spousal cognition and loneliness was stronger among those with close marital bonds. Implications Findings highlight substantial opportunity to identify and address loneliness and depression among spouses of PWD with close relational bonds to improve quality of life. VL - 65 ER - TY - JOUR T1 - End-of-Life Health Care Use Among Socially Isolated Older Adults with Cognitive Impairment JF - Journal of Pain and Symptom Management Y1 - 2022 A1 - Ashwin Kotwal A1 - Irena Cenzer A1 - Alexander Smith KW - cognitive impairment KW - End-of-life care KW - Medicare KW - socially isolated AB - Outcomes 1. Understand how social isolation is defined and should be considered among older adults with cognitive impairment. 2. Understand how social isolation and cognitive impairment can lead to reduced healthcare use at the end of life and the role of clinicians in addressing social needs Original Research Background At the end of life, older adults may rely on others to access healthcare, particularly if they have impaired cognition. Research Objectives To determine whether socially isolated older adults with and without cognitive impairment have different patterns of end-of-life healthcare use. Methods We used nationally representative 2006-2016 Health and Retirement Study data linked to Medicare claims to examine adults age >50 interviewed once in the last 4 years of life (N = 2,073). We measured three self-report subscales of social relationships: household contacts, social network interaction, and community engagement. The three subscales were combined to create an overall social isolation measure. End-of-life health outcomes included emergency department (ED) visits, hospitalizations, ICU stays, and hospice use in the last months of life. Cognitive impairment (CI) included CIND or dementia. We used logistic regression to test the adjusted association of each social measure with each end-of-life outcome and tested for significant interactions with CI (p < 0.1). Results Our sample had a mean age of 82 (52% female, 9% Black, 5% Hispanic, 47% had CI). There were significant interactions between social isolation or network interaction and CI for all end-of-life outcomes; social isolation was associated with lower hospice use (aOR = 0.61, p = 0.05), ED use (aOR = 0.55, p = 0.03), ICU use (aOR = 0.62, p = 0.05), and hospitalizations (aOR = 0.63, p = 0.04) for patients with CI, whereas there was no association for those with no CI (hospice, aOR = 1.1; ED, aOR = 1.1; ICU, aOR = 1.0; hospitalizations, aOR = 1.1). Conclusion Cognitively impaired older adults who were socially isolated or had reduced social network interaction had fewer ED visits, hospitalizations, ICU stays, and hospice use at the end of life. Implications for Research, Policy, or Practice Cognitively impaired, isolated older adults may struggle to access end-of-life healthcare. Further research is needed to determine whether low rates of acute care and hospice are concordant with their wishes or are due to a lack of support in accessing health services. VL - 63 IS - 5 ER - TY - JOUR T1 - Physical inactivity in older adults with cognitive impairment without dementia: room for improvement. JF - Aging Clinical and Experimental Research Y1 - 2022 A1 - Miller, Matthew J A1 - Irena Cenzer A1 - Deborah E Barnes A1 - Kenneth E Covinsky KW - cognitive impairment KW - Disability KW - Physical activity KW - Physical function AB -

BACKGROUND: Persons with cognitive impairment without dementia are at high risk of adverse health outcomes. Tailored intervention targeting moderate-vigorous physical activity (MVPA) may reduce these risks.

AIMS: To identify the prevalence and predictors of physical inactivity among older adults with cognitive impairment, no dementia (CIND); and estimate the proportion of inactive people with CIND who are capable of greater MVPA.

METHODS: We studied 1875 community dwelling participants (over age 65) with CIND in the Health and Retirement Study. Physical inactivity was defined as MVPA ≤ 1x/week. Associations of physical inactivity with sociodemographic, health, and physical function were examined using chi-square and modified Poisson regression. We considered physically inactive participants capable of greater MVPA if they reported MVPA at least 1-3x/month, no difficulty walking several blocks, or no difficulty climbing several flights of stairs.

RESULTS: Fifty-six percent of participants with CIND were physically inactive. Variables with the highest age, sex, and race/ethnicity adjusted risk ratio (ARR) for physical inactivity were self-rated health (poor [76.9%]vs. excellent [34.2%]; ARR [95% CI] 2.27 [1.56-3.30]), difficulty walking (across the room [86.5%] vs. none [40.5%]; ARR [95% CI] 2.09 [1.87-2.35]), total assets (lowest quartile [62.6%] vs. highest quartile [43.1%]; ARR [95% CI] 1.54 [1.29-1.83]), and lower education attainment (less than high school [59.6%] vs college graduate [42.8%]; ARR [95% CI] 1.46 [1.17-1.83]). Among physically inactive older adults with CIND, 61% were estimated to be capable of greater MVPA.

CONCLUSIONS: Although physical inactivity is prevalent among older adults with CIND, many are capable of greater MVPA. Developing tailored physical activity interventions for this vulnerable population may improve cognitive, health, and quality of life outcomes.

VL - 34 IS - 4 ER - TY - JOUR T1 - The epidemiology of social isolation and loneliness among older adults during the last years of life. JF - Journal of the American Geriatrics Society Y1 - 2021 A1 - Ashwin A Kotwal A1 - Irena Cenzer A1 - Linda J. Waite A1 - Kenneth E Covinsky A1 - Perissinotto, Carla M A1 - W John Boscardin A1 - Louise C Hawkley A1 - Dale, William A1 - Smith, Alexander K KW - Cognition KW - end of life KW - Loneliness KW - Palliative care KW - social isolation AB -

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.

VL - 69 IS - 11 ER - TY - JOUR T1 - Life satisfaction among older adults with impairment in activities of daily living. JF - Age and Ageing Y1 - 2021 A1 - Boccaccio, Dominic E A1 - Irena Cenzer A1 - Kenneth E Covinsky KW - Activities of Daily Living KW - functional impairment KW - Life Satisfaction AB -

BACKGROUND: Many older adults experience decline in function, but maintain high levels of life satisfaction. The factors associated with high life satisfaction among those with functional impairment are not well understood.

OBJECTIVE: Examine the proportion of older adults with functional impairment reporting high life satisfaction and the predictors of high life satisfaction.

