Excess prevalence of preexisting chronic conditions in older adults with incident epilepsy.

OBJECTIVE: Prior studies have examined chronic conditions in older adults with prevalent epilepsy, but rarely among those with incident epilepsy. Identifying the chronic conditions with which older adults present at epilepsy incidence assists with the evaluation of disease burden in this patient population and informs coordinated care development. The aim of this study was to identify preexisting chronic conditions with excess prevalence in older adults with incident epilepsy compared to those without. METHODS: Using a random sample of 4 999 999 fee-for-service Medicare beneficiaries aged >65 years, we conducted a retrospective cohort study of epilepsy incidence in 2019. Non-Hispanic Black and Hispanic beneficiaries were oversampled. We identified preexisting chronic conditions from the 2016-2018 Medicare Beneficiary Summary Files and compared chronic condition prevalence between Medicare beneficiaries with and without incident epilepsy in 2019. We characterized variations in preexisting excess chronic condition prevalence by age, sex, and race/ethnicity, adjusting for the racial/ethnic oversampling. RESULTS: We observed excess prevalence of most preexisting chronic conditions in beneficiaries with incident epilepsy (n = 20 545, weighted n = 19 631). For stroke, for example, the adjusted prevalence rate ratio (APRR) was 4.82 (99% CI:4.60, 5.04), meaning that, compared to those without epilepsy, beneficiaries with incident epilepsy in 2019 had 4.82 times the stroke prevalence. Similarly, beneficiaries with incident epilepsy had a higher prevalence rate for preexisting neurological conditions (APRR = 3.17, 99% CI = 3.08-3.27), substance use disorders (APRR = 3.00, 99% CI = 2.81-3.19), and psychiatric disorders (APRR = 1.98, 99% CI = 1.94-2.01). For most documented chronic conditions, excess prevalence among beneficiaries with incident epilepsy in 2019 was larger for younger age groups compared to older age groups, and for Hispanic beneficiaries compared to both non-Hispanic White and non-Hispanic Black beneficiaries. SIGNIFICANCE: Compared to epilepsy-free Medicare beneficiaries, those with incident epilepsy in 2019 had a higher prevalence of most preexisting chronic conditions. Our findings highlight the importance of health promotion and prevention, multidisciplinary care, and elucidating shared pathophysiology to identify opportunities for prevention.

To Provide or Protect? Masculinity, Economic Precarity, and Protective Gun Ownership in the United States.

Protection is now the modal motivation for gun ownership, and men continue to outnumber women among gun owners. While research has linked economic precarity (e.g., insecurity and anxiety) to gun ownership and attitudes, separating economic well-being from constructions of masculinity is challenging. In response to blocked economic opportunities, some gun owners prioritize armed protection, symbolically replacing the masculine role of "provider" with one associated with "protection." Thus, understanding both persistently high rates of gun ownership in the United States (in spite of generally declining crime) alongside the gender gap in gun ownership requires deeper investigations into the meaning of guns in the United States and the role of guns in conceptualizations of American masculinity. We use recently collected crowdsourced survey data to test this provider-to-protector shift, exploring how economic precarity may operate as a cultural-level masculinity threat for some, and may intersect with marital/family status to shape gun attitudes and behaviors for both gun owners and nonowners. Results show that investments in stereotypical masculine ideals, rather than economic precarity, are linked to support for discourses associated with protective gun ownership and empowerment.

Impact of Instrumental Activities of Daily Living Limitations on Hospital Readmission: an Observational Study Using Machine Learning.

