Caroline S. Blaum

Geriatric conditions and disability: the Health and Retirement Study.

Context Geriatric conditions, such as incontinence and falling, are prevalent and associated with disability in older adults. Contribution Using national survey data, the authors found that almost half of older U.S. adults had geriatric conditions. Some were as prevalent as common conditions, such as heart disease. The authors confirmed a strong association between having a geriatric condition and dependency in activities of daily living. Caution Conditions and dependence were identified by self-report. Implications Geriatric conditions are often overlooked in older adults, but they are as common as other chronic diseases and are as strongly associated with disability. The Editors Geriatric conditions, such as incontinence and falling, fall outside the traditional disease model of clinical medicine and thus may be overlooked in the care of older adults (1). Yet, these conditions are a necessary focus for geriatricians in their management of patients. A recent American Geriatrics Society statement includes expertise in the diagnosis and care of geriatric conditions among its core attributes and competencies (2). Although certain geriatric conditions have been studied extensively, the aggregate effect of those conditions on health and disability in the older adult population has not been investigated. One obstacle is the lack of consensus on the definition of a geriatric condition or geriatric syndrome (35). Citing an early edition of the Geriatrics Review Syllabus and drawing on other sources (6), Flacker (7) noted that geriatric syndromes are understood to have the following features: They occur in older, especially vulnerable, adults; are multifactorial in cause; are precipitated by a variety of acute insults; are typically episodic in nature; and are often followed by functional decline. This lack of consensus on the definitions leads to variation in what is considered a geriatric condition or geriatric syndrome (4, 5). For instance, there is consensus that cognitive impairment, falls, incontinence, and delirium are geriatric syndromes, but less agreement that malnutrition and neglect and abuse also qualify. In this paper, we use the term geriatric condition and include all conditions for which survey data were available. Use of the term geriatric condition, to indicate a collection of symptoms and signs common in older adults not necessarily related to a specific disease, avoids the ambiguity associated with the term syndrome (2). We examined the association, both individually and in aggregate, between geriatric conditions and dependency in activities of daily living (ADLs) in older Americans. We used nationally representative data that include information on geriatric conditions, chronic diseases, disability, and demographic characteristics. We hypothesized that having 1 or more geriatric conditions is strongly associated with ADL dependency, independent of prevalent diseases. Methods Data We obtained data from the 2000 wave of the Health and Retirement Study (HRS), a biennial longitudinal health interview survey of a cohort of adults age 50 years or older in the United States. Sponsored by the National Institute on Aging and performed by the Institute for Social Research at the University of Michigan, the HRS is designed to study health transitions among older adults (8, 9). Of the 19580 HRS respondents interviewed in 2000, we identified 11093 respondents age 65 years or older, who represented 34.5 million U.S. adults in this age group in that year. The HRS investigators interviewed sampled respondents and their spouses. When the eligible respondent could not be interviewed, often because of medical or cognitive problems, a proxy (n= 1392)frequently the spouse (n= 698)was enlisted to answer questions for that respondent. The HRS was approved by the Behavioral Sciences Committee institutional review board at the University of Michigan. The data used for this analysis are publicly available and contain no unique identifiers, thus ensuring respondent anonymity. Variables and Their Measurement Geriatric Conditions The 2000 wave assessed self-reported information on 7 geriatric conditions and their activity or severity. We used survey data on the following geriatric conditions in their active or severe forms: 1) falls resulting in injury; 2) incontinence requiring use of pads or other absorbent undergarments; 3) low body mass index (BMI) (<18.5 kg/m2, based on self-reported height and weight); 4) dizziness (dizziness or lightheadedness as a persistent or troublesome problem); 5) vision impairment (fair or poor eyesight despite use of corrective lenses); 6) hearing impairment (fair or poor hearing despite use of hearing aids); and 7) cognitive impairment. The HRS assesses for cognitive impairment by 1 of 2 means. For self-respondents, cognitive impairment is determined by using a performance-based measurea modified version of the Telephone Interview for Cognitive