Post-acute sequelae of SARS-CoV-2 (PASC) in nursing home residents: A retrospective cohort study.

BACKGROUND: Post-acute sequelae of SARS-CoV-2 (PASC) describes a syndrome of physical and cognitive decline that persists after acute symptoms of infection resolve. Few studies have explored PASC among nursing home (NH) residents. METHODS: A retrospective cohort study was conducted at two NHs in Michigan. COVID-positive patients were identified from March 21, 2020 to October 26, 2021. The comparison group were patients who lived at the same NH but who were never infected during the study period. Minimum Data Set was used to examine trajectories of functional dependence (Activity of Daily Living [ADL] composite score) and cognitive function (Brief Interview for Mental Status [BIMS]). Linear mixed-effects models were constructed to estimate short-term change in function and cognition immediately following diagnosis and over time for an additional 12 months, compared to pre-COVID and non-COVID trajectories and adjusting for sex, age, and dementia status. RESULTS: We identified 171 residents (90 COVID-19 positive, 81 non-COVID) with 719 observations for our analyses. Cohort characteristics included: 108 (63%) ≥ 80 yrs.; 121 (71%) female; 160 (94%) non-Hispanic white; median of 3 comorbidities (IQR 2-4), with no significant differences in characteristics between groups. COVID-19 infection affected the trajectory of ADL recovery for the first 9 months following infection, characterized by an immediate post-infection decrease in functional status post-infection (-0.60 points, p = 0.002) followed by improvement toward the expected functional trajectory sans infection (0.04 points per month following infection, p = 0.271). CONCLUSIONS: NH residents experienced a significant functional decline that persisted for 9 months following acute infection. Further research is needed to determine whether increased rehabilitation services after COVID-19 may help mitigate this decline.

The Association of Cognitive Status and Post-Operative Opioid Prescribing in Older Adults.

Objective: To examine the differences in opioid prescribing by cognitive status following common elective surgical procedures among Medicare beneficiaries. Background: Older individuals commonly experience changes in cognition with age. Although opioid prescribing is common after surgery, differences in opioid prescribing after surgery by cognitive status are poorly understood. Methods: We conducted a retrospective analysis of patients ≥65 years participating in the Health and Retirement Study (HRS) linked with Medicare claims data who underwent surgeries between January 2007 and November 2016 and had cognitive assessments before the index operation. Cognitive status was defined as normal cognition, mild cognitive impairment (MCI), or dementia. Outcomes assessed were initial perioperative opioid fill rates, refill rates, and high-risk prescriptions fill rates. The total amount of opioids filled during the 30-day postdischarge period was also assessed. Adjusted rates were estimated for patient factors using the Cochran-Armitage test for trend. Results: Among the 1874 patients included in the analysis, 68% had normal cognition, 21.3% had MCI, and 10.7% had dementia. Patients with normal cognition (58.1%) and MCI (54.5%) had higher initial preoperative fill rates than patients with dementia (33.5%) (P < 0.001). Overall, patients with dementia had similar opioid refill rates (21%) to patients with normal cognition (24.1%) and MCI (26.5%) (P = 0.322). Although prior opioid exposure did not differ by cognitive status (P = 0.171), among patients with high chronic preoperative use, those with dementia had lower adjusted prescription sizes filled within 30 days following discharge (281 OME) than patients with normal cognition (2147 OME) and MCI (774 OME) (P < 0.001; P = 0.009 respectively). Among opioid-naive patients, patients with dementia also filled smaller prescription sizes (97 OME) compared to patients with normal cognition (205 OME) and patients with MCI (173 OME) (P < 0.001 and P = 0.019, respectively). Conclusions: Patients with dementia are less likely to receive postoperative prescriptions, less likely to refill prescriptions, and receive prescriptions of smaller sizes compared to patients with normal cognition or MCI. A cognitive assessment is an additional tool surgeons can use to determine a patient's individualized postoperative pain control plan.

Patient Cognitive Status and Physician Recommendations for Cardiovascular Disease Treatment: Results of Two Nationwide, Randomized Survey Studies.

