A multiyear cross-sectional study of U.S. national prescribing patterns of first-generation sedating antihistamines in older adults with skin disease.

BACKGROUND: First-generation antihistamines (FGAs) are classified as 'potentially inappropriate' for use in older patients (patients aged ≥ 65 years). However, the prevalence of and factors associated with FGA prescription have not been studied. OBJECTIVES: To examine FGA prescription rates for older patients who visited dermatology offices, and compare them to those for younger patients (patients aged 18-65 years) who visited dermatology offices and those for older patients who visited primary-care physicians (PCPs). METHODS: This was a multiyear cross-sectional observational study using data from the U.S. National Ambulatory Medical Care Survey (2006-2015). Visits by patients aged 18 years or older were included in the study; the data comprised 15 243 dermatology office visits and 66 036 PCP office visits. The main outcome was FGA prescription. Other variables included physician specialty (dermatologist or PCP), patient's age, diagnosis of dermatological conditions and reason for visit. RESULTS: For dermatology visits, the overall FGA prescription rate for older patients was similar to that for younger patients (1·5% vs. 1·2%; P = 0·19), even when the diagnosis was dermatitis or pruritus (3·7% vs. 4·8%; P = 0·21) or when itch was a complaint (7·6% vs. 6·7%; P = 0·64). However, the rate of FGA prescription for dermatology visits was lower than that for PCP visits, in analyses matched for patient and visit characteristics (3·9% vs. 7·4%; P = 0·02). CONCLUSIONS: Our findings suggest that FGAs are overprescribed to older patients but that dermatologists are less likely to prescribe FGAs than PCPs. What's already known about this topic? First-generation antihistamines (FGAs) have been shown to pose substantial risks to older adults, including cognitive impairment, falls, confusion, dry mouth and constipation. Therefore, FGAs have been classified as 'potentially inappropriate' for use in older patients by the American Geriatrics Society. It has also been shown that dermatologists do not always take patient characteristics (e.g. age or life expectancy) into account when deciding on a treatment, instead following a 'one-size-fits-all' approach. What does this study add? FGAs are often prescribed during dermatology visits, and prescription rates do not differ between older and younger patients. There were no significant differences in prescription rates when comparing younger and older adults with the same diagnosis or symptom (e.g. dermatitis, pruritus or itch). FGAs are prescribed at higher rates in primary-care offices than in dermatology offices.

Frailty predicts waitlist mortality in liver transplant candidates.

We aimed to determine whether frailty, a validated geriatric construct of increased vulnerability to physiologic stressors, predicts mortality in liver transplant candidates. Consecutive adult outpatients listed for liver transplant with laboratory Model for End-Stage Liver Disease (MELD) ≥ 12 at a single center (97% recruitment rate) underwent four frailty assessments: Fried Frailty, Short Physical Performance Battery (SPPB), Activities of Daily Living (ADL) and Instrumental ADL (IADL) scales. Competing risks models associated frailty with waitlist mortality (death/delisting for being too sick for liver transplant). Two hundred ninety-four listed liver transplant patients with MELD ≥ 12, median age 60 years and MELD 15 were followed for 12 months. By Fried Frailty score ≥3, 17% were frail; 11/51 (22%) of the frail versus 25/243 (10%) of the not frail died/were delisted (p = 0.03). Each 1-unit increase in the Fried Frailty score was associated with a 45% (95% confidence interval, 4-202) increased risk of waitlist mortality adjusted for MELD. Similarly, the adjusted risk of waitlist mortality associated with each 1-unit decrease (i.e. increasing frailty) in the Short Physical Performance Battery (hazard ratio 1.19, 95% confidence interval 1.07-1.32). Frailty is prevalent in liver transplant candidates. It strongly predicts waitlist mortality, even after adjustment for liver disease severity demonstrating the applicability and importance of the frailty construct in this population.

Longitudinal Associations between Concurrent Changes in Phenotypic Frailty and Lower Urinary Tract Symptoms among Older Men.

