TY - JOUR T1 - Association of Social Support With Functional Outcomes in Older Adults Who Live Alone. JF - JAMA Internal Medicine Y1 - 2022 A1 - Sachin J Shah A1 - Margaret C Fang A1 - Wannier, S Rae A1 - Michael A Steinman A1 - Kenneth E Covinsky KW - health outcomes KW - Social Support AB -

Importance: Older adults who live alone are at risk for poor health outcomes. Whether social support mitigates the risk of living alone, particularly when facing a sudden change in health, has not been adequately reported.

Objective: To assess if identifiable support buffers the vulnerability of a health shock while living alone.

Design, Setting, and Participants: In this longitudinal, prospective, nationally representative cohort study from the Health and Retirement Study (enrollment March 2006 to April 2015), 4772 community-dwelling older adults 65 years or older who lived alone in the community and could complete activities of daily living (ADLs) and instrumental ADLs independently were followed up biennially through April 2018. Statistical analysis was completed from May 2020 to March 2021.

Exposures: Identifiable support (ie, can the participant identify a relative/friend who could help with personal care if needed), health shock (ie, hospitalization, new diagnosis of cancer, stroke, heart attack), and interaction (multiplicative and additive) between the 2 exposures.

Main Outcomes and Measures: The primary outcomes were incident ADL dependency, prolonged nursing home stay (≥30 days), and death.

Results: Of 4772 older adults (median [IQR] age, 73 [68-81] years; 3398 [71%] women) who lived alone, at baseline, 1813 (38%) could not identify support, and 3013 (63%) experienced a health shock during the study. Support was associated with a lower risk of a prolonged nursing home stay at 2 years (predicted probability, 6.7% vs 5.2%; P = .002). Absent a health shock, support was not associated with a prolonged nursing home stay (predicted probability over 2 years, 1.9% vs 1.4%; P = .21). However, in the presence of a health shock, support was associated with a lower risk of a prolonged nursing home stay (predicted probability over 2 years, 14.2% vs 10.9%; P = .002). Support was not associated with incident ADL dependence or death.

Conclusions and Relevance: In this longitudinal cohort study among older adults who live alone, identifiable support was associated with a lower risk of a prolonged nursing home stay in the setting of a health shock.