BACKGROUND: Clinical guidelines recommend that older patients (65+) with mild cognitive impairment (MCI) and early-stage dementia receive similar guideline-concordant care after cardiovascular disease (CVD) events as those with normal cognition (NC). However, older patients with MCI and dementia receive less care for CVD and other conditions than those with NC. Whether physician recommendations for guideline-concordant treatments after two common CVD events, acute myocardial infarction (AMI) and acute ischemic stroke (stroke), differ between older patients with NC, MCI, and early-stage dementia is unknown. OBJECTIVE: To test the influence of patient cognitive status (NC, MCI, early-stage dementia) on physicians' recommendations for guideline-concordant treatments for AMI and stroke. DESIGN: We conducted two parallel, randomized survey studies for AMI and stroke in the US using clinical vignettes where the hypothetical patient's cognitive status was randomized between physicians. PARTICIPANTS: The study included cardiologists, neurologists, and generalists who care for most patients hospitalized for AMI and stroke. MAIN MEASURES: The primary outcome was a composite quality score representing the number of five guideline-concordant treatments physicians recommended for a hypothetical patient after AMI or stroke. KEY RESULTS: 1,031 physicians completed the study (58.5% response rate). Of 1,031 respondents, 980 physicians had complete information. After adjusting for physician factors, physicians recommended similar treatments after AMI and stroke in hypothetical patients with pre-existing MCI (adjusted ratio of expected composite quality score, 0.98 [95% CI, 0.94, 1.02]; P = 0.36) as hypothetical patients with NC. Physicians recommended fewer treatments to hypothetical patients with pre-existing early-stage dementia than to hypothetical patients with NC (adjusted ratio of expected composite quality score, 0.90 [0.86, 0.94]; P < 0.001). CONCLUSION: In these randomized survey studies, physicians recommended fewer guideline-concordant AMI and stroke treatments to hypothetical patients with early-stage dementia than those with NC. We did not find evidence that physicians recommend fewer treatments to hypothetical patients with MCI than those with NC.

Validation of Self-Reported Cancer Diagnoses by Respondent Cognitive Status in the U.S. Health and Retirement Study.

BACKGROUND: Cancer and dementia are becoming increasingly common co-occurring conditions among older adults. Yet, the influence of participant cognitive status on the validity of self-reported data among older adults in population-based cohorts is unknown. We thus compared self-reported cancer diagnoses in the U.S. Health and Retirement Study (HRS) against claims from linked Medicare records to ascertain the validity of self-reported diagnoses by participant cognitive and proxy interview status. METHODS: Using data from HRS participants aged ≥67 who had at least 90% continuous enrollment in fee-for-service Medicare, we examined the validity of self-reported first incident cancer diagnoses from biennial HRS interviews against diagnostic claim records in linked Medicare data (reference standard) for interviews from 2000 to 2016. Cognitive status was classified as normal, cognitive impairment no dementia (CIND), or dementia using the Langa-Weir method. We calculated the sensitivity, specificity, and κ for cancer diagnosis. RESULTS: Of the 8 280 included participants, 23.6% had cognitive impairment without dementia (CIND) or dementia, and 10.7% had a proxy respondent due to an impairment. Self-reports of first incident cancer diagnoses for participants with normal cognition had 70.2% sensitivity and 99.8% specificity (κ = 0.79). Sensitivity declined substantially with cognitive impairment and proxy response (56.7% for CIND, 53.0% for dementia, 60.0% for proxy respondents), indicating poor validity for study participants with CIND, dementia, or a proxy respondent. CONCLUSIONS: Self-reported cancer diagnoses in the U.S. HRS have poor validity for participants with cognitive impairment, dementia, or a proxy respondent. Population-based cancer research among older adults will be strengthened with linkage to Medicare claims.

The Influence of Cognitive Impairment on Postoperative Outcomes.

OBJECTIVE: To examine differences in rates of elective surgery, postoperative mortality, and readmission by pre-existing cognitive status among Medicare beneficiaries undergoing surgery. BACKGROUND: MCI is common among older adults, but the impact of MCI on surgical outcomes is understudied. METHODS: We conducted a retrospective cohort study of individuals ≥65 who underwent surgery between 2001 and 2015 using data from the nationally-representative Health and Retirement Study linked with Medicare claims. Cognitive status was assessed by the modified telephone interview for cognitive status score and categorized as normal cognition (score: 12-27), MCI (7-11), and dementia (<7). Outcomes were 30- and 90-day postoperative mortality and readmissions. We used Cox proportional hazard models to estimate the risk of each outcome by cognition, adjusting for patient characteristics. RESULTS: In 6,590 patients, 69.9% had normal cognition, 20.1% had MCI, and 9.9% had dementia. Patients with MCI (79.9%) and dementia (73.6%) were less likely to undergo elective surgery than patients with normal cognition (85.9%). Patients with MCI had similar postoperative mortality and readmissions rates as patients with normal cognition. However, patients with dementia had significantly higher postoperative 90-day mortality (5.2% vs 8.4%, P = 0.002) and readmission rates (13.9% vs 17.3%, P = 0.038). CONCLUSION: Patients with self-reported MCI are less likely to undergo elective surgery but have similar postoperative outcomes compared with patients with normal cognition. Despite the variability of defining MCI, our findings suggest that MCI may not confer additional risk for older individuals undergoing surgery, and should not be a barrier for surgical care.