DESIGN: Cross-sectional cohort study.

SETTING: Health and Retirement Study.

SUBJECTS: A total of 7,287 community-dwelling participants, 65 years or older, who completed the leave-behind questionnaire in 2014 or 2016.

METHODS: The main predictor was having difficulty or needing help in performing Activities of Daily Living (ADL). The primary outcome was reporting high life satisfaction, defined using a three-item Diener scale. Significant factors were identified using modified Poisson regression models adjusted for demographic characteristics.

RESULTS: Those with no ADL impairment were more likely to report high levels of life satisfaction than those with ADL difficulty or ADL dependence (54.4 vs 38.6 vs 27.6%, P < 0.001). Among those with ADL dependence, we identified several factors associated with high life satisfaction, including: not being lonely (38.2 vs 23.2%, ARR = 1.6 (1.2, 2.2)), satisfied with family life (35.1 vs 12.8%, ARR = 2.7 (1.6, 4.4)), and satisfied with financial situation (40.8 vs 16.6%, ARR = 2.5 (1.8, 3.6)). Similar associations were present among those with ADL difficulty.

CONCLUSIONS: A substantial proportion of older adults with ADL impairment report high life satisfaction, and it is associated with social and economic well-being. Understanding the factors associated with high life satisfaction can lead to clinical practices and policy guidelines that promote life satisfaction in older adults.

VL - 50 IS - 6 ER - TY - JOUR T1 - Advance Care Planning Prior to Death in Older Adults with Hip Fracture JF - Journal of General Internal Medicine Y1 - 2020 A1 - Kata, Anna A1 - Irena Cenzer A1 - Rebecca L. Sudore A1 - Kenneth E Covinsky A1 - Victoria L. Tang KW - Advance care planning KW - advance directive KW - Hip fracture KW - Older Adults KW - surrogate decision-making AB - Background Although hip fractures in older adults are associated with a high degree of mortality and disability, the use of advance care planning (ACP) in this population is unknown. Objective To determine the prevalence of ACP and need for surrogate decision-making prior to death in older adults with hip fracture and to identify factors associated with ACP. Design Retrospective cohort study using Health and Retirement Study (HRS) interviews linked to Medicare fee-for-service claims data. Participants Six hundred six decedent participants aged 65 or older who sustained a hip fracture during HRS enrollment and had a proxy participate in the exit HRS survey. Main Measures Survey responses by proxies were used to determine ACP, defined by either advance directive completion or surrogate designation, and to assess decision-making at the end of life. Multivariate logistic regression was used to analyze correlates of ACP. Key Results Prior to death, 54.9% of all participants had an advance directive and 68.9% had designated a surrogate decision-maker; however, 24.5% had no ACP. Of the total cohort, 32.5% required decisions to be made about treatment at the end of life and lacked capacity to make these decisions themselves. In this subset, 19.9% had no ACP. In all participants, ACP was less likely in non-white individuals (adjusted odds ratio (aOR) 0.14, 95% CI 0.06–0.31), those with less than a high school education (aOR 0.58, 95% CI 0.35–0.97), and those with a net worth below the median of the cohort (aOR 0.49, 95% CI 0.26–0.72). No clinical factors were found to be associated with ACP completion prior to death. Conclusions A considerable number of older adults with hip fracture required surrogate decision-making at the end of life, of whom one fifth had no ACP prior to death. Clinicians providing care for these patients are uniquely poised to address ACP. SN - 1525-1497 JO - Journal of General Internal Medicine ER - TY - THES T1 - Geriatrics principles in health care of older adults and the use of real-world data in aging-related research Y1 - 2020 A1 - Irena Cenzer KW - Aging KW - Healthcare AB - In this PhD project, we investigate how taking into consideration unique characteristics of older patients, as well as using appropriate research methods and data to study this group, would allow for better healthcare for this growing part of the population. As part of this PhD project, we performed two studies using RWDs, which examined the role of geriatric principles in care of older adults. In the first study, we used national survey of physicians to examine the use of potentially harmful first generation antihistamines in older adults. In the second study, we examined the patient relevant measures of wellbeing in older adults diagnosed with multiple myeloma using longitudinal survey and claims data. The structure of this thesis is as follows. The reminder of Section 1 contains the background on the two topics that the PhD project focuses on – geriatrics principles in health care and RWDs. In subsection 1.2. we starts with describing the geriatric principles of care, and presenting the rationale for using them in clinical care of older adults. Next, in subsection 1.3. we describe what RWDs are, and discuss their potentials and limitations in health care research. Section 2 presents the overall goal of this PhD project, as well as the detailed objectives of each of the two studies that are part of this PhD project. We summarize each study in detail in Section 3, including the methodology, main results, and the studies’ contribution to understanding the two topics of the PhD project (geriatric principles in health care and RWDs). The last subsection of Section 3, subsection 3.3., outlines the main conclusions the two PhD studies. Section 4 includes the bibliography of sources used in this PhD project. Finally, section 5 includes the two publications included in this PhD project, as they were published. PB - Ludwig Maximilian University of Munich CY - Munich VL - Doctor of Philosophy UR - https://edoc.ub.uni-muenchen.de/26876/1/Cenzer_Irena.pdf ER - TY - JOUR T1 - Patient-reported measures of well-being in older multiple myeloma patients: use of secondary data source JF - Aging Clinical and Experimental Research Y1 - 2020 A1 - Irena Cenzer A1 - Karin Berger A1 - Rodriguez, A.M. A1 - Ostermann, H. A1 - Kenneth E Covinsky AB - Background: Changes in well-being of patients with multiple myeloma (MM) before and after diagnosis have not been quantified. Aims: Explore the use of secondary data to examine the changes in the well-being of older patients with MM. Methods: We used the Health and Retirement Study (HRS), linked to Medicare claims to identify older MM patients. We compared patient-reported measures (PRM), including physical impairment, sensory impairment, and patient experience (significant pain, self-rated health, depression) in the interviews before and after MM diagnosis using McNemar’s test. We propensity-matched each MM patient to five HRS participants without MM diagnosis based on baseline characteristics. We compared the change in PRM between the MM patients and their matches. Results: We identified 92 HRS patients with MM diagnosis (mean age = 74.6, SD = 8.4). Among the surviving patients, there was a decline in well-being across most measures, including ADL difficulty (23% to 40%, p value = 0.016), poor or fair self-rated health (38% to 61%, p value = 0.004), and depression (15% to 30%, p value = 0.021). Surviving patients reported worse health than participants without MM across most measures, including ADL difficulty (40% vs. 27%, p value = 0.04), significant pain (38% vs. 22%, p value = 0.01), and depression (29% vs. 11%, p value = 0.003). Discussion: Secondary data were used to identify patients with MM diagnosis, and examine changes across multiple measures of well-being. MM diagnosis negatively affects several aspects of patients’ well-being, and these declines are larger than those experienced by similar participants without MM. Conclusion: The results of this study are valuable addition to understanding the experience of patients with MM, despite several data limitations. © 2020, The Author(s). N1 - cited By 0 ER - TY - JOUR T1 - Who Becomes a High Utilizer? A Case-Control Study of Older Adults in the USA JF - Journal of General Internal Medicine Y1 - 2020 A1 - Smith, Grant M. A1 - Irena Cenzer A1 - Kenneth E Covinsky A1 - David B. Reuben A1 - Alexander K Smith AB - Frequently hospitalized patients represent a high-cost population at risk of poor outcomes. These high-utilizers represent only 1.6% of admitted patients, but they account for 8% of admissions and 7% of direct costs.1,2 While prior studies have identified risk factors for 30-day readmissions,3 little is known about risk factors associated with patients who accrue multiple admissions over a longer period of time. Prior studies using cross-sectional analyses have also neglected to identify upstream risk factors for becoming a high-utilizer.3,4 Proactively identifying patients years before entering a cycle of frequent hospitalizations may allow for early intervention to prevent hospitalizations and improve outcomes. We sought to identify distinguishing comorbid conditions, functional limitations, and social risk factors that differentiate patients, who had 5 or more hospitalizations over a 2-year period, years before they became high-utilizers. VL - 35 SN - 1525-1497 UR - https://doi.org/10.1007/s11606-019-05331-w IS - 2 JO - Journal of General Internal Medicine ER - TY - JOUR T1 - Assessing Risk for Adverse Outcomes in Older Adults: The Need to Include Both Physical Frailty and Cognition. JF - Journal of the American Geriatrics Society Y1 - 2019 A1 - Márlon J. R. Aliberti A1 - Irena Cenzer A1 - Alexander K Smith A1 - Sei J. Lee A1 - Kristine Yaffe A1 - Kenneth E Covinsky KW - Cognition & Reasoning KW - Frailty KW - Risk Factors AB -