VL - 182 IS - 1 ER - TY - JOUR T1 - Association of Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention With Memory Decline in Older Adults Undergoing Coronary Revascularization JF - JAMA Y1 - 2021 A1 - Elizabeth L Whitlock A1 - L Grisell Diaz-Ramirez A1 - Alexander K Smith A1 - W John Boscardin A1 - Kenneth E Covinsky A1 - Michael S. Avidan A1 - M. Maria Glymour KW - cardiology KW - cardiothoracic surgery KW - ischemic heart disease AB - It is uncertain whether coronary artery bypass grafting (CABG) is associated with cognitive decline in older adults compared with a nonsurgical method of coronary revascularization (percutaneous coronary intervention [PCI]).To compare the change in the rate of memory decline after CABG vs PCI.Retrospective cohort study of community-dwelling participants in the Health and Retirement Study, who underwent CABG or PCI between 1998 and 2015 at age 65 years or older. Data were modeled for up to 5 years preceding and 10 years following revascularization or until death, drop out, or the 2016-2017 interview wave. The date of final follow-up was November 2017.CABG (including on and off pump) or PCI, ascertained from Medicare fee-for-service billing records.The primary outcome was a summary measure of cognitive test scores and proxy cognition reports that were performed biennially in the Health and Retirement Study, referred to as memory score, normalized as a z score (ie, mean of 0, SD of 1 in a reference population of adults aged ≥72 years). Memory score was analyzed using multivariable linear mixed-effects models, with a prespecified subgroup analysis of on-pump and off-pump CABG. The minimum clinically important difference was a change of 1 SD of the population-level rate of memory decline (0.048 memory units/y).Of 1680 participants (mean age at procedure, 75 years; 41% female), 665 underwent CABG (168 off pump) and 1015 underwent PCI. In the PCI group, the mean rate of memory decline was 0.064 memory units/y (95% CI, 0.052 to 0.078) before the procedure and 0.060 memory units/y (95% CI, 0.048 to 0.071) after the procedure (within-group change, 0.004 memory units/y [95% CI, −0.010 to 0.018]). In the CABG group, the mean rate of memory decline was 0.049 memory units/y (95% CI, 0.033 to 0.065) before the procedure and 0.059 memory units/y (95% CI, 0.047 to 0.072) after the procedure (within-group change, −0.011 memory units/y [95% CI, −0.029 to 0.008]). The between-group difference-in-differences estimate for memory decline for PCI vs CABG was 0.015 memory units/y (95% CI, −0.008 to 0.038; P = .21). There was statistically significant increase in the rate of memory decline after off-pump CABG compared with after PCI (difference-in-differences: mean increase in the rate of decline of 0.046 memory units/y [95% CI, 0.008 to 0.084] after off-pump CABG), but not after on-pump CABG compared with PCI (difference-in-differences: mean slowing of decline of 0.003 memory units/y [95% CI, −0.024 to 0.031] after on-pump CABG).Among older adults undergoing coronary revascularization with CABG or PCI, the type of revascularization procedure was not significantly associated with differences in the change of rate of memory decline. VL - 325 SN - 0098-7484 IS - 19 ER - TY - JOUR T1 - Advance Care Planning Prior to Death in Older Adults with Hip Fracture JF - Journal of General Internal Medicine Y1 - 2020 A1 - Kata, Anna A1 - Irena Cenzer A1 - Rebecca L. Sudore A1 - Kenneth E Covinsky A1 - Victoria L. Tang KW - Advance care planning KW - advance directive KW - Hip fracture KW - Older Adults KW - surrogate decision-making AB - Background Although hip fractures in older adults are associated with a high degree of mortality and disability, the use of advance care planning (ACP) in this population is unknown. Objective To determine the prevalence of ACP and need for surrogate decision-making prior to death in older adults with hip fracture and to identify factors associated with ACP. Design Retrospective cohort study using Health and Retirement Study (HRS) interviews linked to Medicare fee-for-service claims data. Participants Six hundred six decedent participants aged 65 or older who sustained a hip fracture during HRS enrollment and had a proxy participate in the exit HRS survey. Main Measures Survey responses by proxies were used to determine ACP, defined by either advance directive completion or surrogate designation, and to