Combating Heightened Social Isolation of Nursing Home Elders: The Telephone Outreach in the COVID-19 Outbreak Program.

OBJECTIVE: Social isolation and loneliness-common concerns in older adults-are exacerbated by the COVID-19 pandemic. To address social isolation in nursing home residents, the Yale School of Medicine Geriatrics Student Interest Group initiated a Telephone Outreach in the COVID-19 Outbreak (TOCO) Program that implements weekly phone calls with student volunteers. METHODS: Local nursing homes were contacted; recreation directors identified appropriate and interested elderly residents. Student volunteers were paired with elderly residents and provided phone call instructions. RESULTS: Three nursing homes opted to participate in the program. Thirty elderly residents were paired with student volunteers. Initial reports from recreation directors and student volunteers were positive: elderly residents look forward to weekly phone calls and express gratitude for social connectedness. CONCLUSIONS: The TOCO program achieved initial success and promotes the social wellbeing of nursing home residents. We hope to continue this program beyond the COVID-19 pandemic in order to address this persistent need in a notably vulnerable patient population.

Care Transitions Between Hospitals and Skilled Nursing Facilities: Perspectives of Sending and Receiving Providers.

BACKGROUND: One in four Medicare patients hospitalized for acute medical illness is discharged to a skilled nursing facility (SNF); 23% of these patients are readmitted to the hospital within 30 days. The care transition from hospital to SNF is often marked by disruptions in care and poor communication among hospital and SNF providers. A study was conducted to identify the perspectives of sending and receiving providers regarding care transitions between the hospital and the SNF. METHODS: Hospital (N = 25) and SNF (N = 16) providers participated in qualitative interviews assessing patient transfers and experiences with unplanned hospital readmissions. Data were analyzed by a multidisciplinary coding team using the constant comparison method. RESULTS: Four main themes emerged: increasing patient complexity, identifying an optimal care setting, rising financial pressure, and barriers to effective communication. The data highlighted hospital and SNF providers' shared concerns about patient-level risk factors and escalating costs of care. The data also identified issues that separate hospital and SNF providers, including different access to resources and information. CONCLUSION: Hospital and SNF providers are challenged to meet the needs of complex patients. They are asked to establish comprehensive care plans for patients with significant medical and psychosocial issues while navigating tense relationships between health care institutions and rising financial pressures. The concerns of both hospital and SNF providers must be considered in order to develop practices that can improve the quality, cost, and safety of care transitions.

The association between beta-blockers and outcomes in patients with heart failure and concurrent Alzheimer's disease and related dementias.

BACKGROUND: Contemporary patients with heart failure with reduced ejection fraction (HFrEF) are older and have a higher prevalence of cognitive impairment than those studied in trials. The risk/benefit trade-off of routine beta-blocker (BB) use in patients with HFrEF and Alzheimer's disease and related dementias (ADRD) has not been explored. This study aimed to determine the association between BB use and outcomes among patients with HFrEF and ADRD. METHODS: Using a random 40% sample of Medicare Parts A, B, and D data we identified patients with ≥1 hospitalization for HFrEF between 2008 and 2018. Each patient was classified based on BB use prior to admission and after discharge. Outcomes include 90-day and 1-year mortality and readmission. RESULTS: Between 2008 and 2018, we identified 357,030 patients hospitalized with HFrEF; 12.7% had ADRD. Patients with HFrEF and ADRD had higher 90-day and 1-year mortality compared to patients with HFrEF-only. Among patients admitted on a BB, 60.5% of patients with HFrEF-only were continued on therapy after discharge, compared to 56.8% of patients with HFrEF and ADRD. Discontinuing BB was associated with a 2.2-fold higher risk of 90-day mortality (p < 0.001) among patients with HF-only and a 2.- fold higher risk of 90-day mortality (p < 0.001) among patients with HFrEF + ADRD. Not starting a BB was associated with a 1.8-fold higher risk of 90-day mortality (p < 0.001) among patients with HFrEF-only and a 1.7-fold higher risk of 90-day mortality (p < 0.001) among patients with HFrEF + ADRD. Similar risks were seen at 1 year. CONCLUSIONS: BB therapy is associated with significantly lower short and long-term mortality rates among all patients with HFrEF; the magnitude of these associated benefits appear at least as large in patients with HFrEF and ADRD compared to patients with HFrEF-only.