BACKGROUND: Limitations in instrumental activities of daily living (IADL) hinder a person's ability to live independently in the community and self-manage their conditions, but its impact on hospital readmission has not been firmly established. OBJECTIVE: To test the importance of IADL dependency as a predictor of 30-day readmissions and quantify its impact relative to other morbidities. DESIGN: A retrospective cohort study of the population-based Health and Retirement Study linked to Medicare claims data. Random forest was used to rank each predictor variable in terms of its ability to predict readmission. Classification and regression tree (CART) was used to identify complex multimorbidity combinations associated with high or low risk of readmission. Generalized linear regression was used to estimate the adjusted relative risk of readmission for IADL limitations. SUBJECTS: Hospitalizations of adults age 65 and older (n = 20,007), from 6617 unique subjects. MAIN MEASURES: The main outcome was 30-day all-cause unplanned readmission. The main predictor of interest was self-reported IADL limitation. Other key predictors were self-reported complex multimorbidity including chronic diseases, geriatric syndromes, and activities of daily living (ADL) limitations, along with demographic, socioeconomic, and behavioral factors. KEY RESULTS: The overall 30-day readmission rate in the study was 16.4%. Random forest analysis ranked ADLs and IADL limitations as the two most important predictors of 30-day readmission. CART identified hospitalizations of patients with IADL limitations and diabetes as a subgroup at the highest risk of readmission (26% readmitted). Multivariable regression analyses showed that ADL limitations were associated with 1.17 (1.06-1.29) times higher risk of readmission even after adjusting for other patient covariates. Risk prediction was modest though for even the best model (AUC = 0.612). CONCLUSIONS: IADL limitations are key predictors of 30-day readmission as demonstrated using several machine learning methods. Routine assessment of functional abilities in hospital settings could help identify those most at risk.

Changes in Case-Mix and Health Outcomes of Medicare Fee-for-Service Beneficiaries and Managed Care Enrollees During the Years 1992-2011.

BACKGROUND: Recent studies suggest that managed care enrollees (MCEs) and fee-for-service beneficiaries (FFSBs) have become similar in case-mix over time; but comparisons of health outcomes have yielded mixed results. OBJECTIVE: To examine changes in differentials between MCEs and FFSBs both in case-mix and health outcomes over time. DESIGN: Temporal study of the linked Health and Retirement Study (HRS) and Medicare data, comparing case-mix and health outcomes between MCEs and FFSBs across 3 time periods: 1992-1998, 1999-2004, and 2005-2011. We used multivariable analysis, stratified by, and pooled across the study periods. The unit of analysis was the person-wave (n=167,204). SUBJECTS: HRS participants who were also enrolled in Medicare. MEASURES: Outcome measures included self-reported fair/poor health, 2-year self-rated worse health, and 2-year mortality. Our main covariate was a composite measure of multimorbidity (MM), MM0-MM3, defined as the co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes. RESULTS: The case-mix differential between MCEs and FFSBs persisted over time. Results from multivariable models on the pooled data and incorporating interaction terms between managed care status and study period indicated that MCEs and FFSBs were as likely to die within 2 years from the HRS interview (P=0.073). This likelihood remained unchanged across the study periods. However, MCEs were more likely than FFSBs to report fair/poor health in the third study period (change in probability for the interaction term: 0.024, P=0.008), but less likely to rate their health worse in the last 2 years, albeit at borderline significance (change in probability: -0.021, P=0.059). CONCLUSIONS: Despite the persistence of selection bias, the differential in self-reported fair/poor status between MCEs and FFSBs seems to be closing over time.

Older Adults Undergoing Total Hip or Knee Arthroplasty: Chronicling Changes in Their Multimorbidity Profile in the Last Two Decades.

BACKGROUND: Despite the ubiquitous use of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in older adults, little is known about the multimorbidity (MM) profile of this patient population. This study evaluates the temporal trends of MM, hypothesizing that patients with MM have had an increasingly greater representation in THA and TKA patients over time. METHODS: Data on a US representative sample of older adults from the linked Health and Retirement Study and Medicare data from 1993 to 2012 were used. The Health and Retirement Study is a biennial survey that collects data on a broad array of measures, including self-reported chronic conditions and geriatric syndromes, which were used to account for MM. Medicare data were used to identify fee-for-service Medicare beneficiaries who underwent THA (n = 479) or TKA (n = 998) during the study years, which were grouped into 3 periods: 1993-1999, 2000-2006, and 2007-2012. Multivariable logistic regression analysis was conducted to obtain age-, gender-, and race-adjusted time trends for MM. RESULTS: Compared to the earliest study period, and for both THA and TKA patients, there were significantly fewer patients with stroke and/or poor cognitive performance in the most recent study period. In addition, more TKA than THA patients presented with 2+ chronic conditions. Nearly 70% presented with co-occurring chronic conditions and geriatric syndromes, and this percentage did not change significantly over time. CONCLUSION: The high representation of THA and TKA patients presenting with co-occurring chronic conditions and geriatric syndromes in this patient population warrants detailed exploration of the effects of geriatric syndromes on postoperative outcomes.