BACKGROUND: Physical frailty is a powerful tool for identifying nondisabled individuals at high risk of adverse outcomes. The extent to which cognitive impairment in those without dementia adds value to physical frailty in detecting high-risk individuals remains unclear.

OBJECTIVES: To estimate the effects of combining physical frailty and cognitive impairment without dementia (CIND) on the risk of basic activities of daily living (ADL) dependence and death over 8 years.

DESIGN: Prospective cohort study.

SETTING: The Health and Retirement Study (HRS).

PARTICIPANTS: A total of 7338 community-dwelling people, 65 years or older, without dementia and ADL dependence at baseline (2006-2008). Follow-up assessments occurred every 2 years until 2014.

MEASUREMENTS: The five components of the Cardiovascular Health Study defined physical frailty. A well-validated HRS method, including verbal recall, series of subtractions, and backward count task, assessed cognition. Primary outcomes were time to ADL dependence and death. Hazard models, considering death as a competing risk, associated physical frailty and CIND with outcomes after adjusting for sociodemographics, comorbidities, depression, and smoking status.

RESULTS: The prevalence of physical frailty was 15%; CIND, 19%; and both deficits, 5%. In unadjusted and adjusted analyses, combining these factors identified older adults at an escalating risk for ADL dependence (no deficit = 14% [reference group]; only CIND = 26%, sub-hazard ratio [sHR] = 1.5, 95% confidence interval [CI] = 1.3-1.8; only frail = 33%, sHR = 1.7, 95% CI = 1.4-2.0; both deficits = 46%, sHR = 2.0, 95%CI = 1.6-2.6) and death (no deficit = 21%; only CIND = 41%, HR = 1.6, 95% CI = 1.4-1.9; only frail = 56%, HR = 2.2, 95% CI = 1.7-2.7; both deficits = 66%, HR = 2.6, 95% CI = 2.0-3.3) over 8-year follow-up. Adding the cognitive measure to models that already included physical frailty alone increased accuracy in identifying those at higher risk of ADL dependence (Harrell's concordance [C], 0.74 vs 0.71; P < .001) and death (Harrell's C, 0.70 vs 0.67; P < .001).

CONCLUSION: Physical frailty and CIND are independent predictors of incident disability and death. Because together physical frailty and CIND identify vulnerable older adults better, optimal risk assessment should supplement measures of physical frailty with measures of cognitive function.

VL - 67 IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/30468258?dopt=Abstract ER - TY - JOUR T1 - Relationship Between Expectation of Death and Location of Death Varies by Race/Ethnicity. JF - American Journal of Hospital Palliative Care Y1 - 2018 A1 - Rafael D Romo A1 - Irena Cenzer A1 - Brie A Williams A1 - Alexander K Smith KW - End of life decisions KW - Mortality KW - Racial/ethnic differences KW - Subjective Expectations AB -

BACKGROUND: Older black and Latino Americans are more likely than white Americans to die in the hospital. Whether ethnic differences in expectation of death account for this disparity is unknown.

OBJECTIVES: To determine whether surviving family members' expectation of death has a differential association with site of death according to race or ethnicity.

METHODS: We conducted an analysis of decedents from the Health and Retirement Study, a nationally representative study of US older adults. Telephone surveys were conducted with family members for 5979 decedents (decedents were 55% were women, 85% white, 9% black, and 6% Latino). The outcome of interest was death in the hospital; the predictor variable was race/ethnicity, and the intervening variable was expectation of death. Covariates included sociodemographics (gender, age, household net worth, educational attainment level, religion) and health factors (chronic conditions, symptoms, health-care utilization).