assess decision-making at the end of life. Multivariate logistic regression was used to analyze correlates of ACP. Key Results Prior to death, 54.9% of all participants had an advance directive and 68.9% had designated a surrogate decision-maker; however, 24.5% had no ACP. Of the total cohort, 32.5% required decisions to be made about treatment at the end of life and lacked capacity to make these decisions themselves. In this subset, 19.9% had no ACP. In all participants, ACP was less likely in non-white individuals (adjusted odds ratio (aOR) 0.14, 95% CI 0.06–0.31), those with less than a high school education (aOR 0.58, 95% CI 0.35–0.97), and those with a net worth below the median of the cohort (aOR 0.49, 95% CI 0.26–0.72). No clinical factors were found to be associated with ACP completion prior to death. Conclusions A considerable number of older adults with hip fracture required surrogate decision-making at the end of life, of whom one fifth had no ACP prior to death. Clinicians providing care for these patients are uniquely poised to address ACP. SN - 1525-1497 JO - Journal of General Internal Medicine ER - TY - JOUR T1 - Association of Functional, Cognitive, and Psychological Measures With 1-Year Mortality in Patients Undergoing Major Surgery JF - JAMA Surgery Y1 - 2020 A1 - Victoria L. Tang A1 - Jing, Bocheng A1 - W John Boscardin A1 - Ngo, Sarah A1 - Silvestrini, Molly A1 - Finlayson, Emily A1 - Kenneth E Covinsky KW - Cognition KW - Mortality KW - Surgery AB - More older adults are undergoing major surgery despite the greater risk of postoperative mortality. Although measures, such as functional, cognitive, and psychological status, are known to be crucial components of health in older persons, they are not often used in assessing the risk of adverse postoperative outcomes in older adults.To determine the association between measures of physical, cognitive, and psychological function and 1-year mortality in older adults after major surgery.Retrospective analysis of a prospective cohort study of participants 66 years or older who were enrolled in the nationally representative Health and Retirement Study and underwent 1 of 3 types of major surgery.Major surgery, including abdominal aortic aneurysm repair, coronary artery bypass graft, and colectomy.Our outcome was mortality within 1 year of major surgery. Our primary associated factors included functional, cognitive, and psychological factors: dependence in activities of daily living (ADL), dependence in instrumental ADL, inability to walk several blocks, cognitive status, and presence of depression. We adjusted for other demographic and clinical predictors.Of 1341 participants, the mean (SD) participant age was 76 (6) years, 737 (55\%) were women, 99 (7\%) underwent abdominal aortic aneurysm repair, 686 (51\%) coronary artery bypass graft, and 556 (42\%) colectomy; 223 (17\%) died within 1 year of their operation. After adjusting for age, comorbidity burden, surgical type, sex, race/ethnicity, wealth, income, and education, the following measures were significantly associated with 1-year mortality: more than 1 ADL dependence (29\% vs 13\%; adjusted hazard ratio [aHR], 2.76; P = .001), more than 1 instrumental ADL dependence (21\% vs 14\%; aHR, 1.32; P = .05), the inability to walk several blocks (17\% vs 11\%; aHR, 1.64; P = .01), dementia (21\% vs 12\%; aHR, 1.91; P = .03), and depression (19\% vs 12\%; aHR, 1.72; P = .01). The risk of 1-year mortality increased within the increasing risk factors present (0 factors: 10.0\%; 1 factor: 16.2\%; 2 factors: 27.8\%).In this older adult cohort, 223 participants (17\%) who underwent major surgery died within 1 year and poor function, cognition, and psychological well-being were significantly associated with mortality. Measures in function, cognition, and psychological well-being need to be incorporated into the preoperative assessment to enhance surgical decision-making and patient counseling. UR - https://jamanetwork.com/journals/jamasurgery/article-abstract/2762522 ER - TY - JOUR T1 - Assessing Risk for Adverse Outcomes in Older Adults: The Need to Include Both Physical Frailty and Cognition. JF - Journal of the American Geriatrics Society Y1 - 2019 A1 - Márlon J. R. Aliberti A1 - Irena Cenzer A1 - Alexander K Smith A1 - Sei J. Lee A1 - Kristine Yaffe A1 - Kenneth E Covinsky KW - Cognition & Reasoning KW - Frailty KW - Risk Factors AB -

