Hospitalization Risk Among Older Adults with Sensory Impairments: Development of a Prognostic Model.

OBJECTIVES: To develop a prognostic model for hospital admissions over a 1-year period among community-dwelling older adults with self-reported hearing and/or vision impairments based on readily obtainable clinical predictors. DESIGN: Retrospective cohort study. SETTING: Medicare Current Beneficiary Survey from 1999 to 2006. PARTICIPANTS: Community-dwelling Medicare beneficiaries, aged 65 years and older, with self-reported hearing and/or vision impairment (N = 15,999). MEASUREMENTS: The primary outcome was any hospital admission over a predefined 1-year study period. Candidate predictors included demographic factors, prior healthcare utilization, comorbidities, functional impairment, and patient-level factors. We analyzed the association of all candidate predictors with any hospital admission over the 1-year study period using multivariable logistic regression. The final model was created using a penalized regression method known as the least absolute shrinkage and selection operator. Model performance was assessed by discrimination (concordance statistic (c-statistic)) and calibration (evaluated graphically). Internal validation was performed via bootstrapping, and results were adjusted for overoptimism. RESULTS: Of the 15,999 participants, the mean age was 78 years and 55% were female. A total of 2,567 participants (16.0%) had at least one hospital admission in the 1-year study period. The final model included seven variables independently associated with hospitalization: number of inpatient admissions in the previous year, number of emergency department visits in the previous year, activities of daily living difficulty score, poor self-rated health, and self-reported history of myocardial infarction, stroke, and nonskin cancer. The c-statistic of the final model was 0.717. The optimism-corrected c-statistic after bootstrap internal validation was 0.716. A calibration plot suggested that the model tended to overestimate risk among patients at the highest risk for hospitalization. CONCLUSION: This prognostic model can help identify which community-dwelling older adults with sensory impairments are at highest risk for hospitalization and may inform allocation of healthcare resources.

Effects of diet and exercise on weight-related outcomes for breast cancer survivors and their adult daughters: an analysis of the DAMES trial.

PURPOSE: Few trials have aimed to promote diet and exercise behaviors in both cancer survivors and their family members and examine their associations with weight-related outcomes. We conducted a secondary analysis to examine associations between change in diet and exercise behaviors and weight-related outcomes for overweight breast cancer survivors and their overweight adult daughters in the Daughters And MothErS Against Breast Cancer (DAMES) randomized trial. METHODS: The DAMES trial assessed the impact of two iteratively tailored, mailed print diet and exercise interventions against standard brochures over a 12-month period. This analysis examined change in diet and exercise behaviors and weight-related variables from baseline to post-intervention for the 50 breast cancer survivors and their adult daughters randomized to the intervention arms. To reduce the potential for type II error in this pilot, p values <0.10 were considered statistically significant. RESULTS: For mothers, change in diet quality was uniquely related to change in BMI (ß = -0.12, p = 0.082), weight (ß = -0.12, p = 0.060), and waist circumference (ß = -0.38, p = 0.001), whereas change in caloric intake was related to waist circumference (ß = 0.21, p = 0.002). For daughters, change in caloric intake was related to change in waist circumference (ß = 0.12, p = 0.055). However, change in diet quality was not associated with weight-related outcomes in daughters. Additionally, change in exercise was not associated with weight-related outcomes in mothers or daughters. CONCLUSIONS: Findings support mail-based and other tailored interventions for weight loss in this population, with an emphasis on diet quality for breast cancer survivors and caloric intake for their adult daughters.

Daughters and Mothers Against Breast Cancer (DAMES): main outcomes of a randomized controlled trial of weight loss in overweight mothers with breast cancer and their overweight daughters.