RESULTS: Decedents' race/ethnicity was statistically related to the expectation of death and death in the hospital. When death was not expected, whites and Latinos were more likely to die in the hospital than when death was expected (49% vs 29% for whites and 55% vs 37% for Latinos; P < .001). There was no difference in site of death according to family's expectation of death among blacks.

CONCLUSION: Expectation of death did not fully account for site of death and played a greater role among whites and Latinos than among black Americans. Discussing prognosis by itself is unlikely to address ethnic disparities. Other factors appear to play an important role as well.

U1 - http://www.ncbi.nlm.nih.gov/pubmed/29724110?dopt=Abstract ER - TY - JOUR T1 - Difficulty managing medications and finances in older adults: A 10-year cohort study. JF - Journal of the American Geriatrics Society Y1 - 2017 A1 - Bleijenberg, Nienke A1 - Sei J. Lee A1 - Irena Cenzer A1 - W John Boscardin A1 - Kenneth E Covinsky KW - Financial literacy KW - Older Adults KW - Prescription Medication KW - Risk Factors AB -

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.

VL - 65 IS - 7 ER - TY - JOUR T1 - Functional impairment: An unmeasured marker of Medicare costs for postacute care of older adults. JF - Journal of the American Geriatrics Society Y1 - 2017 A1 - S. Ryan Greysen A1 - Irena Cenzer A1 - W John Boscardin A1 - Kenneth E Covinsky KW - Functional limitations KW - Medicare linkage KW - Medicare/Medicaid/Health Insurance AB -

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.

VL - 65 IS - 9 U1 - http://www.ncbi.nlm.nih.gov/pubmed/28636200?dopt=Abstract ER - TY - JOUR T1 - Rates of Recovery to Pre-Fracture Function in Older Persons with Hip Fracture: an Observational Study. JF - J Gen Intern Med Y1 - 2017 A1 - Victoria L. Tang A1 - Rebecca L. Sudore A1 - Irena Cenzer A1 - W John Boscardin A1 - Alexander K Smith A1 - Christine S Ritchie A1 - Margaret Wallhagen A1 - Finlayson, Emily A1 - Petrillo, Laura A1 - Kenneth E Covinsky KW - Activities of Daily Living KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Comorbidity KW - Dementia KW - Female KW - Geriatric Assessment KW - Hip Fractures KW - Humans KW - Longitudinal Studies KW - Male KW - Mobility Limitation KW - Recovery of Function KW - Walking AB -

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'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 ± 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.

VL - 32 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27605004?dopt=Abstract ER - TY - JOUR T1 - Survival, functional status, and eating ability after percutaneous endoscopic gastrostomy tube placement for acute stroke JF - Journal of the American Geriatrics Society Y1 - 2017 A1 - Meisel, Karl A1 - Robert M. Arnold A1 - Irena Cenzer A1 - W John Boscardin KW - Gastrostomy KW - Palliative care KW - Stroke AB -

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.

VL - 65 IS - 8 U1 - http://www.ncbi.nlm.nih.gov/pubmed/28449220?dopt=Abstract ER - TY - JOUR T1 - High Levels of Geriatric Palliative Care Needs in Hip Fracture Patients Before the Hip Fracture. JF - J Pain Symptom Manage Y1 - 2016 A1 - Christine S Ritchie A1 - Amy Kelley A1 - Irena Cenzer A1 - Margaret Wallhagen A1 - Kenneth E Covinsky KW - Activities of Daily Living KW - Aged, 80 and over KW - Dementia KW - depression KW - Female KW - Hip Fractures KW - Humans KW - Interviews as Topic KW - Male KW - multimorbidity KW - pain KW - Palliative care KW - Patient Acceptance of Health Care KW - Prodromal Symptoms KW - Vulnerable Populations AB -

CONTEXT: Most hip fracture care models are grounded in curative models where the goal is to return the patient to independent function. In many instances, however, hip fractures contribute to continued functional decline and mortality. Although the negative impact of hip fractures is appreciated once they have occurred, what is less understood is what proportion of older adults have high illness burden before experiencing hip fracture and might benefit from geriatric palliative care.

OBJECTIVES: Using data from the Health and Retirement Study linked to Medicare claims (January 1992 through December 2010), we sought to understand the extent of premorbid illness burden before hip fracture.

METHODS: Characteristics were based on the interview before hip fracture. Features used to indicate need for geriatric palliative care included evidence of functional and medical vulnerability, pain, and depression.

RESULTS: Eight hundred fifty-six older adults who experienced a hip fracture were compared to 851 age-, gender-, and race-matched controls. Older adults with hip fractures had significantly more premorbid functional vulnerability (activities of daily living dependent 25.7% vs. 16.1% [P < 0.001]; dementia 16.2% vs. 7.3% (P < 0.001); use of helpers 41.2% vs. 28.7% [P < 0.001]). They also experienced more medical vulnerability (multimorbidity 43% vs. 29.8% [P < 0.001]; high health care utilization 30.0% vs. 20.9% [P < 0.001]; and poor prognosis 36.1% vs. 25.4% [P < 0.001] in controls). There was no difference in premorbid pain and depression between subsequent hip fracture patients and controls.

CONCLUSIONS: A significant proportion of older adults have evidence of functional and medical vulnerability before hip fracture. For these individuals, integration of geriatric palliative care may be particularly important for optimizing quality of life and addressing the high morbidity experienced by this population.

VL - 52 UR - http://www.sciencedirect.com/science/article/pii/S0885392416302214 IS - 4 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27521282?dopt=Abstract ER - TY - JOUR T1 - One-Year Mortality After Hip Fracture: Development and Validation of a Prognostic Index. JF - J Am Geriatr Soc Y1 - 2016 A1 - Irena Cenzer A1 - Victoria L. Tang A1 - W John Boscardin A1 - Christine S Ritchie A1 - Margaret Wallhagen A1 - Espaldon, Roxanne A1 - Kenneth E Covinsky KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Cause of Death KW - Cohort Studies KW - Comorbidity KW - Disability Evaluation KW - Female KW - Hip Fractures KW - Humans KW - Incidence KW - Longitudinal Studies KW - Male KW - Prognosis KW - Retrospective Studies KW - Risk Assessment KW - Survival Analysis KW - United States AB -

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.