Identifying Specific Combinations of Multimorbidity that Contribute to Health Care Resource Utilization: An Analytic Approach.

BACKGROUND: Multimorbidity affects the majority of elderly adults and is associated with higher health costs and utilization, but how specific patterns of morbidity influence resource use is less understood. OBJECTIVE: The objective was to identify specific combinations of chronic conditions, functional limitations, and geriatric syndromes associated with direct medical costs and inpatient utilization. DESIGN: Retrospective cohort study using the Health and Retirement Study (2008-2010) linked to Medicare claims. Analysis used machine-learning techniques: classification and regression trees and random forest. SUBJECTS: A population-based sample of 5771 Medicare-enrolled adults aged 65 and older in the United States. MEASURES: Main covariates: self-reported chronic conditions (measured as none, mild, or severe), geriatric syndromes, and functional limitations. Secondary covariates: demographic, social, economic, behavioral, and health status measures. OUTCOMES: Medicare expenditures in the top quartile and inpatient utilization. RESULTS: Median annual expenditures were $4354, and 41% were hospitalized within 2 years. The tree model shows some notable combinations: 64% of those with self-rated poor health plus activities of daily living and instrumental activities of daily living disabilities had expenditures in the top quartile. Inpatient utilization was highest (70%) in those aged 77-83 with mild to severe heart disease plus mild to severe diabetes. Functional limitations were more important than many chronic diseases in explaining resource use. CONCLUSIONS: The multimorbid population is heterogeneous and there is considerable variation in how specific combinations of morbidity influence resource use. Modeling the conjoint effects of chronic conditions, functional limitations, and geriatric syndromes can advance understanding of groups at greatest risk and inform targeted tailored interventions aimed at cost containment.

Cut to the Quick: The Consequences of Youth Violent Victimization for the Timing of Dating Debut and First Union Formation.

Concentrated in adolescence, violent victimization is developmentally disruptive. It undermines physical, mental, and socioemotional well-being and compromises youths' transitions into and progression through key life course tasks. Youth violent victimization (YVV) has been linked to precocious exits from adolescence and premature entries into adulthood. This includes early entry into coresidential romantic unions, which is but one stage of a relationship sequence generally beginning via dating debut. Using data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) and Cox regression, we examine the effects of YVV on the timing of dating debut and progression to first coresidential unions during adolescence and the transition to adulthood. We pay particular attention to how these effects may be structured by age and gender. Overall, we find that victims begin dating sooner and progress more quickly from dating to first unions than do non-victims. However, youths victimized in early adolescence withdraw from dating and union formation, whereas late adolescent victims appear to overinvest in relationships-at least temporarily-displaying accelerated entry into dating and rapid progression to first unions. We conclude by discussing the implication of these age-graded patterns for intervention efforts and youth well-being more broadly.

Combinations of Chronic Conditions, Functional Limitations, and Geriatric Syndromes that Predict Health Outcomes.

BACKGROUND: The strategic framework on multiple chronic conditions released by the US Department of Health and Human Services calls for identifying homogeneous subgroups of older adults to effectively target interventions aimed at improving their health. OBJECTIVE: We aimed to identify combinations of chronic conditions, functional limitations, and geriatric syndromes that predict poor health outcomes. DESIGN, SETTING AND PARTICIPANTS Data from the 2010-2012 Health and Retirement Study provided a representative sample of U.S. adults 50 years of age or older (n = 16,640). MAIN MEASURES: Outcomes were: Self-reported fair/poor health, self-rated worse health at 2 years, and 2-year mortality. The main independent variables included self-reported chronic conditions, functional limitations, and geriatric syndromes. We conducted tree-based classification and regression analysis to identify the most salient combinations of variables to predict outcomes. KEY RESULTS: Twenty-nine percent and 23 % of respondents reported fair/poor health and self-rated worse health at 2 years, respectively, and 5 % died in 2 years. The top combinations of conditions identified through our tree analysis for the three different outcome measures (and percent respondents with the outcome) were: a) for fair/poor health status: difficulty walking several blocks, depressive symptoms, and severe pain (> 80 %); b) for self-rated worse health at 2 years: 68.5 years of age or older, difficulty walking several blocks and being in fair/poor health (60 %); and c) for 2-year mortality: 80.5 years of age or older, and presenting with limitations in both ADLs and IADLs (> 40 %). CONCLUSIONS: Rather than chronic conditions, functional limitations and/or geriatric syndromes were the most prominent conditions in predicting health outcomes. These findings imply that accounting for chronic conditions alone may be less informative than also accounting for the co-occurrence of functional limitations and geriatric syndromes, as the latter conditions appear to drive health outcomes in older individuals.

