@article {12231, title = {Incidence of potentially disruptive medical and social events in older adults with and without dementia.}, journal = {Journal of the American Geriatrics Society}, volume = {70}, year = {2022}, pages = {1461-1470}, abstract = {

BACKGROUND: Potentially disruptive medical, surgical, and social events-such as pneumonia, hip fracture, and widowhood-may accelerate the trajectory of decline and impact caregiving needs in older adults, especially among people with dementia (PWD). Prior research has focused primarily on nursing home residents with dementia. We sought to assess the incidence of potentially disruptive events in community-dwelling people with and without dementia.

METHODS: Retrospective cohort study of participants aged 65+ enrolled in the Health and Retirement Study between 2010 and 2018 (n~=~9346), including a subset who were married-partnered at baseline (n~=~5105). Dementia was defined with a previously validated algorithm. We calculated age-adjusted and gender-stratified incidence per 1000 person-years and incidence rate ratios of: 1) hospitalization for pneumonia, 2) hip fracture, and 3) widowhood in people with and without dementia.

RESULTS: PWD (n~=~596) were older (mean age 84 vs. 75) and a higher proportion were female (67\% vs. 57\%) than people without dementia (PWoD) (n~=~8750). Age-adjusted incidence rates (per 1000 person-years) of pneumonia were higher in PWD (113.1; 95\% CI 94.3, 131.9) compared to PWoD (62.1; 95\% CI 54.7, 69.5), as were hip fractures (12.3; 95\% CI 9.1, 15.6 for PWD compared to 8.1; 95\% CI 6.9, 9.2 in PWoD). Point estimates of widowhood incidence were slightly higher for PWD (25.3; 95\% CI 20.1, 30.5) compared to PWoD (21.9; 95\% CI 20.3, 23.5), but differences were not statistically significant. The association of dementia with hip fracture-but not pneumonia or widowhood-was modified by gender (male incidence rate ratio [IRR] 2.24, 95\% CI 1.34, 3.75 versus female IRR 1.31 95\% CI 0.92,1.86); interaction term p~=~0.02).

CONCLUSIONS: Compared to PWoD, community-dwelling PWD had higher rates of pneumonia and hip fracture, but not widowhood. Knowing how often PWD experience these events can aid in anticipatory guidance and care planning for this growing population.

}, keywords = {Dementia, Hip fracture, Pneumonia, Widowhood}, issn = {1532-5415}, doi = {10.1111/jgs.17682}, author = {Hunt, Lauren J and R Sean Morrison and Gan, Siqi and Espejo, Edie and Katherine A Ornstein and W John Boscardin and Smith, Alexander K} } @article {doi:10.1111/jgs.16294, title = {Hospice Utilization in the United States: A Prospective Cohort Study Comparing Cancer and Noncancer Deaths}, journal = {Journal of the American Geriatrics Society}, volume = {68}, year = {2020}, pages = {783-793}, abstract = {OBJECTIVES Reliable national estimates of hospice use and underuse are needed. Additionally, drivers of hospice use in the United States are poorly understood, especially among noncancer populations. Thus the objectives of this study were to (1) provide reliable estimates of hospice use among adults in the United States; and (2) identify factors predicting use among decedents and within subsamples of cancer and noncancer deaths. DESIGN We conducted a prospective cohort study using the Health and Retirement Study survey. Excluding sudden deaths, we used data from the 2012 survey wave to predict hospice use in general, and then separately for cancer and non-cancer deaths. SETTING Study data were provided by a population-based sample of older adults from the U.S. PARTICIPANTS We constructed a sample of 1,209 participants who died between the 2012 and 2014 survey waves. MEASUREMENTS Hospice utilization was reported by proxy. Exposure variables included demographics, functionality (activities of daily living [ADLs]), health, depression, dementia, advance directives, nursing home residency, and cause of death. RESULTS Hospice utilization rate was 52.4\% for the sample with 70.8\% for cancer deaths and 45.4\% for noncancer deaths. Fully adjusted model results showed being older (odds ratio [OR] = 1.54), less healthy (OR = .79), having dementia (OR = 1.52), and having cancer (OR = 5.47) were linked to greater odds of receiving hospice. Among cancer deaths, being older (OR = 1.64) and female (OR = 2.54) were the only predictors of hospice use. Among noncancer deaths, increased age (OR = 1.58), more education (OR = 1.56), being widowed (OR = 1.55), needing help with ADLs (OR = 1.13), and poor health (OR = .77) were associated with hospice utilization. CONCLUSION Findings suggest hospice remains underutilized, especially among individuals with noncancer illness. Extrapolating results to the US population, we estimate that annually nearly a million individuals who are likely eligible for hospice die without its services. Most (84\%) of these decedents have a noncancer condition. Interventions are needed to increase appropriate hospice utilization, particularly in noncancer care settings.}, keywords = {End-of-life care, Health and Retirement Study, healthcare utilization, Hospice}, doi = {10.1111/jgs.16294}, url = {https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.16294}, author = {John G. Cagle and Lee, Joonyup and Katherine A Ornstein and Jack M. Guralnik} } @article {10064, title = {An examination of downstream effects of bereavement on healthcare utilization for surviving spouses in a national sample of older adults.}, journal = {Pharmacoeconomics}, volume = {37}, year = {2019}, month = {2019 Apr}, pages = {585-596}, abstract = {

