William W. Hung

Recent trends in chronic disease, impairment and disability among older adults in the United States

BackgroundTo examine concurrent prevalence trends of chronic disease, impairment and disability among older adults.MethodsWe analyzed the 1998, 2004 and 2008 waves of the Health and Retirement Study, a nationally representative survey of older adults in the United States, and included 31,568 community dwelling adults aged 65 and over. Measurements include: prevalence of chronic diseases including hypertension, heart disease, stroke, diabetes, cancer, chronic lung disease and arthritis; prevalence of impairments, including impairments of cognition, vision, hearing, mobility, and urinary incontinence; prevalence of disability, including activities of daily living (ADLs) and instrumental activities of daily living (IADLs).ResultsThe proportion of older adults reporting no chronic disease decreased from 13.1% (95% Confidence Interval [CI], 12.4%-13.8%) in 1998 to 7.8% (95% CI, 7.2%-8.4%) in 2008, whereas the proportion reporting 1 or more chronic diseases increased from 86.9% (95% CI, 86.2%-89.6%) in 1998 to 92.2% (95% CI, 91.6%-92.8%) in 2008. In addition, the proportion reporting 4 or more diseases increased from 11.7% (95% CI, 11.0%-12.4%) in 1998 to 17.4% (95% CI, 16.6%-18.2%) in 2008. The proportion of older adults reporting no impairments was 47.3% (95% CI, 46.3%-48.4%) in 1998 and 44.4% (95% CI, 43.3%-45.5%) in 2008, whereas the proportion of respondents reporting 3 or more was 7.2% (95% CI, 6.7%-7.7%) in 1998 and 7.3% (95% CI, 6.8%-7.9%) in 2008. The proportion of older adults reporting any ADL or IADL disability was 26.3% (95% CI, 25.4%-27.2%) in 1998 and 25.4% (95% CI, 24.5%-26.3%) in 2008.ConclusionsMultiple chronic disease is increasingly prevalent among older U.S. adults, whereas the prevalence of impairment and disability, while substantial, remain stable.

Cognitive Decline among Patients with Chronic Obstructive Pulmonary Disease

RATIONALE Prior research has suggested an association between chronic obstructive pulmonary disease (COPD) and the development of cognitive decline; however, these studies have been cross-sectional or small case series. OBJECTIVES To determine whether COPD increases the risk of cognitive decline among older adults surveyed in a large, population-based longitudinal cohort. METHODS We included data from the 1996 to 2002 waves of the Health and Retirement Study, a biennial nationally representative survey. We studied respondents who completed cognitive testing in 1996 and at least one subsequent survey, and excluded those with unknown history of COPD. Clinical history of COPD was based on self-report; severity was categorized based on use of oxygen or disease-related activity limitations. Our primary outcome was cognitive performance, measured using a validated 35-point scale. We examined the effect of COPD on cognition using multivariable mixed linear models accounting for repeated measurements, adjusted for sociodemographic and clinical characteristics. MEASUREMENTS AND MAIN RESULTS A total of 4,150 adults were included in our study. Among them, 12% reported a history of COPD (29% severe, 71% nonsevere disease). On repeated measurement, mean cognition scores of older adults with both severe and nonsevere COPD were significantly lower when compared with adults without COPD (2.6 points [P < 0.001] and 0.9 points [P < 0.001], respectively). After multivariable adjustment, mean scores of adults with severe COPD remained lower (0.9 point [P < 0.001]), whereas mean score of adults with nonsevere COPD was no longer different (P = 0.39) when compared with adults without COPD. CONCLUSIONS Severe COPD was associated with lower cognitive performance on standardized measurement over time.