Functional status in older women diagnosed with pelvic organ prolapse.

BACKGROUND: Functional status plays an important role in the comprehensive characterization of older adults. Functional limitations are associated with an increased risk of adverse treatment outcomes, but there are limited data on the prevalence of functional limitations in older women with pelvic floor disorders. OBJECTIVE: The aim of the study was to describe the prevalence of functional limitations based on health status in older women with pelvic organ prolapse (POP). STUDY DESIGN: This pooled, cross-sectional study utilized data from the linked Health and Retirement Study and Medicare files from 1992 through 2008. The analysis included 890 women age ≥65 years with POP. We assessed self-reported functional status, categorized in strength, upper and lower body mobility, activities of daily living (ADL), and instrumental ADL (IADL) domains. Functional limitations were evaluated and stratified by respondents self-reported general health status. Descriptive statistics were used to compare categorical and continuous variables, and logistic regression was used to measure differences in the odds of functional limitation by increasing age. RESULTS: The prevalence of functional limitations was 76.2% in strength, 44.9% in upper and 65.8% in lower body mobility, 4.5% in ADL, and 13.6% in IADL. Limitations were more prevalent in women with poor or fair health status than in women with good health status, including 91.5% vs 69.9% in strength, 72.9% vs 33.5% in upper and 88.0% vs 56.8% in lower body mobility, 11.6% vs 0.9% in ADL, and 30.6% vs 6.7% in IADL; all P < .01. The odds of all functional limitations also increased significantly with advancing age. CONCLUSION: Functional limitations, especially in strength and body mobility domains, are highly prevalent in older women with POP, particularly in those with poor or fair self-reported health status. Future research is necessary to evaluate if functional status affects clinical outcomes in pelvic reconstructive and gynecologic surgery and whether it should be routinely assessed in clinical decision-making when treating older women with POP.

Multimorbidity redefined: prospective health outcomes and the cumulative effect of co-occurring conditions.

INTRODUCTION: Multimorbidity is common among middle-aged and older adults; however the prospective effects of multimorbidity on health outcomes (health status, major health decline, and mortality) have not been fully explored. This study addresses this gap in the literature. METHODS: We used self-reported data from the 2008 and 2010 Health and Retirement Study. Our study population included 13,232 adults aged 50 or older. Our measure of baseline multimorbidity in 2008 was based on the occurrence or co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes, as follows: MM0, no chronic conditions, functional limitations, or geriatric syndromes; MM1, occurrence (but no co-occurrence) of chronic conditions, functional limitations, or geriatric syndromes; MM2, co-occurrence of any 2 of chronic conditions, functional limitations, or geriatric syndromes; and MM3, co-occurrence of all 3 of chronic conditions, functional limitations, and geriatric syndromes. Outcomes in 2010 included fair or poor health status, major health decline, and mortality. RESULTS: All 3 outcomes were significantly associated with multimorbidity. Compared with MM0 (respectively for fair or poor health and major health decline), the adjusted odds ratios (AORs) and 95% confidence intervals were as follows: 2.61 (1.79-3.78) and 2.20 (1.42-3.41) for MM1; 7.49 (5.20-10.77) and 3.70 (2.40-5.71) for MM2; and 22.66 (15.64-32.83) and 4.72 (3.03-7.37) for MM3. Multimorbidity was also associated with mortality: an adult classified as MM3 was nearly 12 times (AOR, 11.87 [5.72-24.62]) as likely as an adult classified as MM0 to die within 2 years. CONCLUSION: Given the strong and significant association between multimorbidity and prospective health status, major health decline, and mortality, multimorbidity may be used - both in clinical practice and in research - to identify older adults with heightened vulnerability for adverse outcomes.

INTIMATE PARTNER VIOLENCE RISK AMONG VICTIMS OF YOUTH VIOLENCE: ARE EARLY UNIONS BAD, BENEFICIAL, OR BENIGN?