BACKGROUND: Few studies to date have used the cancer diagnosis as a teachable moment to promote healthy behavior changes in survivors of cancer and their family members. Given the role of obesity in the primary and tertiary prevention of breast cancer, the authors explored the feasibility of a mother-daughter weight loss intervention. METHODS: A randomized controlled trial of a mailed weight loss intervention was undertaken among 68 mother-daughter dyads (n = 136), each comprised of a survivor of breast cancer (AJCC stage 0-III) and her adult biological daughter. All women had body mass indices ≥ 25 kg/m(2) and underwent in-person assessments at baseline, 6 months, and 12 months, with accelerometry and exercise capacity performed on a subset of individuals. All women received a personalized workbook and 6 newsletters over a 1-year period that promoted weight loss; exercise; and a nutrient-rich, low-energy density diet. A total of 25 dyads received individually tailored instruction (individual), 25 dyads received team-tailored instruction (TEAM), and 18 dyads received standardized brochures (control). RESULTS: The trial met its accrual target, experienced 90% retention, and caused no serious adverse events. Significant differences in baseline to 12-month changes were observed between individual versus control mothers for body mass index, weight, and waist circumference (WC); significant differences also were observed in the WC of corresponding daughters (P < .05). Significant differences were found between individual versus control and team versus control dyads for WC (P = .0002 and .018, respectively), minutes per week of physical activity (P = .031 and .036, respectively), and exercise capacity (P = .047 for both). CONCLUSIONS: Significant improvements in lifestyle behaviors and health outcomes are possible with tailored print interventions directed toward survivors of cancer and their family members. For greater impact, more research is needed to expand this work beyond the mother-daughter dyad.

Incidence and predictors of all and preventable adverse drug reactions in frail elderly persons after hospital stay.

BACKGROUND: Adverse drug reactions (ADR) negatively impact life quality and are sometimes fatal. This study examines the incidence and predictors of all and preventable ADRs in frail elderly persons after hospital discharge, a highly vulnerable but rarely studied population. METHODS: The design was a prospective cohort study involving 808 frail elderly persons who were discharged from 11 Veteran Affairs hospitals to outpatient care. The main outcome measure was number of ADRs per patient as determined by blinded geriatrician and geropharmacist pairs using Naranjo's ADR algorithm. For all ADRs (possible, probable, or definite), preventability was assessed. Discordances were resolved by consensus conferences. RESULTS: Overall, 33% of patients had one or more ADRs for a rate of 1.92 per 1000 person-days of follow-up. The rate for preventable ADRs was 0.71 per 1000 person-days of follow-up. Independent risk factors for all ADRs were number of medications (adjusted [Adj.] hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.05-1.10 per medication), use of warfarin (Adj. HR, 1.51; 95% CI, 1.22-1.87), and (marginally) the use of benzodiazepines (Adj. HR, 1.23; 95% CI, 0.95-1.58). Counterintuitively, use of sedatives and/or hypnotics was inversely related to ADR risk (Adj. HR, 0.14; 95% CI, 0.04-0.57). Similar trends were seen for number of medications and warfarin use as predictors of preventable ADRs. CONCLUSIONS: ADRs are very common in frail elderly persons after hospital stay, and polypharmacy and warfarin use consistently increase the risk of ADRs.

Unnecessary drug use in frail older people at hospital discharge.

OBJECTIVES: To determine the prevalence and predictors of unnecessary drug use at hospital discharge in frail elderly patients. DESIGN: Cross-sectional. SETTING: Eleven Veterans Affairs Medical Centers. PARTICIPANTS: Three hundred eighty-four frail older patients from the Geriatric Evaluation and Management Drug Study. MEASUREMENTS: Assessment of unnecessary drug use was determined by the consensus of a clinical pharmacist and physician pair applying the Medication Appropriateness Index to each regularly scheduled medication at hospital discharge. Those drugs that received an inappropriate rating for indication, efficacy, or therapeutic duplication were defined as unnecessary. RESULTS: Forty-four percent of patients had at least one unnecessary drug, with the most common reason being lack of indication. The most commonly prescribed unnecessary drug classes were gastrointestinal, central nervous system, and therapeutic nutrients/minerals. Factors associated (P<.05) with unnecessary drug use included hypertension (adjusted odds ratio (AOR)=0.61, 95% confidence interval (CI)=0.38-0.96), multiple prescribers (AOR=3.35, 95% CI=1.16-9.68), and nine or more medications (AOR=2.24, 95% CI=1.25-3.99). CONCLUSION: A high prevalence of unnecessary drug use at discharge was found in frail hospitalized elderly patients. Additional studies are needed to identify predictors and prevalence of unnecessary drug use in nonveteran populations so that interventions can be designed to reduce the problem.