Hip Fracture Management Tailoring Care for the Older Patient

Hip fracture is a potentially devastating condition for older adults. Hip fracture leads to pain and immobilization with complications ranging from delirium to functional loss and death. Although a mainstay of treatment is orthopedic repair, a multidisciplinary comanagement approach, including medical specialists and rehabilitation, may maximize patient recovery. Using the case of Mr W, an older man who sustained a fall and hip fracture, we present evidence-based components of care both in the hospital and outpatient settings. Preoperatively, clinicians should correct medical abnormalities and consider the appropriateness, timing, and type of surgical repair in the context of the patients life expectancy and goals of care. Perioperative care should include prophylaxis with antibiotics, chemoprophylaxis for venous thromboembolism, and correction of major clinical abnormalities prior to surgery. Pain control, delirium, and pressure ulcer prevention are important inpatient care elements. Multidisciplinary models incorporating these care elements can decrease complications during inpatient stay. Rehabilitation strategies should be tailored to patient needs; early mobilization followed by rehabilitation exercises in institutional, home, and group settings should be considered to maximize restoration of locomotive abilities. Attention to care transitions is necessary and treatment for osteoporosis should be considered. The road to recovery for hip fracture patients is long and most patients may not regain their prefracture functional status. Understanding and anticipating issues that may arise in the older patient with hip fracture, while delivering evidence-based care components, is necessary to maximize patient recovery.

Association of chronic diseases and impairments with disability in older adults: a decade of change?

Background:Little is known about how the relationship between chronic disease, impairment, and disability has changed over time among older adults. Objective:To examine how the associations of chronic disease and impairment with specific disability have changed over time. Research Design:Repeated cross-sectional analysis, followed by examining the collated sample using time interaction variables, of 3 recent waves of the Health and Retirement Study. Subjects:The subjects included 10,390, 10,621 and 10,557 community-dwelling adults aged 65 years and above in 1998, 2004, and 2008. Measurements:Survey-based history of chronic diseases including hypertension, heart disease, heart failure, stroke, diabetes, cancer, chronic lung disease, and arthritis; impairments, including cognition, vision, and hearing; and disability, including mobility, complex activities of daily living (ADL), and self-care ADL. Results:Over time, the relationship of chronic diseases and impairments with disability was largely unchanged; however, the association between hypertension and complex ADL disability weakened from 1998 to 2004 and 2008 [odds ratio (OR)=1.24; 99% confidence interval (CI), 1.06–1.46; OR=1.07; 99% CI, 0.90–1.27; OR=1.00; 99% CI, 0.83–1.19, respectively], as it did for hypertension and self-care disability (OR=1.32; 99% CI, 1.13–1.54; OR=0.97; 99% CI, 0.82–1.14; OR=0.99; 99% CI, 0.83–1.17). The association between diabetes and self-care disability strengthened from 1998 to 2004 and 2008 (OR=1.21; 99% CI, 1.01–1.46; OR=1.37; 99% CI, 1.15–1.64; OR=1.52; 99% CI, 1.29–1.79), as it also did for lung disease and self-care disability (OR=1.64; 99% CI, 1.33–2.03; OR=1.63; 99% CI, 1.32–2.01; OR=2.11; 99% CI, 1.73–2.57). Conclusions:Although relationships between diseases, impairments, and disability were largely unchanged, disability became less associated with hypertension and more with diabetes and lung disease.

