Brian Kaskie

Long-term declines in ADLs, IADLs, and mobility among older Medicare beneficiaries

BackgroundMost prior studies have focused on short-term (≤ 2 years) functional declines. But those studies cannot address aging effects inasmuch as all participants have aged the same amount. Therefore, the authors studied the extent of long-term functional decline in older Medicare beneficiaries who were followed for varying time lengths, and the authors also identified the risk factors associated with those declines.MethodsThe analytic sample included 5,871 self- or proxy-respondents who had complete baseline and follow-up survey data that could be linked to their Medicare claims for 1993-2007. Functional status was assessed using activities of daily living (ADLs), instrumental ADLs (IADLs), and mobility limitations, with declines defined as the development of two of more new difficulties. Multiple logistic regression analysis was used to focus on the associations involving respondent status, health lifestyle, continuity of care, managed care status, health shocks, and terminal drop.ResultsThe average amount of time between the first and final interviews was 8.0 years. Declines were observed for 36.6% on ADL abilities, 32.3% on IADL abilities, and 30.9% on mobility abilities. Functional decline was more likely to occur when proxy-reports were used, and the effects of baseline function on decline were reduced when proxy-reports were used. Engaging in vigorous physical activity consistently and substantially protected against functional decline, whereas obesity, cigarette smoking, and alcohol consumption were only associated with mobility declines. Post-baseline hospitalizations were the most robust predictors of functional decline, exhibiting a dose-response effect such that the greater the average annual number of hospital episodes, the greater the likelihood of functional status decline. Participants whose final interview preceded their death by one year or less had substantially greater odds of functional status decline.ConclusionsBoth the additive and interactive (with functional status) effects of respondent status should be taken into consideration whenever proxy-reports are used. Encouraging exercise could broadly reduce the risk of functional decline across all three outcomes, although interventions encouraging weight reduction and smoking cessation would only affect mobility declines. Reducing hospitalization and re-hospitalization rates could also broadly reduce the risk of functional decline across all three outcomes.

Improving the Mental Health of Older Adults

Publisher Summary This chapter analyzed evidence for the effectiveness of psychological interventions with older adults, the importance of ethnic diversity issues in mental health and aging within the population of dementia caregivers, and the influence of public policies on the accessibility of mental health services for older adults. The aging of the population worldwide suggests that older adults will become a larger part of the client populations for professional psychologists. Also, successive generations of American adults have higher prevalence of mental disorders, suggesting that future cohorts of older adults will have a higher need for psychological services. Older adults have more positive attitudes toward mental health services than younger adults, and rate psychological treatments as more credible and acceptable than drug therapy for the treatment of depression. The presumed widespread negativity of mental health professionals toward older adults was either exaggerated from the beginning or has changed over time.

Defining emergency department episodes by severity and intensity: A 15-year study of Medicare beneficiaries

BackgroundEpisodes of Emergency Department (ED) service use among older adults previously have not been constructed, or evaluated as multi-dimensional phenomena. In this study, we constructed episodes of ED service use among a cohort of older adults over a 15-year observation period, measured the episodes by severity and intensity, and compared these measures in predicting subsequent hospitalization.MethodsWe conducted a secondary analysis of the prospective cohort study entitled the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD). Baseline (1993) data on 5,511 self-respondents ≥70 years old were linked to their Medicare claims for 1991-2005. Claims then were organized into episodes of ED care according to Medicare guidelines. The severity of ED episodes was measured with a modified-NYU algorithm using ICD9-CM diagnoses, and the intensity of the episodes was measured using CPT codes. Measures were evaluated against subsequent hospitalization to estimate comparative predictive validity.ResultsOver 15 years, three-fourths (4,171) of the 5,511 AHEAD participants had at least 1 ED episode, with a mean of 4.5 episodes. Cross-classification indicated the modified-NYU severity measure and the CPT-based intensity measure captured different aspects of ED episodes (kappa = 0.18). While both measures were significant independent predictors of hospital admission from ED episodes, the CPT measure had substantially higher predictive validity than the modified-NYU measure (AORs 5.70 vs. 3.31; p < .001).ConclusionsWe demonstrated an innovative approach for how claims data can be used to construct episodes of ED care among a sample of older adults. We also determined that the modified-NYU measure of severity and the CPT measure of intensity tap different aspects of ED episodes, and that both measures were predictive of subsequent hospitalization.

