Christianna S. Williams

Driving Cessation and Increased Depressive Symptoms: Prospective Evidence from the New Haven EPESE

OBJECTIVES: The purpose of this study was to determine the association between driving cessation and depressive symptoms among older drivers. Previous efforts in this area have focused on the factors associated with cessation, not the consequences of having stopped.

Assessing risk for the onset of functional dependence among older adults: the role of physical performance.

BACKGROUND: Approximately 10% of nondisabled, community‐dwelling adults aged 75 years and older lose independence in basic activities of daily living (ADLs) each year. The purpose of this study was to evaluate whether simple tests of physical performance could identify older adults, independent in their basic ADLs, who were at increased risk for the onset of functional dependence.

Characteristics Associated with Fear of Falling and Activity Restriction in Community-Living Older Persons

To identify the characteristics associated with restricting activity because of fear of falling (activity restriction) and to determine which characteristics distinguish older persons who restrict activity from those who have fear of falling but do not restrict their activities (fear of falling alone).

Prognostic Importance of Emotional Support for Elderly Patients Hospitalized With Heart Failure

BACKGROUND Several studies have indicated that a variety of social relationships are important predictors of morbidity and mortality in patients with coronary artery disease, but little attention has been focused on the prognostic importance of these factors in the growing population of elderly patients with heart failure. To address this issue, we sought to determine whether emotional support is associated with fatal and nonfatal cardiovascular events in elderly patients hospitalized with heart failure. METHODS AND RESULTS We reviewed the medical records of 292 subjects aged > or =65 years who were hospitalized with clinical heart failure and were part of the New Haven, Conn, cohort of the Established Population for the Epidemiologic Study of the Elderly, a longitudinal, community-based study of aging that included a comprehensive assessment of psychosocial support. In the unadjusted analysis, lack of emotional support was significantly associated with the 1-year risk of fatal and nonfatal cardiovascular outcomes [odds ratio, 2.4; 95% confidence interval, 1.1 to 4.9]. After adjustment for demographic factors, clinical severity, comorbidity and functional status, social ties, and instrumental support, the absence of emotional support remained associated with a significantly higher risk (odds ratio, 3.2; 95% confidence interval, 1.4 to 7.8). The test for interaction between emotional support and sex was significant (P=.01). In the fully adjusted model, the odds ratio for women was 8.2 (95% confidence interval, 2.5 to 27.2) compared with 1.0 (95% confidence interval, 0.3 to 3.3) for men. CONCLUSIONS Among elderly patients hospitalized with clinical heart failure, the absence of emotional support, measured before admission, is a strong, independent predictor of the occurrence of fatal and nonfatal cardiovascular events in the year after admission. In this cohort, the association is restricted to women.

Risk factors for heart failure in the elderly: a prospective community-based study

PURPOSE The risk factors for the development of heart failure are not clearly defined, particularly for older adults. We undertook the current investigation to examine the associations of traditional cardiovascular risk factors, comorbidity, and psychosocial factors with the risk of heart failure during 10 years of follow-up in a community-based elderly population. SUBJECTS AND METHODS We evaluated 1,749 subjects, 65 years of age or older, free of heart failure, myocardial infarction, and angina at baseline, who were participating in the New Haven, Connecticut cohort of the Established Population for Epidemiologic Studies of the Elderly program. Cox proportional hazards regression models were used to determine risk ratios (RR) and 95% confidence intervals (CI). RESULTS During 13,811 person-years of follow-up, 173 subjects developed incident heart failure, as confirmed by chart review. Five factors were independent predictors of heart failure: male sex (RR = 1.7; CI, 1.3 to 2.4), older age (RR = 1.9; CI, 1.3 to 2.7 for age 75 to 84 years, RR = 3.0; CI, 1.7 to 5.5 for age 85 years and older, compared with < or = 74 years), diabetes (RR = 2.9; CI, 2.0 to 4.3), pulse pressure > or = 70 mm Hg (RR = 2.3; CI, 1.3 to 4.3, compared with <50 mm Hg), and body mass index > or = 28 kg/m2 (RR = 1.6; CI, 1.0 to 2.4, compared with <24 kg/ m2). Myocardial infarction occurred during follow-up in 8% of the cohort and was also an important predictor of heart failure (RR = 21; CI, 15 to 31). CONCLUSIONS Age and traditional cardiovascular risk factors are associated with the development of heart failure in the elderly. Preventive strategies should focus on the management of diabetes, blood pressure, and weight, in addition to the prevention and management of myocardial infarction.