BACKGROUND: Lower urinary tract symptoms (LUTS) are associated with prevalent frailty and functional impairment, but longitudinal associations remain unexplored. OBJECTIVES: To assess the association of change in phenotypic frailty with concurrent worsening LUTS severity among older men without clinically significant LUTS at baseline. DESIGN: Multicenter, prospective cohort study. SETTING: Population-based. PARTICIPANTS: Participants included community-dwelling men age ≥65 years at enrollment in the Osteoporotic Fractures in Men study. MEASUREMENTS: Data were collected at 4 visits over 7 years. Phenotypic frailty score (range: 0-5) was defined at each visit using adapted Fried criterion and men were categorized at baseline as robust (0), pre-frail (1-2), or frail (3-5). Within-person change in frailty was calculated at each visit as the absolute difference in number of criteria met compared to baseline. LUTS severity was defined using the American Urologic Association Symptom Index (AUASI; range: 0-35) and men with AUASI ≥8 at baseline were excluded. Linear mixed effects models were adjusted for demographics, health-behaviors, and comorbidities to quantify the association between within-person change in frailty and AUASI. RESULTS: Among 3235 men included in analysis, 48% were robust, 45% were pre-frail, and 7% were frail. Whereas baseline frailty status was not associated with change in LUTS severity, within-person increases in frailty were associated with greater LUTS severity (quadratic P<0.001). Among robust men at baseline, mean predicted AUASI during follow-up was 4.2 (95% CI 3.9, 4.5) among those meeting 0 frailty criteria, 4.6 (95% CI 4.3, 4.9) among those meeting 1 criterion increasing non-linearly to 11.2 (95% CI 9.8, 12.6) among those meeting 5 criteria. CONCLUSIONS: Greater phenotypic frailty was associated with non-linear increases in LUTS severity in older men over time, independent of age and comorbidities. Results suggest LUTS and frailty share an underlying mechanism that is not targeted by existing LUTS interventions.

Towards a combined prognostic index for survival in HIV infection: the role of 'non-HIV' biomarkers.

BACKGROUND: As those with HIV infection live longer, 'non-AIDS' condition associated with immunodeficiency and chronic inflammation are more common. We ask whether 'non-HIV' biomarkers improve differentiation of mortality risk among individuals initiating combination antiretroviral therapy (cART). METHODS: Using Poisson models, we analysed data from the Veterans Aging Cohort Study (VACS) on HIV-infected veterans initiating cART between 1 January 1997 and 1 August 2002. Measurements included: HIV biomarkers (CD4 cell count, HIV RNA and AIDS-defining conditions); 'non-HIV' biomarkers (haemoglobin, transaminases, platelets, creatinine, and hepatitis B and C serology); substance abuse or dependence (alcohol or drug); and age. Outcome was all cause mortality. We tested the discrimination (C statistics) of each biomarker group alone and in combination in development and validation data sets, over a range of survival intervals, and adjusting for missing data. RESULTS: Of veterans initiating cART, 9784 (72%) had complete data. Of these, 2566 died. Subjects were middle-aged (median age 45 years), mainly male (98%) and predominantly black (51%). HIV and 'non-HIV' markers were associated with each other (P < 0.0001) and discriminated mortality (C statistics 0.68-0.73); when combined, discrimination improved (P < 0.0001). Discrimination for the VACS Index was greater for shorter survival intervals [30-day C statistic 0.86, 95% confidence interval (CI) 0.80-0.91], but good for intervals of up to 8 years (C statistic 0.73, 95% CI 0.72-0.74). Results were robust to adjustment for missing data. CONCLUSIONS: When added to HIV biomarkers, 'non-HIV' biomarkers improve differentiation of mortality. When evaluated over similar intervals, the VACS Index discriminates as well as other established indices. After further validation, the VACS Index may provide a useful, integrated risk assessment for management and research.

A 10-min Targeted Geriatric Assessment Predicts Mortality in Fast-Paced Acute Care Settings: A Prospective Cohort Study.