VL - 64 UR - http://www.ncbi.nlm.nih.gov/pubmed/27295578 IS - 9 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27295578?dopt=Abstract ER - TY - JOUR T1 - Skin Cancer in U.S. Elderly Adults: Does Life Expectancy Play a Role in Treatment Decisions? JF - J Am Geriatr Soc Y1 - 2016 A1 - Linos, Eleni A1 - Chren, Mary-Margaret A1 - Irena Cenzer A1 - Kenneth E Covinsky KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Carcinoma, Basal Cell KW - Carcinoma, Squamous Cell KW - Comorbidity KW - Cost-Benefit Analysis KW - Cross-Sectional Studies KW - Curettage KW - Decision Support Techniques KW - Disability Evaluation KW - Electrosurgery KW - Female KW - Humans KW - Keratinocytes KW - Life Expectancy KW - Male KW - Mohs Surgery KW - Prognosis KW - Skin Neoplasms AB -

OBJECTIVES: To examine whether life expectancy influences treatment pattern of nonmelanoma skin cancer, or keratinocyte carcinoma (KC), the most common malignancy and the fifth most costly cancer to Medicare.

DESIGN: Nationally representative cross-sectional study.

SETTING: Nationally representative Health and Retirement Study linked to Medicare claims.

PARTICIPANTS: Treatments (N = 9,653) from individuals aged 65 and older treated for basal or squamous cell carcinoma between 1992 and 2012 (N = 2,702) were included.

MEASUREMENTS: Limited life expectancy defined according to aged 85 and older, medical comorbidities, Charlson Comorbidity Index score of 3 or greater, difficulty in at least one activity of daily living (ADL), and a Lee index of 13 or greater. Treatment type (Mohs micrographic surgery (MMS) (most intensive, highest cost), excision, or electrodesiccation and curettage (ED&C) (least intensive, lowest cost)), according to procedure code.

RESULTS: Most KCs (61%) were treated surgically. Rates of MMS (19%), excision (42%), and ED&C (39%) were no different in participants with limited life expectancy and those with normal life expectancy. For example, 19% of participants with difficulty or dependence in ADLs, 20% of those with a Charlson comorbidity score greater than 3, and 15% of those in their last year of life underwent MMS; participants who died within 1 year of diagnosis were treated in the same way as those who lived longer.

CONCLUSION: A one-size-fits-all approach in which advanced age, health status, functional status, and prognosis are not associated with intensiveness of treatment appears to guide treatment for KC, a generally nonfatal condition. Although intensive treatment of skin cancer when it causes symptoms may be indicated regardless of life expectancy, persons with limited life expectancy should be given choices to ensure that the treatment matches their goals and preferences.

VL - 64 UR - http://www.ncbi.nlm.nih.gov/pubmed/27303932 IS - 8 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27303932?dopt=Abstract ER - TY - JOUR T1 - Functional impairment and hospital readmission in Medicare seniors. JF - JAMA Intern Med Y1 - 2015 A1 - S. Ryan Greysen A1 - Irena Cenzer A1 - Andrew D. Auerbach A1 - Kenneth E Covinsky KW - Activities of Daily Living KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Cohort Studies KW - Comorbidity KW - Female KW - Heart Failure KW - Humans KW - Income KW - Logistic Models KW - Male KW - Medicare KW - Myocardial Infarction KW - Patient Readmission KW - Pneumonia KW - Risk Assessment KW - Risk Factors KW - Sex Factors KW - United States AB -

IMPORTANCE: Medicare currently penalizes hospitals for high readmission rates for seniors but does not account for common age-related syndromes, such as functional impairment.

OBJECTIVE: To assess the effects of functional impairment on Medicare hospital readmissions given the high prevalence of functional impairments in community-dwelling seniors.

DESIGN, SETTING, AND PARTICIPANTS: We created a nationally representative cohort of 7854 community-dwelling seniors in the Health and Retirement Study, with 22,289 Medicare hospitalizations from January 1, 2000, through December 31, 2010.

MAIN OUTCOMES AND MEASURES: Outcome was 30-day readmission assessed by Medicare claims. The main predictor was functional impairment determined from the Health and Retirement Study interview preceding hospitalization, stratified into the following 5 levels: no functional impairments, difficulty with 1 or more instrumental activities of daily living, difficulty with 1 or more activities of daily living (ADL), dependency (need for help) in 1 to 2 ADLs, and dependency in 3 or more ADLs. Adjustment variables included age, race/ethnicity, sex, annual income, net worth, comorbid conditions (Elixhauser score from Medicare claims), and prior admission. We performed multivariable logistic regression to adjust for clustering at the patient level to characterize the association of functional impairments and readmission.

RESULTS: Patients had a mean (SD) age of 78.5 (7.7) years (range, 65-105 years); 58.4% were female, 84.9% were white, 89.6% reported 3 or more comorbidities, and 86.0% had 1 or more hospitalizations in the previous year. Overall, 48.3% had some level of functional impairment before admission, and 15.5% of hospitalizations were followed by readmission within 30 days. We found a progressive increase in the adjusted risk of readmission as the degree of functional impairment increased: 13.5% with no functional impairment, 14.3% with difficulty with 1 or more instrumental activities of daily living (odds ratio [OR], 1.06; 95% CI, 0.94-1.20), 14.4% with difficulty with 1 or more ADL (OR, 1.08; 95% CI, 0.96-1.21), 16.5% with dependency in 1 to 2 ADLs (OR, 1.26; 95% CI, 1.11-1.44), and 18.2% with dependency in 3 or more ADLs (OR, 1.42; 95% CI, 1.20-1.69). Subanalysis restricted to patients admitted with conditions targeted by Medicare (ie, heart failure, myocardial infarction, and pneumonia) revealed a parallel trend with larger effects for the most impaired (16.9% readmission rate for no impairment vs 25.7% for dependency in 3 or more ADLs [OR, 1.70; 95% CI, 1.04-2.78]).

