Development of loneliness and social isolation after spousal loss: A systematic review of longitudinal studies on widowhood.

BACKGROUND: Spousal loss is a stressful life event that is associated with loneliness and social isolation, both of which affect mental and physical health. The primary objective of this paper was to synthesize longitudinal studies that investigated loneliness and social isolation in widowhood. METHODS: A systematic search of the literature was conducted using three electronic databases. 26 longitudinal studies published through June 2024 were included for further analysis. Participant characteristics, study design, and key findings were extracted. RESULTS: Most studies were from the United States or Europe, included more widows than widowers, and assessed loneliness in older adults aged >60 years. Loneliness peaked directly following spousal death, but findings were inconsistent regarding the lasting effects of widowhood. Heterogeneity in the longitudinal trajectories of loneliness was noted, with studies showing linear increases, decreases, or curvilinear relationships over time. Several factors modified the relationship between widowhood and loneliness, including volunteerism, military experience, income, and age. Widowers consistently reported greater loneliness and worse social isolation when compared with widows. Few studies investigated social isolation specifically, but those that did found that social isolation may decrease in widowhood. CONCLUSIONS: As the world grapples with a social pandemic of loneliness and social isolation, widowed adults may be uniquely affected. Few studies investigated the longitudinal trajectory of loneliness and especially social isolation in widowhood, and those that did found heterogenous results. Future work is needed to understand why some widowed adults are uniquely affected by feelings of loneliness and social isolation while others are not, and whether potentially modifiable factors that moderate or mediate this relationship could be leveraged by psychosocial interventions.

Associations between vicarious racism and psychoactive substance use depend on strength of ethnic identity.

Racism is a pervasive threat to health with differential impact based on race and ethnicity. Considering the continued perpetration and visibility of racism online and in the news, vicarious racism, or "secondhand" racism when hearing about or witnessing racism being committed against members of one's ethnic or racial group, is a particularly urgent threat in the context of such disparities and their subsequent health consequences. The current study examines if frequency of exposure to vicarious racism and the emotional impact of those experiences are linked to psychoactive substance use, and explores the role of ethnic identity in moderating these relationships. In a cross-sectional survey, 504 adult participants aged 18-78 (M age = 30.15, SD = 11.52, 52.6% female) identifying as Black/African American or Latine reported on their experiences with vicarious racism and alcohol, marijuana, and tobacco use over the past 30 days. Logistic regression was utilized to test hypotheses. Primary findings indicate that greater emotional impact of vicarious racism was associated with a 50% increase in odds of alcohol consumption and that ethnic identity moderated the association between vicarious racism and marijuana use. Greater emotional impact of vicarious racism was related to more marijuana use for those lower on ethnic identity, whereas there was no association for those higher on ethnic identity. Vicarious racism was not related to tobacco use. Results suggest that ethnic identity might be protective in the association of vicarious racism on substance use. Further research on this topic is needed as vicarious racism becomes an increasingly common experience among marginalized populations.

Experiences of Aging with Opioid Use Disorder and Comorbidity in Opioid Treatment Programs: A Qualitative Analysis.

