Carla Perissinotto

Loneliness in Older Persons: A Predictor of Functional Decline and Death

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.

Living Alone, Socially Isolated or Lonely—What are We Measuring?

M any older adults live alone. For example, in the United States, over 45 % of women over the age of 75 years live alone. Much attention has been placed on older adults who are living alone, because of the recent studies that have shown that both loneliness and social isolation are associated with poor health outcomes. These studies have also suggested that living alone is not necessarily indicative of having poor social support or of feeling lonely. While it may be reasonable to believe that living alone is a good proxy for these types of social measures, there is increasing recognition that the measures of social well-being are complex concepts and go beyond simply describing the situational facts of a person’s life. In actuality, social isolation and loneliness are complex self-perceptions that may not be fully captured by whether or not someone lives alone. This demands that as clinicians, we must dig deeper into a patient’s personal perspective. For example, measures of loneliness go beyond just asking about whether a person has social contacts, but also ask about the subjective feeling of feeling left out, isolated or not belonging. Accordingly, this raises the question of whether we should consider living alone as a risk factor for poor health outcomes and if this risk is adequately measured by asking if a patient lives alone, or if we must concomitantly include composite measures of social isolation and loneliness. In this issue of JGIM, Ennis et al. report on the association of living alone with hospitalization in community-dwelling elders. In this retrospective longitudinal cohort study, Ennis et al. followed 2,636 participants over 65 years of age from the Adults Changes in Thought (ACT) study for an average of 8.4 years. The main measures examined included hospitalization for all causes and for ambulatory care sensitive conditions (ACSCs). After adjusting for several factors, the authors concluded that living alone was associated with a lower risk for all-cause (OR=0.76; 95 % CI 0.61, 0.94), but not ACSC hospitalization. The authors also concluded that dementia did not modify any of their findings. Asking about living alone may be a useful starting point for understanding an individual’s social support. However, when placed in the context of studies that have shown detrimental effects of social isolation and loneliness, Ennis’ findings imply that this question alone does not offer a complete picture of an individual’s social milieu. This study by Ennis et al. is one of several recent studies attempting to clarify the intricacies of social support—a term that may encompass some or all of the concepts of living alone, loneliness, and social isolation. While some studies approach the experience of social isolation as unidimensional and describe it as the lack of interaction with social contacts, others have developed composite measures that incorporate both the quality and quantity of social relationships. These inconsistencies in terminology and methodology can make it difficult to understand what is actually being measured and the significance of the conclusions reached. This challenge of understanding exactly what is being measured when older adults are described as living alone is apparent in this study. In addition to asking whether patients lived alone, the authors also used a composite measure of social support, (the Interpersonal Support Evaluation List or ISEL), which provides a global measure of perceived social support across four domains (belonging, self-esteem, appraisal, and tangible help). Since the ISEL measure includes the concepts of social isolation and loneliness together, it is difficult to determine whether these factors individually had an effect on the risk of hospitalization. The authors found that subjects who lived alone scored slightly lower on the social support measure than those living with others, but the absolute difference was strikingly small. Yet, it is clear that many persons who live alone have effective social support, while many who live with others have poor social support. In our research on the effects of loneliness on functional decline and death, we found a remarkably similar relationship between living alone and loneliness. While those who lived alone were more likely to report loneliness, many who live alone are not lonely and many who live with others still feel lonely. Living alone by itself is clearly an insufficient measure of social well-being and connectivity. The significant limitations of living alone as a measure of social support is probably a major reason why Ennis et al. did not find that living alone was a risk factor for hospitalization. Another difficulty in examining the association of living alone with health outcomes is the possibility of confounding by functional status. Older persons often choose to move in with family or others when they develop functional impairments that make independent living difficult. These Published online August 5, 2014

The Importance of Cognitive Assessment Before Ventricular Device Placement A Teachable Moment