Restricted activity among community-living older persons: incidence, precipitants, and health care utilization.

Restricted activity, defined as staying in bed for at least half a day or cutting down on ones usual activities because of an illness or injury (1), has high face validity as a measure of health and functional status, especially for older persons, who often value quality of life over longevity (2). The importance of restricted activity was recognized more than 20 years ago in the U.S. Surgeon Generals original Healthy People Report (3), which identified reduction of restricted activity as one of its two major goals for older persons. Subsequently, several clinical trials of preventive interventions have included restricted activity as a key outcome measure (4-7). Despite this attention, relatively little is known about the epidemiology of restricted activity among older persons. Previous studies, based largely on one-time assessments, have suggested that only a minority of community-living older persons experience restricted activity in the course of 1 year (8, 9). The factors precipitating restricted activity, moreover, have not been well defined. Finally, whether older persons seek medical attention in the setting of restricted activity has not been studied. Those who do not seek attention may consider restricted activity to be a normal part of aging and may miss a chance for successful evaluation and intervention. In this prospective cohort study, we sought to better elucidate the epidemiology of restricted activity in community-living older persons. Our goals were to more accurately estimate the rate of restricted activity, identify the health-related and non-health-related problems leading to restricted activity, and determine whether restricted activity is associated with increased health care utilization. Methods Study Sample The study sample comprised the 754 participants of the Precipitating Events Project, a longitudinal study of nondisabled, community-living persons 70 years of age or older. Participants in the Precipitating Events Project were identified from a computerized list of 3157 age-eligible members of a large health plan in New Haven, Connecticut. Members were eligible if they were communityliving, English-speaking, and nondisabled (that is, required no personal assistance) in four key activities of daily livingbathing, walking, dressing, and transferring from a chair. Plan members were excluded on the basis of three criteria: diagnosis of a terminal illness with a life expectancy less than 12 months, plans to move out of the New Haven area during the next 12 months, and significant cognitive impairment with no available proxy. Enrollment To minimize potential selection effects, a computerized randomization program was used to assign each age-eligible health plan member a unique number. Screening for eligibility and enrollment proceeded sequentially from March 1998 to October 1999. Potential participants were sent a letter that briefly described the study and explained that they would be contacted by phone. During the phone interview, eligibility was assessed, and a home visit was scheduled among consenting eligible persons. During the home visit, eligibility was verified, informed consent was obtained, and a comprehensive baseline assessment was completed. On the basis of gait speed, cognitive status, and age, participants were categorized into one of three risk groups for disability by using a model developed and validated in an earlier study (Table 1) (10). To ensure that enough participants were included in each risk group, participants were enrolled in a 4:2:1 ratio for low, intermediate, and high risk for disability, respectively. Table 1. Risk Model for Disability and Number of Participants Enrolled, according to Phase Assembly of the Precipitating Events Project cohort is shown in the Figure. We applied our stratified sampling strategy in three phases. In phase 1, all eligible and consenting persons were enrolled. In phase 2, persons were excluded from the study if they indicated during the screening telephone interview that they had walked 0.5 mile or for 30 minutes continuously without stopping within the past month. In phase 3, persons who were eligible based on the screening telephone interview were excluded from the study if they were found to have low risk for disability during the home visit. The enrollment procedures in phases 2 and 3 were otherwise identical to those in phase 1. Figure. Assembly of Precipitating Events Project cohort. The number of participants enrolled in each of the three phases is shown in Table 1. During phase 1, 77% of the participants had low risk for disability. Phase 2 was designed to decrease this percentage by excluding persons who were likely to have low risk for disability. The sensitivity and specificity of the screening question used during phase 2 were 66% and 76%, respectively, for low disability risk (based on gold standard data from the first 282 participants enrolled during phase 1). Other candidate screening questions, alone or in combination, had a lower sensitivity or specificity (or both). As shown in the Figure, only 4.6% (126 of 2735) of the health plan members who could be contacted declined to complete the screening telephone interview, and 75.2% (754 of 1002) of the eligible members agreed to participate in the study. Persons who declined to participate did not differ significantly from those who were enrolled in terms of age or sex. Baseline Data Collection Trained research nurses used standard instruments to perform baseline interviews and assessments. Clinical data included 13 self-reported, physician-diagnosed chronic conditions: hypertension; myocardial infarction; congestive heart failure; stroke; diabetes; arthritis; hip fracture; fracture of wrist, arm, or spine since 50 years of age; amputation of leg; chronic lung disease; cirrhosis or liver disease; cancer (other than minor skin cancers); and Parkinson disease. Cognitive status was assessed by using the Folstein Mini-Mental State Examination (11). Timed rapid gait was assessed by having the participants walk back and forth over a 10-foot course as quickly and safely as possible (10). Follow-up Data Collection The occurrence of restricted activity and health-related and non-health-related problems leading to restricted activity were ascertained during monthly telephone interviews by using a standardized, four-step protocol. First, participants were asked two questions related to restricted activity: Since we last talked on [date of last interview], have you stayed in bed for at least half a day due to an illness, injury, or other problem? and Since we last talked on [date of last interview], have you cut down on your usual activities due to an illness, injury, or other problem? Second, if participants had restricted activity (that is, answered yes to either question), they were asked sequentially whether they had had any of 24 prespecified problems since we last talked on [date of last interview]. To develop our list of potential problems, we identified common physical and mental health symptoms that community-living older persons had reported in previous studies (12-14), and we supplemented these symptoms with other events that we deemed important on the basis of our own clinical and research experience (15). Third, immediately after each yes response to a specific problem, participants were asked, Did this problem cause you to stay in bed for at least half a day or to cut down on your usual activities? (that is, did it lead to restricted activity). Finally, participants with restricted activity were asked to specify any other reasons why they stayed in bed for at least half a day or cut down on their usual activities. Participants without restricted activity were not asked about the specific problems. During pilot testing, we found that the test-retest reliability of this four-step protocol was high, with a value of 0.90 for the presence or absence of restricted activity and a value of 0.75 or greater for the presence or absence of 20 of the 24 problems leading to restricted activity (mean time between assessments, 4.1 days among 20 persons). The value was less than 0.6 for only 3 of the problems (swelling in feet or ankles, fear of falling, and frequent or painful urination). During the monthly telephone interviews, participants were also asked whether they had stayed at least overnight in a hospital and whether they had seen a physician in the office or emergency department since their last interview. The research protocol was approved by the Yale University School of Medicine Institutional Review Board. Statistical Analysis We calculated the rate of restricted activity for the overall cohort and for subgroups defined by sex and risk for disability by dividing the number of months in which participants reported staying in bed for at least half a day or cutting down on their usual activities by the total person-months of follow-up. These analyses were repeated for staying in bed for at least half a day and for cutting down on ones usual activities alone (that is, without staying in bed for at least half a day). We then calculated the overall and stratified rates for each of the prespecified problems leading to restricted activity by using person-months with restricted activity as the denominator. The mean number of problems per episode of restricted activity was also calculated. Finally, the rates of health care utilization, including physician office visits, emergency department visits, and hospital admissions, were calculated for months with and months without restricted activity. The events of interest in this study were potentially recurrent in nature; that is, participants may have experienced restricted activity or used health care services in more than one month. Because standard statistical approaches based on the binomial or Poisson distributions assume independence among events, we used alternative methods, designed specifically for recurrent events, t