BACKGROUND: The number of older adults entering opioid treatment programs (OTPs) to treat opioid use disorder (OUD) is increasing. However, the lived experiences of aging in OTPs have not been examined. OBJECTIVE: To explore the aging experience with OUD and barriers to medical care for older adults who receive care in OTPs. DESIGN: From November 2021 to July 2022, we conducted 1-to-1, semi-structured qualitative interviews in English and Spanish, audio-recorded, transcribed, systematically coded, and analyzed to identify key themes regarding the challenges of aging with OUD and managing chronic diseases. PARTICIPANTS: Thirty-six adults aged ≥ 55 enrolled in OTPs in San Diego, California. APPROACH: A descriptive qualitative approach was used. Major themes and subthemes were identified through thematic analysis until thematic saturation was reached. KEY RESULTS: All participants were on methadone and had a mean age of 63.4 (SD 5.1) years; 11 (30.6%) identified as female, 14 (39%) as Hispanic/Latino, and 11 (36%) as Black, with a mean duration of methadone treatment of 5.6 years. Chronic diseases were common, with 21 (58.3%) reporting hypertension, 9 (25%) reporting untreated hepatitis C, and 32 (88.9%) having ≥ 2 chronic diseases. Three major themes emerged: (1) avoidance of medical care due to multiple intersectional stigmas, including those related to drug use, substance use disorder (SUD) treatment, ageism, and housing insecurity; (2) increasing isolation with aging and loss of family and peer groups; (3) the urgent need for integrating medical and aging-focused care with OUD treatment in the setting of increasing health and functional challenges. CONCLUSIONS: Older adults with OUD reported increasing social isolation and declining health while experiencing multilevel stigma and discrimination. The US healthcare system must transform to deliver age-friendly care that integrates evidence-based geriatric models of care incorporated with substance use disorder treatment and addresses the intersectional stigma this population has experienced in healthcare settings.

Primary care nurse practitioner work environments and emergency department utilization among older adults with substance use disorders in rural areas.

INTRODUCTION: The prevalence of substance use disorders (SUDs) is growing among older adults, and older adults in rural areas face disparities in access to SUD care. Rural older adults with SUDs commonly have comorbid chronic conditions that puts them at risk for frequent acute healthcare utilization. In rural areas, primary care for patients with SUDs are increasingly provided by nurse practitioners (NPs), and quality primary care services may decrease ED visits in this population. Yet, NP-delivered primary care for rural older adults with SUDs may be limited by work environment barriers, which include lack of support, autonomy, and visibility. This study assessed the relationship between the NP work environment and ED utilization among rural older adults with SUDs. METHODS: This was a secondary analysis of cross-sectional data from a large survey of NPs in six U.S. states merged with Medicare claims. The study measured the NP work environment by the four subscales of the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ), which measure 1) independent practice and support, 2) NP-physician relations, 3) NP-administration, and 4) professional visibility. Multilevel logistic regression models, adjusted for practice and patient covariates, assess the relationship between the NP work environment and all-cause ED use. RESULTS: The sample included 1152 older adults with SUDs who received care at 126 rural NP primary care practices. NP independent practice and support at the practice was associated with 49 % lower odds of all-cause ED visits among older adults with SUDs. There were no relationships between the other NP-PCOCQ subscales and all-cause ED visits. CONCLUSIONS: Organizational support for NP independent practice is associated with lower odds of all-cause ED utilization among rural older adults with SUDs. Practice administrators should ensure that NPs have access to support and resources to enhance their ability to care for rural older adults with SUDs. Ultimately, these practice changes could reduce ED utilization and health disparities in this population.

Trends in Characteristics of Prescription Opioid-related Poisonings among Older Adults in the United States, 2015-2021.

OBJECTIVES: Few studies have considered how trends in opioid poisonings have changed among older adults. The objective of this study was to examine trends in fatal and nonfatal opioid-related poisonings ("exposures") among older adults. METHODS: National poison center data were used to examine trends in characteristics of reported exposures to commonly prescribed opioids between 2015 and 2021 among adults 60 years or older. We estimated the proportion of opioid exposures by demographic characteristics, the specific opioid(s) involved, exposure type, route of administration, other substances co-used, and medical outcomes for each calendar year. We estimated whether there were linear changes in prevalence by year using logistic regression. RESULTS: Although there was a decrease in the number of opioid exposures within the study population from 7706 in 2015 to 7337 in 2021 (a 4.8% decrease, P = 0.04), exposures increased for adults aged 70 to 79 years (a 14.0% increase, P < 0.001). The proportion classified as "abuse" increased by 63.3% ( P < 0.001). There were significant decreases in the proportion involving hydromorphone (a 23.3% decrease, P < 0.001) and morphine (a 22.0% decrease, P < 0.001), with an increase involving buprenorphine (a 216.0% increase, P < 0.001). The proportion increased for co-use of cocaine (a 488.9% increase, P < 0.001) and methamphetamine (a 220.0% increase, P = 0.02), with a decrease in co-use of benzodiazepines (a 25.5% decrease, P < 0.001). The proportion of major medical outcomes increased by 93.9% ( P < 0.001). CONCLUSIONS: National patterns of opioid-related poisonings are shifting among older adults, including the types of opioids involved and co-use of other drugs. These results can inform prevention and harm reduction efforts aimed at older adults.