Multimorbidity and long-term disability and physical functioning decline in middle-aged and older Americans: an observational study.

BACKGROUND: Multimorbidity is highly prevalent and associated with several adverse health outcomes, including functional limitations. While maintaining physical functioning is relevant for all adults, identifying those with multimorbidity at risk for faster rates of physical functioning decline may help to target interventions to delay the onset and progression of disability. We quantified the association of multimorbidity with rates of long-term disability and objective physical functioning decline. METHODS: In the Health and Retirement Study, we computed the Multimorbidity-Weighted Index (MWI) by assigning previously validated weights (based on physical functioning) to each chronic condition. We used an adjusted negative binomial regression to assess the association of MWI with disability (measured by basic and instrumental activities of daily living [ADLs, IADLs]) over 16 years, and linear mixed effects models to assess the association of MWI with gait speed and grip strength over 8 years. RESULTS: Among 16,616 participants (mean age 67.3, SD 9.7 years; 57.8% women), each additional MWI point was associated with a 10% increase in incidence rate of disability (IRR: 1.10; 95%CI: 1.09, 1.10). In 2,748 participants with data on gait speed and grip strength, each additional MWI point was associated with a decline in gait speed of 0.004 m/s (95%CI: -0.006, -0.001). The association with grip strength was not statistically significant (-0.01 kg, 95%CI: -0.73, 0.04). The rate of decline increased with time for all outcomes, with a significant interaction between time and MWI for disability progression only. CONCLUSION: Multimorbidity, as weighted on physical functioning, was associated with long-term disability, including faster rates of disability progression, and decline in gait speed. Given the importance of maintaining physical functioning and preserving functional independence, MWI is a readily available tool that can help identify adults to target early on for interventions.

Widowhood and cognition among older women in India: New insights on widowhood duration and mediators.

Background: Widowhood, a marital status that disproportionately affects older women, has been associated with poorer health compared to married individuals. However, relatively little is known about the association between widowhood in later-life and cognitive health in low- and middle-income countries. Methods: To address this research gap, we used data from the Longitudinal Aging Study in India (2017-19) to investigate the widowhood disparity in cognitive health among mid-aged and older women in India, including how this relationship varies by the duration of widowhood. We further examined the extent to which economic, social, and health conditions mediate this association. Results: Cognition scores for widowed women were on average lower by almost 0.1 standard deviations compared to married women. Overall, this disparity increased with widowhood duration, with non-linearities in this association. The disparity in cognition scores increased with widowhood duration up to twenty years but did not increase further among those with longer widowhood duration. Worse physical and mental health were found to mediate almost thirty percent of the total association between widowhood and cognition. These mediators were most useful in explaining the association between lower cognition and widowhood among women who experienced widowhood for ten years or longer. Conclusion: The study highlights the significant disadvantage in cognitive functioning among older widowed women in India. The study also provides evidence on potential mediators, suggesting differential effects of mediators at different stages of widowhood.

Long-term household material socioeconomic resources and cognitive health in a population-based cohort of older adults in rural northeast South Africa, 2001-2015.

Material resources owned by households that affect daily living conditions may be salient for cognitive health during aging, especially in low-income settings, but there is scarce evidence on this topic. We investigated relationships between long-term trends in household material resources and cognitive function among older adults in a population-representative study in rural South Africa. Data were from baseline interviews with 4580 adults aged ≥40 in "Health and Ageing in Africa: A Longitudinal Study of an INDEPTH Community in South Africa" (HAALSI) in 2014/2015 linked to retrospective records on their household material resources from the Agincourt Health and Socio-Demographic Surveillance System (HDSS) from 2001 to 2013. Household material resources were assessed biennially in the Agincourt HDSS using a five-point index that captured dwelling materials, water and sanitation, sources of power, livestock, and technological amenities. Cognitive function was assessed in HAALSI and analyzed as a z-standardized latent variable capturing time orientation, episodic memory, and numeracy. We evaluated the relationships between quintiles of each of the mean resource index score, volatility in resource index score, and change in resource index score and subsequent cognitive function, overall and by resource type. Higher mean household resources were positively associated with cognitive function (ßadj = 0.237 standard deviation [SD] units for the highest vs. lowest quintile of mean resource index score; 95% CI: 0.163-0.312; p-trend<0.0001), as were larger improvements over time in household resources (ßadj = 0.122 SD units for the highest vs. lowest quintile of change in resources; 95% CI: 0.040-0.205; p-trend = 0.001). Results were robust to sensitivity analyses assessing heterogeneity by age and restricting to those with formal education. The findings were largely driven by technological amenities including refrigerators, stoves, telephones, televisions, and vehicles. These amenities may support cognitive function through improving nutrition and providing opportunities for cognitive stimulation through transportation and social contact outside of the home.

