Catherine A. Sarkisian

Guidelines for improving the care of the older person with diabetes mellitus.

BACKGROUND AND SIGNIFICANCE iabetes mellitus (DM) is highly prevalent and increasing in persons aged 65 and older, particularly among racial and ethnic minorities. Estimates have placed the proportion of adults aged 65 to 74 with physician-diagnosed DM at nearly 25% in some ethnic groups. 1 Estimates from the Centers for Disease Control and Prevention indicate that, in 1998, 12.7% of persons aged 70 and older had a diagnosis of DM, up from 11.6% in 1990. 2 There are also large numbers of older adults, almost 11% of the U.S. population aged 60 to 74, with undiagnosed DM. 1 Older persons with DM have higher rates of premature death, functional disability, and coexisting illnesses such as hypertension, coronary heart disease (CHD), and stroke 3,4 than do those without DM. Older adults with DM are also at greater risk than other older persons for several common geriatric syndromes, such as depression, 5,6 cognitive impairment, 7 urinary incontinence, 8 injurious falls, 9–11 and persistent pain. 12,13 Although there are numerous evidence-based guidelines for DM, few guidelines are specifically targeted toward the needs of older persons 14 and help clinicians prioritize care for the heterogeneous population of older adults they may see in their practices. Moreover, the main emphasis of most DM guidelines is on intensive blood glucose control and prevention of microvascular complications. Although control of hyperglycemia is important, in older persons with DM, greater reduction in morbidity and mortality may result from control of cardiovascular risk factors than from tight glycemic control. Additionally, little is known about how well providers of health care for older persons with DM adhere to recommendations for the screening and treatment of common geriatric syndromes, such as depression, injurious falls, urinary incontinence, cognitive impairment, chronic pain, and polypharmacy, which are more prevalent with DM and may significantly influence quality of life. Although interventions to reduce the incidence of geriatric syndromes and to ameliorate their symptoms have been studied in general populations of older adults, few studies have focused on the identification and treatment of these common syndromes in older adults with DM. Moreover, because conditions such as cognitive impairment, polypharmacy, and injurious falls may interfere with the provision of appropriate DM care, the identification and management of these syndromes may enhance the effectiveness of DM management for the busy primary care provider. The purpose of this guideline is to improve the care of older persons with DM by providing a set of evidencebased recommendations that include DM-specific recommendations individualized to persons with DM who are aged 65 and older and recommendations for the screening and detection of geriatric syndromes. Table 1 summarizes the components of care included in the guidelines and the number of randomized controlled trials (RCTs) and systematic evidence reviews that were evaluated for the care recommendations.

Vision impairment and combined vision and hearing impairment predict cognitive and functional decline in older women.

Objectives: To determine the association between vision and hearing impairment and subsequent cognitive and functional decline in community‐residing older women.

Do older adults expect to age successfully? The association between Expectations Regarding aging and beliefs Regarding healthcare seeking among older adults

OBJECTIVES: To measure expectations regarding aging among community‐residing‐older adults, identify characteristics associated with having low expectations regarding aging, and examine whether expectations regarding aging are associated with healthcare‐seeking beliefs for age‐associated conditions.

The relationship between expectations for aging and physical activity among older adults.

AbstractBACKGROUND: New strategies to increase physical activity among sedentary older adults are urgently needed. OBJECTIVE: To examine whether low expectations regarding aging (age-expectations) are associated with low physical activity levels among older adults. DESIGN: Cross-sectional survey. PARTICIPANTS: Six hundred and thirty-six English- and Spanish-speaking adults aged 65 years and above attending 14 community-based senior centers in the Los Angeles region. Over 44% were non-Latino whites, 15% were African American, and 36% were Latino. The mean age was 77 years (range 65 to 100). MEASUREMENTS: Self-administered written surveys including previously tested measures of age-expectations and physical activity level in the previous week. RESULTS: Over 38% of participants reported <30 minutes of moderate-vigorous physical activity in the previous week. Older adults with lower age-expectations were more likely to report this very low level of physical activity than those with high age-expectations, even after controlling for the independent effect of age, sex, ethnicity, level of education, physical and mental health-related quality of life, comorbidity, activities of daily living impairment, depressive symptoms, self-efficacy, survey language, and clustering at the senior center. Compared with the quintile of participants having the highest age-expectations, participants with the lowest quintile of age-expectations had an adjusted odds ratio of 2.6 (95% confidence intervals: 1.5, 4.5) of reporting <30 minutes of moderate-vigorous physical activity in the previous week. CONCLUSIONS: In this diverse sample of older adults recruited from senior centers, low age-expectations are independently associated with very low levels of physical activity. Harboring low age-expectations may act as a barrier to physical activity among sedentary older adults.

Experiences of Social Stigma and Implications for Healthcare Among a Diverse Population of HIV Positive Adults

Stigma profoundly affects the lives of people with HIV/AIDS. Fear of being identified as having HIV or AIDS may discourage a person from getting tested, from accessing medical services and medications, and from disclosing their HIV status to family and friends. In the present study, we use focus groups to identify the most salient domains of stigma and the coping strategies that may be common to a group of diverse, low-income women and men living with HIV in Los Angeles, CA (n=48). We also explore the impact of stigma on health and healthcare among HIV positive persons in our sample. Results indicate that the most salient domains of stigma include: blame and stereotypes of HIV, fear of contagion, disclosure of a stigmatized role, and renegotiating social contracts. We use the analysis to develop a framework where stigma is viewed as a social process composed of the struggle for both internal change (self-acceptance) and reintegration into the community. We discuss implications of HIV-related stigma for the mental and physical health of HIV-positive women and men and suggestions for possible interventions to address stigma in the healthcare setting.