Opinion TEACHABLE MOMENT Stephanie E. Rogers, MD, MS, MPH, PA Department of Geriatrics, University of California, San Francisco. Liviu Klein, MD, MS Division of Cardiology, University of California, San Francisco. Carla Maria Perissinotto, MD, MHS Department of Geriatrics, University of California, San Francisco. Corresponding Author: Stephanie E. Rogers, MD, MS, MPH, PA, Department of Geriatrics, University of California, San Francisco, 4150 Clement St, 181G, San Francisco, CA 94121 (stephanie.rogers @ucsf.edu). LESS IS MORE The Importance of Cognitive Assessment Before Ventricular Device Placement A Teachable Moment Story From the Front Lines A 76-year-old man with systolic heart failure presented to the advanced heart failure service after optimal medi- cal management including biventricular pacing failed to improve his symptoms. A left ventricular assist device (LVAD) as destination therapy was offered to the pa- tient after he was determined not to be a transplant can- didate owing to advanced age. The risks and benefits of such a device were discussed with the patient and his family. Although the family had noticed some subtle hints of changes in his memory, such as repeating questions, word-finding difficulties, and missing appointments, these issues were not brought to the attention of the medical team, nor were they evident during multiple clinical encounters. Formal cognitive testing was not documented. The patient and his family opted to proceed with LVAD placement, which improved the patient’s heart fail- ure symptoms. However, his postoperative course was complicated by worsening behavioral outbursts, wan- dering and getting lost, locking himself in a room (re- quiring a locksmith), and, most distressing, multiple at- tempts at pulling out his heart pump driveline and disconnecting the batteries. Formal neuropsychiatric testing revealed a diagnosis of long-standing demen- tia. The family had difficulty caring for him at home, and placement in a facility was difficult owing to the reluc- tance of any facility to undertake the complex manage- ment of an LVAD, especially in a patient who was unco- operative and confused. Teachable Moment Recent studies have shown that as many as 81% of patients who meet the criteria for dementia never have a formal diagnosis. 1 Spontaneous detection by physi- cians less accurately classifies a patient with dementia than a brief, structured, cognitive assessment tool. 2 The present case illustrates an example of how failing to formally assess older adults for cognitive impairment Published Online: March 30, 2015. doi:10.1001/jamainternmed.2015.0468. Conflict of Interest Disclosures: None reported. 1. Cordell CB, Borson S, Boustani M, et al; Medicare Detection of Cognitive Impairment Workgroup. Alzheimer’s Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimers Dement. 2013;9(2):141-150. doi:10.1016/j.jalz.2012.09.011. before a procedure can lead to unintended harms or outcomes. A diagnosis of cognitive impairment or dementia can help clinicians anticipate how a patient may tolerate or adhere to the requirements of a recom- mended therapy and in turn allow patients and families a better understanding of the risks and benefits of an intervention. The American College of Surgeons and the Ameri- can Geriatrics Society recently published their Best Practices Guidelines, 3 which included a recommenda- tion to preoperatively assess for cognitive impairment in any patient older than 65 years without a known history of cognitive impairment or dementia. Demen- tia is the strongest risk factor for the development of postoperative delirium, 4 and cognitive impairment is also associated with an increased risk of perioperative mortality, worse surgical outcomes, longer hospital stays, increased risk of postoperative functional decline, 3 and increased postdischarge institution- alization. 4 In light of this, identifying individuals with cognitive impairment before an intervention is critical to allow a more comprehensive discussion of risks and benefits. As a result of this case, the formal LVAD evalua- tion at our institution now includes routine cognitive testing using the Montreal Cognitive Assessment test even in asymptomatic patients. If they score 21 or lower of a possible 30, formal neuropsychiatric testing is performed to further evaluate. During the first year of implementation of this new process, 3 previously undetected cases of considerable cognitive impair- ment (likely to interfere with the patients’ ability to properly care for and use the LVAD) were detected through routine testing, and these patients did not undergo the intervention. This formal cognitive assessment now guides the consent process, allows families and medical teams to make better-informed decisions, and may help prevent unintended harms or outcomes. 2. Borson S, Scanlan JM, Watanabe J, Tu S-P, Lessig M. Improving identification of cognitive impairment in primary care. Int J Geriatr Psychiatry. 2006;21 (4):349-355. doi:10.1002/gps.1470. Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012;215(4):453-466. doi:10.1016/j .jamcollsurg.2012.06.017. 3. Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF; American College of Surgeons National Surgical Quality Improvement Program; American Geriatrics Society. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of 4. Robinson TN, Raeburn CD, Tran ZV, Angles EM, Brenner LA, Moss M. Postoperative delirium in the elderly: risk factors and outcomes. Ann Surg. 2009; 249(1):173-178. doi:10.1097/SLA.0b013e31818e4776. JAMA Internal Medicine June 2015 Volume 175, Number 6 (Reprinted) Copyright 2015 American Medical Association. All rights reserved. Downloaded From: http://archinte.jamanetwork.com/ by a UCSF LIBRARY User on 06/30/2015 jamainternalmedicine.com

A Quality of Care Framework for Home-Based Medical Care

More than 6 million adults in the United States are homebound or semi-homebound and would benefit from home-based medical care (HBMC). There is currently no nationally recognized quality of care framework for home-based medical care. We sought to capture diverse stakeholder perspectives on the essential aspects of quality HBMC and create a quality of care framework for homebound adults. A qualitative analysis of semistructured interviews from purposive sampling of key HBMC stakeholders was performed. Leaders from 12 exemplar HBMC practices (clinicians and administrators), advocacy groups (American Association of Retired Persons, National Partnership for Women and Families, Kaiser Family Foundation), and representatives from 3 key professional medical societies associated with HBMC participated in phone interviews. Semistructured interviews were based on domains of quality developed by the National Quality Forum (NQF) for individuals with multiple chronic conditions. We identified 3 categories of quality HBMC: provider and practice activities; provider characteristics; and outcomes for patients, caregivers, and providers. Within these 3 categories, we identified 10 domains and 49 standards for quality HBMC. These included 3 new domains (comprehensive assessment, patient/caregiver education, and provider competency) as well as specification and adaptation of the NQF Framework for Multiple Chronic Conditions domains for HBMC. Notably, several quality domains emanating from the NQF Framework for Multiple Chronic Conditions (transitions, access, and patient/caregiver engagement) were applicable to HBMC. This quality of care framework serves as a guide for HBMC practices seeking to improve their care quality and as a starting point for health systems and payers to ensure value from HBMC practices with whom they work.