Benefits and harms of oral anticoagulants for atrial fibrillation in nursing home residents with advanced dementia.

BACKGROUND: Approximately 20% of older persons with dementia have atrial fibrillation (AF). Nearly all have stroke risks that exceed the guideline-recommended threshold for anticoagulation. Although individuals with dementia develop profound impairments and die from the disease, little evidence exists to guide anticoagulant discontinuation, and almost one-third of nursing home residents with advanced dementia and AF remain anticoagulated in the last 6 months of life. We aimed to quantify the benefits and harms of anticoagulation in this population. METHODS: Using Minimum Data Set and Medicare claims, we conducted a retrospective cohort study with 14,877 long-stay nursing home residents aged ≥66 between 2013 and 2018 who had advanced dementia and AF. We excluded individuals with venous thromboembolism and valvular heart disease. We measured anticoagulant exposure quarterly, using Medicare Part D claims. The primary outcome was all-cause mortality; secondary outcomes were ischemic stroke and serious bleeding. We performed survival analyses with multivariable adjustment and inverse probability of treatment (IPT) weighting. RESULTS: In the study sample, 72.0% were female, 82.7% were aged ≥80 years, and 13.5% were nonwhite. Mean CHA2 DS2 VASC score was 6.19 ± 1.58. In multivariable survival analysis, anticoagulation was associated with decreased risk of death (HR 0.71, 95% CI 0.67-0.75) and increased bleeding risk (HR 1.15, 95% CI 1.02-1.29); the association with stroke risk was not significant (HR 1.08, 95% CI 0.80-1.46). Results were similar in models with IPT weighting. While >50% of patients in both groups died within a year, median weighted survival was 76 days longer for anticoagulated individuals. CONCLUSION: Persons with advanced dementia and AF derive clinically modest life prolongation from anticoagulation, at the cost of elevated risk of bleeding. The relevance of this benefit is unclear in a group with high dementia-related mortality and for whom the primary goal is often comfort.

Presentation, Treatment, and Outcomes of Older Adults Hospitalized for Acute Myocardial Infarction According to Cognitive Status: The SILVER-AMI Study.

BACKGROUND: While survival after acute myocardial infarction has improved substantially, older adults remain at heightened risk for hospital readmissions and death. Evidence for the role of cognitive impairment in older myocardial infarction survivors' risk for these outcomes is limited. METHODS: 3041 patients aged ≥75 years hospitalized with acute myocardial infarction (mean age 82 ± 5 years, 56% male) recruited from 94 US hospitals. Cognition was assessed using the Telephone Interview for Cognitive Status; scores of <27 and <22 indicated mild and moderate/severe impairment, respectively. Readmissions and death at 6 months post-discharge were ascertained via participant report and medical record review. Associations between cognition and outcomes were evaluated with multivariable-adjusted logistic regression. RESULTS: Mild and moderate/severe cognitive impairment were present in 11% and 6% of the cohort, respectively. Readmission and death at 6 months occurred in 41% and 9% of participants, respectively. Mild and moderate/severe cognitive impairment were associated with increased risk of readmission (odds ratio [OR] 1.36; 95% confidence interval [CI], 1.08-1.72 and OR 1.58; 95% CI, 1.18-2.12, respectively) and death (OR 2.19; 95% CI, 1.54-3.11 and OR 3.82; 95% CI, 2.63-5.56, respectively) in unadjusted analyses. Significant associations between moderate/severe cognitive impairment and death (OR 1.69; 95% CI, 1.10-2.59) persisted after adjustment for demographics, myocardial infarction characteristics, comorbidity burden, functional status, and depression, but not for readmissions. CONCLUSIONS: Moderate-to-severe cognitive impairment is associated with heightened risk of death in older acute myocardial infarction patients in the months after hospitalization, but not with readmission. Routine cognitive screening may identify older myocardial infarction survivors at risk for poor outcomes who may benefit from closer oversight and support in the post-discharge period.

Risk Model for Decline in Activities of Daily Living Among Older Adults Hospitalized With Acute Myocardial Infarction: The SILVER-AMI Study.