Associations of Age at Diagnosis and Duration of Diabetes With Morbidity and Mortality Among Older Adults.

Importance: Older adults vary widely in age at diagnosis and duration of type 2 diabetes, but treatment often ignores this heterogeneity. Objectives: To investigate the associations of diabetes vs no diabetes, age at diagnosis, and diabetes duration with negative health outcomes in people 50 years and older. Design, Setting, and Participants: This cohort study included participants in the 1995 through 2018 waves of the Health and Retirement Study (HRS), a population-based, biennial longitudinal health interview survey of older adults in the US. The study sample included adults 50 years or older (n = 36 060) without diabetes at entry. Data were analyzed from June 1, 2021, to July 31, 2022. Exposures: The presence of diabetes, specifically the age at diabetes diagnosis, was the main exposure of the study. Age at diagnosis was defined as the age when the respondent first reported diabetes. Adults who developed diabetes were classified into 3 age-at-diagnosis groups: 50 to 59 years, 60 to 69 years, and 70 years and older. Main Outcomes and Measures: For each diabetes age-at-diagnosis group, a propensity score-matched control group of respondents who never developed diabetes was constructed. The association of diabetes with the incidence of key outcomes-including heart disease, stroke, disability, cognitive impairment, and all-cause mortality-was estimated and the association of diabetes vs no diabetes among the age-at-diagnosis case and matched control groups was compared. Results: A total of 7739 HRS respondents developed diabetes and were included in the analysis (4267 women [55.1%]; mean [SD] age at diagnosis, 67.4 [9.9] years). The age-at-diagnosis groups included 1866 respondents at 50 to 59 years, 2834 at 60 to 69 years, and 3039 at 70 years or older; 28 321 HRS respondents never developed diabetes. Age at diagnosis of 50 to 59 years was significantly associated with incident heart disease (hazard ratio [HR], 1.66 [95% CI, 1.40-1.96]), stroke (HR, 1.64 [95% CI, 1.30-2.07]), disability (HR, 2.08 [95% CI, 1.59-2.72]), cognitive impairment (HR, 1.30 [95% CI, 1.05-1.61]), and mortality (HR, 1.49 [95% CI, 1.29-1.71]) compared with matched controls, even when accounting for diabetes duration. These associations significantly decreased with advancing age at diagnosis. Respondents with diabetes diagnosed at 70 years or older only showed a significant association with the outcome of elevated mortality (HR, 1.08 [95% CI, 1.01-1.17]). Conclusions and Relevance: The findings of this cohort study suggest that age at diabetes diagnosis was differentially associated with outcomes and that younger age groups were at elevated risk of heart disease, stroke, disability, cognitive impairment, and all-cause mortality. These findings reinforce the clinical heterogeneity of diabetes and highlight the importance of improving diabetes management in adults with earlier diagnosis.

Glaucoma and cognitive function trajectories in a population-based study: Findings from the health and retirement study.

INTRODUCTION: Prior studies on the association of glaucoma and cognitive function have reported mixed results. METHODS: The Health and Retirement Study (HRS) is a nationally representative panel survey of Americans age ≥ 51 years. HRS-linked Medicare claims data were used to identify incident glaucoma cases (by glaucoma type). Cognitive function was measured using the Telephone Interview for Cognitive Status (TICS), administered in each wave (every 2 years). Separate linear mixed models were fitted with either prevalent or incident glaucoma as a predictor of TICS trajectories and adjusting for age, race/ethnicity, educational attainment, gender, and medical history. Negative model estimates indicate associations of glaucoma with worse cognitive function scores or steeper per-year declines in cognitive function scores. RESULTS: Analyses of prevalent glaucoma cases included 1344 cases and 5729 controls. Analyses of incident glaucoma included 886 cases and 4385 controls. In fully-adjusted models, those with prevalent glaucoma had similar TICS scores to controls (ß = 0.01; 95% Confidence Interval [CI]: -0.15, 0.18; p = 0.86). However, in those with incident glaucoma, we detected a statistically significant association between glaucoma and lower TICS scores (ß = -0.29; 95% CI: -0.50, -0.08; p = 0.007). However, there was no statistically significant association between either prevalent or incident glaucoma and per-year rates of change in TICS scores. When categorizing glaucoma by type (primary open angle glaucoma, normal tension glaucoma, or other glaucoma), no significant associations were detected between either prevalent or incident glaucoma and levels of or rates of change in TICS scores in fully covariate adjusted models. CONCLUSION: The observed associations between glaucoma and cognitive function were small and unlikely to be clinically meaningful. Compared to prior studies on this topic, this investigation provides robust evidence based on its larger sample size, longitudinal follow-up, and repeated measures of cognitive function in a population-based sample.