Status, which is a validated cognitive screening instrument patterned on the Mini-Mental State Examination (10) and is specifically designed for population-based studies. We defined severe cognitive impairment as a score of 8 or less on the 35-point cognitive scale. This cut-point has previously been used by researchers because the proportion of people that it identifies as having serious cognitive impairment is consistent with other estimates of the prevalence of dementia (1113). Detailed information on the cognitive measures that make up the modified Telephone Interview for Cognitive Status is available on the HRS Web site (hrsonline.isr.umich.edu/docs/userg/dr-006.pdf). Respondents unable to complete the survey interview were assigned proxy respondents by a trained interviewer according to study protocol. Each proxy was asked to assess the respondents memory. Respondents reported to have fair or poor memory were considered to have severe cognitive impairment (13). Disability Of the traditional ADLs (14), we included bathing, dressing, eating, toileting, and transferring in our analysis but excluded continence, because we considered incontinence to be a geriatric condition. Our definition of ADL dependency required respondents to both have difficulty with and receive assistance for the task. Difficulty included the inability to perform the task because of a health or memory problem. Chronic Diseases We considered the following diseases surveyed in the HRS to be chronic: heart disease, chronic lung disease, diabetes, cancer, musculoskeletal conditions, stroke, and psychiatric problems. Respondents reported whether a physician had diagnosed each disease. Questions about the diseases included those indicating their activity or severity (for example, receiving treatment). We limited each chronic disease to its active or severe form. Because our dependent variable was ADL dependency, we tried to avoid activity or severity constraints that were inherently functional in nature (15). For example, musculoskeletal conditions included arthritis requiring medication or other treatment and/or joint replacement in the past 2 years and/or hip fracture in the past 2 years. We limited stroke to persons who required medication for stroke (or its complications) or had remaining problems (such as weakness in arms or legs and difficulty speaking or swallowing). Demographic Factors Demographic variables were age, sex, race (white, African American, other), marital status (married, unmarried), educational attainment, and net financial worth (total household assets minus current debt) (8). Statistical Analysis We used multivariate logistic regression modeling to examine the association between geriatric conditions (numbers of conditions/individual conditions) and the probability of having 1 or more ADL dependencies. Then, we sequentially introduced groups of variables into the model, first demographic variables and then chronic disease variables, because these are known to be associated with ADL dependencies. We used variance inflation factors to investigate and rule out multicollinearity among the independent variables. We obtained estimates of risk ratios from the logistic models. We then used bootstrapping to produce the CIs; we performed the bootstrapping by resampling at the primary sampling unit for the bootstrapping (16). The dependent variables for each model are: any ADL dependency (model 1) and each particular ADL dependency (models 2 to 6). The independent variables for each model are the 7 geriatric conditions. Each model controlled for 6 demographic characteristics and the 7 chronic diseases. Regression diagnostics performed on our initial unweighted models suggested that the logistic regression models were a reasonable fit for our data and that the models evaluating groups of geriatric conditions and groups of diseases showed the best fits. We systematically tested interactions between the independent variables. Those that were considered clinically significant were not statistically significant (for example, vision impairment and hearing impairment), and those that were statistically significant we did not consider to be clinically significant (for example, falls and lung disease). Therefore, we did not include these terms in the final model. To adjust for the complex sample design of the HRS, the differential probability of selection, and nonresponse, all analyses were weighted and adjusted by using the Stata statistical package (release 8.0; Stata, College Station, Texas); thus, we could take advantage of the nationally representative data set to produce national population estimates. Role of the Funding Sources This study was supported by grants from the John A. Hartford Foundation and the National Institute on Aging and by the Ann Arbor Veterans Affairs Geriatric Research, Education and Clinical Center. The funding sources had no role in the design, conduct, or analysis of the study or in the decision to submit the manuscript for publication. Results Ta