Background Functional decline (ie, a decrement in ability to perform everyday activities necessary to live independently) is common after acute myocardial infarction (AMI) and associated with poor long-term outcomes; yet, we do not have a tool to identify older AMI survivors at risk for this important patient-centered outcome. Methods and Results We used data from the prospective SILVER-AMI (Comprehensive Evaluation of Risk Factors in Older Patients With Acute Myocardial Infarction) study of 3041 patients with AMI, aged ≥75 years, recruited from 94 US hospitals. Participants were assessed during hospitalization and at 6 months to collect data on demographics, geriatric impairments, psychosocial factors, and activities of daily living. Clinical variables were abstracted from the medical record. Functional decline was defined as a decrement in ability to independently perform essential activities of daily living (ie, bathing, dressing, transferring, and ambulation) from baseline to 6 months postdischarge. The mean age of the sample was 82±5 years; 57% were men, 90% were White, and 13% reported activity of daily living decline at 6 months postdischarge. The model identified older age, longer hospital stay, mobility impairment during hospitalization, preadmission physical activity, and depression as risk factors for decline. Revascularization during AMI hospitalization and ability to walk a quarter mile before AMI were associated with decreased risk. Model discrimination (c=0.78) and calibration were good. Conclusions We identified a parsimonious model that predicts risk of activity of daily living decline among older patients with AMI. This tool may aid in identifying older patients with AMI who may benefit from restorative therapies to optimize function after AMI.

Treatment of Hypertension in Complex Older Adults: How Many Medications Are Needed?

Background: Many older adults with hypertension receive multiple antihypertensives. It is unclear whether treatment with several antihypertensive classes results in greater cardiovascular benefits than fewer antihypertensive classes. Objectives: We investigated (a) the longitudinal associations between treatment with ≥ 3 versus 1-2 classes and death and major adverse cardiovascular events (MACE) and (b) whether these associations varied by the presence of mobility disability. Methods: We included 6,011 treated hypertensive adults ≥65 from the Medical Expenditure Panel Survey (MEPS), a nationally representative community sample. Times to MACE and death were compared between those receiving ≥3 versus 1-2 classes using multivariable proportional hazards regression. We used inverse probability of treatment weighting to account for indication and contraindication bias. Results: There were no significant differences in the risk of mortality (hazard ratio [HR] = 0.96, p = .769) or MACE (HR = 1.10, p = .574) between the exposure groups, and there were no significant exposure × mobility disability interactions. Discussion: We found no benefit of ≥3 versus 1-2 antihypertensive classes in reducing mortality and cardiovascular events in a representative cohort of older adults, raising concern about the added benefit of additional antihypertensives in the real world.

Functional Outcomes After Hip Fracture in Independent Community-Dwelling Patients.

OBJECTIVES: To determine predictors of new activities of daily living (ADLs) disability and worsened mobility disability and secondarily increased daily care hours received, in previously independent hip fracture patients. DESIGN: Retrospective cohort study. SETTING: Academic hospital with ambulatory follow-up. PARTICIPANTS: Community-dwelling adults 65 years or older independent in ADLs undergoing hip fracture surgery in 2015 (n = 184). MEASUREMENTS: Baseline, 3- and 6-month ADLs, mobility, and daily care hours received were ascertained by telephone survey and chart review. Comorbidities, medications, and characteristics of hospitalization were extracted from patient charts. Models for each outcome used logistic regression with a backward elimination strategy, adjusting a priori for age, sex, and race. RESULTS: Predictors of new ADL disability at 3 months were dementia (odds ratio [OR] = 11.81; P = .001) and in-hospital delirium (OR = 4.20; P = .002), and at 6 months were age (OR = 1.04; P = .014), dementia (OR = 9.91; P = .001), in-hospital delirium (OR = 3.00; P = .031) and preadmission opiates (OR = 7.72; P = .003). Predictors of worsened mobility at 3 months were in-hospital delirium (OR = 4.48; P = .001) and number of medications (OR = 1.13; P = .003), and at 6 months were age (OR = 1.06; P = .001), preadmission opiates (OR = 7.23; P = .005), in-hospital delirium (OR = 3.10; P = .019), and number of medications (OR = 1.13; P = .013). Predictors of increased daily care hours received at 3 and 6 months were age (3 months: OR = 1.07; P = .014; 6 months: OR = 1.06; P = .017) and number of medications (3 months: OR = 1.13; P = .004; 6 months: OR = 1.22; P = .013). The proportion of patients with ADL disability and care hours received did not change from 3 to 6 months, yet there were significant improvements in mobility. CONCLUSION: Age, dementia, in-hospital delirium, number of medications, and preadmission opiate use were predictors of poor outcomes in independent older adults following hip fracture. Further investigation is needed to identify factors associated with improved mobility measures from 3 to 6 months to ultimately optimize recovery.