CONCLUSIONS AND RELEVANCE: Functional impairment is associated with increased risk of 30-day all-cause hospital readmission in Medicare seniors, especially those admitted for heart failure, myocardial infarction, or pneumonia. Functional impairment may be an important but underaddressed factor in preventing readmissions for Medicare seniors.

PB - 175 VL - 175 IS - 4 N1 - Times Cited: 0 0 U1 - http://www.ncbi.nlm.nih.gov/pubmed/25642907?dopt=Abstract U2 - PMC4388787 U4 - Medicare/Functional impairment/hospital readmission/ADL and IADL Impairments ER - TY - JOUR T1 - Increase in Disability Prevalence Before Hip Fracture. JF - J Am Geriatr Soc Y1 - 2015 A1 - Irena Cenzer A1 - W John Boscardin A1 - Christine S Ritchie A1 - Margaret Wallhagen A1 - Kenneth E Covinsky KW - Activities of Daily Living KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Dementia KW - Disability Evaluation KW - Disabled Persons KW - Educational Status KW - Female KW - Health Surveys KW - Hip Fractures KW - Humans KW - Income KW - Male KW - Mobility Limitation KW - Prevalence KW - United States AB -

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.

PB - 63 VL - 63 IS - 10 N1 - Times Cited: 0 0 U1 - http://www.ncbi.nlm.nih.gov/pubmed/26480970?dopt=Abstract U2 - PMC4699653 U4 - medicare/ADMINISTRATIVE DATA/Disabilities/Hip Fractures/ADL/IADL ER - TY - JOUR T1 - Dysphoria and anhedonia as risk factors for disability or death in older persons: implications for the assessment of geriatric depression. JF - Am J Geriatr Psychiatry Y1 - 2014 A1 - Kenneth E Covinsky A1 - Irena Cenzer A1 - Kristine Yaffe A1 - Sarah O'Brien A1 - Dan G. Blazer KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Anhedonia KW - depression KW - Disabled Persons KW - Female KW - Humans KW - Interview, Psychological KW - Longitudinal Studies KW - Male KW - Middle Aged KW - Mortality KW - Risk Factors AB -

OBJECTIVES: Either dysphoria (sadness) or anhedonia (loss of interest in usually pleasurable activities) is required for a diagnosis of major depression. Although major depression is a known risk factor for disability in older persons, few studies have examined the relationship between the two core symptoms of major depression and disability or mortality. Our objective was to examine the relationship between these two core symptoms and time to disability or death.

METHODS: In a longitudinal cohort study, we used the nationally representative Health and Retirement Study to examine this relationship in 11,353 persons older than 62 years (mean: 73 years) followed for up to 13 years. Dysphoria and anhedonia were assessed with the Short Form Composite International Diagnostic Interview. Our outcome measure was time to either death or increased disability, defined as the new need for help in a basic activity of daily living. We adjusted for a validated disability risk index and other confounders.

RESULTS: Compared with subjects without either dysphoria or anhedonia, the risk for disability or death was not elevated in elders with dysphoria without anhedonia (adjusted hazard ratio [HR]: 1.11; 95% confidence interval [CI]: 0.91-1.36). The risk was elevated in those with anhedonia without dysphoria (HR: 1.30; 95% CI: 1.06-1.60) and those with both anhedonia and dysphoria (HR: 1.28; 95% CI: 1.13-1.46).

CONCLUSION: Our results highlight the need for clinicians to learn whether patients have lost interest in usually pleasurable activities, even if they deny sadness.

PB - 22 VL - 22 IS - 6 N1 - Times Cited: 0 U1 - http://www.ncbi.nlm.nih.gov/pubmed/23602308?dopt=Abstract U2 - PMC3766414 U4 - depression/activities of daily living/anhedonia/dysphoria/health status/quality of life ER - TY - JOUR T1 - Pain as a risk factor for disability or death. JF - J Am Geriatr Soc Y1 - 2013 A1 - James S Andrews A1 - Irena Cenzer A1 - Yelin, Edward A1 - Kenneth E Covinsky KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Cohort Studies KW - Disabled Persons KW - Female KW - Geriatric Assessment KW - Health Status KW - Humans KW - Life Style KW - Male KW - Middle Aged KW - pain KW - Prevalence KW - Prognosis KW - Prospective Studies KW - Severity of Illness Index KW - Sex Distribution KW - Sex Factors KW - United States AB -

OBJECTIVES: To determine whether pain predicts future activity of daily living (ADL) disability or death in individuals aged 60 and older.

DESIGN: Prospective cohort study.

SETTING: The 1998 to 2008 Health and Retirement Study (HRS), a nationally representative study of older community-living individuals.

PARTICIPANTS: Twelve thousand six hundred thirty-one participants in the 1998 HRS aged 60 and older who did not need help in any ADL.

MEASUREMENTS: Participants reporting that they had moderate or severe pain most of the time were defined as having significant pain. The primary outcome was time to development of ADL disability or death over 10 yrs, assessed at five successive 2-year intervals. ADL disability was defined as needing help performing any ADL: bathing, dressing, transferring, toileting, eating, or walking across a room. A discrete hazards survival model was used to examine the relationship between pain and incident disability over each 2-year interval using only participants who started the interval with no ADL disability. Several potential confounders were adjusted for at the start of each interval: demographic factors, seven chronic health conditions, and functional limitations (ADL difficulty and difficulty with five measures of mobility).

RESULTS: At baseline, 2,283 (18%) participants had significant pain. Participants with pain were more likely (all P < .001) to be female (65% vs 54%), have ADL difficulty (e.g., transferring 12% vs 2%, toileting 11% vs 2%), have difficulty walking several blocks (60% vs 21%), and have difficulty climbing one flight of stairs (40% vs 12%). Over 10 years, participants with pain were more likely to develop ADL disability or death (58% vs 43%, unadjusted hazard ratio (HR) = 1.67, 95% confidence interval (CI) = 1.57-1.79), although after adjustment for confounders, participants with pain were not at greater risk for ADL disability or death (HR = 0.98, 95% CI = 0.91-1.07). Adjustment for functional status almost entirely explained the difference between the unadjusted and adjusted results.

