%0 Journal Article %J JAMA Internal Medicine %D Forthcoming %T Development and External Validation of Models to Predict Need for Nursing Home Level of Care in Community-Dwelling Older Adults With Dementia. %A Deardorff, W James %A Jeon, Sun Y %A Barnes, Deborah E %A Boscardin, W John %A Kenneth M. Langa %A Covinsky, Kenneth E %A Mitchell, Susan L %A Lee, Sei J %A Smith, Alexander K %K Community-dwelling %K Dementia %K home care %K Nursing %X

IMPORTANCE: Most older adults living with dementia ultimately need nursing home level of care (NHLOC).

OBJECTIVE: To develop models to predict need for NHLOC among older adults with probable dementia using self-report and proxy reports to aid patients and family with planning and care management.

DESIGN, SETTING, AND PARTICIPANTS: This prognostic study included data from 1998 to 2016 from the Health and Retirement Study (development cohort) and from 2011 to 2019 from the National Health and Aging Trends Study (validation cohort). Participants were community-dwelling adults 65 years and older with probable dementia. Data analysis was conducted between January 2022 and October 2023.

EXPOSURES: Candidate predictors included demographics, behavioral/health factors, functional measures, and chronic conditions.

MAIN OUTCOMES AND MEASURES: The primary outcome was need for NHLOC defined as (1) 3 or more activities of daily living (ADL) dependencies, (2) 2 or more ADL dependencies and presence of wandering/need for supervision, or (3) needing help with eating. A Weibull survival model incorporating interval censoring and competing risk of death was used. Imputation-stable variable selection was used to develop 2 models: one using proxy responses and another using self-responses. Model performance was assessed by discrimination (integrated area under the receiver operating characteristic curve [iAUC]) and calibration (calibration plots).

RESULTS: Of 3327 participants with probable dementia in the Health and Retirement Study, the mean (SD) age was 82.4 (7.4) years and 2301 (survey-weighted 70%) were female. At the end of follow-up, 2107 participants (63.3%) were classified as needing NHLOC. Predictors for both final models included age, baseline ADL and instrumental ADL dependencies, and driving status. The proxy model added body mass index and falls history. The self-respondent model added female sex, incontinence, and date recall. Optimism-corrected iAUC after bootstrap internal validation was 0.72 (95% CI, 0.70-0.75) in the proxy model and 0.64 (95% CI, 0.62-0.66) in the self-respondent model. On external validation in the National Health and Aging Trends Study (n = 1712), iAUC in the proxy and self-respondent models was 0.66 (95% CI, 0.61-0.70) and 0.64 (95% CI, 0.62-0.67), respectively. There was excellent calibration across the range of predicted risk.

CONCLUSIONS AND RELEVANCE: This prognostic study showed that relatively simple models using self-report or proxy responses can predict need for NHLOC in community-dwelling older adults with probable dementia with moderate discrimination and excellent calibration. These estimates may help guide discussions with patients and families in future care planning.

%B JAMA Internal Medicine %G eng %R 10.1001/jamainternmed.2023.6548 %0 Journal Article %J JAMA Internal Medicine %D 2022 %T Development and External Validation of a Mortality Prediction Model for Community-Dwelling Older Adults With Dementia. %A Deardorff, W James %A Barnes, Deborah E %A Jeon, Sun Y %A Boscardin, W John %A Kenneth M. Langa %A Covinsky, Kenneth E %A Mitchell, Susan L %A Whitlock, Elizabeth L %A Smith, Alexander K %A Lee, Sei J %K community dwelling %K Dementia %K mortality risk %X

Importance: Estimating mortality risk in older adults with dementia is important for guiding decisions such as cancer screening, treatment of new and chronic medical conditions, and advance care planning.

Objective: To develop and externally validate a mortality prediction model in community-dwelling older adults with dementia.

Design, Setting, and Participants: This cohort study included community-dwelling participants (aged ≥65 years) in the Health and Retirement Study (HRS) from 1998 to 2016 (derivation cohort) and National Health and Aging Trends Study (NHATS) from 2011 to 2019 (validation cohort).

Exposures: Candidate predictors included demographics, behavioral/health factors, functional measures (eg, activities of daily living [ADL] and instrumental activities of daily living [IADL]), and chronic conditions.

Main Outcomes and Measures: The primary outcome was time to all-cause death. We used Cox proportional hazards regression with backward selection and multiple imputation for model development. Model performance was assessed by discrimination (integrated area under the receiver operating characteristic curve [iAUC]) and calibration (plots of predicted and observed mortality).

