%0 Journal Article %J Circulation %D 2021 %T Long-Term Functional Outcomes in Older Adults After Hospitalization for Extracranial Hemorrhage %A Anna L Parks %A Sun Y Jeon %A John J Boscardin %A Michael A Steinman %A Alexander K Smith %A Margaret C Fang %A Kenneth E Covinsky %A Sachin J Shah %K anticoagulation %K antiplatelet drugs %K hemorrhage %X Introduction: Antiplatelet and anticoagulant medications often used to manage cardiovascular disease increase the risk of extracranial hemorrhage (ECH), such as gastrointestinal bleeding. There are few long-term data on the loss of function following ECH. This study’s goal was to measure the acute and persistent loss of independence in activities of daily living (ADLs) after ECH hospitalization. Methods: We used data from 1995-2015 from the Health and Retirement Study, a longitudinal, nationally representative survey of older Americans. We included subjects over age 65 who consented to Medicare linkage. We examined the association of ECH hospitalization with ability to perform all ADLs independently (walk across a room, dress, bathe, eat, toilet, get out of bed). To compare rates of ADL independence over time between those with ECH and a control group without ECH, we fit a logistic regression model that included an interaction term between ECH hospitalization and time and adjusted for comorbidities and sociodemographics. Results: In a cohort of 8950 with an average follow-up time of 7.3 years (65,335 person-years), 882 (10%) participants were hospitalized for ECH. Mean age was 78, and 59% were women. In the control group without ECH, the baseline rate of ADL independence declined by an average of 3.1% per year (average marginal effect [AME], 95% CI -3.1% to -3.3%). Assuming hospitalization for ECH at 5.2 years, the median time to ECH in this cohort, ECH was associated with an immediate decrease in ADL independence from 68% to 53% (AME -15%, 95% CI -11% to -18%). Following ECH, the average annual baseline rate of function loss did not change. Conclusions: In this nationally representative cohort, ECH hospitalization was associated with an immediate and pronounced decline in function that was equivalent to accelerating ADL disability by 5 years. After ECH, ADL independence continued to decline and did not recover to pre-ECH levels of independence over time. %B Circulation %V 144 %P A10778 %G eng %N Suppl _1 %R 10.1161/circ.144.suppl_1.10778 %0 Journal Article %J Journal of General Internal Medicine %D 2020 %T Who Becomes a High Utilizer? A Case-Control Study of Older Adults in the USA %A Smith, Grant M. %A Irena Cenzer %A Kenneth E Covinsky %A David B. Reuben %A Alexander K Smith %X Frequently hospitalized patients represent a high-cost population at risk of poor outcomes. These high-utilizers represent only 1.6% of admitted patients, but they account for 8% of admissions and 7% of direct costs.1,2 While prior studies have identified risk factors for 30-day readmissions,3 little is known about risk factors associated with patients who accrue multiple admissions over a longer period of time. Prior studies using cross-sectional analyses have also neglected to identify upstream risk factors for becoming a high-utilizer.3,4 Proactively identifying patients years before entering a cycle of frequent hospitalizations may allow for early intervention to prevent hospitalizations and improve outcomes. We sought to identify distinguishing comorbid conditions, functional limitations, and social risk factors that differentiate patients, who had 5 or more hospitalizations over a 2-year period, years before they became high-utilizers. %B Journal of General Internal Medicine %V 35 %P 596 - 598 %8 2020/02/01 %@ 1525-1497 %G eng %U https://doi.org/10.1007/s11606-019-05331-w %N 2 %! Journal of General Internal Medicine %0 Journal Article %J Journal of the American Geriatrics Society %D 2019 %T Assessing Risk for Adverse Outcomes in Older Adults: The Need to Include Both Physical Frailty and Cognition. %A Márlon J. R. Aliberti %A Irena Cenzer %A Alexander K Smith %A Sei J. Lee %A Kristine Yaffe %A Kenneth E Covinsky %K Cognition & Reasoning %K Frailty %K Risk Factors %X

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.

%B Journal of the American Geriatrics Society %V 67 %P 477-483 %G eng %N 3 %1 http://www.ncbi.nlm.nih.gov/pubmed/30468258?dopt=Abstract %R 10.1111/jgs.15683 %0 Journal Article %J American Journal of Hospital Palliative Care %D 2018 %T Relationship Between Expectation of Death and Location of Death Varies by Race/Ethnicity. %A Rafael D Romo %A Irena Cenzer %A Brie A Williams %A Alexander K Smith %K End of life decisions %K Mortality %K Racial/ethnic differences %K Subjective Expectations %X

BACKGROUND: Older black and Latino Americans are more likely than white Americans to die in the hospital. Whether ethnic differences in expectation of death account for this disparity is unknown.