Bad company: Loneliness longitudinally predicts the symptom cluster of pain, fatigue, and depression in older adults.

BACKGROUND: Pain, fatigue, and depression frequently co-occur as a symptom cluster. While commonly occurring in those with cancer and autoimmune disease, the cluster is also found in the absence of systemic illness or inflammation. Loneliness is a common psychosocial stressor associated with the cluster cross-sectionally. We investigated whether loneliness predicted the development of pain, fatigue, depression, and the symptom cluster over time. METHODS: Data from the Health and Retirement Study were used. We included self-respondents ≥50 year-old who had at least two measurements of loneliness and the symptom cluster from 2006-2016 (n = 5974). Time-varying loneliness was used to predict pain, fatigue, depression, and the symptom cluster in the subsequent wave(s) using generalized estimating equations (GEE) and adjusting for sociodemographic covariates, living arrangement, and the presence of the symptom(s) at baseline. RESULTS: Loneliness increased the odds of subsequently reporting pain (aOR 1.22, 95% CI 1.08, 1.37), fatigue (aOR 1.47, 95% CI 1.32, 1.65), depression (aOR 2.33, 95% CI 2.02, 2.68), as well as the symptom cluster (aOR 2.15, 95% CI 1.74, 2.67). The median time between the baseline and final follow-up measurement was 7.6 years (IQR 4.1, 8.2). CONCLUSIONS: Loneliness strongly predicts the development of pain, fatigue, and depression as well as the cluster of all three symptoms several years later in a large, nonclinical sample of older American adults. Future studies should examine the multiple pathways through which loneliness may produce this cluster, as well as examine whether other psychosocial stressors also increase risk. It is possible that interventions which address loneliness in older adults may prevent or mitigate the cluster of pain, fatigue, and depression.

Validation of Self-reported Cancer Diagnoses Using Medicare Diagnostic Claims in the US Health and Retirement Study, 2000-2016.

BACKGROUND: The US Health Retirement Study (HRS) is an ongoing population-representative cohort of US adults ages >50 with rich data on health during aging. Self-reported cancer diagnoses have been collected since 1998, but they have not been validated. We compared self-reported cancer diagnoses in HRS interviews against diagnostic claims from linked Medicare records. METHODS: Using HRS-Medicare linked data, we examined the validity of first incident cancer diagnoses self-reported in biennial interviews from 2000 to 2016 against ICD-9 and ICD-10 diagnostic claim records as the gold standard. Data were from 8,242 HRS participants ages ≥65 with 90% continuous enrollment in fee-for-service Medicare. We calculated the sensitivity, specificity, and κ for first incident invasive cancer diagnoses (all cancers combined, and each of bladder, breast, colorectal/anal, uterine, kidney, lung, and prostate cancers) cumulatively over the follow-up and at each biennial study interview. RESULTS: Overall, self-reports of first incident cancer diagnoses from 2000 to 2016 had 73.2% sensitivity and 96.2% specificity against Medicare claims (κ = 0.73). For specific cancer types, sensitivities ranged from 44.7% (kidney) to 75.0% (breast), and specificities ranged from 99.2% (prostate) and 99.9% (bladder, uterine, and kidney). Results were similar in sensitivity analyses restricted to individuals with 100% continuous fee-for-service Medicare enrollment and when restricted to individuals with at least 24 months of Medicare enrollment. CONCLUSIONS: Self-reported cancer diagnoses in the HRS have reasonable validity for use in population-based research that is maximized with linkage to Medicare. IMPACT: These findings inform the use of the HRS for population-based cancer and aging research.

Subjective social position and cognitive function in a longitudinal cohort of older, rural South African adults, 2014-2019.

BACKGROUND: The relationship between subjective social position (SSP) and cognitive ageing unclear, especially in low-income settings. We aimed to investigate the relationship between SSP and cognitive function over time among older adults in rural South Africa. METHODS: Data were from 3771 adults aged ≥40 in the population-representative 'Health and Ageing in Africa: A Longitudinal Study of an INDEPTH Community in South Africa' from 2014/2015 (baseline) to 2018/2019 (follow-up). SSP was assessed at baseline with the 10-rung MacArthur Network social position ladder. Outcomes were composite orientation and episodic memory scores at baseline and follow-up (range: 0-24). Mortality- and attrition-weighted linear regression estimated the associations between baseline SSP with cognitive scores at each of the baseline and follow-up. Models were adjusted for age, age2, sex, country of birth, father's occupation, education, employment, household assets, literacy, marital status and health-related covariates. RESULTS: SSP responses ranged from 0 (bottom ladder rung/lowest social position) to 10 (top ladder rung/highest social position), with a mean of 6.6 (SD: 2.3). SSP was positively associated with baseline cognitive score (adjusted ß=0.198 points per ladder rung increase; 95% CI 0.145 to 0.253) and follow-up cognitive score (adjusted ß=0.078 points per ladder rung increase; 95% CI 0.021 to 0.136). CONCLUSION: Independent of objective socioeconomic position measures, SSP is associated with orientation and episodic memory scores over two time points approximately 3 years apart among older rural South Africans. Future research is needed to establish the causality of the observed relationships, whether they persist over longer follow-up periods and their consistency in other populations.