Chiropractic Episodes and the Co-Occurrence of Chiropractic and Health Services Use Among Older Medicare Beneficiaries

OBJECTIVE The purpose of this study was to define and characterize episodes of chiropractic care among older Medicare beneficiaries and to evaluate the extent to which chiropractic services were used in tandem with conventional medicine. METHODS Medicare Part B claims histories for 1991 to 2007 were linked to the nationally representative survey on Assets and Health Dynamics among the Oldest Old baseline interviews (1993-1994) to define episodes of chiropractic sensitive care using 4 approaches. Chiropractic and nonchiropractic patterns of service use were examined within these episodes of care. Of the 7447 Assets and Health Dynamics among the Oldest Old participants, 971 used chiropractic services and constituted the analytic sample. RESULTS There were substantial variations in the number and duration of episodes and the type and volume of services used across the 4 definitions. Depending on how the episode was constructed, the mean number of episodes per chiropractic user ranged from 3.74 to 23.12, the mean episode duration ranged from 4.7 to 28.8 days, the mean number of chiropractic visits per episode ranged from 0.88 to 2.8, and the percentage of episodes with co-occurrent use of chiropractic and nonchiropractic providers ranged from 4.9% to 10.9% over the 17-year period. CONCLUSION Treatment for back-related musculoskeletal conditions was sought from a variety of providers, but there was little co-occurrent service use or coordinated care across provider types within care episodes. Chiropractic treatment dosing patterns in everyday practice were much lower than that used in clinical trial protocols designed to establish chiropractic efficacy for back-related conditions.

The Growing Shortage of Vascular Neurologists in The Era of Health Reform Planning is Brain

The incidence of stroke has surpassed 800 000 cases each year, and acute stroke has become the leading cause of disability in the United States. Given that a person’s chronological age is a primary risk factor,1 and the United States will be experiencing exponential growth in the elderly population over the next 20 years, the incidence of stroke will grow substantially and the demand for dedicated stroke care will increase accordingly.2 In this report, we consider contemporary evidence-based practices for stroke care, the supply of vascular neurologists (VNs) and neurointerventionalists (NIs), potential causes for the supply–demand imbalance, and solutions aimed to increasing the supply of VNs within the ongoing healthcare reform effort. Evidence-based practices for stroke include medical interventions applicable to every patient and invasive endovascular interventions applicable only to a smaller subset of qualified patients. One of the most common evidence-based medical approaches for treating acute stroke includes use of recombinant tissue plasminogen activator in eligible patients given within 4.5 hours of when they were last seen normal,3 a treatment that is delivered most effectively within dedicated acute care stroke units with established clinical pathways for secondary prevention and management.4 In 2003, the Primary Stroke Center Certification program of the Joint Commission initiated an effort to increase the number of units with expertise in delivering evidence-based medical stroke care.5 A key component of these units is a stroke team, offering 24/7 coverage by physicians with advanced knowledge of evaluating and treating acute vascular diseases and who are able to recommend best emergent and preventive management.6 It has since become best practice in stroke treatment and management7 to incorporate these stroke units within a regional hub and spoke network in which the unit (ie, the hub) supports satellite clinics with video-based telemedicine8 …

Promoting a "good death": determinants of pain-management policies in the United States.