BACKGROUND: While bereavement is associated with increased mortality, it is unclear how bereaved families utilize the healthcare system after the death of their loved ones.

OBJECTIVE: The aim of this study was to examine the association between bereavement and healthcare expenditures for surviving spouses.

METHODS: We used data from the Health and Retirement Study, a nationally representative cohort study of older adults linked to Medicare claims. We determined a spouse{\textquoteright}s total Medicare expenditures 2~years before and after their partner{\textquoteright}s death across six biennial interview waves. Using coarsened exact matching, we created a comparison group of non-bereaved dyads. Costs were wage index- and inflation-adjusted to 2017 dollars. We used generalized linear models and difference-in-differences (DID) analysis to calculate the average marginal effects of bereavement on Medicare spending by gender. We also examined subgroup differences based on caregiver status, cause of death, and length of terminal illness.

RESULTS: Our sample consisted of 941 bereaved dyads and a comparison group of 8899 matched dyads. Surviving female spouses (68\% of the sample) had a $3500 increase in spending 2~years after death (p < 0.05). Using DID analyses, bereavement was associated with a $625 quarterly increase in Medicare expenditures over 2~years for women. There was no significant increase in post-death spending for male bereaved surviving spouses. Results were consistent for spouses who survived at least 2~years after the death of their spouse (70\% of the sample) CONCLUSIONS: Bereavement is associated with increased healthcare spending for women regardless of their caregiving status, the cause of death, or length of terminal illness. Further study is required to examine why men and women have different patterns of healthcare spending relative to the death of their spouses.

}, keywords = {Bereavement, Health Services Utilization, Medicare claims, Medicare linkage, Medicare/Medicaid/Health Insurance, Widowhood}, issn = {1179-2027}, doi = {10.1007/s40273-019-00787-4}, author = {Katherine A Ornstein and Melissa M Garrido and Albert L Siu and Bollens-Lund, Evan and Rahman, Omari-Khalid and Amy Kelley} } @article {9553, title = {Impact of In-Hospital Death on Spending for Bereaved Spouses.}, journal = {Health Services Research}, volume = {53}, year = {2018}, pages = {2696-2717}, abstract = {

OBJECTIVE: To examine how patients{\textquoteright} location of death relates to health care utilization and spending for surviving spouses.

DATA SOURCES/STUDY SETTING: Health and Retirement Study (HRS) 2000-2012 linked to the Dartmouth Atlas and Medicare claims data.

STUDY DESIGN: This was an observational study. We matched bereaved spouses whose spouses died in a hospital to those whose spouses died outside the hospital using propensity scores based on decedent and spouse demographic and clinical characteristics, care preferences, and regional practice patterns.

DATA COLLECTION/EXTRACTION METHODS: We identified 1,348 HRS decedents with surviving spouses. We linked HRS data from each dyad with Medicare claims and regional characteristics.

PRINCIPAL FINDINGS: In multivariable models, bereaved spouses of decedents who died in the hospital had $3,106 higher Medicare spending 12~months postdeath (p~=~.04) compared to those whose spouses died outside a hospital. Those surviving spouses were also significantly more likely to have an ED visit (OR = 1.5; p~<~.01) and hospital admission (OR~= 1.4; p~=~.02) in the year after their spouse{\textquoteright}s in-hospital death. Increased Medicare spending for surviving spouses persisted through the 24-month period postdeath ($5,310; p~=~.02).

