Timothy E. Stump

Outcomes of Percutaneous Endoscopic Gastrostomy Among Older Adults in a Community Setting

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) has become the preferred method to provide enteral tube feeding to older adults who have difficulty eating, but the impact of PEG on patient outcomes is poorly understood. The objective of this study was to describe changes in nutrition, functional status, and health‐related quality of life among older adults receiving PEG.

Cost Analysis of the Geriatric Resources for Assessment and Care of Elders Care Management Intervention

OBJECTIVES: To provide, from the healthcare delivery system perspective, a cost analysis of the Geriatric Resources for Assessment and Care of Elders (GRACE) intervention, which is effective in improving quality of care and outcomes.

Transitions in Care for Older Adults with and without Dementia

To describe transitions in care of persons with dementia with attention to nursing facility transitions.

Mortality, Symptoms, and Functional Impairment in Late‐Life Depression

OBJECTIVE: To determine whether depressive symptoms measured at baseline are associated with mortality and to describe the course of depressive symptoms and their relation to physical decline in patients over a 6-year period.DESIGN: Prospective cohort study conducted from 1990 through 1996.SETTING: Urban academic primary care group practice.PATIENTS: A cohort of 3,767 patients aged 60 years and older screened for depressive symptoms during routine office visits using the Centers for Epidemiologic Studies Depression Scale (CES-D) participated in the mortality study. A subsample of 300 patients with CES-D scores 16 or above and a subsample of 100 patients with CES-D scores less than 16 participated in the study of the course of depressive symptoms and physical decline.MEASUREMENTS AND MAIN RESULTS: Mortality by December 1995 was measured for all screened patients; reinterviewed patients completed the CES-D and the Sickness Impact Profile (SIP). The mean follow-up period was 45 months (± SD 12.2 months); 561 (14.9%) of the patients died by December 1995. In proportional hazards models, age, gender, race, history of smoking, serum albumin value, and an ideal body weight in the lowest 10% were significant correlates of time to death, but the baseline CES-D was not. Patients with depressive symptoms had significantly worse physical and psychosocial functioning scores on the SIP than did patients without depressive symptoms. Using the generalized estimating equation method, the strongest predictor of the current CES-D score was the patient’s prior CES-D score. However, worsening physical functioning score on the SIP was also independently correlated with worse CES-D scores (p ≤ .001).CONCLUSIONS: Symptoms of depression were not associated with mortality in this cohort of older adults. However, patients with depressive symptoms reported greater functional impairment than did those without depressive symptoms. Moreover, decline in physical functioning was independently correlated with a concurrent increase in depressive symptoms.

Cognitive impairment and mortality in older primary care patients

OBJECTIVE: To assess the impact of cognitive impairment on mortality in older primary care patients after controlling for confounding effects of demographic and comorbid chronic conditions.

Cognitive Impairment: An Independent Predictor of Excess Mortality: A Cohort Study

BACKGROUND Dementia is a leading cause of death among older adults, but less is known about the mortality risk associated with milder forms of cognitive impairment. OBJECTIVE To determine whether cognitive impairment is independently associated with increased long-term mortality in primary care patients aged 60 years and older. DESIGN Linkage of electronic health records from a cohort recruited between January 1991 and May 1993 with data from the National Death Index through 31 December 2006. SETTING A public safety-net hospital and its community health centers. PATIENTS 3957 older adults aged 60 to 102 years who were screened at scheduled primary care appointments. MEASUREMENTS At baseline, patients were screened for cognitive impairment by using the Short Portable Mental Status Questionnaire and were categorized into groups with no, mild, or moderate to severe cognitive impairment. Baseline data from comprehensive electronic health records were linked with vital status obtained from the National Death Index. Kaplan-Meier survival curves compared time to death for the groups with cognitive impairment. Cox proportional hazards models controlled for mortality risk factors. RESULTS At baseline, 3157 patients had no cognitive impairment, 533 had mild impairment, and 267 had moderate to severe impairment. Overall, 2385 of the 3957 patients (60.3%) died during the observation period: 1812 (57.4%) patients with no cognitive impairment, 363 (68.1%) patients with mild impairment, and 210 (78.7%) patients with moderate to severe impairment. Both mild and moderate to severe cognitive impairment were associated with increased mortality hazard independent of other mortality risk factors (hazard ratio, 1.184 [95% CI, 1.051 to 1.334] and for mild impairment 1.447 [CI, 1.235 to 1.695] for moderate to severe impairment). Median survival for all 3957 participants was 129 months. Median survival for participants with no, mild, and moderate to severe cognitive impairment was 138, 106, and 63 months, respectively. LIMITATIONS Cognition was assessed only at enrollment by using a screening instrument. Participants were drawn from a single safety-net health system and had low educational and socioeconomic status, which limits generalizability to other populations. Changes in cognition, function, and comorbid conditions were not measured over time. CONCLUSION Both mild and moderate to severe cognitive impairment as identified by the Short Portable Mental Status Questionnaire are associated with an increased risk for mortality. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.