Association of Patient Priorities-Aligned Decision-Making With Patient Outcomes and Ambulatory Health Care Burden Among Older Adults With Multiple Chronic Conditions: A Nonrandomized Clinical Trial.

Importance: Health care may be burdensome and of uncertain benefit for older adults with multiple chronic conditions (MCCs). Aligning health care with an individual's health priorities may improve outcomes and reduce burden. Objective: To evaluate whether patient priorities care (PPC) is associated with a perception of more goal-directed and less burdensome care compared with usual care (UC). Design, Setting, and Participants: Nonrandomized clinical trial with propensity adjustment conducted at 1 PPC and 1 UC site of a Connecticut multisite primary care practice that provides care to almost 15% of the state's residents. Participants included 163 adults aged 65 years or older who had 3 or more chronic conditions cared for by 10 primary care practitioners (PCPs) trained in PPC and 203 similar patients who received UC from 7 PCPs not trained in PPC. Participant enrollment occurred between February 1, 2017, and March 31, 2018; follow-up extended for up to 9 months (ended September 30, 2018). Interventions: Patient priorities care, an approach to decision-making that includes patients' identifying their health priorities (ie, specific health outcome goals and health care preferences) and clinicians aligning their decision-making to achieve these health priorities. Main Outcomes and Measures: Primary outcomes included change in patients' Older Patient Assessment of Chronic Illness Care (O-PACIC), CollaboRATE, and Treatment Burden Questionnaire (TBQ) scores; electronic health record documentation of decision-making based on patients' health priorities; medications and self-management tasks added or stopped; and diagnostic tests, referrals, and procedures ordered or avoided. Results: Of the 366 patients, 235 (64.2%) were female and 350 (95.6%) were white. Compared with the UC group, the PPC group was older (mean [SD] age, 74.7 [6.6] vs 77.6 [7.6] years) and had lower physical and mental health scores. At follow-up, PPC participants reported a 5-point greater decrease in TBQ score than those who received UC (ß [SE], -5.0 [2.04]; P = .01) using a weighted regression model with inverse probability of PCP assignment weights; no differences were seen in O-PACIC or CollaboRATE scores. Health priorities-based decisions were mentioned in clinical visit notes for 108 of 163 (66.3%) PPC vs 0 of 203 (0%) UC participants. Compared with UC patients, PPC patients were more likely to have medications stopped (weighted comparison, 52.0% vs 33.8%; adjusted odds ratio [AOR], 2.05; 95% CI, 1.43-2.95) and less likely to have self-management tasks (57.5% vs 62.1%; AOR, 0.59; 95% CI, 0.41-0.84) and diagnostic tests (80.8% vs 86.4%; AOR, 0.22; 95% CI, 0.12-0.40) ordered. Conclusions and Relevance: This study's findings suggest that patient priorities care may be associated with reduced treatment burden and unwanted health care. Care aligned with patients' priorities may be feasible and effective for older adults with MCCs. Trial Registration: ClinicalTrials.gov identifier: NCT03600389.

Principle of rational prescribing and deprescribing in older adults with multiple chronic conditions.

Although the majority of older adults in the developed world live with multiple chronic conditions (MCCs), the task of selecting optimal treatment regimens is still fraught with difficulty. Older adults with MCCs may derive less benefit from prescribed medications than healthier patients as a result of the competing risk of several possible outcomes including, but not limited to, death before a benefit can be accrued. In addition, these patients may be at increased risk of medication-related harms in the form of adverse effects and significant burdens of treatment. At present, the balance of these benefits and harms is often uncertain, given that older adults with MCCs are often excluded from clinical trials. In this review, we propose a framework to consider patients' own priorities to achieve optimal treatment regimens. To begin, the practicing clinician needs information on the patient's goals, what the patient is willing and able to do to achieve these goals, an estimate of the patient's clinical trajectory, and what the patient is actually taking. We then describe how to integrate this information to understand what matters most to the patient in the context of an array of potential tradeoffs. Finally, we propose conducting serial therapeutic trials of prescribing and deprescribing, with success measured as progress towards the patient's own health outcome goals. The process described in this manuscript is truly an iterative process, which should be repeated regularly to account for changes in the patient's priorities and clinical status. With this process, we aim to achieve optimal prescribing, that is, treatment regimens that maximize benefits that matter to the patient and minimize burdens and potential harms.