Youth violent victimization (YVV) is a risk factor for precocious exits from adolescence via early coresidential union formation. It remains unclear, however, whether these early unions 1) are associated with intimate partner violence (IPV) victimization, 2) interrupt victim continuity or victim-offender overlap through protective and prosocial bonds, or 3) are inconsequential. By using data from the National Longitudinal Study of Adolescent to Adult Health (N = 11,928; 18-34 years of age), we examine competing hypotheses for the effect of early union timing among victims of youth violence (n = 2,479)-differentiating across victimization only, perpetration only, and mutually combative relationships and considering variation by gender. The results from multinomial logistic regression models indicate that YVV increases the risk of IPV victimization in first unions, regardless of union timing; the null effect of timing indicates that delaying union formation would not reduce youth victims' increased risk of continued victimization. Gender-stratified analyses reveal that earlier unions can protect women against IPV perpetration, but this is partly the result of an increased risk of IPV victimization. The findings suggest that YVV has significant transformative consequences, leading to subsequent victimization by coresidential partners, and this association might be exacerbated among female victims who form early unions. We conclude by discussing directions for future research.

Understanding the Utility of Less Than Six-Month Prognosis Using Administrative Data Among U.S. Nursing Home Residents With Cancer.

Background: There is a dearth of studies evaluating the utility of reporting prognostication among nursing home (NH) residents with cancer. Objective: To study factors associated with documented less than six-month prognosis, and its relationship with end-of-life (EOL) care quality measures among residents with cancer. Methods: The Surveillance, Epidemiology, and End Results linked with Medicare, and the Minimum Data Set databases was used to identify 20,397 NH residents in the United States with breast, colorectal, lung, pancreatic, or prostate cancer who died between July 2016 and December 2018. Of these, 2205 residents (10.8%) were documented with less than six-month prognosis upon NH admission. Main outcomes were more than one hospitalization, more than one emergency department visit, and any intensive care unit admission within the last 30 days of life as aggressive EOL care markers, as well as admission to hospice, receipt of advance care planning and palliative care, and survival. Specificity and sensitivity of prognosis were assessed using six-month mortality as the outcome. Propensity score matching adjusted for selection biases, and logistic regression examined association. Results: Specificity and sensitivity of documented less than six-month prognosis for mortality were 94.2% and 13.7%, respectively. Residents with documented less than six-month prognosis had greater odds of being admitted to hospice than those without (adjusted odds ratio: 3.27, 95% confidence interval: 2.86-3.62), and lower odds to receive aggressive EOL care. Conclusion: In this cohort study, documented less than six-month prognosis was associated with less aggressive EOL care. Despite its high specificity, however, low sensitivity limits its utility to operationalize care on a larger population of residents with terminal illness.

Incidence of Aggressive End-of-Life Care Among Older Adults With Metastatic Cancer Living in Nursing Homes and Community Settings.

Importance: Nearly 10% of the 1.5 million persons residing in nursing homes (NHs) have received or will receive a diagnosis of cancer. Although aggressive end-of-life (EOL) care is common among community-dwelling patients with cancer, little is known about such patterns of care among NH residents with cancer. Objective: To compare markers of aggressive EOL care between older adults with metastatic cancer who are NH residents and their community-dwelling counterparts. Design, Setting, and Participants: This cohort study used the Surveillance, Epidemiology, and End Results database linked with the Medicare database and the Minimum Data Set (including NH clinical assessment data) for deaths occurring from January 1, 2013, to December 31, 2017, among 146 329 older patients with metastatic breast, colorectal, lung, pancreas, or prostate cancer, with a lookback period in claims data through July 1, 2012. Statistical analysis was conducted between March 2021 and September 2022. Exposures: Nursing home status. Main Outcomes and Measures: Markers of aggressive EOL care were cancer-directed treatment, intensive care unit admission, more than 1 emergency department visit or more than 1 hospitalization in the last 30 days of life, hospice enrollment in the last 3 days of life, and in-hospital death. Results: The study population included 146 329 patients 66 years of age or older (mean [SD] age, 78.2 [7.3] years; 51.9% men). Aggressive EOL care was more common among NH residents than community-dwelling residents (63.6% vs 58.3%). Nursing home status was associated with 4% higher odds of receiving aggressive EOL care (adjusted odds ratio [aOR], 1.04 [95% CI, 1.02-1.07]), 6% higher odds of more than 1 hospital admission in the last 30 days of life (aOR, 1.06 [95% CI, 1.02-1.10]), and 61% higher odds of dying in the hospital (aOR, 1.61 [95% CI, 1.57-1.65]). Conversely, NH status was associated with lower odds of receiving cancer-directed treatment (aOR, 0.57 [95% CI, 0.55-0.58]), intensive care unit admission (aOR, 0.82 [95% CI, 0.79-0.84]), or enrollment in hospice in the last 3 days of life (aOR, 0.89 [95% CI, 0.86-0.92]). Conclusions and Relevance: Despite increased emphasis to reduce aggressive EOL care in the past several decades, such care remains common among older persons with metastatic cancer and is slightly more prevalent among NH residents than their community-dwelling counterparts. Multilevel interventions to decrease aggressive EOL care should target the main factors associated with its prevalence, including hospital admissions in the last 30 days of life and in-hospital death.