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's concordance [C], 0.74 vs 0.71; P < .001) and death (Harrell'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.

VL - 67 IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/30468258?dopt=Abstract ER - TY - JOUR T1 - Association between persistent pain and memory decline and dementia in a longitudinal cohort of elders JF - JAMA Internal Medicine Y1 - 2017 A1 - Elizabeth L Whitlock A1 - L Grisell Diaz-Ramirez A1 - M. Maria Glymour A1 - W John Boscardin A1 - Kenneth E Covinsky KW - Chronic pain KW - Cognitive Ability KW - Memory AB - Importance: Chronic pain is common among the elderly and is associated with cognitive deficits in cross-sectional studies; the population-level association between chronic pain and longitudinal cognition is unknown. Objective: To determine the population-level association between persistent pain, which may reflect chronic pain, and subsequent cognitive decline. Design, Setting, and Participants: Cohort study with biennial interviews of 10 065 community-dwelling older adults in the nationally representative Health and Retirement Study who were 62 years or older in 2000 and answered pain and cognition questions in both 1998 and 2000. Data analysis was conducted between June 24 and October 31, 2016. Exposures: “Persistent pain,” defined as a participant reporting that he or she was often troubled with moderate or severe pain in both the 1998 and 2000 interviews. Main Outcomes and Measures: Coprimary outcomes were composite memory score and dementia probability, estimated by combining neuropsychological test results and informant and proxy interviews, which were tracked from 2000 through 2012. Linear mixed-effects models, with random slope and intercept for each participant, were used to estimate the association of persistent pain with slope of the subsequent cognitive trajectory, adjusting for demographic characteristics and comorbidities measures in 2000 and applying sampling weights to represent the 2000 US population. We hypothesized that persistent pain would predict accelerated memory decline and increased probability of dementia. To quantify the impact of persistent pain on functional independence, we combined our primary results with information on the association between memory and ability to manage medications and finances independently. Results: Of the 10,065 eligible HRS sample members, 60% were female, and median baseline age was 73 years (interquartile range, 67-78 years). At baseline, persistent pain affected 10.9% of participants and was associated with worse depressive symptoms and more limitations in activities of daily living. After covariate adjustment, persistent pain was associated with 9.2% (95% CI, 2.8%-15.0%) more rapid memory decline compared with those without persistent pain. After 10 years, this accelerated memory decline implied a 15.9% higher relative risk of inability to manage medications and an 11.8% higher relative risk of inability to manage finances independently. Adjusted dementia probability increased 7.7% faster (95% CI, 0.55%-14.2%); after 10 years, this translates to an absolute 2.2% increase in dementia probability for those with persistent pain. Conclusions and Relevance: Persistent pain was associated with accelerated memory decline and increased probability of dementia. VL - 177 UR - https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2629448 IS - 8 ER - TY - JOUR T1 - Additive effects of cognitive function and depressive symptoms on mortality in elderly community-living adults. JF - J Gerontol A Biol Sci Med Sci Y1 - 2003 A1 - Kala M. Mehta A1 - Kristine Yaffe A1 - Kenneth M. Langa A1 - Laura Sands A1 - Whooley, Mary A1 - Kenneth E Covinsky KW - Aged KW - Cognition KW - depression KW - Female KW - Humans KW - Male KW - Mortality KW - Proportional Hazards Models KW - Risk Factors AB -

BACKGROUND: Poor cognitive function and depressive symptoms are common in the elderly, frequently coexist, and are interrelated. Both risk factors are independently associated with mortality. Few studies have comprehensively described how the combination of poor cognitive function and depressive symptoms affect the risk for mortality. Our aim was to examine whether the combination of varying levels of cognitive function and depressive symptoms affect the risk of mortality in community-living elderly adults.

METHODS: We studied 6301 elderly adults (mean age, 77 years; 62% women; 81% white) enrolled in the Asset and Health Dynamics Among the Oldest Old (AHEAD) study, a prospective study of community-living participants conducted from 1993 to 1995. Cognitive function and depressive symptoms were measured using two validated measures developed for the AHEAD study. On each measure, participants were divided into tertiles representing the best, middle, and worst scores, and then placed into one of nine mutually exclusive groups ranging from best functioning on both measures to worst functioning on both measures. Mortality rates were assessed in each of the nine groups. Cox proportional hazards models were used to control for potentially confounding characteristics such as demographics, education, income, smoking, alcohol consumption, comorbidity, and baseline functional impairment.

RESULTS: During 2 years of follow-up, 9% (548) of the participants died. Together, cognitive function and depressive symptoms differentiated between elderly adults at markedly different risk for mortality, ranging from 3% in those with the best function on both measures to 16% in those with the worst function on both measures (p <.001). Furthermore, for each level of cognitive function, more depressive symptoms were associated with higher mortality rates, and for each level of depressive symptoms, worse cognitive function was associated with higher mortality rates. In participants with the best cognitive function, mortality rates were 3%, 5%, and 9% in participants with low, middle, and high depressive symptoms, respectively (p <.001 for trend). The corresponding rates were 6%, 7%, and 12% in participants with the middle level of cognitive function (p <.001 for trend), and 10%, 13%, and 16% in participants with the worst level of cognitive function (p <.001 for trend). After adjustment for confounders, participants with the worst function on both measures remained at considerably higher risk for death than participants with the best function on both measures (adjusted hazard ratio, 3.1; 95% confidence interval, 2.0-4.7).

CONCLUSIONS: Cognitive function and depressive symptoms can be used together to stratify elderly adults into groups that have significantly different rates of death. These two risk factors are associated with an increased risk in mortality in a progressive, additive manner.

PB - 58A VL - 58 IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/12730257?dopt=Abstract U4 - Cognitive Function/Depressive Symptoms/Mortality ER -