CONCLUSION: Although there are strong cross-sectional relationships between pain and functional limitations, individuals with pain are not at higher risk of subsequent disability or death after accounting for functional limitations. Like many geriatric syndromes, pain and disability may represent interrelated phenomena that occur simultaneously and require unified treatment paradigms.

PB - 61 VL - 61 UR - http://search.proquest.com.proxy.lib.umich.edu/docview/1356928876?accountid=14667 IS - 4 N1 - Date revised - 2013-05-01 Last updated - 2013-05-31 DOI - 0b2ff290-e53b-4073-a3d7csamfg102v; 17944301; 0002-8614; 1532-5415 SubjectsTermNotLitGenreText - Demography; Mortality; Mobility; Risk factors; Disabilities; Survival; Pain U1 - http://www.ncbi.nlm.nih.gov/pubmed/23521614?dopt=Abstract U2 - PMC3628294 U4 - Demography/Risk Abstracts/Mortality/Mobility/Risk factors/Disabilities/Survival ER - TY - JOUR T1 - Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there. JF - Health Aff (Millwood) Y1 - 2012 A1 - Alexander K Smith A1 - Ellen P McCarthy A1 - Ellen Weber A1 - Irena Cenzer A1 - W John Boscardin A1 - Jonathan Fisher A1 - Kenneth E Covinsky KW - Aged KW - Aged, 80 and over KW - Emergency Service, Hospital KW - Female KW - Hospital Mortality KW - Hospitalization KW - Humans KW - Insurance Claim Review KW - Male KW - Terminal Care KW - Terminally Ill KW - United States AB -

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.

PB - 31 VL - 31 IS - 6 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22665840?dopt=Abstract U2 - PMC3736978 U4 - elderly/Medicare/Primary Care/public policy/Health care policy/emergency department service use/emergency department service use ER - TY - JOUR T1 - How safe is your neighborhood? Perceived neighborhood safety and functional decline in older adults. JF - J Gen Intern Med Y1 - 2012 A1 - Vivien K Sun A1 - Irena Cenzer A1 - Helen Kao A1 - Cyrus Ahalt A1 - Brie A Williams KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Health Status Disparities KW - Humans KW - Longitudinal Studies KW - Male KW - Middle Aged KW - Perception KW - Residence Characteristics KW - Safety KW - Surveys and Questionnaires AB -

BACKGROUND: Neighborhood characteristics are associated with health and the perception of safety is particularly important to exercise and health among older adults. Little is known about the relationship between perception of neighborhood safety and functional decline in older adults.

OBJECTIVE: To determine the relationship between perceived neighborhood safety and functional decline in older adults.

DESIGN/SETTING: Longitudinal, community-based.

PARTICIPANTS: 18,043 persons, 50 years or older, who participated in the 1998 and 2008 Health and Retirement Study.

MAIN MEASURES: The primary outcome was 10-year functional decline (new difficulty or dependence in any Activity of Daily Living, new mobility difficulty, and/or death). The primary predictor was perceived neighborhood safety categorized into three groups: "very safe", "moderately safe", and "unsafe." We evaluated the association between perceived neighborhood safety and 10-year functional decline using a modified Poisson regression to generate unadjusted and adjusted relative risks (ARR).

KEY RESULTS: At baseline 11,742 (68.0%) participants perceived their neighborhood to be very safe, 4,477 (23.3%) moderately safe, and 1,824 (8.7%) unsafe. Over 10 years, 10,338 (53.9%) participants experienced functional decline, including 6,266 (50.2%) who had perceived their neighborhood to be very safe, 2,839 (61.2%) moderately safe, and 1,233 (63.6%) unsafe, P < 0.001. For the 11,496 (63.3%) of participants who were functionally independent at baseline, perceived neighborhood safety was associated with 10-year functional decline (moderately safe ARR 1.15 95% CI 1.09-1.20; unsafe ARR 1.21 95% CI: 1.03-1.31 compared to very safe group). The relationship between perceived neighborhood safety and 10-year functional decline was not statistically significant for participants who had baseline functional impairment.

CONCLUSION: Asking older adults about their perceived neighborhood safety may provide important information about their risk of future functional decline. These findings also suggest that future studies might focus on assessing whether interventions that promote physical activity while addressing safety concerns help reduce functional decline in older adults.

VL - 27 IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22160889?dopt=Abstract U2 - PMC3326109 U4 - neighborhood Characteristics/Safety/Functional decline/Functional decline/Activities Of Daily Living/Mobility/HEALTH ER - TY - JOUR T1 - Loneliness in older persons: a predictor of functional decline and death. JF - Arch Intern Med Y1 - 2012 A1 - Perissinotto, Carla M A1 - Irena Cenzer A1 - Kenneth E Covinsky KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Female KW - Humans KW - Loneliness KW - Longitudinal Studies KW - Male KW - Middle Aged KW - Mortality KW - United States KW - Upper Extremity KW - Walking AB -

BACKGROUND: Loneliness is a common source of distress, suffering, and impaired quality of life in older persons. We examined the relationship between loneliness, functional decline, and death in adults older than 60 years in the United States.

METHODS: This is a longitudinal cohort study of 1604 participants in the psychosocial module of the Health and Retirement Study, a nationally representative study of older persons. Baseline assessment was in 2002 and follow-up assessments occurred every 2 years until 2008. Subjects were asked if they (1) feel left out, (2) feel isolated, or (3) lack companionship. Subjects were categorized as not lonely if they responded hardly ever to all 3 questions and lonely if they responded some of the time or often to any of the 3 questions. The primary outcomes were time to death over 6 years and functional decline over 6 years on the following 4 measures: difficulty on an increased number of activities of daily living (ADL), difficulty in an increased number of upper extremity tasks, decline in mobility, or increased difficulty in stair climbing. Multivariate analyses adjusted for demographic variables, socioeconomic status, living situation, depression, and various medical conditions.