Aggressive end-of-life care across gradients of cognitive impairment in nursing home patients with metastatic cancer.

BACKGROUND: Studies examining end-of-life (EOL) care in older cancer patients are scarce, and prior studies have not accounted for gradients of cognitive impairment (COG-I). We examine EOL care patterns across COG-I gradients, hypothesizing that greater COG-I severity is associated with lower odds of receiving aggressive EOL care. METHODS: Using data from the linked Surveillance Epidemiology and End Results (SEER) -Medicare -Minimum Data Set (MDS) 3.0, we identified patients with nursing facility stays (NFS) and who died with metastatic cancer from 2013 to 2017. Markers of aggressive EOL care were: cancer-directed treatment, intensive care unit admission, >1 emergency department visit, or >1 hospitalization in the last 30 days of life, hospice enrollment in the last 3 days of life, and in-hospital death. In addition to descriptive analysis, we conducted multivariable logistic regression analysis to evaluate the independent association between COG-I severity and receipt of aggressive EOL care. RESULTS: Of the 40,833 patients in our study population, 49.2% were cognitively intact; 24.4% had mild COG-I; 19.7% had moderate COG-I; and 6.7% had severe COG-I. The percent of patients who received aggressive EOL care was 62.6% and 74.2% among those who were cognitively intact and those with severe COG-I, respectively. Compared with cognitively intact patients, those with severe COG-I had 86% higher odds of receiving any type of aggressive EOL care (adjusted odds ratio (aOR): 1.86 (95% confidence interval: 1.70-2.04)), which were primarily associated with higher odds of in-hospital death. The odds of in-hospital death associated with severe COG-I were higher among those with short- than with long-term stays (aOR:2.58 (2.35-2.84) and aOR:1.40 (1.17-1.67), respectively). CONCLUSIONS: Contrary to our hypothesis, aggressive EOL care in older metastatic cancer patients with NFS was highest among those suffering severe COG-I. These findings can inform the development of interventions to help reduce aggressive EOL care in this patient population.

Adolescent Violent Victimization and Precocious Union Formation.

This article bridges scholarship in criminology and family sociology by extending arguments about "precocious exits" from adolescence to consider early union formation as a salient outcome of violent victimization for youths. Research indicates that early union formation is associated with several negative outcomes; yet the absence of attention to union formation as a consequence of violent victimization is noteworthy. We address this gap by drawing on life course theory and data from the National Longitudinal Study of Adolescent Health (Add Health) to examine the effect of violent victimization ("street" violence) on the timing of first co-residential union formation-differentiating between marriage and cohabitation-in young adulthood. Estimates from Cox proportional hazard models show that adolescent victims of street violence experience higher rates of first union formation, especially marriage, early in the transition to adulthood; however, this effect declines with age, as such unions become more normative. Importantly, the effect of violent victimization on first union timing is robust to controls for nonviolent delinquency, substance abuse, and violent perpetration. We conclude by discussing directions for future research on the association between violent victimization and coresidential unions with an eye toward the implications of such early union formation for desistance.

Widening the social context of disablement among married older adults: Considering the role of nonmarital relationships for loneliness.

Utilizing the stress process and life course perspectives, we investigated the influence of non-spousal social support on the associations between marital quality, physical disability, and loneliness among married older adults. Using data from the National Social Life, Health, and Aging Project (NSHAP), we found that the association between physical disability and loneliness was partially accounted for by the fact that physical disability was associated with less supportive nonmarital relationships. While physically-disabled older adults in higher-quality marriages were buffered from loneliness, supportive non-martial relationships did not offset elevated loneliness among those in low-quality marriages. These associations were largely similar for men and women. Thus, although both marital and nonmarital relationships are important for loneliness, when confronted with a stressor such as disablement it is the marital relationship alone that matters.