Many Americans do not experience a good death. The inadequate treatment of pain at the end of life has been associated with a lack of supportive public policies more than a lack of evidence-based clinical practices or organizational efforts. Given a widespread lack of understanding about pain policies, we examine the critical role played by state medical boards in developing pain policies and then apply event history analysis to identify the variables most critical to the formation of these policies. We develop an integrated model and evaluate the adoption of eight different types of pain policies. The analytic models incorporate fifteen years of observational data and test the impact of contextual, political, extrinsic, and institutional variables. They reveal that the presence of legal counselors on state medical boards has consistently increased the likelihood that state boards adopt policies associated with progressive pain management. Further, policy has been negatively influenced by historical activity: boards that previously adopted one pain policy have been less likely to subsequently adopt additional pain policies. This work illuminates mechanisms behind state pain-policy adoption and provides valuable information for advocates who seek to improve pain-management policy and reduce the amount of pain at the end of life.

Older adults who persistently present to the emergency department with severe, non-severe, and indeterminate episode patterns.

BackgroundIt is well known that older adults figure prominently in the use of emergency departments (ED) across the United States. Previous research has differentiated ED visits by levels of clinical severity and found health status and other individual characteristics distinguished severe from non-severe visits. In this research, we classified older adults into population groups that persistently present with severe, non-severe, or indeterminate patterns of ED episodes. We then contrasted the three groups using a comprehensive set of covariates.MethodsUsing a unique dataset linking individual characteristics with Medicare claims for calendar years 1991-2007, we identified patterns of ED use among the large, nationally representative AHEAD sample consisting of 5,510 older adults. We then classified one group of older adults who persistently presented to the ED with clinically severe episodes and another group who persistently presented to the ED with non-severe episodes. These two groups were contrasted using logistic regression, and then contrasted against a third group with a persistent pattern of ED episodes with indeterminate levels of severity using multinomial logistic regression. Variable selection was based on Andersens behavioral model of health services use and featured clinical status, demographic and socioeconomic characteristics, health behaviors, health service use patterns, local health care supply, and other contextual effects.ResultsWe identified 948 individuals (17.2% of the entire sample) who presented a pattern in which their ED episodes were typically defined as severe and 1,076 individuals (19.5%) who typically presented with non-severe episodes. Individuals who persistently presented to the ED with severe episodes were more likely to be older (AOR 1.52), men (AOR 1.28), current smokers (AOR 1.60), experience diabetes (AOR (AOR 1.80), heart disease (AOR 1.70), hypertension (AOR 1.32) and have a greater amount of morbidity (AOR 1.48) than those who persistently presented to the ED with non-severe episodes. When contrasted with 1,177 individuals with a persistent pattern of indeterminate severity ED use, persons with severe patterns were older (AOR 1.36), more likely to be obese (AOR 1.36), and experience heart disease (AOR 1.49) and hypertension (AOR 1.36) while persons with non-severe patterns were less likely to smoke (AOR 0.63) and have diabetes (AOR 0.67) or lung disease (AOR 0.58).ConclusionsWe distinguished three large, readily identifiable groups of older adults which figure prominently in the use of EDs across the United States. Our results suggest that one group affects the general capacity of the ED to provide care as they persistently present with severe episodes requiring urgent staff attention and greater resource allocation. Another group persistently presents with non-severe episodes and creates a considerable share of the excess demand for ED care. Future research should determine how chronic disease management programs and varied co-payment obligations might impact the use of the ED by these two large and distinct groups of older adults with consistent ED use patterns.

Prior Hospitalization and the Risk of Heart Attack in Older Adults: A 12-Year Prospective Study of Medicare Beneficiaries