OBJECTIVES: To determine whether surviving family members' expectation of death has a differential association with site of death according to race or ethnicity.

METHODS: We conducted an analysis of decedents from the Health and Retirement Study, a nationally representative study of US older adults. Telephone surveys were conducted with family members for 5979 decedents (decedents were 55% were women, 85% white, 9% black, and 6% Latino). The outcome of interest was death in the hospital; the predictor variable was race/ethnicity, and the intervening variable was expectation of death. Covariates included sociodemographics (gender, age, household net worth, educational attainment level, religion) and health factors (chronic conditions, symptoms, health-care utilization).

RESULTS: Decedents' race/ethnicity was statistically related to the expectation of death and death in the hospital. When death was not expected, whites and Latinos were more likely to die in the hospital than when death was expected (49% vs 29% for whites and 55% vs 37% for Latinos; P < .001). There was no difference in site of death according to family's expectation of death among blacks.

CONCLUSION: Expectation of death did not fully account for site of death and played a greater role among whites and Latinos than among black Americans. Discussing prognosis by itself is unlikely to address ethnic disparities. Other factors appear to play an important role as well.

%B American Journal of Hospital Palliative Care %G eng %1 http://www.ncbi.nlm.nih.gov/pubmed/29724110?dopt=Abstract %R 10.1177/1049909118773989 %0 Journal Article %J J Gen Intern Med %D 2017 %T Rates of Recovery to Pre-Fracture Function in Older Persons with Hip Fracture: an Observational Study. %A Victoria L. Tang %A Rebecca L. Sudore %A Irena Cenzer %A W John Boscardin %A Alexander K Smith %A Christine S Ritchie %A Margaret Wallhagen %A Finlayson, Emily %A Petrillo, Laura %A Kenneth E Covinsky %K Activities of Daily Living %K Age Factors %K Aged %K Aged, 80 and over %K Comorbidity %K Dementia %K Female %K Geriatric Assessment %K Hip Fractures %K Humans %K Longitudinal Studies %K Male %K Mobility Limitation %K Recovery of Function %K Walking %X

BACKGROUND: Knowledge about expected recovery after hip fracture is essential to help patients and families set realistic expectations and plan for the future.

OBJECTIVES: To determine rates of functional recovery in older adults who sustained a hip fracture based on one's previous function.

DESIGN: Observational study.

PARTICIPANTS: We identified subjects who sustained a hip fracture while enrolled in the nationally representative Health and Retirement Study (HRS) using linked Medicare claims. HRS interviews subjects every 2 years. Using information from interviews collected during the interview preceding the fracture and the first interview 6 or more months after the fracture, we determined the proportion of subjects who returned to pre-fracture function.

MAIN MEASURES: Functional outcomes of interest were: (1) ADL dependency, (2) mobility, and (3) stair-climbing ability. We examined baseline characteristics associated with a return to: (1) ADL independence, (2) walking one block, and (3) climbing a flight of stairs.

KEY RESULTS: A total of 733 HRS subjects ≥65 years of age sustained a hip fracture (mean age 84 ± 7 years, 77 % female). Thirty-one percent returned to pre-fracture ADL function, 34 % to pre-fracture mobility function, and 41 % to pre-fracture climbing function. Among those who were ADL independent prior to fracture, 36 % returned to independence, 27 % survived but needed ADL assistance, and 37 % died. Return to ADL independence was less likely for those ≥85 years old (26 % vs. 44 %), with dementia (8 % vs. 39 %), and with a Charlson comorbidity score >2 (23 % vs. 44 %). Results were similar for those able to walk a block and for those able to climb a flight of stairs prior to fracture.

CONCLUSIONS: Recovery rates are low, even among those with higher levels of pre-fracture functional status, and are worse for patients who are older, cognitively impaired, and who have multiple comorbidities.

%B J Gen Intern Med %V 32 %P 153-158 %8 2017 Feb %G eng %N 2 %1 http://www.ncbi.nlm.nih.gov/pubmed/27605004?dopt=Abstract %R 10.1007/s11606-016-3848-2 %0 Journal Article %J JAMA Intern Med %D 2013 %T Disability during the last two years of life. %A Alexander K Smith %A Louise C Walter %A Yinghui Miao %A W John Boscardin %A Kenneth E Covinsky %K Activities of Daily Living %K Aged %K Aged, 80 and over %K Disability Evaluation %K Disabled Persons %K Educational Status %K Female %K Frail Elderly %K Humans %K Income %K Longitudinal Studies %K Male %K Marital Status %K Middle Aged %K Prospective Studies %K Sex Distribution %K Socioeconomic factors %K United States %X

IMPORTANCE: Whereas many persons at advanced ages live independently and are free of disability, we know little about how likely older people are to be disabled in the basic activities of daily living that are necessary for independent living as they enter the last years of life.