CONCLUSIONS: Bereaved spouses of decedents who died in the hospital had significantly greater Medicare spending and health care utilization themselves after their spouses{\textquoteright} death.

}, keywords = {Bereavement, End of life decisions, Medicare linkage, Medicare/Medicaid/Health Insurance}, issn = {1475-6773}, doi = {10.1111/1475-6773.12841}, author = {Katherine A Ornstein and Melissa M Garrido and Albert L Siu and Bollens-Lund, Evan and Kenneth M. Langa and Amy Kelley} } @article {8818, title = {The Use of Life-Sustaining Procedures in the Last Month of Life Is Associated With More Depressive Symptoms in Surviving Spouses.}, journal = {J Pain Symptom Manage}, volume = {53}, year = {2017}, month = {2017 02}, pages = {178-187.e1}, abstract = {

CONTEXT: Family caregivers of individuals with serious illness who undergo intensive life-sustaining medical procedures at the end of life may be at risk of negative consequences including depression.

OBJECTIVES: The objective of this study was to determine the association between patients{\textquoteright} use of life-sustaining procedures at the end of life and depressive symptoms in their surviving spouses.

METHODS: We used data from the Health and Retirement Study, a longitudinal survey of U.S. residents, linked to Medicare claims data. We included married Medicare beneficiaries aged 65~years and older who died between 2000 and 2011 (n~=~1258) and their surviving spouses. The use of life-sustaining procedures (i.e., intubation/mechanical ventilation, tracheostomy, gastrostomy tube insertion, enteral/parenteral nutrition, and cardiopulmonary resuscitation) in the last month of life was measured via claims data. Using propensity score matching, we compared change in depressive symptoms of surviving spouses.

RESULTS: Eighteen percent of decedents underwent one or more life-sustaining procedures in the last month of life. Those whose spouses underwent life-sustaining procedures had a 0.32-point increase in depressive symptoms after death (scale range~=~0-8) and a greater likelihood of clinically significant depression (odds ratio~=~1.51) compared with a matched sample of spouses of those who did not have procedures (P~<~0.05).

CONCLUSION: Surviving spouses of those who undergo intensive life-sustaining procedures at the end of life experience a greater magnitude of increase in depressive symptoms than those whose spouses do not undergo such procedures. Further study of the circumstances and decision making surrounding these procedures is needed to understand their relationship with survivors{\textquoteright} negative mental health consequences and how best to provide appropriate support.

}, keywords = {Aged, Aged, 80 and over, Caregivers, depression, Female, Humans, Intubation, Longitudinal Studies, Male, Mental Health, Respiration, Artificial, Spouses, Survivors, Terminal Care}, issn = {1873-6513}, doi = {10.1016/j.jpainsymman.2016.08.023}, url = {http://linkinghub.elsevier.com/retrieve/pii/S0885392416307850http://api.elsevier.com/content/article/PII:S0885392416307850?httpAccept=text/plainhttp://api.elsevier.com/content/article/PII:S0885392416307850?httpAccept=text/xml}, author = {Katherine A Ornstein and Melissa D. Aldridge and Melissa M Garrido and Rebecca Jean Gorges and Bollens-Lund, Evan and Albert L Siu and Kenneth M. Langa and Amy Kelley} } @article {8408, title = {Spousal Characteristics and Older Adults{\textquoteright} Hospice Use: Understanding Disparities in End-of-Life Care.}, journal = {J Palliat Med}, volume = {19}, year = {2016}, month = {2016 05}, pages = {509-15}, publisher = {19}, abstract = {

BACKGROUND: Hospice use has been shown to benefit quality of life for patients with terminal illness and their families, with further evidence of cost savings for Medicare and other payers. While disparities in hospice use by patient diagnosis, race, and region are well documented and attention to the role of family members in end-of-life decision-making is increasing, the influence of spousal characteristics on the decision to use hospice is unknown.

OBJECTIVES: To determine the association between spousal characteristics and hospice use.

DESIGN: We used data from the Health and Retirement Study (HRS), a prospective cohort study, linked to the Dartmouth Atlas of Health Care and Medicare claims.

SETTING: National study of 1567 decedents who were married or partnered at the time of death (2000-2011).