Violent Victimization and Adolescents' Attitudes Toward Romantic Relationships and Sexual Activity.

Violent victimization in adolescence spurs risk-taking behaviors (e.g., violent offending and substance use/abuse), undermines mental well-being, disrupts developmental transitions, and even has interpersonal and relational consequences. Adolescent victims initiate earlier and progress faster through sexual and romantic relationships. Because the reasons for the links between victimization and relationship behaviors remain unclear, we explored how violent victimization might shape how adolescents think and feel about intimate/romantic relationships. We focus specifically on interest in forming relationships and expectations about intimate/sexual activity occurring within relationships. Using data from the National Longitudinal Study of Adolescent to Adult Health (Add Health; n = 10,570 [54% girls; 56% non-Hispanic white; ages 11-18]), we found that adolescent victims of violence were more pessimistic about marriage and more favorable toward sexual activity, with patterns varying by age at victimization and gender. Late adolescent victims were marginally more interested in romantic relationships but were pessimistic about marriage. Early adolescent and girl victims were less favorable toward sexual activity in relationships, while later adolescent and boy victims were more permissive. Violent victimization may foster problematic attitudes toward intimate relationships, which may account for previously observed increased involvement in risky relational and sex behaviors.

Heath status, frailty, and multimorbidity in patients with emergency general surgery conditions.

BACKGROUND: Although nearly 1 million older adults are admitted for emergency general surgery conditions yearly, the extent to which baseline health influences the development and treatment of emergency general surgery conditions is unknown. We evaluated baseline health and older patients with and without emergency general surgery conditions. METHODS: We used the prospectively collected Medicare Current Beneficiary Survey with Medicare claims and 2 validated health frameworks: (1) Deficit Accumulation Frailty Score and (2) Complex Multimorbidity. Self-reported health and function items were used to derive pre-emergency general surgery conditions Deficit Accumulation Frailty Score and Complex Multimorbidity scores. Deficit Accumulation Frailty Score ranges from 0 (no frailty deficits) to 100 (all possible deficits present). Complex Multimorbidity is a 3-point categorical rank based on the presence of chronic conditions, functional limitations, and geriatric syndromes. Specific survey factors were also examined to determine association with development of emergency general surgery conditions or use of operative management. RESULTS: Of 54,417 individuals, 1,960 had emergency general surgery conditions (median age 79 [interquartile range 73-84]). Patients with emergency general surgery conditions had significantly higher Deficit Accumulation Frailty Score (19 [interquartile range 11-31] vs 14 [8-24]) and were more likely to be in the most severe Complex Multimorbidity category (38% vs 29%). Emergency general surgery conditions patients had higher proportions of nearly every health category, with the most striking differences in functional limitations. Patients who were treated nonoperatively had the poorest overall baseline health. CONCLUSION: Patients who developed emergency general surgery conditions had more severe health burden than patients who did not, particularly in functional status. Clinicians must better understand the interaction between baseline health vulnerability and emergency surgical disease to improve prognostication and ensure alignment of patient goals and treatment strategies.

Association of Complex Multimorbidity and Long-term Survival After Emergency General Surgery in Older Patients With Medicare.

