@article {9922, title = {Assessing Risk for Adverse Outcomes in Older Adults: The Need to Include Both Physical Frailty and Cognition.}, journal = {Journal of the American Geriatrics Society}, volume = {67}, year = {2019}, pages = {477-483}, abstract = {

BACKGROUND: Physical frailty is a powerful tool for identifying nondisabled individuals at high risk of adverse outcomes. The extent to which cognitive impairment in those without dementia adds value to physical frailty in detecting high-risk individuals remains unclear.

OBJECTIVES: To estimate the effects of combining physical frailty and cognitive impairment without dementia (CIND) on the risk of basic activities of daily living (ADL) dependence and death over 8 years.

DESIGN: Prospective cohort study.

SETTING: The Health and Retirement Study (HRS).

PARTICIPANTS: A total of 7338 community-dwelling people, 65 years or older, without dementia and ADL dependence at baseline (2006-2008). Follow-up assessments occurred every 2 years until 2014.

MEASUREMENTS: The five components of the Cardiovascular Health Study defined physical frailty. A well-validated HRS method, including verbal recall, series of subtractions, and backward count task, assessed cognition. Primary outcomes were time to ADL dependence and death. Hazard models, considering death as a competing risk, associated physical frailty and CIND with outcomes after adjusting for sociodemographics, comorbidities, depression, and smoking status.

RESULTS: The prevalence of physical frailty was 15\%; CIND, 19\%; and both deficits, 5\%. In unadjusted and adjusted analyses, combining these factors identified older adults at an escalating risk for ADL dependence (no deficit = 14\% [reference group]; only CIND = 26\%, sub-hazard ratio [sHR] = 1.5, 95\% confidence interval [CI] = 1.3-1.8; only frail = 33\%, sHR = 1.7, 95\% CI = 1.4-2.0; both deficits = 46\%, sHR = 2.0, 95\%CI = 1.6-2.6) and death (no deficit = 21\%; only CIND = 41\%, HR = 1.6, 95\% CI = 1.4-1.9; only frail = 56\%, HR = 2.2, 95\% CI = 1.7-2.7; both deficits = 66\%, HR = 2.6, 95\% CI = 2.0-3.3) over 8-year follow-up. Adding the cognitive measure to models that already included physical frailty alone increased accuracy in identifying those at higher risk of ADL dependence (Harrell{\textquoteright}s concordance [C], 0.74 vs 0.71; P < .001) and death (Harrell{\textquoteright}s C, 0.70 vs 0.67; P < .001).

CONCLUSION: Physical frailty and CIND are independent predictors of incident disability and death. Because together physical frailty and CIND identify vulnerable older adults better, optimal risk assessment should supplement measures of physical frailty with measures of cognitive function.

}, keywords = {Cognition \& Reasoning, Frailty, Risk Factors}, issn = {1532-5415}, doi = {10.1111/jgs.15683}, author = {M{\'a}rlon J. R. Aliberti and Irena Cenzer and Alexander K Smith and Sei J. Lee and Kristine Yaffe and Kenneth E Covinsky} } @article {7821, title = {Advance care planning and the quality of end-of-life care in older adults.}, journal = {J Am Geriatr Soc}, volume = {61}, year = {2013}, note = {Times Cited: 0}, month = {2013 Feb}, pages = {209-14}, publisher = {61}, abstract = {

OBJECTIVES: To determine whether advance care planning influences quality of end-of-life care.

DESIGN: In this observational cohort study, Medicare data and survey data from the Health and Retirement Study (HRS) were combined to determine whether advance care planning was associated with quality metrics.

SETTING: The nationally representative HRS.

PARTICIPANTS: Four thousand three hundred ninety-nine decedent subjects (mean age 82.6 at death, 55\% women).

MEASUREMENTS: Advance care planning (ACP) was defined as having an advance directive (AD), durable power of attorney (DPOA) or having discussed preferences for end-of-life care with a next of kin. Outcomes included previously reported quality metrics observed during the last month of life (rates of hospital admission, in-hospital death, >14 days in the hospital, intensive care unit admission, >1 emergency department visit, hospice admission, and length of hospice <= 3 days).

RESULTS: Seventy-six percent of subjects engaged in ACP. Ninety-two percent of ADs stated a preference to prioritize comfort. After adjustment, subjects who engaged in ACP were less likely to die in a hospital (adjusted relative risk (aRR) = 0.87, 95\% confidence interval (CI) = 0.80-0.94), more likely to be enrolled in hospice (aRR = 1.68, 95\% CI = 1.43-1.97), and less likely to receive hospice for 3 days or less before death (aRR = 0.88, 95\% CI = 0.85-0.91). Having an AD, a DPOA or an ACP discussion were each independently associated with a significant increase in hospice use (P < .01 for all).

CONCLUSION: ACP was associated with improved quality of care at the end of life, including less in-hospital death and increased use of hospice. Having an AD, assigning a DPOA and conducting ACP discussions are all important elements of ACP.

}, keywords = {Adaptation, Psychological, Advance care planning, Aged, 80 and over, Female, Humans, Male, Quality of Life, Terminal Care, United States}, issn = {1532-5415}, doi = {10.1111/jgs.12105}, author = {Bischoff, Kara E and Rebecca L. Sudore and Yinghui Miao and W John Boscardin and Alexander K Smith} }