MEASURES: Hospice use at least 1 day in the last year of life as measured via Medicare claims data. Spousal factors (e.g., education and health status) measured via survey.

RESULTS: In multivariate models controlling for patient factors and regional variation, spouses with lower educational attainment than their deceased spouse had decreased likelihood of hospice use (odds ratio [OR] = 0.58; 95\% confidence interval [CI] = 0.40-0.82). Health of the spouse was not significantly associated with likelihood of decedent hospice use in adjusted models.

IMPLICATIONS: Although the health of the surviving spouse was not associated with hospice use, their educational level was a predictor of hospice use. Spousal and family characteristics, including educational attainment, should be examined further in relation to disparities in hospice use. Efforts to increase access to high-quality end-of-life care for individuals with serious illness must also address the needs and concerns of caregivers and family.

}, keywords = {Hospice Care, Hospices, Humans, Medicare, Prospective Studies, Quality of Life, Terminal Care, United States}, issn = {1557-7740}, doi = {10.1089/jpm.2015.0399}, url = {http://dx.doi.org/10.1089/jpm.2015.0399}, author = {Katherine A Ornstein and Melissa D. Aldridge and Christine A Mair and Rebecca Jean Gorges and Albert L Siu and Amy Kelley} } @article {8258, title = {Association Between Hospice Use and Depressive Symptoms in Surviving Spouses.}, journal = {JAMA Intern Med}, volume = {175}, year = {2015}, note = {10.1001/jamainternmed.2015.1722}, month = {2015 Jul}, pages = {1138-46}, publisher = {175}, abstract = {

IMPORTANCE: Family caregivers of individuals with serious illness are at risk for depressive symptoms and depression. Hospice includes the provision of support services for family caregivers, yet evidence is limited regarding the effect of hospice use on depressive symptoms among surviving caregivers.

OBJECTIVE: To determine the association between hospice use and depressive symptoms in surviving spouses.

DESIGN, SETTING, AND PARTICIPANTS: We linked data from the Health and Retirement Study, a nationally representative longitudinal survey of community-dwelling US adults 50 years or older, to Medicare claims. Participants included a propensity score-matched sample of 1016 Health and Retirement Study decedents with at least 1 serious illness and their surviving spouses interviewed between August 2002 and May 2011. We compared the spouses of individuals enrolled in hospice with the spouses of individuals who did not use hospice, performing our analysis between January 30, 2014, and January 16, 2015.

EXPOSURES: Hospice enrollment for at least 3 days in the year before death.

MAIN OUTCOMES AND MEASURES: Spousal depressive symptom scores measured 0 to 2 years after death with the Center for Epidemiologic Studies Depression Scale, which is scored from 0 (no symptoms) to 8 (severe symptoms).

RESULTS: Of the 1016 decedents in the matched sample, 305 patients (30.0\%) used hospice services for 3 or more days in the year before death. Of the 1016 spouses, 51.9\% had more depressive symptoms over time (mean [SD] change, 2.56 [1.65]), with no significant difference related to hospice use. A minority (28.2\%) of spouses of hospice users had improved Center for Epidemiologic Studies Depression Scale scores compared with 21.7\% of spouses of decedents who did not use hospice, although the difference was not statistically significant (P = .06). Among the 662 spouses who were the primary caregivers, 27.3\% of spouses of hospice users had improved Center for Epidemiologic Studies Depression Scale scores compared with 20.7\% of spouses of decedents who did not use hospice; the difference was not statistically significant (P = .10). In multivariate analysis, the odds ratio for the association of hospice enrollment with improved depressive symptoms after the spouse{\textquoteright}s death was 1.63 (95\% CI, 1.00-2.65).

CONCLUSIONS AND RELEVANCE: After bereavement, depression symptoms increased overall for surviving spouses regardless of hospice use. A modest reduction in depressive symptoms was more likely among spouses of hospice users than among spouses of nonhospice users.

}, keywords = {Aged, Aged, 80 and over, Caregivers, depression, Female, Hospice Care, Hospices, Humans, Male, Prospective Studies, Spouses, Survivors}, issn = {2168-6114}, doi = {10.1001/jamainternmed.2015.1722}, url = {http://dx.doi.org/10.1001/jamainternmed.2015.1722}, author = {Katherine A Ornstein and Melissa D. Aldridge and Melissa M Garrido and Rebecca Jean Gorges and Diane E Meier and Amy Kelley} }