OBJECTIVES: To estimate whether a 10-minute Targeted Geriatric Assessment (10-TaGA) adds utility to sociodemographic characteristics and comorbidities in predicting one-year mortality in busy acute care settings. We have also compared the performance of 10-TaGA with the Identification of Seniors at Risk (ISAR) scale. DESIGN: Prospective cohort study. SETTING: Geriatric day hospital specializing in acute care in Brazil. PARTICIPANTS: 751 older adults aged 79.4 ± 8.4 years (64% female), presenting non-surgical, medical illness requiring hospital-level care (e.g., intravenous therapy, laboratory test, radiology) for ≤ 12 hours. MEASUREMENTS: The 10-TaGA, an easy-to-administer screening tool based on the comprehensive geriatric assessment (CGA), provided a measure of cumulative deficits ranging from 0 (no deficits) to 1 (highest deficit) on admission. Standard risk factors, including sociodemographics (age, gender, ethnicity, income) and the Charlson comorbidity index, were evaluated. The ISAR, a well-validated screening tool, was used for comparison. RESULTS: During one year of follow-up, 130 (17%) participants died. Compared to the ISAR, 10-TaGA offered better accuracy in identifying older patients at risk of death (area under the receiver operating characteristic curve: [AUC] 0.70 vs 0.65; P = 0.03). In a Cox regression model adjusted for sociodemographics and comorbidities, each 0.1 increment in the 10-TaGA score (range 0-1) was associated with increased mortality (hazard ratio = 1.42, 95% confidence interval 1.27-1.59). The addition of 10-TaGA markedly improved the discrimination of the model, which already incorporated standard risk factors (AUC 0.76 vs 0.71; P = 0.005); adding ISAR (AUC 0.73 vs 0.71; P = 0.09) did not have this marked effect. CONCLUSION: The 10-TaGA is an independent predictor of one-year mortality in acute care patients. This multidimensional screening tool offers better accuracy than ISAR when differentiating between older people at low and high risk of death in healthcare settings where providers have limited time and resources.

A prospective study of physical activity and cognitive decline in elderly women: women who walk.

BACKGROUND: Several studies have suggested that physical activity is positively associated with cognitive function in elderly persons. Evidence about this association has been limited by the cross-sectional design of most studies and by the frequent lack of adjustment for potential confounding variables. We determined whether physical activity is associated with cognitive decline in a prospective study of older women. METHODS: We studied 5925 predominantly white community-dwelling women (aged > or =65 years) who were recruited at 4 clinical centers and were without baseline cognitive impairment or physical limitations. We measured cognitive performance using a modified Mini-Mental State Examination at baseline and 6 to 8 years later. Physical activity was measured by self-reported blocks (1 block approximately 160 m) walked per week and by total kilocalories (energy) expended per week in recreation, blocks walked, and stairs climbed. Cognitive decline was defined as a 3-point decline or greater on repeated modified Mini-Mental State Examination. RESULTS: Women with a greater physical activity level at baseline were less likely to experience cognitive decline during the 6 to 8 years of follow-up: cognitive decline occurred in 17%, 18%, 22%, and 24% of those in the highest, third, second, and lowest quartile of blocks walked per week (P< .001 for trend). Almost identical results were obtained by quartile of total kilocalories expended per week. After adjustment for age, educational level, comorbid conditions, smoking status, estrogen use, and functional limitation, women in the highest quartile remained less likely than women in the lowest quartile to develop cognitive decline (for blocks walked: odds ratio, 0.66 [95% confidence interval, 0.54-0.82]; for total kilocalories: odds ratio, 0.74 [95% confidence interval, 0.60-0.90]). CONCLUSIONS: Women with higher levels of baseline physical activity were less likely to develop cognitive decline. This association was not explained by differences in baseline function or health status. This finding supports the hypothesis that physical activity prevents cognitive decline in older community-dwelling women.

Depressed mood and survival in seriously ill hospitalized adults. The SUPPORT Investigators.