Trends in past-month cannabis use among US adults across a range of disabilities and health conditions, 2015-2019.

INTRODUCTION: While there is increasing interest in the use of cannabis to manage a range of health-related symptoms, little is known about trends in recent cannabis use with respect to various health conditions. METHODS: We examined data from a US representative sample of noninstitutionalized adults age ≥ 18 from the 2015-2019 National Survey on Drug Use and Health (N = 214,505). We estimated the pooled prevalences followed by linear time trends, overall, and by disability (i.e., difficulty hearing, seeing, thinking, walking, dressing, doing errands) and lifetime (i.e., bronchitis, cancer, diabetes, hepatitis, kidney disease) and current (i.e., asthma, depression, heart disease, hypertension) health condition status using logistic regression. Models with year-by-condition status interaction terms were used to assess differential time trends, adjusting for demographic characteristics. RESULTS: From 2015 to 2019, cannabis use increased significantly among adults with and without each disability and health condition examined. However, the increase was more rapid among those with (versus without) difficulty hearing (89.8% increase [4.9% to 9.3%] vs. 37.9% increase [8.7% to 12.0%], p = 0.015), difficulty walking (84.1% increase [6.3% to 11.6%] vs. 36.8% increase [8.7% to 11.9%], p < 0.001), 2-3 impairments (75.3% increase [9.3% to 16.3%] vs. 36.6% increase [8.2% to 11.2%], p = 0.041), and kidney disease (135.3% increase [3.4% to 8.0%] vs. 38.4% increase [8.6% to 11.9%], p = 0.045). CONCLUSION: Given the potential adverse effects of cannabis, prevention and harm reduction efforts should focus on groups at increasingly higher risk for use, including those with disabilities and kidney disease.

Prevalence and Correlates of Past Year Ecstasy/MDMA Use in the United States.

OBJECTIVES: 3,4-Methylenedioxymethamphetamine (MDMA) (also known as "ecstasy" or "Molly") has regained attention in recent years for its efficacy in treating posttraumatic stress disorder, and the drug was granted breakthrough therapy designation for such use by the US Food and Drug Administration in 2017. However, little is known about the current epidemiology of recreational ecstasy/MDMA use. METHODS: We estimated past-year prevalence and correlates of ecstasy/MDMA use based on a representative sample of noninstitutionalized US individuals 12 years or older from the 2015-2020 National Survey on Drug Use and Health (N = 315,661). RESULTS: An estimated 0.9% (95% confidence interval [CI] = 0.9-1.0) of individuals used ecstasy/MDMA in the past year. Compared with those ages 35-49 years, all younger age groups were at increased odds for use, while those older than 50 years (adjusted odds ratio [aOR] = 0.14, 95% CI = 0.08-0.23) were at low odds for use. Compared with heterosexual men, those identifying as bisexual women (aOR = 1.32, 95% CI = 1.02-1.72) were at increased odds for use, and compared with White individuals, those identifying as Asian (aOR = 1.92, 95% CI = 1.42-2.59), Black (aOR = 1.70, 95% CI = 1.41-2.06), or multiracial (aOR = 1.61, 95% CI = 1.19-2.16) were at increased odds for use. Past-year use of other drugs (e.g., cannabis, ketamine), prescription drug misuse (e.g., pain relievers, stimulants), nicotine dependence (aOR = 1.21, 95% CI = 1.00-1.45), and alcohol use disorder (aOR = 1.41, 95% CI = 1.25-1.58) were also associated with increased odds for use. CONCLUSIONS: While use of ecstasy/MDMA continues to be relatively rare, findings from this study can help inform prevention and harm reduction strategies, especially among certain subpopulations that are at high risk for use.