OBJECTIVE: To determine national estimates of disability during the last 2 years of life.

DESIGN: Prospective cohort study.

SETTING: A nationally representative study of older adults in the United States.

PARTICIPANTS: Participants 50 years and older who died while enrolled in the Health and Retirement Study between 1995 and 2010. Each participant was interviewed once at a varying time point in the last 24 months of life. We used these interviews to calculate national estimates of the prevalence of disability across the 2 years prior to death. We modeled the prevalence of disability in the 2 years prior to death for groups defined by age at death and sex.

MAIN OUTCOMES AND MEASURES: Disability was defined as need for help with at least 1 of the following activities of daily living: dressing, bathing, eating, transferring, walking across the room, and using the toilet.

RESULTS: There were 8232 decedents (mean [SD] age at death, 79 [11] years; 52% women). The prevalence of disability increased from 28% (95% CI, 24%-31%) 2 years before death to 56% (95% CI, 52%-60%) in the last month of life. Those who died at the oldest ages were much more likely to have disability 2 years before death (ages 50-69 years, 14%; 70-79 years, 21%; 80-89 years, 32%; 90 years or more, 50%; P for trend, <.001). Disability was more common in women 2 years before death (32% [95% CI, 28%-36%]) than men (21% [95% CI, 18%-25%]; P < .001), even after adjustment for older age at death.

CONCLUSIONS AND RELEVANCE: Those who live to an older age are likely to be disabled, and thus in need of caregiving assistance, many months or years prior to death. Women have a substantially longer period of end-of-life disability than men.

%B JAMA Intern Med %I 173 %V 173 %P 1506-13 %8 2013 Sep 09 %G eng %N 16 %1 http://www.ncbi.nlm.nih.gov/pubmed/23836120?dopt=Abstract %2 PMC3773297 %4 Medical Sciences/Older people/Disability/Disability/Palliative care/Aging/United States--US %$ 69096 %R 10.1001/jamainternmed.2013.8738 %0 Journal Article %J Health Aff (Millwood) %D 2012 %T Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there. %A Alexander K Smith %A Ellen P McCarthy %A Ellen Weber %A Irena Cenzer %A W John Boscardin %A Jonathan Fisher %A Kenneth E Covinsky %K Aged %K Aged, 80 and over %K Emergency Service, Hospital %K Female %K Hospital Mortality %K Hospitalization %K Humans %K Insurance Claim Review %K Male %K Terminal Care %K Terminally Ill %K United States %X

Emergency department use contributes to high end-of-life costs and is potentially burdensome for patients and family members. We examined emergency department use in the last months of life for patients age sixty-five or older who died while enrolled in a longitudinal study of older adults in the period 1992-2006. We found that 51 percent of the 4,158 [corrected] decedents visited the emergency department in the last month of life, and 75 percent in the last six months of life. Repeat visits were common. A total of 77 percent of the patients seen in the emergency department in the last month of life were admitted to the hospital, and 68 percent of those who were admitted died there. In contrast, patients who enrolled in hospice at least one month before death rarely visited the emergency department in the last month of life. Policies that encourage the preparation of patients and families for death and early enrollment in hospice may prevent emergency department visits at the end of life.

%B Health Aff (Millwood) %I 31 %V 31 %P 1277-85 %8 2012 Jun %G eng %N 6 %1 http://www.ncbi.nlm.nih.gov/pubmed/22665840?dopt=Abstract %2 PMC3736978 %4 elderly/Medicare/Primary Care/public policy/Health care policy/emergency department service use/emergency department service use %$ 69508 %R 10.1377/hlthaff.2011.0922 %0 Journal Article %J Ann Intern Med %D 2010 %T The epidemiology of pain during the last 2 years of life. %A Alexander K Smith %A Irena Cenzer %A Sara J Knight %A Kathleen A Puntillo %A Eric W Widera %A Brie A Williams %A W John Boscardin %A Kenneth E Covinsky %K Aged %K Aged, 80 and over %K Arthritis %K Chronic disease %K Cross-Sectional Studies %K Death %K Female %K Humans %K Male %K pain %K Palliative care %K Prevalence %K Quality of Life %K Socioeconomic factors %K Terminally Ill %K Time Factors %X

BACKGROUND: The epidemiology of pain during the last years of life has not been well described.