RESULTS: The mean age of subjects was 71 years. Fifty-nine percent were women; 81% were white, 11%, black, and 6%, Hispanic; and 18% lived alone. Among the elderly participants, 43% reported feeling lonely. Loneliness was associated with all outcome measures. Lonely subjects were more likely to experience decline in ADL (24.8% vs 12.5%; adjusted risk ratio [RR], 1.59; 95% CI, 1.23-2.07); develop difficulties with upper extremity tasks (41.5% vs 28.3%; adjusted RR, 1.28; 95% CI, 1.08-1.52); experience decline in mobility (38.1% vs 29.4%; adjusted RR, 1.18; 95% CI, 0.99-1.41); or experience difficulty in climbing (40.8% vs 27.9%; adjusted RR, 1.31; 95% CI, 1.10-1.57). Loneliness was associated with an increased risk of death (22.8% vs 14.2%; adjusted HR, 1.45; 95% CI, 1.11-1.88).

CONCLUSION: Among participants who were older than 60 years, loneliness was a predictor of functional decline and death.

PB - 172 VL - 172 IS - 14 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22710744?dopt=Abstract U3 - 22710744 U4 - loneliness/functional decline/functional decline/Mortality/psychosocial/Quality of Life/Multivariate Analysis ER - TY - JOUR T1 - Subjective social status and functional decline in older adults. JF - J Gen Intern Med Y1 - 2012 A1 - Bonnie Chen A1 - Kenneth E Covinsky A1 - Irena Cenzer A1 - Nancy E Adler A1 - Brie A Williams KW - Activities of Daily Living KW - Aged KW - Aging KW - Female KW - Health Status Disparities KW - Humans KW - Longitudinal Studies KW - Male KW - Middle Aged KW - Mobility Limitation KW - Risk Factors KW - Self Report KW - Social Class AB -

BACKGROUND: It is unknown whether subjective assessment of social status predicts health outcomes in older adults.

OBJECTIVE: To describe the relationship between subjective social status and functional decline in older adults.

DESIGN: Longitudinal cohort study.

SETTING: The Health and Retirement Study, a nationally representative survey of community-dwelling older adults (2004-2008).

PARTICIPANTS: Two thousand five hundred and twenty-three community-dwelling older adults.

MAIN MEASURES: Self-report of social status (SSS), categorized into three groups, reported by participants who marked a 10-rung ladder to represent where they stand in society. Four-year functional decline (new difficulty in any of five activities of daily living, mobility decline and/or death)

KEY RESULTS: Mean age was 64; 46% were male, 85% were white. At baseline, lower SSS was associated with being younger, unmarried, of nonwhite race/ethnicity, higher rates of chronic medical conditions and ADL impairment (P < 0.01). Over 4 years, 50% in the lowest SSS group declined in function, compared to the middle and highest groups (28% and 26%), P-trend <0.001. Those in the lowest rungs of SSS were at increased risk of 4-year functional decline (unadjusted RR = 1.91, CI 1.-9-2.46). The relationship between a subjective belief that one is worse off than others and functional decline persisted after serial adjustment for demographics, objective SES measures, and baseline health and functional status (RR 1.36, CI 1.08-1.73).

CONCLUSIONS: In older adults, the belief that one is in the lowest rungs of social status is a measure of socioeconomic distress and of significant risk for functional decline. These findings suggest that self-report of low subjective social status may give clinicians additional information about which older adults are at high risk for future functional decline.

VL - 27 IS - 6 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22215272?dopt=Abstract U2 - PMC3358399 U4 - health outcomes/socioeconomic Differences/social status/social status/functional decline/functional decline/ADL and IADL Impairments ER - TY - JOUR T1 - The epidemiology of pain during the last 2 years of life. JF - Ann Intern Med Y1 - 2010 A1 - Alexander K Smith A1 - Irena Cenzer A1 - Sara J Knight A1 - Kathleen A Puntillo A1 - Eric W Widera A1 - Brie A Williams A1 - W John Boscardin A1 - Kenneth E Covinsky KW - Aged KW - Aged, 80 and over KW - Arthritis KW - Chronic disease KW - Cross-Sectional Studies KW - Death KW - Female KW - Humans KW - Male KW - pain KW - Palliative care KW - Prevalence KW - Quality of Life KW - Socioeconomic factors KW - Terminally Ill KW - Time Factors AB -

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.

PB - 153 VL - 153 IS - 9 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21041575?dopt=Abstract U2 - PMC3150170 ER - TY - JOUR T1 - Length of stay for older adults residing in nursing homes at the end of life. JF - J Am Geriatr Soc Y1 - 2010 A1 - Kelly, Anne A1 - Conell-Price, Jessamyn A1 - Kenneth E Covinsky A1 - Irena Cenzer A1 - Chang, Anna A1 - W John Boscardin A1 - Alexander K Smith KW - Advance care planning KW - Aged KW - Aged, 80 and over KW - Female KW - Follow-Up Studies KW - Humans KW - Length of Stay KW - Male KW - Middle Aged KW - Nursing homes KW - Palliative care KW - Retrospective Studies KW - United States AB -

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 ± 9.0; 59.1% were female, and 81.5% were white. Median and mean length of stay before death were 5 months (interquartile range 1-20) and 13.7 ± 18.4 months, respectively. Fifty-three percent died within 6 months of placement. Large differences in median length of stay were observed according to sex (men, 3 months vs women, 8 months) and net worth (highest quartile, 3 months vs lowest quartile, 9 months) (all P <.001). These differences persisted after adjustment for age, sex, marital status, net worth, geographic region, and diagnosed chronic conditions (cancer, hypertension, diabetes mellitus, lung disease, heart disease, and stroke).

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.

PB - 58 VL - 58 IS - 9 U1 - http://www.ncbi.nlm.nih.gov/pubmed/20738438?dopt=Abstract U2 - PMC2945440 U4 - nursing Homes/MORTALITY/death/health outcomes ER -