Expert consensus-based guidance on approaches to opioid management in individuals with advanced cancer-related pain and nonmedical stimulant use.

BACKGROUND: Clinicians treating cancer-related pain with opioids regularly encounter nonmedical stimulant use (i.e., methamphetamine, cocaine), yet there is little evidence-based management guidance. The aim of the study is to identify expert consensus on opioid management strategies for an individual with advanced cancer and cancer-related pain with nonmedical stimulant use according to prognosis. METHODS: The authors conducted two modified Delphi panels with palliative care and addiction experts. In Panel A, the patient's prognosis was weeks to months and in Panel B the prognosis was months to years. Experts reviewed, rated, and commented on the case using a 9-point Likert scale from 1 (very inappropriate) to 9 (very appropriate) and explained their responses. The authors applied the three-step analytical approach outlined in the RAND/UCLA to determine consensus and level of clinical appropriateness of management strategies. To better conceptualize the quantitative results, they thematically analyzed and coded participant comments. RESULTS: Consensus was achieved for all management strategies. The 120 Experts were mostly women (47 [62%]), White (94 [78%]), and physicians (115 [96%]). For a patient with cancer-related and nonmedical stimulant use, regardless of prognosis, it was deemed appropriate to continue opioids, increase monitoring, and avoid opioid tapering. Buprenorphine/naloxone transition was inappropriate for a patient with a short prognosis and of uncertain appropriateness for a patient with a longer prognosis. CONCLUSION: Study findings provide urgently needed consensus-based guidance for clinicians managing cancer-related pain in the context of stimulant use and highlight a critical need to develop management strategies to address stimulant use disorder in people with cancer. PLAIN LANGUAGE SUMMARY: Among palliative care and addiction experts, regardless of prognosis, it was deemed appropriate to continue opioids, increase monitoring, and avoid opioid tapering in the context of cancer-related pain and nonmedical stimulant use. Buprenorphine/naloxone transition as a harm reduction measure was inappropriate for a patient with a short prognosis and of uncertain appropriateness for a patient with a longer prognosis.

Co-occurring Medical Multimorbidity, Mental Illness, and Substance Use Disorders Among Older Criminal Legal System-Involved Veterans.

BACKGROUND: Older veterans involved in the criminal legal system (CLS) may have patterns of multimorbidity that place them at risk for poor health outcomes. OBJECTIVES: To estimate the prevalence of medical multimorbidity (≥2 chronic medical diseases), substance use disorders (SUDs), and mental illness among CLS-involved veterans aged 50 and older. RESEARCH DESIGN: Using Veterans Health Administration health records, we estimated the prevalence of mental illness, SUD, medical multimorbidity, and the co-occurrence of these conditions among veterans by CLS involvement as indicated by Veterans Justice Programs encounters. Multivariable logistic regression models assessed the association between CLS involvement, the odds for each condition, and the co-occurrence of conditions. SUBJECTS: Veterans aged 50 and older who received services at Veterans Health Administration facilities in 2019 (n=4,669,447). METHODS: Mental illness, SUD, medical multimorbidity. RESULTS: An estimated 0.5% (n=24,973) of veterans aged 50 and older had CLS involvement. For individual conditions, veterans with CLS involvement had a lower prevalence of medical multimorbidity compared with veterans without but had a higher prevalence of all mental illnesses and SUDs. After adjusting for demographic factors, CLS involvement remained associated with concurrent mental illness and SUD (adjusted odds ratio [aOR] 5.52, 95% CI=5.35-5.69), SUD and medical multimorbidity (aOR=2.09, 95% CI=2.04-2.15), mental illness and medical multimorbidity (aOR=1.04, 95% CI=1.01-1.06), and having all 3 simultaneously (aOR=2.42, 95% CI=2.35-2.49). CONCLUSIONS: Older veterans involved in the CLS are at high risk for co-occurring mental illness, SUDs, and medical multimorbidity, all of which require appropriate care and treatment. Integrated care rather than disease-specific care is imperative for this population.