The Association Between Mild Cognitive Impairment Diagnosis and Patient Treatment Preferences: a Survey of Older Adults.

BACKGROUND: Older patients (65+) with mild cognitive impairment (MCI) receive less guideline-concordant care for cardiovascular disease (CVD) and other conditions than patients with normal cognition (NC). One potential explanation is that patients with MCI want less treatment than patients with NC; however, the treatment preferences of patients with MCI have not been studied. OBJECTIVE: To determine whether patients with MCI have different treatment preferences than patients with NC. DESIGN: Cross-sectional survey conducted at two academic medical centers from February to December 2019 PARTICIPANTS: Dyads of older outpatients with MCI and NC and patient-designated surrogates. MAIN MEASURES: The modified Life-Support Preferences-Predictions Questionnaire score measured patients' preferences for life-sustaining treatment decisions in six health scenarios including stroke and acute myocardial infarction (range, 0-24 treatments rejected with greater scores indicating lower desire for treatment). KEY RESULTS: The survey response rate was 73.4%. Of 136 recruited dyads, 127 (93.4%) completed the survey (66 MCI and 61 NC). The median number of life-sustaining treatments rejected across health scenarios did not differ significantly between patients with MCI and patients with NC (4.5 vs 6.0; P=0.55). Most patients with MCI (80%) and NC (80%) desired life-sustaining treatments in their current health (P=0.99). After adjusting for patient and surrogate factors, the difference in mean counts of rejected treatments between patients with MCI and patients with NC was not statistically significant (adjusted ratio, 1.08, 95% CI, 0.80-1.44; P=0.63). CONCLUSION: We did not find evidence that patients with MCI want less treatment than patients with NC. These findings suggest that other provider and system factors might contribute to patients with MCI getting less guideline-concordant care.

Validation of Claims Algorithms to Identify Alzheimer's Disease and Related Dementias.

BACKGROUND: Using billing data generated through health care delivery to identify individuals with dementia has become important in research. To inform tradeoffs between approaches, we tested the validity of different Medicare claims-based algorithms. METHODS: We included 5 784 Medicare-enrolled, Health and Retirement Study participants aged older than 65 years in 2012 clinically assessed for cognitive status over multiple waves and determined performance characteristics of different claims-based algorithms. RESULTS: Positive predictive value (PPV) of claims ranged from 53.8% to 70.3% and was highest using a revised algorithm and 1 year of observation. The tradeoff of greater PPV was lower sensitivity; sensitivity could be maximized using 3 years of observation. All algorithms had low sensitivity (31.3%-56.8%) and high specificity (92.3%-98.0%). Algorithm test performance varied by participant characteristics, including age and race. CONCLUSION: Revised algorithms for dementia diagnosis using Medicare administrative data have reasonable accuracy for research purposes, but investigators should be cognizant of the tradeoffs in accuracy among the approaches they consider.

Environmental contamination with SARS-CoV-2 in nursing homes.

BACKGROUND: SARS-CoV-2 outbreaks in nursing homes (NHs) have been devastating and have led to the creation of coronavirus disease 2019 (COVID-19) units within NHs to care for affected patients. Frequency and persistence of SARS-CoV-2 environmental contamination in these units have not been studied. METHODS: A prospective cohort study was conducted between October 2020 and January 2021 in four Michigan NHs. Swabs from high-touch surfaces in COVID-19-infected patient rooms were obtained at enrollment and follow-up. Demographic and clinical data were collected from clinical records. Primary outcome of interest was the probability of SARS-CoV-2 RNA detection from specific environmental surfaces in COVID-19 patient rooms. We used multivariable logistic regression to assess patient risk factors for SARS-CoV-2 contamination. Pairwise Phi coefficients were calculated to measure correlation of site-specific environmental detection upon enrollment and during follow-up. RESULTS: One hundred and four patients with COVID-19 were enrolled (61.5% >80 years; 67.3% female; 89.4% non-Hispanic White; 51% short stay) and followed up for 241 visits. The study population had significant disabilities in activities of daily living (ADL; 81.7% dependent in four or more ADLs) and comorbidities, including dementia (55.8%), diabetes (40.4%), and heart failure (32.7%). Over the 3-month study period, 2087 swab specimens were collected (1896 COVID-19 patient rooms, 191 common areas). SARS-CoV-2 positivity was 28.4% (538/1896 swabs) on patient room surfaces and 3.7% (7/191 swabs) on common area surfaces. Nearly 90% (93/104) of patients had SARS-CoV-2 contamination in their room at least once. Environmental contamination upon enrollment correlated with contamination of the same site during follow-up. Functional independence increased the odds of proximate contamination. CONCLUSIONS: Environmental detection of viral RNA from surfaces in the rooms of COVID-19 patients is nearly universal and persistent; more investigation is needed to determine the implications of this for infectiousness. Patients with greater independence are more likely than fully dependent patients to contaminate their immediate environment.