OBJECTIVES: To assess the relationship among depressed mood, physical functioning, and severity of illness and to determine the relationship between depressed mood and survival time, controlling for severity of illness, baseline functioning, and characteristics of patients. METHODS: Prospective cohort study of data for 3529 seriously ill hospitalized adults who received care at 5 tertiary care teaching hospitals and who completed a depressed mood assessment 7 to 11 days after admission to the study. The Profile of Mood States depression subscale was used to assess depressed mood. A stratified Cox proportional hazards model was used to assess the independent effect of depressed mood on survival time, adjusting for demographic characteristics of patients and health status. RESULTS: Greater magnitudes of depressed mood were associated with worse levels of physical functioning (r = 0.151; P < .001) and more severity of illness. Depressed mood was associated with reduced survival time after adjusting for patient demographics and health status (hazards ratio, 1.134; 95% confidence interval, 1.071-1.200; P < or = .001). CONCLUSION: Seriously ill patients should be assessed for the presence of depressed mood even if they have not been given a diagnosis of depression. Further study is needed to determine whether interventions aimed at relieving depressed mood may improve prognosis.

Is economic hardship on the families of the seriously ill associated with patient and surrogate care preferences? SUPPORT Investigators.

BACKGROUND: Serious illness often causes economic hardship for patients' families. However, it is not known whether this hardship is associated with a preference for the goal of care to focus on maximizing comfort instead of maximizing life expectancy or whether economic hardship might give rise to disagreement between patients and surrogates over the goal of care. METHODS: We performed a cross-sectional study of 3158 seriously ill patients (median age, 63 years; 44% women) at 5 tertiary medical centers with 1 of 9 diagnoses associated with a high risk of mortality. Two months after their index hospitalization, patients and surrogates were surveyed about patients' preferences for the primary goal of care: either care focused on extending life or care focused on maximizing comfort. Patients and surrogates were also surveyed about the financial impact of the illness on the patient's family. RESULTS: A report of economic hardship on the family as a result of the illness was associated with a preference for comfort care over life-extending care (odds ratio, 1.26; 95% confidence interval, 1.07-1.48) in an age-stratified bivariate analysis. Similarly, in a multivariable analysis controlling for patient demographics, illness severity, functional dependency, depression, anxiety, and pain, economic hardship on the family remained associated with a preference for comfort care over life-extending care (odds ratio, 1.31; 95% confidence interval, 1.10-1.57). Economic hardship on the family did not affect either the frequency or direction of patient-surrogate disagreements about the goal of care. CONCLUSIONS: In patients with serious illness, economic hardship on the family is associated with preferences for comfort care over life-extending care. However, economic hardship on the family does not appear to be a factor in patient-surrogate disagreements about the goal of care.

Convergent and discriminant validity of a generic and a disease-specific instrument to measure quality of life in patients with skin disease.

Skindex is a quality-of-life instrument for skin diseases. To determine its convergent validity and its advantage relative to a generic measure, we compared responses of 132 dermatology patients to Skindex and the Medical Outcomes Study 36-item Short-Form Survey (SF-36). We hypothesized that (i) correlations between similar scales would be strong but not redundant (r = 0.5-0.6), and (ii) Skindex scores would correlate more highly with responses about skin disease-related aspects of health, and SF-36 scores would correlate more highly with responses concerning general health. As measured by the SF-36, patients reported general health status similar to the normal population, and SF-36 scores did not correlate with dermatologists' judgments about the severity of skin disease. Correlations between the same scales of the two instruments were as hypothesized (range of r, 0.44-0.56), and patients with low, medium, or high responses to Skindex differed similarly in SF-36 scores. On the other hand, some patients who reported on the SF-36 that they were free of physical symptoms (37% of patients) or social effects (54%) on Skindex, reported such effects from their skin disease. Also, responses about skin-related health aspects correlated more highly with Skindex than SF-36 (for skin condition, mean r = 0.42 vs 0.28; for disfigurement, 0.38 vs 0.24). Conversely, responses concerning general health correlated more highly with SF-36 than Skindex (for self-reported health status, mean r = 0.28 vs 0.16; for co-morbidity, 0.48 vs 0.37). This study further supports the validity of Skindex and also suggests that both generic and disease-specific health status measures can contribute to the assessment of patients with skin diseases.

Health status versus quality of life in older patients: does the distinction matter?