Importance: Although nearly 1 million older patients are admitted for emergency general surgery (EGS) conditions yearly, long-term survival after these acute diseases is not well characterized. Many older patients with EGS conditions have preexisting complex multimorbidity defined as the co-occurrence of at least 2 of 3 key domains: chronic conditions, functional limitations, and geriatric syndromes. The hypothesis was that specific multimorbidity domain combinations are associated with differential long-term mortality after patient admission with EGS conditions. Objective: To examine multimorbidity domain combinations associated with increased long-term mortality after patient admission with EGS conditions. Design, Setting, and Participants: This cohort study included community-dwelling participants aged 65 years and older from the Medicare Current Beneficiary Survey with linked Medicare data (January 1992 through December 2013) and admissions for diagnoses consistent with EGS conditions. Surveys on health and function from the year before EGS conditions were used to extract the 3 domains: chronic conditions, functional limitations, and geriatric syndromes. The number of domains present were summed to calculate a categorical rank: no multimorbidity (0 or 1), multimorbidity 2 (2 of the 3 domains present), and multimorbidity 3 (all 3 domains present). Whether operative treatment was provided during the admission was also identified. Data were cleaned and analyzed between January 16, 2020, and April 29, 2021. Exposures: Mutually exclusive multimorbidity domain combinations (functional limitations and geriatric syndromes; functional limitations and chronic conditions; chronic conditions and geriatric syndromes; or functional limitations, geriatric syndromes, and chronic conditions). Main Outcomes and Measures: Time to death (up to 3 years from EGS conditions admission) in patients with multimorbidity combinations was analyzed using a Cox proportional hazards model and compared with those without multimorbidity; hazard ratios (HRs) and 95% CIs are presented. Models were adjusted for age, sex, and operative treatment. Results: Of 1960 patients (median [IQR] age, 79 [73-85] years; 1166 [59.5%] women), 383 (19.5%) had no multimorbidity, 829 (42.3%) had 2 multimorbidity domains, and 748 (38.2%) had all 3 domains present. A total of 376 (19.2%) were known to have died in the follow-up period, with a median (IQR) follow-up of 377 (138-621) days. Patients with chronic conditions and geriatric syndromes had a mortality risk similar to those without multimorbidity. However, all domain combinations with functional limitations were associated with significantly increased risk of death: functional limitations and chronic conditions (HR, 1.83; 95% CI, 1.03-3.23); functional limitations and geriatric syndromes (HR, 2.91; 95% CI, 1.37-6.18); and functional limitations, geriatric syndromes, and chronic conditions (HR, 2.08; 95% CI, 1.49-2.89). Conclusions and Relevance: Findings of this study suggest that a patient's baseline complex multimorbidity level efficiently identifies risk stratification groups for long-term survival. Functional limitations are rarely considered in risk stratification paradigms for older patients with EGS conditions compared with chronic conditions and geriatric syndromes. However, functional limitations may be the most important risk factor for long-term survival.

Comparing the association between multiple chronic conditions, multimorbidity, frailty, and survival among older patients with cancer.

INTRODUCTION: The high prevalence of multiple chronic conditions (MCC), multimorbidity, and frailty may affect treatment and outcomes for older adults with cancer. The goal of this study was to use three conceptually distinct measures of morbidity to examine the association between these measures and mortality. MATERIALS AND METHODS: Using Medicare claims data linked with the 2012-2016 Ohio Cancer Incidence Surveillance System we identified older adults with incident primary cancer sites of breast, colorectal, lung, or prostate (n = 29,140). We used claims data to identify their Elixhauser comorbidities, Multimorbidity-Weighted Index (MWI), and Claims Frailty Index (CFI) as measures of MCC, multimorbidity, and frailty, respectively. We used Cox proportional hazard models to examine the association between these measures and survival time since diagnosis. RESULTS: Lung cancer patients had the highest levels of MCC, multimorbidity, and frailty. There was a positive association between all three measures and a greater hazard of death after adjusting for age, sex (colorectal and lung only), and stage. Breast cancer patients with 5+ comorbidities had an adjusted hazard ratio (aHR) of 1.63 (95% confidence interval [CI]: 1.38, 1.93), and those with mild frailty had an aHR of 3.38 (95% CI; 2.12, 5.41). The C statistics for breast cancer were 0.79, 0.78, and 0.79 for the MCC, MWI, and CFI respectively. Similarly, lung cancer patients who were moderately or severely frail had an aHR of 1.82 (95% CI: 1.53, 2.18) while prostate cancer patients had an aHR of 3.39 (95% CI: 2.12, 5.41) and colorectal cancer patients had an aHR of 4.51 (95% CI: 3.23, 6.29). Model performance was nearly identical across the MCC, multimorbidity, and frailty models within cancer type. The models performed best for prostate and breast cancer, and notably worse for lung cancer. The frailty models showed the greatest separation in unadjusted survival curves. DISCUSSION: The MCC, multimorbidity, and frailty indices performed similarly well in predicting mortality among a large cohort of older cancer patients. However, there were notable differences by cancer type. This work highlights that although model performance is similar, frailty may serve as a clearer indicator in risk stratification of geriatric oncology patients than simple MCCs or multimorbidity.