Predictors of Mobility and Basic ADL Difficulty among Adults Aged 70 Years and Older

We use data from the 1993-1995 Assets and Health Dynamics of the Oldest-Old survey to estimate predictors of onset of mobility difficulty, onset of basic activity of daily living (ADL) difficulty, and improvement to no mobility difficulty. Onset of mobility difficulty occurred among 20% of those with no difficulty at baseline (n = 2,857) and was most likely among those 85 years of age or over, women, those with a body-mass index of 30 or over, and those who reported lung disease, arthritis, frequent pain, and poor memory. For those with mobility difficulty at baseline (n = 1,871), improvement occurred among 24% and onset of basic ADL difficulty occurred among 25%. Improvement was more likely among those with difficulty in just one mobility item at baseline, and onset of ADL difficulty was most common among those with difficulty in three or more mobility items at baseline.

THE RISK OF HOSPITALIZATION FOR CONGESTIVE HEART FAILURE AMONG OLDER ADULTS

OBJECTIVES The purpose of the study was to estimate the 8-year rate of hospitalization for congestive heart failure (CHF), to report the resources consumed, and to evaluate previously reported risk factors in a nationally representative sample of 7,286 older white and black adults. METHODS Secondary analysis of baseline interview data was linked to Medicare hospitalization and death records for 1984 to 1991. Hospitalization for CHF was defined as having one or more episodes with an International Classification of Diseases (ninth revision, clinical modification) discharge code of 428. Combined and separate analyses of first-listed and second-through fifth-listed CHF discharge diagnoses were conducted. Multivariable proportional hazards models were used to evaluate the risks in pooled analyses of all white and black men and women and in separate stratified analyses of white men and white women. RESULTS Over the 8-year period, 1,102 or 15.1% of the 7,286 older white and black adults were hospitalized for CHF (7.1% with first-listed and 8.1% with second- through fifth-listed diagnoses). The 1- and 5-year combined postdischarge mortality rates were 34.7% and 69.0%, respectively. In descending order, the major risk factors for being hospitalized for CHF in the combined, pooled analysis were age, being a white man, having lower body functional limitations, and having self-reported medical histories of coronary heart disease, heart attack, diabetes, and angina. The increased risk associated with age was not linear, and it diminished significantly over the course of life. Some significant differences were observed in the risk factors for hospitalization for first-listed versus second- through fifth-listed CHF and in the risk factors for white women versus white men. CONCLUSIONS Hospitalization for CHF among older adults is a common, costly event with a poor prognosis. The differential risk for white men remains unexplained and warrants further study.

Consistency and change in functional status among older adults over time.

Consistency and change between 1984 and the last reinterview (either two, four, or six years later) on 22 individual functional status markers and the five summary scales that they form are examined among the 5,986 members of the Longitudinal Study on Aging who were reinterviewed at least once. At baseline, at least three-fifths of the respondents are without limitations on any individual marker. At the last reinterview, at least 43.4% of the respondents are without such limitations. Among those who had limitations at baseline, at least one-fifth get better. For those without limitations at baseline, one-seventeenth to two-fifths get worse. Difficulties in walking and doing heavy housework were the most common, most likely to develop, and least likely to resolve of any of the ADL or IADL items, and lower body limitations were more common, more likely to develop, and less likely to resolve than upper body limitations. Linear panel analysis of the five summary scales indicates that the top predictors of increased functional limitation are baseline levels of functional limitation, older age, decedent status, and poorer perceived health (in that order). Other less consistent and less robust predictors include the length of the exposure window, being female, having a history of arthritis, lower educational attainment, having fewer nonkin social supports, higher prior physician visit levels, and not living alone.

A MEASUREMENT MODEL OF THE MEDICAL OUTCOMES STUDY 36-ITEM SHORT-FORM HEALTH SURVEY IN A CLINICAL SAMPLE OF DISADVANTAGED, OLDER, BLACK, AND WHITE MEN AND WOMEN

The authors assess the factorial validity of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) for use in a clinical sample of disadvantaged, older adults with significant comorbidities. Confirmatory factor analysis was performed using LISREL VIII on data obtained from baseline face-to-face interviews with a clinical sample of 1,051 patients who were at risk for acute deterioration of their clinical condition due either to their age alone (75 years or older), or to their age (50 to 74 years old) and major comorbid conditions. An acceptable eight-factor measurement model reflecting the original specification (ie, subscales) of the SF-36 was obtained (chi-square to degrees of freedom ratio = 2.14; root mean squared residual = .055; adjusted goodness of fit index = .90). That model, however, required relaxing the assumptions associated with seven correlated error terms. Moreover, an alternative nine-factor model that allowed the ¿getting sick¿ and ¿getting worse¿ items to form their own factor, labeled ¿health optimism,¿ fit the data significantly better (8 degrees of freedom chi-square improvement = 61; P< 0.0001). Although continued use of the SF-36 in older, disadvantaged, clinical samples is appropriate, further assessment of the underlying measurement model in other samples using confirmatory factor analytic techniques is needed to resolve the issue of correlated error structures and the existence of the health optimism factor.