PURPOSE: Although health-related quality of life in older people is generally assessed by measuring specific domains of health status, such as activities of daily living or pain, the association between health-status measures and patients' perceptions of their quality of life is not clear. Indeed, it is controversial whether these health-status measures should be considered measures of quality of life at all. Our objective was to determine the association between health-status measures and older patients' perceptions of their global quality of life. SUBJECTS AND METHODS: We performed a cross-sectional study of 493 cognitively intact patients 80 years of age and older, interviewed 2 months after a hospitalization. We measured patients' self-assessed global quality of life and four domains of health status: physical capacity, limitations in performing activities of daily living, psychological distress, and pain. RESULTS: Each of the four scales was significantly correlated with patients' global perceptions of their quality of life (P <0.001). The ability of the health-status scales to discriminate between patients with differing global quality of life was generally good, especially for the physical capacity (c statistic = 0.72) and psychological distress scales (c statistic = 0.70). However, for a substantial minority of patients, scores on the health-status scales did not accurately reflect their global quality of life. For example, global quality of life was described as fair or poor by 15% of patients with the highest (best tertile) physical capacity scores, 25% of patients who were independent in all activities of daily living, 21% of patients with the least psychological distress (best tertile), and by 30% with no pain symptoms. Similarly, global quality of life was described as good or better by 43% of patients with the worst physical capacity (worst tertile), 49% of patients who were dependent in at least two activities of daily living, 47% of patients with the most psychological distress (worst tertile), and 51% of patients with severe pain. CONCLUSION: On average, health status is a reasonable indicator of global quality of life for groups of older patients with recent illness. However, disagreement between patients' reported health status and their perceptions of their global quality of life was common. Therefore, assumptions about the overall quality of life of individual patients should not be based on measures of their health status alone.

Use of standardized ratios to examine variability in hemodialysis vascular access across facilities. Medical Review Board of The Renal Network, Inc.

The type of hemodialysis vascular access (catheter, fistula, graft) is an important determinant of patient morbidity and dialysis efficiency. The relative importance of patient versus provider factors in determining type of vascular access is unclear. We sought to develop a quality improvement tool that adjusts for differences in patient characteristics, thereby allowing examination of provider-related variability in types of vascular access used across facilities. We examined 15,339 patients from 216 chronic hemodialysis units in Indiana, Kentucky, Ohio, and Illinois and found that 20% of patients had catheters, 24% had fistulas, and 56% had grafts. Young, male, and white patients were more likely to have fistulas, whereas old, female, and black patients were more likely to have grafts. Diabetics were more likely to have catheters and less likely to have fistulas. New patients were more likely to have catheters and less likely to have grafts. A facility specific standardized catheter ratio (SCR), standardized fistula ratio (SFR), and standardized graft ratio (SGR) were calculated based on the actual number of patients with each type of vascular access divided by the expected number adjusted for patient characteristics. Facility SCRs ranged from 0.00 to 2.87. Of the 216 facilities, 38 (18%) had an SCR significantly less than 1.00, and 32 (15%) had an SCR significantly greater than 1.00. Similar variability was observed in SFRs and SGRs. In conclusion, the type of vascular access varies greatly across facilities. Use of standardized access ratios adjusted for patient characteristics may help providers examine processes of care that contribute to variability in access use. Analogous to the standardized mortality ratio, the SCR, SFR, and SGR should be effective quality improvement tools.

Justification for a new cohort study of people aging with and without HIV infection.

This supplement contains a series of papers supporting the justification, design, and implementation of a longitudinal cohort study of an aging HIV-positive and HIV-negative veteran population called the Veterans Aging Cohort Study (VACS). Although the papers cover a wide range of topics and several papers address methodologic issues not unique to a study of aging veterans, all are motivated by a unifying set of assumptions. Specifically: (a) HIV/AIDS is a chronic disease in an aging population; (b) conditions among HIV-positive and -negative patients in care have overlapping etiologies; (c) individuals with pre-existing organ injury are at increased risk for iatrogenic injury; (d) cohort studies are uniquely suited to the study of chronic disease complicated by aging, comorbid conditions, drug toxicities, and substance use/abuse; (e) VACS is well positioned to study HIV as a chronic disease in an aging population.

Delivery of preventive services to older black patients using neighborhood health centers.