Trends in emergency department visits associated with cannabis use among older adults in California, 2005-2019.

BACKGROUND: The use of cannabis among older adults is increasing in the United States. While cannabis use has been suggested to help alleviate chronic symptoms experienced by older adults, its potential adverse effects may lead to unintended consequences, including increased acute healthcare utilization related to its use. The objective of this study was to examine trends in cannabis-related emergency department (ED) visits in California. METHODS: Using data from the Department of Healthcare Access and Information, we conducted a trend analysis of cannabis-related ED visits from all acute care hospitals in California from 2005 to 2019. For each calendar year, we determined the cannabis-related ED visit rate per 100,000 ED visits for adults aged ≥65 utilizing primary or secondary diagnosis codes. We estimated the absolute and relative changes in overall cannabis-related visit rates during the study period and by subgroup, including age (65-74, 75-84, ≥85), race/ethnicity, sex, payer/insurance, Charlson comorbidity index score, and cannabis-related diagnosis code. RESULTS: The cannabis-related ED visit rate increased significantly for adults aged ≥65 and all subgroups (p < 0.001). The overall rate increased from 20.7 per 100,000 visits in 2005 to 395.0 per 100,000 ED visits in 2019, a 1804% relative increase. By race/ethnicity, older Black adults had the highest ED visit rate in 2019 and the largest absolute increase while older males had a higher ED visit rate in 2019 and a greater absolute increase than older women. Older adults with a higher Charlson score had a higher ED visit rate in 2019 and a larger absolute increase during the study period. CONCLUSION: Cannabis-related ED visits are increasing among older adults in California and are an adverse effect of cannabis use. Asking about cannabis use and providing education about its use should be a part of routine medical care for older adults.

Past-month binge drinking and cannabis use among middle-aged and older adults in the United States, 2015-2019.

The aging United States population, which includes the large Baby Boomer generation, is leading to an increasing number of middle-aged and older adults who engage in psychoactive substance use. Due to the size of this cohort, and their changing attitudes around psychoactive substance use, there has been a sharp increase in prevalence of past-month cannabis use among adults aged ≥50; however, little is understood about recent trends in the use of both cannabis and excess alcohol use, such as binge drinking, in this population. The current use of both alcohol and cannabis has important health implications for older adults, given their higher prevalence of chronic diseases and prescribed medications. This study aimed to 1) estimate national trends among older adults who report both past-month binge drinking and cannabis use, and 2) examine correlates of reporting both. We examined aggregated data from a nationally representative sample of noninstitutionalized adults aged ≥50 from the 2015 to 2019 National Survey on Drug Use and Health. During the study period, there was an estimated 2.5% increase (a 64.1% relative increase) in past-month cannabis use (linear trend p < 0.001), a non-significant decrease in past-month binge drinking, and a 0.5% estimated increase in both past-month cannabis use and binge drinking (a 26.3% relative increase) (p = 0.03). The sharpest increase in both past-month cannabis use and binge drinking was among adults aged ≥65, with the estimated prevalence increasing from 0.2% in 2015 to 1.1% in 2019 (a 450% relative increase, p < 0.001). Those engaging in past-month binge drinking and cannabis use were more likely to be younger, male, non-Hispanic Black, use tobacco, and report past-year mental health treatment. Results suggest that the prevalence of both past-month cannabis use and binge drinking among middle-aged and older adults increased between 2015 and 2019, especially among adults aged ≥65, which indicates an increased need to screen for both excess alcohol and cannabis use to minimize potential harm.