Results: Of 4267 participants with probable dementia in HRS, the mean (SD) age was 82.2 (7.6) years, 2930 (survey-weighted 69.4%) were female, and 785 (survey-weighted 12.1%) identified as Black. Median (IQR) follow-up time was 3.9 (2.0-6.8) years, and 3466 (81.2%) participants died by end of follow-up. The final model included age, sex, body mass index, smoking status, ADL dependency count, IADL difficulty count, difficulty walking several blocks, participation in vigorous physical activity, and chronic conditions (cancer, heart disease, diabetes, lung disease). The optimism-corrected iAUC after bootstrap internal validation was 0.76 (95% CI, 0.75-0.76) with time-specific AUC of 0.73 (95% CI, 0.70-0.75) at 1 year, 0.75 (95% CI, 0.73-0.77) at 5 years, and 0.84 (95% CI, 0.82-0.85) at 10 years. On external validation in NHATS (n = 2404), AUC was 0.73 (95% CI, 0.70-0.76) at 1 year and 0.74 (95% CI, 0.71-0.76) at 5 years. Calibration plots suggested good calibration across the range of predicted risk from 1 to 10 years.

Conclusions and Relevance: We developed and externally validated a mortality prediction model in community-dwelling older adults with dementia that showed good discrimination and calibration. The mortality risk estimates may help guide discussions regarding treatment decisions and advance care planning.

%B JAMA Internal Medicine %V 182 %P 1161-1170 %G eng %N 11 %R 10.1001/jamainternmed.2022.4326 %0 Journal Article %J J Psychosom Res %D 2014 %T Depression and risk of hospitalization for pneumonia in a cohort study of older Americans. %A Dimitry S Davydow %A Catherine L Hough %A Zivin, Kara %A Kenneth M. Langa %A Wayne J Katon %K Aged %K Aged, 80 and over %K Cohort Studies %K Comorbidity %K depression %K Depressive Disorder %K Female %K Hospitalization %K Humans %K Logistic Models %K Male %K Middle Aged %K Odds Ratio %K Pneumonia %K Risk Assessment %K Risk Factors %K United States %X

OBJECTIVE: The aim of this study is to determine if depression is independently associated with risk of hospitalization for pneumonia after adjusting for demographics, medical comorbidity, health-risk behaviors, baseline cognition and functional impairments.

METHODS: This secondary analysis of prospectively collected data examined a population-based sample of 6704 Health and Retirement Study (HRS) (1998-2008) participants>50years old who consented to have their interviews linked to their Medicare claims and were without a dementia diagnosis. The eight-item Center for Epidemiologic Studies Depression Scale and/or International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) depression diagnoses were used to identify baseline depression. ICD-9-CM diagnoses were used to identify hospitalizations for which the principal discharge diagnosis was for bacterial or viral pneumonia. The odds of hospitalization for pneumonia for participants with depression relative to those without depression were estimated using logistic regression models. Population attributable fractions were calculated to determine the extent that hospitalizations for pneumonia could be attributable to depression.

RESULTS: After adjusting for demographic characteristics, clinical factors, and health-risk behaviors, depression was independently associated with increased odds of hospitalization for pneumonia (odds ratio [OR]: 1.28, 95% confidence interval [95%CI]: 1.08, 1.53). This association persisted after adjusting for baseline cognition and functional impairments (OR: 1.24, 95%CI: 1.03, 1.50). In this cohort, 6% (95%CI: 2%, 10%) of hospitalizations for pneumonia were potentially attributable to depression.

CONCLUSION: Depression is independently associated with increased odds of hospitalization for pneumonia. This study provides additional rationale for integrating mental health care into medical settings in order to improve outcomes for older adults.

%B J Psychosom Res %I 77 %V 77 %P 528-34 %8 2014 Dec %G eng %N 6 %1 http://www.ncbi.nlm.nih.gov/pubmed/25139125?dopt=Abstract %2 PMC4259844 %4 Depression/Pneumonia/Hospitalization/Outcome assessment (health care)/health Care Utilization/mental Health %$ 999999 %R 10.1016/j.jpsychores.2014.08.002 %0 Journal Article %J Alzheimers Dement %D 2013 %T Dementia and out-of-pocket spending on health care services. %A Delavande, Adeline %A Michael D Hurd %A Martorell, Paco %A Kenneth M. Langa %K Aged %K Dementia %K Female %K Financing, Personal %K Health Expenditures %K Humans %K Male %X

BACKGROUND: High levels of out-of-pocket (OOP) spending for health care may lead patients to forego needed services and medications as well as hamper their ability to pay for other essential goods. Because it leads to disability and the loss of independence, dementia may put patients and their families at risk for high OOP spending, especially for long-term care services.