OBJECTIVES: Older black patients are at risk for underutilization of preventive services. Our objectives were to assess the delivery of five preventive services in Title 330-funded health centers in low income neighborhoods in Cleveland, Ohio, and to determine the association of health system factors and health status with the delivery of these services. DESIGN: A cross-sectional study. SETTING: Four neighborhood health centers in low income neighborhoods of Cleveland, Ohio. PARTICIPANTS: A total of 683 black men and women, aged 70 and older, who regarded the health center as their primary source of outpatient care. MEASUREMENTS: Demographic characteristics, independence in basic and instrumental activities of daily living, comorbidity scores, and perceived access were determined by telephone interview. We reviewed charts to determine whether each of five preventive service goals were obtained: influenza vaccination within 1 year; pneumococcal vaccination at any time; mammography within 2 years; Papanicolau screening within 1 year or twice at any time in the past with documentation of normal results; and fecal occult blood testing within 2 years. RESULTS: The defined goals for influenza vaccination, pneumococcal vaccination, mammography, Papanicolau screening, and fecal occult blood testing were achieved for 59%, 64%, 59%, 51%, and 17% of patients, respectively. Influenza and pneumococcal vaccines were obtained more often in persons with greater comorbidity. Mammography and Papanicolau smear were obtained more often in patients without of ADL or IADL impairments. The four clinical sites varied substantially in the delivery of each preventive service. More frequent office visits were associated with greater delivery of all five preventive services. This relationship persisted in multivariable analyses controlling for health status and clinical site. CONCLUSIONS: This study shows that Title 330 federally supported neighborhood health center sites providing primary care to older blacks in Cleveland achieved high rates of performance in four of the five recommended preventive services. In addition, preventive services practices were associated with prognostically relevant health status information. The frequency of office visits was related strongly and consistently to the performance of the various preventive services, indicating that more, not fewer, office visits may be necessary to achieve Healthy People 2000 targets. J Am Geriatr Soc 48:124-130, 2000. Key words: preventive services; blacks; access to care; geriatrics; primary care

Do acute care for elders units increase hospital costs? A cost analysis using the hospital perspective.

OBJECTIVE: To compare the hospital costs of caring for medical patients on a special unit designed to help older people maintain or achieve independence in self-care activities with the costs of usual care. DESIGN: A randomized controlled study. PARTICIPANTS: A total of 650 medical patients (mean age 80 years, 67% women, 41% nonwhite) assigned randomly to either the intervention unit (n = 326) or usual care (n = 324). MEASURES: The hospital's resource-based cost of caring for patients was determined from the hospital's cost-accounting system. The cost of the intervention program was estimated and included in the intervention patients' total hospital cost. RESULTS: The development and maintenance costs of the intervention added $38.43 per bed day to the intervention patients' hospital costs. As a result, the cost per day to the hospital was slightly higher in the intervention patients than in the control patients ($876 vs $847, P = .076). However, the average length of stay was shorter for intervention patients (7.5 vs 8.4 days, P = .449). As a result, the hospital's total cost to care for intervention patients was not greater than caring for usual-care patients ($6608 in intervention patients vs $7240 in control patients, P = .926). Sensitivity analysis demonstrated that the cost of the intervention program would need to be 220% greater than estimated before intervention patients would be more expensive then control patients. There were no examined subgroups of patients in whom care on the intervention unit was significantly more expensive than care on the usual-care unit. Ninety-day nursing home use was lower in intervention than control patients (24.1% vs 32.3%, P = .034). Ninety-day readmission rates (36.7% vs 41.1%, P = .283) and caregiver strain scores (3.3 vs. 2.7, P = .280) were similar. CONCLUSION: Caring for patients on an intervention ward designed to improve functional outcomes in older patients was not more expensive to the hospital than caring for patients on a usual-care ward even though the intervention ward required a commitment of hospital resources.

Functional status before hospitalization in acutely ill older adults: validity and clinical importance of retrospective reports.