Effectiveness of a Multicomponent Intervention to Reduce Multidrug-Resistant Organisms in Nursing Homes: A Cluster Randomized Clinical Trial.

Importance: Multidrug-resistant organisms (MDROs) can cause significant morbidity and mortality. Preventing MDROs can reduce the risk of subsequent transmission and infection. Objective: To determine whether a multicomponent infection prevention intervention can reduce MDRO prevalence in nursing homes (NHs). Design, Setting, and Participants: This cluster randomized clinical trial of a multicomponent intervention was conducted in 6 NHs in Michigan from September 2016 to August 2018. Three NHs adopted a multicomponent intervention, while 3 control NHs continued without investigator intervention. Study visits were conducted at baseline; days 7, 14, 21, and 30; and monthly thereafter for up to 6 months or discharge. Visits included clinical data collection and MDRO surveillance culturing of multiple body sites and high-touch surfaces in patient rooms. Any patients who provided informed consent within 14 days of admission to the NH were enrolled in this study. Non-English speakers and patients receiving hospice care were ineligible. Analysis was performed from November 2018 to February 2020. Interventions: Intervention NHs adopted a multicomponent intervention that included enhanced barrier precautions, chlorhexidine bathing, MDRO surveillance, environmental cleaning education and feedback, hand hygiene promotion, and health care worker education and feedback. Control nursing homes continued standard care practices. Main Outcomes and Measures: The primary outcome, presence of MDROs, was measured longitudinally in the patient and room environment and was evaluated using generalized mixed effect models. The secondary outcome, time to new MDRO acquisition, was assessed using Cox proportional hazard models. Results: A total of 6 NHs were included, with 245 patients (mean [SD] age, 72.5 [13.6] years; 134 [54.7%] women) enrolled; 3 NHs with 113 patients (46.1%) were randomized to the intervention group and 3 NHs with 132 patients (53.9%) were randomized to the control group. A total of 132 patients (53.9%) were White, and 235 patients (95.9%) were receiving postacute care. Over 808 study visits, 3654 patient cultures and 5606 environmental cultures were obtained. The intervention reduced the odds of MDRO prevalence in patients' environment by 43% (aOR, 0.57; 95% CI, 0.35-0.94), but there was no statistically significant difference on the patient level before or after adjustment (aOR, 0.57; 95% CI, 0.29-1.14). There were no significant reductions in time to new acquisition for methicillin-resistant Staphylococcus aureus (hazard ratio [HR], 0.20; 95% CI, 0.04-1.09), vancomycin-resistant enterococci (HR, 0.84; 95% CI, 0.46-1.53), or resistant gram-negative bacilli (HR, 1.14; 95% CI, 0.73-1.78). Conclusions and Relevance: This cluster randomized clinical trial found that the multicomponent intervention reduced the prevalence of MDROs in the environment of NH patients. Our findings highlight the potential for multicomponent interventions to directly and indirectly reduce MDRO prevalence in NHs. Trial Registration: ClinicalTrials.gov Identifier: NCT02909946.

The Effect of Childhood Socioeconomic Position and Social Mobility on Cognitive Function and Change Among Older Adults: A Comparison Between the United States and England.

OBJECTIVES: This study aims to examine the relationship between childhood socioeconomic position (SEP) and cognitive function in later life within nationally representative samples of older adults in the United States and England, investigate whether these effects are mediated by later-life SEP, and determine whether social mobility from childhood to adulthood affects cognitive function and decline. METHOD: Using data from the Health and Retirement Study (HRS) and the English Longitudinal Survey of Ageing (ELSA), we examined the relationships between measures of SEP, cognitive performance and decline using individual growth curve models. RESULTS: High childhood SEP was associated with higher cognitive performance at baseline in both cohorts and did not affect the rate of decline. This benefit dissipated after adjusting for education and adult wealth in the United States. Respondents with low childhood SEP, above median education, and high adult SEP had better cognitive performance at baseline than respondents with a similar childhood background and less upward mobility in both countries. DISCUSSION: These findings emphasize the impact of childhood SEP on cognitive trajectories among older adults. Upward mobility may partially compensate for disadvantage early in life but does not protect against cognitive decline.

