Kenneth E. Covinsky

Assessing the Generalizability of Prognostic Information

This paper describes an approach for evaluating prognostic systems based on the accuracy and generalizability of the systems predictions.

Loss of Independence in Activities of Daily Living in Older Adults Hospitalized with Medical Illnesses: Increased Vulnerability with Age

OBJECTIVES: To describe the changes in activities of daily living (ADL) function occurring before and after hospital admission in older people hospitalized with medical illness and to assess the effect of age on loss of ADL function.

Functional status of elderly adults before and after initiation of dialysis.

BACKGROUND It is unclear whether functional status before dialysis is maintained after the initiation of this therapy in elderly patients with end-stage renal disease (ESRD). METHODS Using a national registry of patients undergoing dialysis, which was linked to a national registry of nursing home residents, we identified all 3702 nursing home residents in the United States who were starting treatment with dialysis between June 1998 and October 2000 and for whom at least one measurement of functional status was available before the initiation of dialysis. Functional status was measured by assessing the degree of dependence in seven activities of daily living (on the Minimum Data Set-Activities of Daily Living [MDS-ADL] scale of 0 to 28 points, with higher scores indicating greater functional difficulty). RESULTS The median MDS-ADL score increased from 12 during the 3 months before the initiation of dialysis to 16 during the 3 months after the initiation of dialysis. Three months after the initiation of dialysis, functional status had been maintained in 39% of nursing home residents, but by 12 months after the initiation of dialysis, 58% had died and predialysis functional status had been maintained in only 13%. In a random-effects model, the initiation of dialysis was associated with a sharp decline in functional status, indicated by an increase of 2.8 points in the MDS-ADL score (95% confidence interval [CI], 2.5 to 3.0); this decline was independent of age, sex, race, and functional-status trajectory before the initiation of dialysis. The decline in functional status associated with the initiation of dialysis remained substantial (1.7 points; 95% CI, 1.4 to 2.1), even after adjustment for the presence or absence of an accelerated functional decline during the 3-month period before the initiation of dialysis. CONCLUSIONS Among nursing home residents with ESRD, the initiation of dialysis is associated with a substantial and sustained decline in functional status.