Cannabis use for Sleep Disturbance Among Older Patients in a Geriatrics Clinic.

Cannabis use is growing among older adults to manage medical concerns including poor sleep. In this study, we characterized how patients seen at a geriatrics clinic use cannabis to address sleep disturbance. Specifically, we conducted an anonymous survey of 568 adults, including 83 who reported cannabis use within the past 3 years, to inquire about such use. We compared cannabis use characteristics between those using it for sleep disturbance versus all other conditions. We considered a p-value <.10 to be statistically significant. Among the cannabis users in our sample, 29% reported using cannabis for sleep disturbance (N = 24). They were more likely than other users to be female (p = .07), consume cannabis more frequently (p = .01), use products containing tetrahydrocannabinol (THC) (vs. cannabidiol [CBD]-only; p < .01), and use cannabis to target more symptoms (p < .01). As cannabis use continues to grow in older populations, it is essential to delineate better how cannabis may be used safely and effectively to improve older adults' sleep health.

Bone Health Management in Elective Orthopaedic Surgery: A Claims-Based Observational Study.

Introduction: There are limited data on the management of bone health, including bone mineral density (BMD) evaluation and osteoporosis (OP) treatment, in patients undergoing elective orthopaedic surgeries. Methods: This was a retrospective cohort study using administrative claims data from Symphony Health, PatientSource for patients aged ≥50 years with documented kyphoplasty/vertebroplasty (KP/VP), total knee arthroplasty (TKA), and total hip arthroplasty (THA). Risk stratification to identify patients at very high risk for fracture (VHRFx) was based on clinical practice guideline recommendations to the extent information on variables of interest were available from the claims database. Results: A total of 251 919 patients met inclusion criteria: KP/VP (31 018), TKA (149 849), and THA (71 052). The majority were female (80.3%) with a mean (SD) age of 68.5 (7.5) years. Patients undergoing KP/VP were older and had a greater comorbidity burden associated with risk for falls, mobility issues, muscle weakness, and respiratory and cardiovascular diseases. In the 6 months before surgery, 11.8% of patients were tested and/or received treatment for OP. Patients undergoing KP/VP were more likely to be tested and/or treated (17.5%) than patients undergoing TKA (11.0%) or THA (10.9%). Overall, men had a lower rate of testing and/or treatment than women (4.6% vs 13.5%). In the 12 months before surgery, patients with an OP diagnosis and at VHRFx (30.8%) had a higher rate of treatment and/or testing than those without OP (11.5%), or those without OP but with a fracture in the year preceding surgery (10.2%). Conclusions: Bone health management is suboptimal in patients undergoing elective orthopaedic surgeries and is worse in men than in women. Proper management of OP before and after surgery may improve outcomes.

Trends in major depressive episodes and mental health treatment among older adults in the United States, 2010-2019.

BACKGROUND: Despite concerns about increasing trends in depression over the past two decades, little is known about recent trends in depression and mental health (MH) treatment among older adults and whether these trends differ by demographic characteristics. METHODS: We examined data from a US representative sample of noninstitutionalized adults aged ≥65 from the 2010-2019 National Survey on Drug Use and Health (N = 31,502). We estimated trends in the prevalence of past-year major depressive episode (MDE) overall and by demographic characteristics. We also estimated trends in MH treatment among those with past-year MDE. RESULTS: From 2010/11 to 2018/19, the estimated prevalence of past-year MDE among older adults increased from 2.0 % (95 % CI: 1.6-2.6) to 3.2 % (95 % CI: 2.7 to 3.7), a 60.0 % increase (p = 0.013). Increases were detected among men (p = 0.038), White individuals (p = 0.018), those who are widowed (p = 0.003), those with an annual household income of <$20,000 (p = 0.020) or $20,000-$49,000 (p = 0.016), and those with some college degree (p = 0.014). Among those with MDE, there were no significant changes detected in any form of past-year MH treatment. LIMITATIONS: NSDUH does not assess individuals who are institutionalized, incarcerated, or experiencing homelessness, and thus the prevalence of MDE may be underestimated. CONCLUSIONS: Although the estimated prevalence of depression is increasing among older adults, there has not been a proportional increase in MH treatment among those with depression. These findings call for urgent expansion of treatment services and training of MH professionals with expertise in older adults to meet the needs of this growing, vulnerable population.