BACKGROUND We investigated whether prior hospitalization was a risk factor for heart attacks among older adults in the survey on Assets and Health Dynamics among the Oldest Old. METHODS Baseline (1993-1994) interview data were linked to 1993-2005 Medicare claims for 5,511 self-respondents aged 70 years and older and not enrolled in managed Medicare. Primary hospital International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) 410.xx discharge codes identified postbaseline hospitalizations for acute myocardial infarctions (AMIs). Participants were censored at death or postbaseline managed Medicare enrollment. Traditional risk factors and other covariates were included. Recent postbaseline non-AMI hospitalizations (ie, prior hospitalizations) were indicated by a time-dependent marker, and sensitivity analyses identified their peak effect. RESULTS The total number of person-years of surveillance was 44,740 with a mean of 8.1 (median = 9.1) per person. Overall, 483 participants (8.8%) suffered postbaseline heart attacks, with 423 participants (7.7%) having their first-ever AMI. As expected, significant traditional risk factors were sex (men); race (whites); marital status (never being married); education (noncollege); geography (living in the South); and reporting a baseline history of angina, arthritis, diabetes, and heart disease. Risk factors were similar for both any postbaseline and first-ever postbaseline AMI analyses. The time-dependent recent non-AMI hospitalization marker did not alter the effects of the traditional risk factors but increased AMI risk by 366% (adjusted hazards ratio = 4.66, p < .0001). Discussion. Our results suggest that some small percentage (<3%) of heart attacks among older adults might be prevented if effective short-term postdischarge planning and monitoring interventions were developed and implemented.

A prospective cohort study of long-term cognitive changes in older Medicare beneficiaries

BackgroundPromoting cognitive health and preventing its decline are longstanding public health goals, but long-term changes in cognitive function are not well-documented. Therefore, we first examined long-term changes in cognitive function among older Medicare beneficiaries in the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD), and then we identified the risk factors associated with those changes in cognitive function.MethodsWe conducted a secondary analysis of a prospective, population-based cohort using baseline (1993-1994) interview data linked to 1993-2007 Medicare claims to examine cognitive function at the final follow-up interview which occurred between 1995-1996 and 2006-2007. Besides traditional risk factors (i.e., aging, age, race, and education) and adjustment for baseline cognitive function, we considered the reason for censoring (entrance into managed care or death), and post-baseline continuity of care and major health shocks (hospital episodes). Residual change score multiple linear regression analysis was used to predict cognitive function at the final follow-up using data from telephone interviews among 3,021 to 4,251 (sample size varied by cognitive outcome) baseline community-dwelling self-respondents that were ≥ 70 years old, not in managed Medicare, and had at least one follow-up interview as self-respondents. Cognitive function was assessed using the 7-item Telephone Interview for Cognitive Status (TICS-7; general mental status), and the 10-item immediate and delayed (episodic memory) word recall tests.ResultsMean changes in the number of correct responses on the TICS-7, and 10-item immediate and delayed word recall tests were -0.33, -0.75, and -0.78, with 43.6%, 54.9%, and 52.3% declining and 25.4%, 20.8%, and 22.9% unchanged. The main and most consistent risks for declining cognitive function were the baseline values of cognitive function (reflecting substantial regression to the mean), aging (a strong linear pattern of increased decline associated with greater aging, but with diminishing marginal returns), older age at baseline, dying before the end of the study period, lower education, and minority status.ConclusionsIn addition to aging, age, minority status, and low education, substantial and differential risks for cognitive change were associated with sooner vs. later subsequent death that help to clarify the terminal drop hypothesis. No readily modifiable protective factors were identified.

The Academy Is Aging in Place: Assessing Alternatives for Modifying Institutions of Higher Education

Institutions of higher education employ a greater proportion of persons over 65 relative to the general labor force, and the median age of the professorate has now surpassed all other occupational groups. Such a novel demographic change in the academic workforce presents several unique challenges. Should institutions modify policies and programs that provide more opportunities for aging faculty to remain healthy and productive, or should efforts focus on facilitating retirement? How universities and colleges choose to retain or retire their aging faculty certainly has become a point for consideration. This forum presents what is known about the aging academic workforce and describes current institutional responses. The discussion then builds on the notion of aging in place, presenting a more holistic approach to the modification of institutional policies and programs that support continued faculty engagement as well as mutually agreeable retirements. In particular, institutions should consider making modifications that increase targeted health and wellness programs, expand retirement counseling services, and offer varied retirement pathway options as viable responses to the continued aging of the academic workforce.