Octogenarians and Nonagenarians Starting Dialysis in the United States

Context Numbers of very elderly persons starting dialysis are increasing in the United States. Contribution This study, using national registry data of patients with end-stage renal disease, showed that octogenarians and nonagenarians starting dialysis increased from 7054 persons in 1996 to 13577 persons in 2003. Patients starting dialysis in 2003 had higher estimated glomerular filtration rates and less morbidity related to chronic kidney disease, but no difference in 1-year mortality rate (approximately 50%), compared with those starting dialysis in 1996. Older age, nonambulatory status, and more comorbid conditions were strongly associated with an increased risk for death. Implications Increasing numbers of the very elderly are receiving dialysis, while overall survival remains low. The Editors The elderly constitute a substantial and growing fraction of the end-stage renal disease (ESRD) population. Data from the U.S. Renal Data System (USRDS) indicate that incidence rates of ESRD are no longer rising among persons younger than 65 years of age but have continued to increase among those 65 years of age and older (1). Researchers have speculated that more liberal acceptance of the very elderly (80 years) into dialysis programs has contributed to the increase in patients with ESRD (2, 3), yet little is known about how patient characteristics and incidence rates have changed over time in this population. The very elderly have a high prevalence of comorbid conditions, including dementia and disability, leading to some controversy about the appropriateness of dialysis initiation in these patients. Nonetheless, outcomes of the very elderly who are treated with dialysis have not been rigorously examined at a national level. Previous studies devoted to the very elderly with ESRD were single-center series. Most were of international ESRD populations with few minority patients, and several studies pooled data from different erasduring which time dialysis practices changed considerably (410). We examined the epidemiology and outcomes of octogenarians and nonagenarians starting dialysis in the United States. Our goals were to describe recent trends in dialysis initiation and to describe differences in patient characteristics and outcomes over time. Methods Analytic Cohort We used data from the USRDS Standard Analysis Files from 1996 through 2003 for these analyses. The USRDS contains data on more than 99% of persons starting dialysis in the United States. We included all persons 65 years of age and older who began dialysis between 1 January 1996 and 31 December 2003 in the analytic cohort (n= 350831). We followed patients until death or until 31 December 2004 to allow for at least 1 year of follow-up. The focus of these analyses was the very elderly; however, we included patients 65 to 79 years of age (the young elderly) in the analyses as a reference group. We excluded patients initiating dialysis after a failed kidney transplantation (n= 4693) because they may differ from patients with true incident ESRD in duration of kidney disease, timing of dialysis initiation, propensity to start (or return) to dialysis, and several other potential confounding factors. We also excluded 6 patients with missing demographic data, leaving 346132 persons in the analytic cohort. Because the current analyses used existing data without any patient identifiers, it received exempt certification from the University of California, San Francisco, Institutional Review Board, San Francisco, California. Covariates We obtained information or demographic characteristics, and comorbid conditions and selected laboratory data at the time of dialysis initiation from the Centers for Medicare & Medicaid Services (CMS) medical evidence form (CMS form 2728), which is typically completed by the attending nephrologist or other designated dialysis personnel. We analyzed age in 5-year increments (for example, 80 to 84 years, 85 to 89 years, and 90 years or more), except in the calculation of incidence rates because U.S. Census estimates are organized into 2 categories of persons older than age 80 years (80 to 84 years and 85 years or more). We categorized race as white, black, and other; the last category included Asians, Pacific Islanders, American Indians, and Alaskan Natives. We defined nonambulatory status as the inability to walk or the inability to transfer, underweight as a body mass index (BMI) less than 18.5 kg/m2 (11), anemia as a hemoglobin concentration less than 100 g/L, and low serum albumin concentration as an albumin level less than 35 g/L. We calculated estimated glomerular filtration rate (GFR) at dialysis initiation by using the Modification of Diet in Renal Disease equation, incorporating age, sex, race, and serum creatinine concentration (12). Statistical Analysis We compared baseline characteristics over time by using analysis of variance for continuous variables and the chi-square test for categorical variables. We tabulated counts of patients starting dialysis and calculated the average annual increase in dialysis initiation by age group and compared this with the corresponding average annual increase in the U.S. population. We determined the unadjusted incidence of dialysis initiation within each age group by using census estimates based on counts from the bridged race dataset of the 2000 U.S. Census report from the U.S. Centers for Disease Control and Prevention for the denominator population (13). We modeled sex- and race-adjusted incidence rates and 95% CIs by using Poisson regression methods. We used similar methods to determine the relative risk, or rate ratio, of starting dialysis in 2003 versus in 1996. Survival curves as a function of clinical characteristics at the start of dialysis were computed by using KaplanMeier methods. We also used Cox proportional hazards models to examine the association of clinical characteristics with death. As a complementary approach, we determined the risk for death associated with the number rather than the type of comorbid condition. For the count of comorbid conditions, we included all conditions measured on the CMS medical evidence form that were statistically significantly associated with an increased risk for death in adjusted models. Role of the Funding Sources The funding sources had no role in the collection, analysis, or interpretation of the data or in the decision to submit this manuscript for publication. The authors had full access to the data for the study. Results Trends in Dialysis Initiation among Octogenarians and Nonagenarians Clinical characteristics of octogenarians and nonagenarians initiating dialysis from 1996 through 2003 are shown in Table 1. The adjusted mean estimated GFR at dialysis initiation and the percentage of patients initiating dialysis with an estimated GFR 15 mL/min per 1.73 m2 or more (before stage 5 chronic kidney disease) increased over time. In parallel with the trend of dialysis initiation at a higher estimated GFR, most morbidity related to chronic kidney disease, such as anemia, underweight, and congestive heart failure, declined over time, as did the fraction of patients with 4 or more comorbid conditions. The prevalence of low serum albumin and nonchronic kidney diseaserelated morbidity remained stable or grew slightly over time. Table 1. Change in Patient Characteristics at Dialysis Initiation among Octogenarians and Nonagenarians from 1996 to 2003* Between 1996 and 2003, 78419 octogenarians and 5577 nonagenarians initiated dialysis in the United States. The number of octogenarians and nonagenarians starting dialysis increased from 7054 persons in 1996 to 13577 persons in 2003, corresponding to an average annual increase in dialysis initiation of 8.6% among those 80 to 84 years of age and 11.9% among those 85 years of age and older. The corresponding average annual increase in the U.S. population was 2.3% among those 80 to 84 years of age and 3.2% among those 85 years of age and older. For comparison, the average annual increase in dialysis initiation among patients 65 to 79 years of age was only 3.5%, while the U.S. population of persons 65 to 79 years of age did not substantially increase during this period. Rates of dialysis initiation increased with age, peaking between age 75 and 84 years, and increased over time for each elderly age group (Figure 1). For persons older than 84 years of age, rates of dialysis initiation were dramatically lower than other elderly age groups; this effect persisted over time. After we accounted for population growth, rates of dialysis initiation increased by 57% (rate ratio, 1.57 [95% CI, 1.53 to 1.62]) among octogenarians and nonagenarians from 1996 to 2003 (Table 2). The rate of growth was similar among age and sex subgroups and among black and white patients. Rates of dialysis initiation declined slightly among other ethnic groups; however, these results should be interpreted with caution because of the relatively small number of nonblack and nonwhite patients in the study. Figure 1. Incidence of dialysis initiation from 1996 to 2003 by year and age group (per 100000 persons in U.S. population), adjusted for sex and race. Table 2. Incidence of Dialysis Initiation (per 100000 Persons) among Octogenarians and Nonagenarians in 1996 and 2003 and Rate Ratio of Dialysis Initiation in 2003 versus 1996 Survival of Octogenarians and Nonagenarians Starting Dialysis The 1-year mortality rate for octogenarians and nonagenarians starting dialysis was 46% and did not materially change over the 7-year period. Median survival after dialysis initiation was 24.9 months (interquartile range, 8.3 to 51.8 months) for patients 65 to 79 years of age; 15.6 months (interquartile range; 4.8 to 35.5 months) for patients 80 to 84 years of age; 11.6 months (interquartile range, 3.7 to 28.5 months) for patients 85 to 89 years of age; and 8.4 months (interquartile range, 2.8 to 21.3 months) for patients 90 years of age or older. Similar t