METHODS: We used data from the Aging, Demographics, and Memory Study, a nationally representative subsample (n = 743) of the Health and Retirement Study, to determine whether individuals with dementia had higher self-reported OOP spending compared with those with cognitive impairment without dementia and those with normal cognitive function. We also examined the relationship between dementia and utilization of dental care and prescription medications-two types of health care that are frequently paid for OOP. Multivariate and logistic regression models were used to adjust for the influence of potential confounders.

RESULTS: After controlling for demographics and comorbidities, those with dementia had more than three times the yearly OOP spending compared with those with normal cognition ($8216 for those with dementia vs. $2570 for those with normal cognition, P < .01). Higher OOP spending for those with dementia was mainly driven by greater expenditures on nursing home care (P < .01). Dementia was not associated with the likelihood of visiting the dentist (P = .76) or foregoing prescription medications owing to cost (P = .34).

CONCLUSIONS: Dementia is associated with high levels of OOP spending but not with the use of dental care or foregoing prescription medications, suggesting that excess OOP spending among those with dementia does not "crowd out" spending on these other health care services.

%B Alzheimers Dement %I 9 %V 9 %P 19-29 %8 2013 Jan %G eng %N 1 %1 http://www.ncbi.nlm.nih.gov/pubmed/23154049?dopt=Abstract %3 23154049 %4 Out of pocket costs/health Care/Long Term Care/Dementia/dental Care/COMORBIDITY/health care services %$ 69685 %R 10.1016/j.jalz.2011.11.003 %0 Journal Article %J Crit Care Med %D 2012 %T Depressive symptoms in spouses of older patients with severe sepsis. %A Dimitry S Davydow %A Catherine L Hough %A Kenneth M. Langa %A Theodore J Iwashyna %K Age Factors %K Aged %K depression %K Female %K Hospitalization %K Humans %K Male %K Multivariate Analysis %K Prospective Studies %K Psychiatric Status Rating Scales %K Sepsis %K Sex Factors %K Spouses %K Time Factors %K United States %X

OBJECTIVE: To examine whether spouses of patients with severe sepsis are at increased risk for depression independent of the spouse's presepsis history, whether this risk differs by sex, and is associated with a sepsis patient's disability after hospitalization.

DESIGN: Prospective longitudinal cohort study.

SETTING: Population-based cohort of U.S. adults over 50 yrs old interviewed as part of the Health and Retirement Study (1993-2008).

PATIENTS: Nine hundred twenty-nine patient-spouse dyads comprising 1,212 hospitalizations for severe sepsis.

MEASUREMENTS AND MAIN RESULTS: Severe sepsis was identified using a validated algorithm in Medicare claims. Depression was assessed with a modified version of the Center for Epidemiologic Studies Depression Scale. All analyses were stratified by gender. The prevalence of substantial depressive symptoms in wives of patients with severe sepsis increased by 14 percentage points at the time of severe sepsis (from 20% at a median of 1.1 yrs presepsis to 34% at a median of 1 yr postsepsis) with an odds ratio of 3.74 (95% confidence interval: 2.20, 6.37), in multivariable regression. Husbands had an 8 percentage point increase in the prevalence of substantial depressive symptoms, which was not significant in multivariable regression (odds ratio 1.90, 95% confidence interval 0.75, 4.71). The increase in depression was not explained by bereavement; women had greater odds of substantial depressive symptoms even when their spouse survived a severe sepsis hospitalization (odds ratio 2.86, 95% confidence interval 1.06, 7.73). Wives of sepsis survivors who were disabled were more likely to be depressed (odds ratio 1.35 per activities of daily living limitation of sepsis survivor, 95% confidence interval 1.12, 1.64); however, controlling for patient disability only slightly attenuated the association between sepsis and wives' depression (odds ratio 2.61, 95% confidence interval 0.93, 7.38).

CONCLUSIONS: Older women may be at greater risk for depression if their spouse is hospitalized for severe sepsis. Spouses of patients with severe sepsis may benefit from greater support and depression screening, both when their loved one dies and when their loved one survives.

%B Crit Care Med %V 40 %P 2335-41 %8 2012 Aug %G eng %N 8 %1 http://www.ncbi.nlm.nih.gov/pubmed/22635049?dopt=Abstract %2 PMC3670798 %4 sepsis/DISABILITY/DISABILITY/HOSPITALIZATION/medicare claims/depression/Depressive Symptoms/respondent incentives/Spousal care/WOMEN %$ 69450 %R 10.1097/CCM.0b013e3182536a81