Inappropriate medication use among frail elderly inpatients.

BACKGROUND: Inappropriate prescribing in frail elderly inpatients has not received as much investigation as in frail elderly nursing home patients. OBJECTIVE: To determine the prevalence and predictors of inappropriate prescribing for hospitalized frail elderly patients. METHODS: The study was conducted at 11 Veterans Affairs Medical Centers and involved a sample of 397 frail elderly inpatients. Inappropriate prescribing was measured by physician-pharmacist pair's consensus ratings for 10 criteria on the Medication Appropriateness Index (MAI). The MAI ratings generated a weighted score of 0-18 per medication (higher score = more inappropriate) and were summed across medications to achieve a patient score. RESULTS: Overall, 365 (91.9%) patients had > or =1 medications with > or =1 MAI criteria rated as inappropriate. The most common problems involved expensive drugs (70.0%), impractical directions (55.2%), and incorrect dosages (50.9%). The most common drug classes with appropriateness problems were gastric (50.6%), cardiovascular (47.6%), and central nervous system (23.9%). The mean +/- SD MAI score per person was 8.9 +/- 7.6. Stepwise ordinal logistic regression analyses revealed that both the number of prescription (adjusted OR 1.28; 95% CI 1.21 to 1.36) and nonprescription drugs (adjusted OR 1.17; 95% CI 1.06 to 1.29) were related to higher MAI scores. Analyses excluding the number of drugs revealed that the Charlson index (adjusted OR 1.62; 95% CI 1.12 to 2.35) and fair/poor self-rated health (adjusted OR 1.15; 95% CI 1.05 to 1.26) were related to higher MAI scores. CONCLUSIONS: Inappropriate drug prescribing is common for frail elderly veteran inpatients and is related to polypharmacy and specific health status characteristics.

Adverse drug reaction risk factors in older outpatients.

BACKGROUND: Adverse drug reactions (ADRs) are common in older (age >or=65 years) outpatients (prevalence, 5%-35%), but there is no consensus on factors that put these patients at high risk for ADRs. Identifying a uniform set of risk factors would be helpful to develop risk models for ADRs for older outpatients and to implement targeted interventions for those patients at high risk for ADRs. OBJECTIVE: The aim of this study was to identify potential risk factors for ADRs in older outpatients through a survey of geriatric experts and to determine their prevalence. METHODS: A comprehensive literature search was conducted to find published articles on ADRs in older patients. Forty-four potential risk factors were identified through the literature search and 6 additional factors were suggested by the expert panel. Through a modified 2-round survey, based on the Delphi consensus method, of an expert panel of 5 physicians and 5 pharmacists, the probability that each of these 50 potential factors could contribute independently to placing an older outpatient at high risk for an ADR was rated on a 5-point Likert scale. After the survey responses were received, means and 95% Cls were calculated. Consensus was defined as a lower 95% confidence limit >or=4.0. Potential risk factors that reached consensus were then applied to a sample of older outpatients to determine their prevalence. RESULTS: After 2 rounds, the expert panel reached consensus on 21 factors, including 12 medication-related factors and 9 patient characteristics. The most prevalent medication-related risk factors were opioid analgesics; warfarin; non-acetylsalicylic acid, non-cyclooxygenase-2 nonsteroidal anti-inflammatory drugs; anticholinergics; and benzodiazepines. The most prevalent patient characteristics included polypharmacy, multiple chronic medical problems, prior ADR, and dementia. CONCLUSIONS: An expert panel was able to reach a consensus on potential risk factors that increase the risk for ADRs in older outpatients. Many risk factors were common in a sample of older outpatients. Future research is needed to determine the predictive validity of these risk factors for ADRs in older outpatients.