Patient and Caregiver Characteristics Associated with Depression in Caregivers of Patients with Dementia

OBJECTIVE: Many patients with dementia who live at home would require nursing home care if they did not have the assistance of family caregivers. However, caregiving sometimes has adverse health consequences for caregivers, including very high rates of depression. The goal of this study was to determine the patient and caregiver characteristics associated with depression among caregivers of patients with dementia.DESIGN: Cross-sectional study.PARTICIPANTS AND SETTING: Five thousand six hundred and twenty-seven patients with moderate to advanced dementia and their primary caregivers upon enrollment in the Medicare Alzheimer’s Disease Demonstration (MADDE) at 8 locations in the United States.MEASUREMENTS: Caregiver depression was defined as 6 or more symptoms on the 15-item Geriatric Depression Scale. Patient characteristics measured included ethnicity and other demographic characteristics, income, activities of daily living (ADL) function, Mini-Mental Status Exam (MMSE) score, and behavioral problems. Caregiver characteristics measured included demographic characteristics, relationship to the patient, hours spent caregiving, and ADL and Instrumental Activities of Daily Living (IADL) function. We used x2 and t tests to measure the bivariate relationships between patient and caregiver predictors and caregiver depression. We used logistic regression to determine the independent predictors of caregiver depression.RESULTS: Thirty-two percent of caregivers reported 6 or more symptoms of depression and were classified as depressed. Independent patient predictors of caregiver depression included younger age (odds ratio [OR], 1.91; 95% confidence interval [CI], 1.33 to 2.76 in patients less than 65 years compared to patients over 85 years), white (OR, 1.53; 95% CI, 1.18 to 1.99) and Hispanic ethnicity (OR, 2.50; 95% CI, 1.69 to 3.70) compared to black ethnicity, education (OR, 1.16; 95% CI, 1.01 to 1.33 for those with less than a high school education), ADL dependence (OR, 1.55; 95% CI, 1.26 to 1.90 for patients dependent in 2 or more ADL compared to patients dependent in no ADL), and behavioral disturbance, particularly angry or aggressive behavior (OR, 1.47; 95% CI, 1.27 to 1.69 for patients with angry or aggressive behavior). Independent caregiver predictors of depression included low income (OR, 1.45; 95% CI, 1.18 to 1.77 for less than