Nonlinear Multisystem Physiological Dysregulation Associated With Frailty in Older Women: Implications for Etiology and Treatment

BACKGROUND Frailty in older adults, defined as a constellation of signs and symptoms, is associated with abnormal levels in individual physiological systems. We tested the hypothesis that it is the critical mass of physiological systems abnormal that is associated with frailty, over and above the status of each individual system, and that the relationship is nonlinear. METHODS Using data on women aged 70-79 years from the Womens Health and Aging Studies I and II, multiple analytic approaches assessed the cross-sectional association of frailty with eight physiological measures. RESULTS Abnormality in each system (anemia, inflammation, insulin-like growth factor-1, dehydroepiandrosterone-sulfate, hemoglobin A1c, micronutrients, adiposity, and fine motor speed) was significantly associated with frailty status. However, adjusting for the level of each system measure, the mean number of systems impaired significantly and nonlinearly predicted frailty. Those with three or more systems impaired were most likely to be frail, with odds of frailty increasing with number of systems at abnormal level, from odds ratios (ORs) of 4.8 to 11 to 26 for those with one to two, three to four, and five or more systems abnormal (p < .05 for all). Finally, two subgroups were identified, one with isolated or no systems abnormal and a second (in 30%) with multiple systems abnormal. The latter group was independently associated with being frail (OR = 2.6, p < .05), adjusting for confounders and chronic diseases and then controlling for individual systems. CONCLUSIONS Overall, these findings indicate that the likelihood of frailty increases nonlinearly in relationship to the number of physiological systems abnormal, and the number of abnormal systems is more predictive than the individual abnormal system. These findings support theories that aggregate loss of complexity, with aging, in physiological systems is an important cause of frailty. Implications are that a threshold loss of complexity, as indicated by number of systems abnormal, may undermine homeostatic adaptive capacity, leading to the development of frailty and its associated risk for subsequent adverse outcomes. It further suggests that replacement of any one deficient system may not be sufficient to prevent or ameliorate frailty.

Examining the Evidence: A Systematic Review of the Inclusion and Analysis of Older Adults in Randomized Controlled Trials

ABSTRACTBACKGROUNDDue to a shortage of studies focusing on older adults, clinicians and policy makers frequently rely on clinical trials of the general population to provide supportive evidence for treating complex, older patients.OBJECTIVESTo examine the inclusion and analysis of complex, older adults in randomized controlled trials.REVIEW METHODSA PubMed search identified phase III or IV randomized controlled trials published in 2007 in JAMA, NEJM, Lancet, Circulation, and BMJ. Therapeutic interventions that assessed major morbidity or mortality in adults were included. For each study, age eligibility, average age of study population, primary and secondary outcomes, exclusion criteria, and the frequency, characteristics, and methodology of age-specific subgroup analyses were reviewed.RESULTSOf the 109 clinical trials reviewed in full, 22 (20.2%) excluded patients above a specified age. Almost half (45.6%) of the remaining trials excluded individuals using criteria that could disproportionately impact older adults. Only one in four trials (26.6%) examined outcomes that are considered highly relevant to older adults, such as health status or quality of life. Of the 42 (38.5%) trials that performed an age-specific subgroup analysis, fewer than half examined potential confounders of differential treatment effects by age, such as comorbidities or risk of primary outcome. Trials with age-specific subgroup analyses were more likely than those without to be multicenter trials (97.6% vs. 79.1%, p < 0.01) and funded by industry (83.3% vs. 62.7%, p < 0.05). Differential benefit by age was found in seven trials (16.7%).CONCLUSIONClinical trial evidence guiding treatment of complex, older adults could be improved by eliminating upper age limits for study inclusion, by reducing the use of eligibility criteria that disproportionately affect multimorbid older patients, by evaluating outcomes that are highly relevant to older individuals, and by encouraging adherence to recommended analytic methods for evaluating differential treatment effects by age.

Comparing Models of Frailty: The Health and Retirement Study

OBJECTIVES: To operationalize and compare three models of frailty, each representing a distinct theoretical view of frailty: as deficiencies in function (Functional Domains model), as an index of health burden (Burden model), and as a biological syndrome (Biologic Syndrome model).

The Co‐Occurrence of Chronic Diseases and Geriatric Syndromes: The Health and Retirement Study

OBJECTIVES: To analyze the co‐occurrence, in adults aged 65 and older, of five conditions that are highly prevalent, lead to substantial morbidity, and have evidence‐based guidelines for management and well‐developed measures of medical care quality.

Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society

Disclosure Information: Disclosures for the members of t Geriatrics Society Postoperative Delirium Panel are listed in Support: Supported by a grant from the John A Hartford Fou to the Geriatrics-for-Specialists Initiative of the American Geri (grant 2009-0079). This article is a supplement to the American Geriatrics Soci Practice Guidelines for Postoperative Delirium in Older Adu at the American College of Surgeons 100 Annual Clinic San Francisco, CA, October 2014.