OBJECTIVES: Retrospective reports of patients' functional status before hospital admission are often used in longitudinal studies and by clinicians caring for hospitalized patients. However, the validity of these reports has not been established. Our aim was to examine the validity of retrospective reports by testing hypotheses about the relationships these measures would have with other clinical measures if they were valid. DESIGN: A prospective cohort study. PARTICIPANTS AND SETTING: A total of 2877 older patients (mean age 81, 36% women) hospitalized on the general medical service at two hospitals. For 1953 of the subjects, the patient was the primary respondent, whereas for 924 subjects, a surrogate was the primary respondent. MEASUREMENTS: Shortly after hospital admission, patients or surrogates reported whether the patient was independent in each of five activities of daily living (ADLs) on admission and at baseline 2 weeks before admission. Outcome measures included reported independence in each ADL 3 months after the hospitalization and survival to 1 year. RESULTS: Patients' retrospective reports of their ADL function 2 weeks before admission had a clinically plausible relationship with ADL function at the time of admission, in that patients independent in an ADL on admission rarely reported they were dependent in that ADL 2 weeks before admission (range 2-6%). Surrogates were somewhat more likely than patients to report that patients independent on admission were dependent 2 weeks before admission (range 5-14%). Retrospective reports of prehospitalization ADL function demonstrated strong evidence of predictive validity for both patients' and surrogates' reports. For example, among patients dependent in bathing on admission, patients who were reported as independent 2 weeks before admission were much more likely than those reported as dependent 2 weeks before admission to be independent 3 months after hospitalization (68% vs 20%, P < .001 for patient respondents; 30% vs 5%, P < .001 for surrogate respondents). Similarly, among patients dependent in bathing on hospital admission, survival 1 year after hospitalization was much higher in patients who were independent in bathing 2 weeks before admission than patients who were dependent 2 weeks before admission (76% vs 59%, P < .001 for patient respondents; 60% vs 45%, P < .001 for surrogate respondents). Results were similar for each of the other four ADLs. In a logistic regression model controlling for the number of ADLs reported as dependent on admission, the number of ADLs reported as dependent 2 weeks before admission was significantly associated with 1-year mortality among both patient (odds ratio (OR) = 1.39 per dependent ADL, 95% confidence interval (CI) - 1.26-1.54) and surrogate (OR = 1.14, 95% CI = 1.06-1.24) respondents. CONCLUSIONS: Hospitalized patients' assessments of their ability to perform ADLs before their hospitalization have evidence of face and predictive validity. These measures are strong predictors of important health outcomes such as functioning and survival. In particular, among patients dependent in ADL function on hospital admission, these results highlight the prognostic importance of inquiring about the patient's functional status before the onset of the acute illness.

Age-related differences in care preferences, treatment decisions, and clinical outcomes of seriously ill hospitalized adults: lessons from SUPPORT.

OBJECTIVES: To review previously published findings about how patient age influenced patterns of care for seriously ill patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). DESIGN: An observational prospective study. SETTING: Five acute care hospitals. PARTICIPANTS: A total of 9105 seriously ill patients enrolled in SUPPORT. MEASUREMENTS: The outcomes examined included patients' preferences for aggressive care, decision making regarding cardiopulmonary resuscitation and use of other life-sustaining treatments, hospital costs, intensity of resource use, and survival. RESULTS: Although older patients preferred less aggressive care than younger patients, many older patients wanted cardiopulmonary resuscitation and care focused on life extension. Patients' families and healthcare providers underestimated older patients' desire for aggressive care. After adjustment for illness severity, comorbidity, baseline function, and patients' preferences for aggressive care, older age was associated with lower hospital costs and resource intensity and higher rates of decisions to withhold life-sustaining treatments. In adjusted analyses, older age was associated with a slight survival disadvantage. This survival disadvantage persisted, even after adjustment for aggressiveness of care, suggesting that the relation between age and survival is not accounted for by less aggressive treatment of older patients. CONCLUSIONS: Even after adjustment for patients' prognoses and care preferences, seriously ill hospitalized older patients were treated less aggressively than younger patients. SUPPORT cannot fully identify whether the relationship between older age and less aggressive treatment is better explained by the withholding of potentially beneficial treatments from older patients, or by the excessive provision of ineffective treatment to younger patients. However, the latter explanation is favored by the SUPPORT finding that less aggressive treatment for older patients does not contribute to the modest survival disadvantage associated with older age.