High Occurrence of Mood and Anxiety Disorders Among Older Adults: The National Comorbidity Survey Replication

10,000/per year, compared to >

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

20,000 per year), the relationship to the patient (OR, 2.73; 95% CI, 1.31 to 5.72 for wife, compared to son of male patient), hours spent caregiving (OR, 1.89; 95% CI, 1.51 to 2.38 for 40 to 79 hours/week compared to less than 40 hours/week), and functional dependence (OR, 2.53; 95% CI, 2.13 to 3.01 for ADL dependent compared to IADL independent).CONCLUSION: Caregiver depression is a complex process, influenced by ethnicity as well as diverse patient and caregiver characteristics. Efforts to identify and treat caregiver depression will need to be multidisciplinary and focus on multiple risk factors simultaneously.

Effects of a Multicomponent Intervention on Functional Outcomes and Process of Care in Hospitalized Older Patients: A Randomized Controlled Trial of Acute Care for Elders (ACE) in a Community Hospital

CONTEXT Little is known about prevalence rates of DSM-IV disorders across age strata of older adults, including common conditions such as individual and coexisting mood and anxiety disorders. OBJECTIVE To determine nationally representative estimates of 12-month prevalence rates of mood, anxiety, and comorbid mood-anxiety disorders across young-old, mid-old, old-old, and oldest-old community-dwelling adults. DESIGN The National Comorbidity Survey Replication (NCS-R) is a population-based probability sample of 9282 participants 18 years and older, conducted between February 2001 and April 2003. The NCS-R survey used the fully structured World Health Organization World Mental Health Survey version of the Composite International Diagnostic Interview. SETTING Continental United States. PARTICIPANTS We studied the 2575 participants 55 years and older who were part of NCS-R (43%, 55-64 years; 32%, 65-74 years; 20%, 75-84 years; 5%, >or=85 years). This included only noninstitutionalized adults, as all NCS-R participants resided in households within the community. MAIN OUTCOME MEASURES Twelve-month prevalence of mood disorders (major depressive disorder, dysthymia, bipolar disorder), anxiety disorders (panic disorder, agoraphobia, specific phobia, social phobia, generalized anxiety disorder, posttraumatic stress disorder), and coexisting mood-anxiety disorder were assessed using DSM-IV criteria. Prevalence rates were weighted to adjust for the complex design to infer generalizability to the US population. RESULTS The likelihood of having a mood, anxiety, or combined mood-anxiety disorder generally showed a pattern of decline with age (P < .05). Twelve-month disorders showed higher rates in women compared with men, a statistically significant trend with age. In addition, anxiety disorders were as high if not higher than mood disorders across age groups (overall 12-month rates: mood, 5% and anxiety, 12%). No differences were found between race/ethnicity groups. CONCLUSION Prevalence rates of DSM-IV mood and anxiety disorders in late life tend to decline with age, but remain very common, especially in women. These results highlight the need for intervention and prevention strategies.

Hospitalization-Associated Disability: “She Was Probably Able to Ambulate, but I’m Not Sure”

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.

The relationship between clinical assessments of nutritional status and adverse outcomes in older hospitalized medical patients

BACKGROUND: Older persons frequently experience a decline in function following an acute medical illness and hospitalization.