Past-year hallucinogen use in relation to psychological distress, depression, and suicidality among US adults.

BACKGROUND: There is renewed interest in the clinical application of hallucinogenic substances to treat a range of psychiatric conditions. However, there is mixed evidence regarding how use of such substances outside of medical settings relates to psychological distress, depression, and suicidality. METHODS: We examined data from a US representative sample of noninstitutionalized adults from the 2015-2020 National Survey on Drug Use and Health (N = 241,675). We evaluated whether past-year use of specific hallucinogens (i.e., LSD, DMT/AMT/Foxy, salvia divinorum, ecstasy [MDMA/Molly], ketamine) is associated with reporting past-year serious psychological distress (SPD), major depressive episode (MDE), and suicidality. Generalized linear models using Poisson and log link were used to estimate adjusted prevalence ratios (aPRs), controlling for sociodemographic characteristics and past-year use of various other illegal drugs. RESULTS: LSD use was associated with an increased likelihood of MDE (aPR = 1.23, 95% CI: 1.10-1.37) and suicidal thinking (aPR = 1.21, 95% CI: 1.09-1.34). Similar associations were observed between salvia divinorum use and suicidal thinking (aPR = 1.41, 95% CI: 1.00-1.97) and between DMT/AMT/Foxy use and suicidal planning (aPR = 1.81 95% CI: 1.17-2.81). On the other hand, ecstasy use was associated with a decreased likelihood of SPD (aPR = 0.83, 95% CI: 0.77-0.89), MDE (aPR = 0.91, 95% CI: 0.83-1.00), and suicidal thinking (aPR = 0.86, 95% CI: 0.75-0.99). CONCLUSION: Findings suggest there are differences among specific hallucinogens with respect to depression and suicidality. More research is warranted to understand consequences of and risk factors for hallucinogen use outside of medical settings among adults experiencing depression or suicidality.

Epidemiology of cardiovascular disease and its risk factors among refugees and asylum seekers: Systematic review and meta-analysis.

BACKGROUND: This is the first systematic review and meta-analysis assessing cardiovascular disease incidence and risk factors among refugees and asylum seekers. METHODS AND RESULTS: PubMed, PsycINFO, CINAHL, and Embase databases were searched for studies in English from January 1, 1977, to March 8, 2020. Inclusion criteria were (1) observation of refugee history in participants; (2) diagnosis of CVD (coronary artery disease, heart failure, stroke, or CVD mortality) and risk factors (hypertension, diabetes, tobacco use, hyperlipidemia, obesity, psychosocial factors); (3) assessment of effect size and spread, (4) adjustment for sex; and (5) comparison with non-refugee migrants or natives. Data were extracted and evaluated by multiple reviewers for study quality. Of the 1158 screened articles, Participants from 7 studies (0.6%) involving 116.989 refugees living in Denmark, Sweden, and the United States were included in the systematic review, of which three studies synthesized the quantitative analyses. A fixed-effects model was created to pool the effect sizes of included studies. The pooled incidence of CVD in refugees was 1.71 (95% CI: 1.03, 2.83) compared with non-refugee counterparts. Pyschosocial factors were associated with increased risk of CVD in refugees but evidence on CVD risk factors varied by nativity and duration since resettlement. CONCLUSIONS: Refugee experience is an independent risk factor for CVD. Robust research on CVD in displaced populations is needed to improve the quality of evidence, clinical and preventive care, and address health equity in this marginalized population globally.