Communication and decision-making in seriously ill patients: findings of the SUPPORT project. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

OBJECTIVES: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) represents one of the largest and most comprehensive efforts to describe patient preferences in seriously ill patients, and to evaluate how effectively patient preferences are communicated. Our objective was to review findings from SUPPORT describing the communication of seriously ill patients' preferences for end-of-life care. METHODS: We identified published reports from SUPPORT describing patient preferences and the communication of those preferences. We abstracted findings that addressed each of the following questions: What patient characteristics predict patient preferences for end of life care? How well do physicians, nurses, and surrogates understand their patients' preferences, and what variables are correlated with this understanding? Does increasing the documentation of existing advance directives result in care more consistent with patients' preferences? RESULTS: Patients who are older, have cancer, are women, believe their prognoses are poor, and are more dependent in ADL function are less likely to want CPR. However, there is considerable variability and geographic variation in these preferences. Physician, nurse, and surrogate understanding of their patient's preferences is only moderately better than chance. Most patients do not discuss their preferences with their physicians, and only about half of patients who do not wish to receive CPR receive DNR orders. Factors other than the patients' preferences and prognoses, including the patient's age, the physician's specialty, and the geographic site of care were strong determinants of whether DNR orders were written. In SUPPORT patients, there was no evidence that increasing the rates of documentation of advance directives results in care that is more consistent with patients' preferences. CONCLUSIONS: SUPPORT documents that physicians and surrogates are often unaware of seriously ill patients' preferences. The care provided to patients is often not consistent with their preferences and is often associated with factors other than preferences or prognoses. Improving these deficiencies in end-of-life care may require systematic change rather than simple interventions.

The relationship between clinical assessments of nutritional status and adverse outcomes in older hospitalized medical patients.

BACKGROUND: Malnutrition is common in hospitalized older people and may predict adverse outcomes. Previous studies of the relationship between nutritional status and hospital outcomes are limited by inadequate accounting for other potential predictors of adverse outcomes, the failure to consider functional outcomes, and the omission of clinical assessments of nutritional status. OBJECTIVE: To measure the relationship between a clinical assessment of nutritional status on hospital admission and subsequent mortality, functional dependence, and nursing home use. DESIGN: Prospective cohort study SETTING: A tertiary care hospital PATIENTS: A total of 369 patients at least 70 years old (mean age 80.3, 62% women) admitted to a general medical service MEASUREMENTS: Nutritional status was measured with the Subjective Global Assessment, a validated measure of nutritional status based on historical and physical exam findings. Patients were classified as severely malnourished (generally at least a 10% weight loss over the previous 6 months and marked physical signs of malnutrition), moderately malnourished (generally a 5 to 10% weight loss and moderate physical signs), or well nourished. Vital status, independence in activities of daily living, and nursing home use were determined through patient or surrogate interview at admission and 90 days and 1 year after discharge. Indices of comorbidity and illness severity were determined from chart review. RESULTS: 219 patients (59.3%) were well nourished, 90 (24.4%) were moderately malnourished, and 60 (16.3%) were severely malnourished. Severely malnourished patients were more likely than moderately malnourished or well nourished patients to die by 90 days (31.7%, 23.3%, and 12.3%, respectively, P < .001) and 1 year (55.0%, 35.6%, and 27.9%, P < .001) after discharge. In logistic regression models controlling for acute illness severity, comorbidity, and functional status on admission, severely malnourished patients were more likely than well nourished patients to die within 1 year of discharge (OR = 2.83, 95% CI, 1.47-5.45), to be dependent in activities of daily living 3 months after discharge (OR = 2.81, 1.06-7.46), and to spend time in a nursing home during the year after discharge (OR = 3.22, 1.05-9.87). CONCLUSION: Malnutrition was common in hospitalized patients with medical illness and was associated with greater mortality, delayed functional recovery, and higher rates of nursing home use. These adverse outcomes were not explained by greater acute illness severity, comorbidity, or functional dependence in malnourished patients on hospital admission.