Lynne Iannone

Health Outcome Prioritization as a Tool for Decision Making Among Older Persons With Multiple Chronic Conditions

Older persons with multiple chronic conditions are at substantial risk for unintended adverse outcomes, such as medication adverse events. Less severe adverse events are commonly referred to as “side effects,” implying that they are secondary to disease-specific benefits. However, patients consider these adverse events to be important outcomes in their own right.1 Such findings suggest that all possible benefits and harms resulting from different treatment options be considered as competing outcomes, among which older persons with multiple chronic conditions face trade-offs. When treatments involve trade-offs, the best option depends upon patients’ preferences. The challenge for older persons with multiple conditions is that these trade-offs encompass both many different specific diseases and non disease-specific health domains.2 One approach to this challenge is to consider treatment in terms of its effects on a set of universal, cross-disease outcomes and to use older persons’ prioritization of these outcomes as an assessment of preferences. These outcomes, examples of which include length of life, physical and cognitive function, and symptoms, include basic domains recognized to be the key components of health.3 The goal of this study was to explore the use of a simple to tool to elicit older persons’ health outcome priorities.

Identification of strategies used to cope with chronic pain in older persons receiving primary care from a Veterans Affairs Medical Center.

Objectives: To identify the strategies used by older persons to cope with chronic noncancer pain, determine the perceived effectiveness of the strategies, and ascertain factors associated with their use.

A Pilot Randomized Controlled Trial of a Decision Support Tool to Improve the Quality of Communication and Decision-Making in Individuals with Atrial Fibrillation

To design a tool for nonvalvular atrial fibrillation (NVAF) to inform individuals of their individual stroke and bleeding risks, assist in clarifying priorities, and promote communication.

Agreement between older persons and their surrogate decision-makers regarding participation in advance care planning.

OBJECTIVES: To examine agreement between older persons and their surrogates regarding participation in advance care planning (ACP).

Development of Personalized Health Messages to Promote Engagement in Advance Care Planning.

To develop and test the acceptability of personalized intervention materials to promote advance care planning (ACP) based on the Transtheoretical Model (TTM), in which readiness to change is a critical organizing construct.

Sleep Disturbances and Driving Practices of Older Drivers

To evaluate the associations between sleep disturbances and driving practices, including driving cessation and trajectories of daily driving mileage (change over time), in older drivers.

A Dyadic Perspective on Engagement in Advance Care Planning

To understand the perspectives of both patients and the person who would make medical decisions for them if they were unable (surrogates) on their participation in advance care planning (ACP).

Age-Related Differences in Sleep–Wake Symptoms of Adults Undergoing Polysomnography

To evaluate age‐related differences in sleep–wake symptoms.

Spirometry, Static Lung Volumes, and Diffusing Capacity

BACKGROUND: Spirometric Z-scores from the Global Lung Initiative (GLI) rigorously account for age-related changes in lung function and are thus age-appropriate when establishing spirometric impairments, including a restrictive pattern and air-flow obstruction. However, GLI-defined spirometric impairments have not yet been evaluated regarding associations with static lung volumes (total lung capacity [TLC], functional residual capacity [FRC], and residual volume [RV]) and gas exchange (diffusing capacity). METHODS: We performed a retrospective review of pulmonary function tests in subjects ≥40 y old (mean age 64.6 y), including pre-bronchodilator measures for: spirometry (n = 2,586), static lung volumes by helium dilution with inspiratory capacity maneuver (n = 2,586), and hemoglobin-adjusted single-breath diffusing capacity (n = 2,508). Using multivariable linear regression, adjusted least-squares means (adjLSMeans) were calculated for TLC, FRC, RV, and hemoglobin-adjusted single-breath diffusing capacity. The adjLSMeans were expressed with and without height-cubed standardization and stratified by GLI-defined spirometry, including normal (n = 1,251), restrictive pattern (n = 663), and air-flow obstruction (mild, [n = 128]; moderate, [n = 150]; and severe, [n = 394]). RESULTS: Relative to normal spirometry, restrictive-pattern had lower adjLSMeans for TLC, FRC, RV, and hemoglobin-adjusted single-breath diffusing capacity (P ≤ .001). Conversely, relative to normal spirometry, mild, moderate, and severe air-flow obstruction had higher adjLSMeans for FRC and RV (P < .001). However, only mild and moderate air-flow obstruction had higher adjLSMeans for TLC (P < .001), while only moderate and severe air-flow obstruction had higher adjLSMeans for RV/TLC (P < .001) and lower adjLSMeans for hemoglobin-adjusted single-breath diffusing capacity (P < .001). Notably, TLC (calculated as FRC + inspiratory capacity) was not increased in severe air-flow obstruction (P ≥ .11) because inspiratory capacity decreased with increasing air-flow obstruction (P < .001), thus opposing the increased FRC (P < .001). Finally, P values were similar whether adjLSMeans were height-cubed standardized. CONCLUSIONS: A GLI-defined spirometric restrictive pattern is strongly associated with a restrictive ventilatory defect (decreased TLC, FRC, and RV), while GLI-defined spirometric air-flow obstruction is strongly associated with hyperinflation (increased FRC) and air trapping (increased RV and RV/TLC). Both spirometric impairments were strongly associated with impaired gas exchange (decreased hemoglobin-adjusted single-breath diffusing capacity).

Engagement in Advance Care Planning and Surrogates’ Knowledge of Patients’ Treatment Goals

A key objective of advance care planning (ACP) is improving surrogates’ knowledge of patients’ treatment goals. Little is known about whether ACP outside of a trial accomplishes this. The objective was to examine patient and surrogate reports of ACP engagement and associations with surrogate knowledge of goals.