National Prescribing Trends for High-Risk Anticholinergic Medications in Older Adults.

OBJECTIVES: To estimate prescribing tends of and correlates independently associated with high-risk anticholinergic prescriptions in adults aged 65 and older in office-based outpatient visits. DESIGN: Repeated cross-sectional analysis. SETTING: National Ambulatory Medical Care Survey (NAMCS). PARTICIPANTS: A national sample of office-based physician visits by adults aged 65 and older from 2006 to 2015 (n=96,996 unweighted). MEASUREMENTS: Prescriptions of high-risk anticholinergics, regardless of indication, were identified, and overall prescribing trends were estimated from 2006 to 2015. Stratified analyses of prescribing trends according to physician specialty and anticholinergic drug class were also performed. We used a multivariable logistic regression analysis to estimate the odds of high-risk anticholinergic prescription. RESULTS: Between 2006 and 2015, a high-risk anticholinergic prescription was listed for 5,876 (6.2%) 96,996 visits of older adults, representative of 14.6 million total visits nationally. The most common drug classes were antidepressants, antimuscarinics, and antihistamines, which accounted for more than 70% of prescribed anticholinergics. Correlates independently associated with greater odds of receiving a high-risk anticholinergic prescription were female sex, the Southern geographic region, specific physician specialties (e.g., psychiatry, urology), receipt of 6 or more concomitantly prescribed medications, and related clinical diagnoses (e.g., urinary continence) (p<.01 for all). CONCLUSION: The prevalence of high-risk anticholinergic prescriptions was stable over time but varied according to physician specialty and drug class. Quality prescribing should be promoted because safer alternatives are available.

Prehospital Delay in Older Adults with Acute Myocardial Infarction: The ComprehenSIVe Evaluation of Risk Factors in Older Patients with Acute Myocardial Infarction Study.

BACKGROUND/OBJECTIVES: Timely administration of antiischemic therapies improves outcomes in individuals with acute myocardial infarction (AMI). Prior literature on delays in AMI care has largely focused on in-hospital delay ("door to balloon" time). Our objective was to identify factors associated with prehospital delay in a contemporary national cohort of older adults with AMI. DESIGN: Cross-sectional analysis of data from the ComprehenSIVe Evaluation of Risk Factors in Older Patients with Acute Myocardial Infarction (SILVER-AMI) study, an observational study of older adults hospitalized for AMI. SETTING: U.S. academic and community hospitals (N = 94). PARTICIPANTS: Individuals aged 75 and older hospitalized for AMI (N = 2,500). MEASUREMENTS: Prehospital delay was defined as symptom duration of 6 hours or longer before hospital presentation and was obtained according to participant or caregiver report during AMI hospitalization. Potential predictors of delay from demographic, clinical presentation, comorbid conditions, function, and social support domains were obtained through in-person assessment during the index hospitalization and medical record abstraction. RESULTS: Nonwhite race (adjusted odds ratio (aOR) = 1.54, P = .002), atypical symptoms (aOR = 1.41, P = .001), and heart failure (HF) (aOR = 1.35, P = .006 for HF) were significantly associated with delay. CONCLUSION: In contrast with younger AMI populations, female sex and diabetes mellitus were not associated with delay in this older cohort, but factors from other domains (nonwhite race, atypical symptoms, and HF) were significantly associated with delay. These results can be used to customize future public health efforts to encourage early presentation for older adults with AMI.

Prostate Cancer in Elderly Men: Screening, Active Surveillance, and Definitive Therapy.

Prostate cancer (PCa) is a common medical condition in the United States, with an estimated 16% of men receiving a diagnosis during their lifetime. Although it is the second leading cause of cancer-specific deaths among men, PCa will not be the cause of death for most men who are diagnosed with it. Although there are notable improvements recently, the relative dearth of high-quality data concerning PCa screening and treatment in older men calls for a thoughtful approach to evaluating such men for screening, diagnosis, and treatment options. This article offers guidance to an approach here.