Evaluation of the Mobile Acute Care of the Elderly (MACE) Service

IMPORTANCE Older adults are particularly vulnerable to adverse events during hospitalization for acute medical problems. The Mobile Acute Care of the Elderly (MACE) service is a novel model of care delivered by an interdisciplinary team, designed to deliver specialized care to hospitalized older adults to improve patient outcomes. OBJECTIVE To evaluate the impact of the MACE service when compared with general medical service (usual care). DESIGN Prospective, matched cohort study. SETTING The Mount Sinai Hospital, an urban tertiary acute care hospital. PARTICIPANTS Patients aged 75 years or older admitted because of an acute illness to either the MACE service or usual care. Patients were matched for age, diagnosis, and ability to ambulate independently. EXPOSURES Admission to the MACE service when compared with admission to usual care. MAIN OUTCOME MEASURES Patient outcomes included incidence of adverse events, including falls, pressure ulcers, restraint use, and catheter-associated urinary tract infections, along with length of stay, rehospitalization within 30 days, functional status at 30 days, and patient satisfaction during care transitions, measured with the 3-item Care Transition Measure. RESULTS A total of 173 matched pairs of patients were recruited. The mean (SD) age was 85.2 (5.3) and 84.7 (5.4) years in the MACE and usual-care groups, respectively. After adjustment for confounders, patients in the MACE group were less likely to experience adverse events (9.5% vs 17.0%; adjusted odds ratio, 0.11; 95% CI, 0.01-0.88; P = .04) and had shorter hospital stays (0.8 days, 95% CI, 0.7-0.9; P = .001) than patients receiving usual care. Patients in the MACE group were not less likely to have a lower rate of rehospitalization within 30 days than those in the usual-care group (odds ratio, 0.91; 95% CI, 0.39-2.10; P = .83). Functional status did not differ between the 2 groups. Care Transition Measure scores were 7.4 points (95% CI, 2.9-11.9; P = .001) higher in the MACE group. CONCLUSIONS AND RELEVANCE Admission to the MACE service was associated with lower rates of adverse events, shorter hospital stays, and better satisfaction. This model has the potential to improve care outcomes among hospitalized older adults. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00927160.

Delirium During Acute Illness in Nursing Home Residents

OBJECTIVES To ascertain the incidence of delirium during acute illness in nursing home residents, describe the timing of delirium after acute illness onset, describe risk factors for delirium, and explore the relationship between delirium and complications of acute illness. DESIGN Prospective observational cohort study. SETTING Three nursing homes in metropolitan New York. PARTICIPANTS Individuals who were expected to remain in the nursing home for at least 2 months, who, as part of a parent study, were receiving opioids, antidepressants, or antipsychotics on a routine basis, and who did not have an acute medical illness at the time of screening. Acute illness surveillance was performed twice weekly through communication with nursing home nursing staff and medical providers using established clinical criteria for incipient cases. MEASUREMENTS We followed patients for 14 days after illness onset, and, if applicable, an additional 14 days each after hospital admission and hospital discharge. Delirium was assessed 3 times weekly using the Confusion Assessment Method (CAM). Physical function decline was calculated using change in the Minimum Data Set Activities of Daily Living Scale (MDS-ADL) and cognitive function decline using change in the Minimum Data Set Cognitive performance scale (MDS-CPS). Falls were ascertained by record review. RESULTS Among 136 nursing home patients followed for a mean of 11.7 months, 78 experienced 232 acute illnesses, of which 162 (71%) were managed in the nursing home. The most common diagnoses were urinary tract infection (20%), cellulitis (15%), and lower respiratory tract infection (9%). Subjects experienced delirium during 41 (17.7%) of 232 acute illnesses. Female sex was associated with a greater risk of delirium (odds ratio 2.59; 95% confidence interval [CI] 1.04-6.43) but there were no other risk factors identified. Delirium was a risk factor for cognitive function decline (odds ratio 4.59; 95% CI 1.99-10.59; P = .0004), but not ADL function decline or falling. CONCLUSION Delirium occurred frequently as a complication of acute illness in the nursing home, and was a risk factor for cognitive function decline. This finding supports the rationale to target individuals at the onset of an acute medical problem in the design of interventions to prevent delirium in the nursing home setting.

Hip Fracture: A Complex Illness Among Complex Patients

In this issue, Vidaan and colleagues present data showing that in-hospital mortality and complications were not significantly associated with surgical delay of less than 120 hours after adjustment ...

A prospective study of symptoms, function, and medication use during acute illness in nursing home residents: design, rationale and cohort description