Development and Psychometric Assessment of a Multidimensional Measure of Internalized HIV Stigma in a Sample of HIV-positive Adults

There is a need for a psychometrically sound measure of the stigma experienced by diverse persons living with HIV/AIDS (PLHA). The goal of this study was to develop and evaluate a multidimentional measure of internalized HIV stigma that captures stigma related to treatment and other aspects of the disease among sociodemographically diverse PLHA. We developed a 28-item measure of internalized HIV stigma composed of four scales based on previous qualitative work. Internal consistency reliability estimates in a sample of 202 PLHA was 0.93 for the overall measure, and exceeded 0.85 for three of the four stigma scales. Items discriminated well across scales, and correlations of the scales with shame, social support, and mental health supported construct validity. This measure should prove useful to investigators examining in the role of stigma in HIV treatment and health outcomes, and evaluating interventions designed to mitigate the impacts of stigma on PLHA.

Determinants of Medical Expenditures in the Last 6 Months of Life

BACKGROUND End-of-life medical expenditures exceed costs of care during other years, vary across regions, and are likely to be unsustainable. Identifying determinants of expenditure variation may reveal opportunities for reducing costs. OBJECTIVE To identify patient-level determinants of Medicare expenditures at the end of life and to determine the contributions of these factors to expenditure variation while accounting for regional characteristics. It was hypothesized that race or ethnicity, social support, and functional status are independently associated with treatment intensity and controlling for regional characteristics, and that individual characteristics account for a substantial proportion of expenditure variation. DESIGN Using data from the Health and Retirement Study, Medicare claims, and The Dartmouth Atlas of Health Care, relationships were modeled between expenditures and patient and regional characteristics. SETTING United States, 2000 to 2006. PARTICIPANTS 2394 Health and Retirement Study decedents aged 65.5 years or older. MEASUREMENTS Medicare expenditures in the last 6 months of life were estimated in a series of 2-level multivariable regression models that included patient, regional, and patient and regional characteristics. RESULTS Decline in function (rate ratio [RR], 1.64 [95% CI, 1.46 to 1.83]); Hispanic ethnicity (RR, 1.50 [CI, 1.22 to 1.85]); black race (RR, 1.43 [CI, 1.25 to 1.64]); and certain chronic diseases, including diabetes (RR, 1.16 [CI, 1.06 to 1.27]), were associated with higher expenditures. Nearby family (RR, 0.90 [CI, 0.82 to 0.98]) and dementia (RR, 0.78 CI, 0.71 to 0.87]) were associated with lower expenditures, and advance care planning had no association. Regional characteristics, including end-of-life practice patterns (RR, 1.09 [CI, 1.06 to 1.14]) and hospital beds per capita (RR, 1.01 [CI, 1.00 to 1.02]), were associated with higher expenditures. Patient characteristics explained 10% of overall variance and retained statistically significant relationships with expenditures after regional characteristics were controlled for. LIMITATION The study limitations include the decedent sample, proxy informants, and a large proportion of unexplained variation. CONCLUSION Patient characteristics, such as functional decline, race or ethnicity, chronic disease, and nearby family, are important determinants of expenditures at the end of life, independent of regional characteristics. PRIMARY FUNDING SOURCE The Brookdale Foundation.

Allostatic Load and Frailty in Older Adults

OBJECTIVES: To examine the association between allostatic load (AL), an index of multisystem physiological dysregulation, and frailty development over a 3‐year follow‐up in a sample of older adults.

Modifiable risk factors predict functional decline among older women : A prospectively validated clinical prediction tool

OBJECTIVE: To identify modifiable predictors of functional decline among community‐residing older women and to derive and validate a clinical prediction tool for functional decline based only on modifiable predictors.

Do Depressed Older Adults Who Attribute Depression to “Old Age” Believe It Is Important to Seek Care?

OBJECTIVE: To determine whether depressed older adults who attribute becoming depressed to “old age” rather than illness are more likely to believe it is not important to seek treatment for depression. DESIGN: Cross-sectional mailed survey. SETTING: Academically affiliated primary care physicians’ network. PARTICIPANTS: Surveys were mailed to 588 patients age ≥65 years who were randomly identified from patient lists of 20 physicians. Surveys were returned by 429 patients (73%). Patients were eligible for this study if they scored ≥2 points on the 5-item Geriatric Depression Scale (n=94) and were not missing key variables (final n=90). MEASUREMENTS AND MAIN RESULTS: Of the 90 depressed patients, 48 (53%) believed that feeling depressed was very important to discuss with a doctor. In unadjusted analysis, older adults who did not believe it is very important to discuss feeling depressed with a doctor were more likely to attribute becoming depressed to aging (41% vs 17%; P=.012). In a logistic regression model adjusting for sociodemographic characteristics, number of impairments in basic and instrumental activities of daily living, medical comorbidity, and physical (PCS-12) and mental (MCS-12) component summary scores from the Medical Outcomes Study Short-Form-12, depressed older adults who attributed depression to aging had a 4.3 times greater odds than those who attributed depression to illness to not believe it is very important to discuss depression with a doctor (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.3 to 14.5). CONCLUSIONS: Among older persons with depression, attributing feeling depressed to old age may be an important barrier to care seeking.