American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults

The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 American Geriatrics Society (AGS) Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at the website of the AGS. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium in older adults; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium in older adults. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate‐to‐high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines, Delirium: Diagnosis, Prevention and Management. Clinical Guideline 103; London (UK): 2010 July 29). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety and improve outcomes.

Characteristics Related to Poor Glycemic Control in NIDDM Patients in Community Practice

OBJECTIVE To identify clinical characteristics related to poor glycemic control in patients with NIDDM cared for by Michigan primary care physicians. RESEARCH DESIGN AND METHODS This study was a cross-sectional secondary analysis of data from 393 NIDDM patients (mean age, 63 ± 11 years; 54% female; 92% white) in the 1990–1991 Michigan Diabetes in Communities II Study. We evaluated patient demographic, clinical, and physiological characteristics, attitudes toward diabetes, and self-care ability. Logistic regression was used for multivariate evaluation of the characteristics of those patients whose glycosylated hemoglobin (normal GHb 4–8%) was in the upper 25% of the study sample (GHb > 11.6%). RESULTS A high meal-stimulated plasma C-peptide was associated with a lower likelihood of poor control (odds ratio [OR] for highest quartile vs. all others = 0.37; 95% CI 0.23-0.58). Longer time since diagnosis (OR for each 5 years duration = 1.28; 95% CI 1.07-1.53), poor self-care ability (OR = 1.85; 95% CI 1.27-2.71), and perceived absence of dietary recommendations (OR = 2.37; 95% CI 1.11–5.08) were also independently associated with presence in the highest GHb quartile. Characteristics that were not significantly related to poor glycemic control included sex, age, obesity, educational level, exercise, self-rated health status, and pharmacological treatment. CONCLUSIONS 1) Poor glycemic control may reflect progressive failure of islet function, although the independent relationships of C-peptide level and time since diagnosis are consistent with concepts of heterogeneous mechanisms underlying NIDDM. 2) Despite the important relationships of biological characteristics of NIDDM to glycemic control, patient attitudes and self-care ability may be useful targets for designing management strategies for certain poorly controlled patients.

Functional Status and Health Outcomes in Older Americans with Diabetes Mellitus

OBJECTIVES: To determine how baseline functional status affects health outcomes in older adults with diabetes mellitus (DM).

Carotenoid and vitamin E status are associated with indicators of sarcopenia among older women living in the community.

Background and aims: Oxidative stress may play a role in the pathogenesis of sarcopenia, and the relationship between dietary antioxidants and sarcopenia needs further elucidation. The aim was to determine whether dietary carotenoids and α-tocopherol are associated with sarcopenia, as indicated by low grip, hip, and knee strength. Methods: Cross-sectional analyses were conducted on 669 non-disabled to severely disabled community-dwelling women aged 70 to 79 who participated in the Women’s Health and Aging Studies. Plasma carotenoids and a-tocopherol were measured. Grip, hip, and knee strength were measured, and low strength was defined as the lowest tertile of each strength measure. Results: Higher plasma concentrations of α-carotene, β-carotene, β-cryptoxanthin, and lutein/zeaxanthin were associated with reduced risk of low grip, hip, and knee strength. After adjusting for potential confounding factors such as age, race, smoking, cardiovascular disease, arthritis, and plasma interleukin-6 concentrations, there was an independent association for women in the highest compared with the lowest quartile of total carotenoids with low grip strength [Odds Ratios (OR) 0.34, 95% Confidence Interval (CI) 0.20-0.59], low hip strength (OR 0.28, 95% CI 0.16-0.48), and low knee strength (OR 0.45, 95% CI 0.27-0.75), and there was an independent association for women in the highest compared with the lowest quartile of α-tocopherol with low grip strength (OR 0.44, 95% CI 0.24-0.78) and low knee strength (OR 0.52, 95% CI 0.29-0.95). Conclusions: Higher carotenoid and α-tocopherol status were independently associated with higher strength measures. These data support the hypothesis that oxidative stress is associated with sarcopenia in older adults, but further longitudinal and interventional studies are needed to establish causality.