BackgroundNursing home residents are at high risk for developing acute illnesses. Compared with community dwelling adults, nursing home residents are often more frail, prone to multiple medical problems and symptoms, and are at higher risk for adverse outcomes from acute illnesses. In addition, because of polypharmacy and the high burden of chronic disease, nursing home residents are particularly vulnerable to disruptions in transitions of care such as medication interruptions in the setting of acute illness. In order to better estimate the effect of acute illness on nursing home residents, we have initiated a prospective cohort which will allow us to observe patterns of acute illnesses and the consequence of acute illnesses, including symptoms and function, among nursing home residents. We also aim to examine the patterns of medication interruption, and identify patient, provider and environmental factors that influence continuity of medication prescribing at different points of care transition.MethodsThis is a prospective cohort of nursing home residents residing in two nursing homes in a metropolitan area. Baseline characteristics including age, gender, race, and comorbid conditions are recorded. Participants are followed longitudinally for a planned period of 3 years. We record acute illness incidence and characteristics, and measure symptoms including depression, pain, withdrawal symptoms, and function using standardized scales.Results76 nursing home residents have been followed for a median of 666 days to date. At baseline, mean age of residents was 74.4 (± 11.9); 32% were female; 59% were white. The most common chronic conditions were dementia (41%), depression (38%), congestive heart failure (25%) and chronic obstructive lung disease (27%). Mean pain score was 4.7 (± 3.6) on a scale of 0 to 10; Geriatric Depression Scale (GDS-15) score was 5.2 (± 4.4). During follow up, 138 acute illness episodes were identified, for an incidence of 1.5 (SD 2.0) episodes per resident per year; 74% were managed in the nursing home and 26% managed in the acute care setting.ConclusionIn this report, we describe the conceptual model and methods of designing a longitudinal cohort to measure acute illness patterns and symptoms among nursing home residents, and describe the characteristics of our cohort at baseline. In our planned analysis, we will further estimate the effect of the use and interruption of medications on withdrawal and relapse symptoms and illness outcomes.

Enhancing the Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department (EQUiPPED): Preliminary Results from Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department, a Novel Multicomponent Interdisciplinary Quality Improvement Initiative

Suboptimal medication prescribing for older adults has been described in a number of emergency department (ED) studies. Despite this, few studies have examined ED‐targeted interventions aimed at reducing the use of potentially inappropriate medications (PIMs). Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the ED (EQUiPPED) is an ongoing multicomponent, interdisciplinary quality improvement initiative in eight Department of Veterans Affairs EDs. The project aims to decrease the use of PIMs, as identified by the Beers criteria, prescribed to veterans aged 65 and older at the time of ED discharge. Interventions include provider education; informatics‐based clinical decision support with electronic medical record–embedded geriatric pharmacy order sets and links to online geriatric content; and individual provider education including academic detailing, audit and feedback, and peer benchmarking. Poisson regression was used to compare the number of PIMs that staff providers prescribed to veterans aged 65 and older discharged from the ED before and after the initiation of the EQUiPPED intervention. Initial data from the first implementation site show that the average monthly proportion of PIMs that staff providers prescribed was 9.4 ± 1.5% before the intervention and 4.6 ± 1.0% after the initiation of EQUiPPED (relative risk = 0.48, 95% confidence interval = 0.40–0.59, P < .001). Preliminary evaluation demonstrated a significant and sustained reduction of ED‐prescribed PIMs in older veterans after implementation of EQUiPPED. Longer follow‐up and replication at collaborating sites would allow for an assessment of the effect on health outcomes and costs.

Predictors and outcomes of unplanned readmission to a different hospital

OBJECTIVES To examine patient, hospital and market factors and outcomes associated with readmission to a different hospital compared with the same hospital. DESIGN A population-based, secondary analysis using multilevel causal modeling. SETTING Acute care hospitals in California in the USA. PARTICIPANTS In total, 509 775 patients aged 50 or older who were discharged alive from acute care hospitals (index hospitalizations), and 59 566 who had a rehospitalization within 30 days following their index discharge. INTERVENTION No intervention. MAIN OUTCOME MEASURE(S) Thirty-day unplanned readmissions to a different hospital compared with the same hospital and also the costs and health outcomes of the readmissions. RESULTS Twenty-one percent of patients with a rehospitalization had a different-hospital readmission. Compared with the same-hospital readmission group, the different-hospital readmission group was more likely to be younger, male and have a lower income. The index hospitals of the different-hospital readmission group were more likely to be smaller, for-profit hospitals, which were also more likely to be located in counties with higher competition. The different-hospital readmission group had higher odds for in-hospital death (8.1 vs. 6.7%; P < 0.0001) and greater readmission hospital costs (