Health Care Utilization and Costs in a Medicare Population by Fall Status

OBJECTIVES The economic impact of trauma in older persons is a matter of increasing concern to public health practitioners and planners, yet it is an issue that has not been widely studied. Available evidence does suggest, however, that falls are the costliest category of injury among older persons. METHODS This study used data from the Health Care Financing Administration and the Connecticut Long-Term Care Registry to isolate the effects of fall severity on hospital, nursing home, home health, and emergency room costs. Multivariate and logistic regression methods were used to control for the influence of a number of clinical and demographic factors believed to be independently related to health care costs. Health care costs of fallers were tracked for 1 year after the fall. The cost experience of this cohort was compared with nonfallers during the same time period. RESULTS The results provide strong evidence that falls are associated with increased health care costs, and that this relation increases monotonically with the frequency and severity of falls. Incurring one or more injurious falls was associated with increased annual hospital costs of

Home-based multicomponent rehabilitation program for older persons after hip fracture: A randomized trial

11,042 (1996), nursing home costs of

Multicomponent targeted intervention to prevent delirium in hospitalized older patients: what is the economic value?

5,325, and total health care costs of

Underestimation of Disability in Community‐Living Older Persons

19,440. Incurring two or more noninjurious falls increased costs substantially as well. CONCLUSIONS The health care costs of falls are pervasive and substantial, and they increase with fall frequency and severity.