OBJECTIVE: To describe the prevalence and correlates of pain during the last 2 years of life.

DESIGN: Observational study. Data from participants who died while enrolled in the Health and Retirement Study were analyzed. The survey interview closest to death was used. Each participant or proxy was interviewed once in the last 24 months of life and was classified into 1 of 24 cohorts on the basis of the number of months between the interview and death. The relationship between time before death and pain was modeled and was adjusted for age, sex, race or ethnicity, education level, net worth, income, terminal diagnosis category, presence of arthritis, and proxy status.

SETTING: The Health and Retirement Study, a nationally representative survey of community-living older adults (1994 to 2006).

PARTICIPANTS: Older adult decedents.

MEASUREMENTS: Clinically significant pain, as indicated by a report that the participant was "often troubled" by pain of at least moderate severity.

RESULTS: The sample included 4703 decedents. Mean age (SD) of participants was 75.7 years (SD, 10.8); 83.1% were white, 10.7% were black, 4.7% were Hispanic; and 52.3% were men. The adjusted prevalence of pain 24 months before death was 26% (95% CI, 23% to 30%). The prevalence remained flat until 4 months before death (28% [CI, 25% to 32%]), then it increased, reaching 46% (CI, 38% to 55%) in the last month of life. The prevalence of pain in the last month of life was 60% among patients with arthritis versus 26% among patients without arthritis (P < 0.001) and did not differ by terminal diagnosis category (cancer [45%], heart disease [48%], frailty [50%], sudden death [42%], or other causes [47%]; P = 0.195).

LIMITATION: Data are cross-sectional; 19% of responses were from proxies; and information about cause, location, and treatment of pain was not available.

CONCLUSION: Although the prevalence of pain increases in the last 4 months of life, pain is present in more than one quarter of elderly persons during the last 2 years of life. Arthritis is strongly associated with pain at the end of life.

PRIMARY FUNDING SOURCE: National Institute on Aging, National Center for Research Resources, National Institute on Musculoskeletal and Skin Diseases, and National Palliative Care Research Center.

%B Ann Intern Med %I 153 %V 153 %P 563-9 %8 2010 Nov 02 %G eng %N 9 %1 http://www.ncbi.nlm.nih.gov/pubmed/21041575?dopt=Abstract %2 PMC3150170 %$ 23690 %R 10.7326/0003-4819-153-9-201011020-00005 %0 Journal Article %J J Am Geriatr Soc %D 2010 %T Length of stay for older adults residing in nursing homes at the end of life. %A Kelly, Anne %A Conell-Price, Jessamyn %A Kenneth E Covinsky %A Irena Cenzer %A Chang, Anna %A W John Boscardin %A Alexander K Smith %K Advance care planning %K Aged %K Aged, 80 and over %K Female %K Follow-Up Studies %K Humans %K Length of Stay %K Male %K Middle Aged %K Nursing homes %K Palliative care %K Retrospective Studies %K United States %X

OBJECTIVES: To describe lengths of stay of nursing home decedents.

DESIGN: Retrospective cohort study.

SETTING: The Health and Retirement Study (HRS), a nationally representative survey of U.S. adults aged 50 and older.

PARTICIPANTS: One thousand eight hundred seventeen nursing home residents who died between 1992 and 2006.

MEASUREMENTS: The primary outcome was length of stay, defined as the number of months between nursing home admission and date of death. Covariates were demographic, social, and clinical factors drawn from the HRS interview conducted closest to the date of nursing home admission.

RESULTS: The mean age of decedents was 83.3 ± 9.0; 59.1% were female, and 81.5% were white. Median and mean length of stay before death were 5 months (interquartile range 1-20) and 13.7 ± 18.4 months, respectively. Fifty-three percent died within 6 months of placement. Large differences in median length of stay were observed according to sex (men, 3 months vs women, 8 months) and net worth (highest quartile, 3 months vs lowest quartile, 9 months) (all P <.001). These differences persisted after adjustment for age, sex, marital status, net worth, geographic region, and diagnosed chronic conditions (cancer, hypertension, diabetes mellitus, lung disease, heart disease, and stroke).

CONCLUSION: Nursing home lengths of stay are brief for the majority of decedents. Lengths of stay varied markedly according to factors related to social support.

%B J Am Geriatr Soc %I 58 %V 58 %P 1701-6 %8 2010 Sep %G eng %N 9 %L newpubs20101012_Kelley.pdf %1 http://www.ncbi.nlm.nih.gov/pubmed/20738438?dopt=Abstract %2 PMC2945440 %4 nursing Homes/MORTALITY/death/health outcomes %$ 23590 %R 10.1111/j.1532-5415.2010.03005.x