Preexisting Mild Cognitive Impairment, Dementia, and Receipt of Treatments for Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Differences in acute ischemic stroke (AIS) treatment by cognitive status are unclear, but some studies have found patients with preexisting dementia get less treatment. We compared AIS care by preexisting cognitive status. METHODS: Cross-sectional analysis of prospectively obtained data on 836 adults ≥45 with AIS from the population-based Brain Attack Surveillance in Corpus Christi project from 2008 to 2013. We compared receipt of a composite quality measure representing the percentage of 7 treatments/procedures received (ordinal scale; values, <0.75, 0.75-0.99, and 1.0), a binary defect-free quality score, and individual treatments after AIS between patients with preexisting dementia (Informant Questionnaire on Cognitive Decline in the Elderly score ≥3.44), mild cognitive impairment (MCI, score 3.1-3.43), and normal cognition (score ≤3). RESULTS: Among patients with AIS, 42% had normal cognition (47% women; median age [interquartile range], 65 [56-76]), 32% had MCI (54% women; median age, 70 [60-78]), 26% had dementia (56% women; median age, 78 [64-85]). After AIS, 44% of patients with preexisting dementia and 55% of patients with preexisting MCI or normal cognition received defect-free care. Compared with cognitively normal patients, patients with preexisting MCI had similar cumulative odds (unadjusted cumulative odds ratio =0.99, P=0.92), and patients with preexisting dementia had 36% lower cumulative odds of receiving the composite quality measure (unadjusted cumulative odds ratio [OR]=0.64, P=0.005). However, the dementia-quality association became nonsignificant after adjusting for patient factors, namely sex, comorbidity, and body mass index (adjusted cumulative OR [acOR]=0.79, P=0.19). Independent of patient factors, preexisting MCI was negatively associated with receipt of IV tPA (intravenous tissue-type plasminogen activator; acOR=0.36, P=0.04), rehabilitation assessment (acOR=0.28, P=0.016), and echocardiogram (acOR=0.48, P<0.001). Preexisting dementia was negatively associated with receipt of antithrombotic by day 2 (acOR=0.39, P=0.04) and echocardiogram (acOR=0.42, P<0.001). CONCLUSIONS: Patients with preexisting MCI and dementia, compared with cognitively normal patients, may receive less frequently some treatments and procedures, but not the composite quality measure, after AIS.

Trajectory of Cognitive Decline After Sepsis.

OBJECTIVES: Cognitive impairment is an important consequence of sepsis. We sought to determine long-term trajectories of cognitive function after sepsis. DESIGN: Prospective study of the Reasons for Geographic and Racial Differences in Stroke cohort. SETTING: United States. PATIENTS: Twenty-one thousand eight-hundred twenty-three participants greater than or equal to 45 years, mean (sd) age 64.3 (9.2) years at first cognitive assessment, 30.9% men, and 27.1% Black. MEASUREMENTS AND MAIN RESULTS: The main exposure was time-dependent sepsis hospitalization. The primary outcome was global cognitive function (Six-Item Screener range, 0-6). Secondary outcomes were incident cognitive impairment (Six-Item Screener score ≤ 4 [impaired] vs ≥5 [unimpaired]), new learning (Consortium to Establish a Registry for Alzheimer Disease Word List Learning range, 0-30), verbal memory (word list delayed recall range, 0-10), and executive function/semantic fluency (animal fluency test range, ≥ 30). Over a median follow-up of 10 years (interquartile range, 6-12 yr), 840 (3.8%) experienced sepsis (incidence 282 per 1,000 person-years). Sepsis was associated with faster long-term declines in Six-Item Screener (-0.02 points per year faster [95% CI, -0.01 to -0.03]; p < 0.001) and faster long-term rates of incident cognitive impairment (odds ratio 1.08 per year [95% CI, 1.02-1.15]; p = 0.008) compared with presepsis slopes. Although cognitive function acutely changed after sepsis (0.05 points [95% CI, 0.01-0.09]; p = 0.01), the odds of acute cognitive impairment (Six-Item Screener ≤ 4) immediately after sepsis was not significant (odds ratio, 0.81 [95% CI, 0.63-1.06]; p = 0.12). Sepsis hospitalization was not associated with acute changes or faster declines in word list learning, word list delayed recall, or animal fluency test. CONCLUSIONS: Sepsis is associated with accelerated long-term decline in global cognitive function.