A randomized controlled trial of a novel home-based palliative care program: A report of a trial that could not be completed.

BACKGROUND: In response to a growing need for accessible, efficient, and effective palliative care services, we designed, implemented, and evaluated a novel palliative care at home (PC@H) model for people with serious illness that is centered around a community health worker, a registered nurse, and a social worker, with an advanced practice nurse and a physician for support. Our objectives were to measure the impact of receipt of PC@H on patient symptoms, quality of life, and healthcare utilization and costs. METHODS: We enrolled 136 patients with serious illness in this parallel, randomized controlled trial. Our primary outcome was change in symptom burden at 6 weeks. Secondary outcomes included change in symptom burden at 3 months, change in quality of life at 6 weeks and 3 months, estimated using a group t-test. In an exploratory aim, we examined the impact of PC@H on healthcare utilization and cost using a generalized linear model. RESULTS: PC@H resulted in a greater improvement in patient symptoms at 6 weeks (1.30 score improvement, n = 37) and 3 months (3.14 score improvement, n = 21) compared with controls. There were no differences in healthcare utilization and costs between the two groups. Unfortunately, due to the COVID-19 pandemic and a loss of funding, the trial was not able to be completed as originally intended. CONCLUSIONS: A palliative care at home model that leverages community health workers, registered nurses, and social workers as the primary deliverers of care may result in improved patient symptoms and quality of life compared with standard care. We did not demonstrate significant differences in healthcare utilization and cost associated with receipt of PC@H, likely due to inability to reach the intended sample size and insufficient statistical power, due to elements beyond the investigators' control such as the COVID-19 public health emergency and changes in grant funding.

National Institute on Aging's 50th anniversary: Advancing aging research and the health and well-being of older adults.

The National Institute on Aging (NIA), part of the National Institutes of Health (NIH), was founded in 1974 to support and conduct research on aging and the health and well-being of older adults. Fifty years ago, the concept of studying aging generated much skepticism. Early NIA-funded research findings helped establish the great value of aging research and provided the foundation for significant science advances that have improved our understanding of the aging process, diseases and conditions associated with aging, and the effects of health inequities, as well as the need to promote healthy aging lifestyles. Today, we celebrate the many important contributions to aging research made possible by NIA, as well as opportunities to continue to make meaningful progress. NIA emphasizes that the broad aging research community must continue to increase and expand our collective efforts to recruit and train a diverse next generation of aging researchers.

The Prevalence of Cognitive Impairment Among Medicare Beneficiaries Who Use Outpatient Physical Therapy.

OBJECTIVE: The objective of this study was to estimate the prevalence of cognitive impairment (including cognitive impairment no dementia [CIND] and dementia) among Medicare fee-for-service beneficiaries who used outpatient physical therapy and to estimate the prevalence of cognitive impairment by measures that are relevant to rehabilitation practice. METHODS: This cross-sectional analysis included 730 Medicare fee-for-service beneficiaries in the 2016 wave of the Health and Retirement Study with claims for outpatient physical therapy. Cognitive status, our primary variable of interest, was categorized as normal, CIND, or dementia using a validated approach, and population prevalence of cognitive impairment (CIND and dementia) was estimated by sociodemographic variables and Charlson comorbidity index score. Age-, gender- (man/woman), race-/ethnicity-adjusted population prevalence of CIND and dementia were also calculated for walking difficulty severity, presence of significant pain, self-reported fall history, moderate-vigorous physical activity (MVPA) ≤1×/week, and sleep disturbance frequency using multinomial logistic regression. RESULTS: Among Medicare beneficiaries with outpatient physical therapist claims, the prevalence of any cognitive impairment was 20.3% (CIND:15.2%, dementia:5.1%). Cognitive impairment was more prevalent among those who were older, Black, had lower education attainment, or higher Charlson comorbidity index scores. The adjusted population prevalence of cognitive impairment among those who reported difficulty walking across the room was 29.8%, difficulty walking 1 block was 25.9%, difficulty walking several blocks was 20.8%, and no difficulty walking was 16.3%. Additionally, prevalence of cognitive impairment among those with MVPA ≤1×/week was 27.1% and MVPA >1×/week was 14.1%. Cognitive impairment prevalence did not vary by significant pain, self-reported fall history, or sleep disturbance. CONCLUSION: One in 5 older adults who use outpatient physical therapist services have cognitive impairment. Furthermore, cognitive impairment is more common in older physical therapist patients who report worse physical function and less physical activity. IMPACT: Physical therapists should consider cognitive screening for vulnerable older adults to inform tailoring of clinical practice toward a patient's ability to remember and process rehabilitation recommendations.

Health care utilization and costs in the years preceding dementia identification.

INTRODUCTION: There is evidence that health care utilization increases after incident dementia, particularly after dementia diagnosis and toward the end of life; however, less is known about utilization in the years before dementia identification. METHODS: In this retrospective cohort study we obtained data on n = 5547 beneficiaries from the Health and Retirement Study (HRS)-Medicare linked sample (n = 1241 with and n = 4306 without dementia) to compare longitudinal trends in health care costs and utilization in the 6 years preceding dementia identification relative to a confounder-balanced reference group without dementia. RESULTS: We found that persons with dementia had a greater prevalence of outpatient emergency department (ED), inpatient hospital, skilled nursing, and home health use, and total health care costs in the years preceding dementia identification compared to their similar counterparts without dementia across a comparable timespan in later life. CONCLUSIONS: This study provides evidence to suggest greater healthcare burden may exist well before clinical manifestation and identification of dementia. HIGHLIGHTS: Several studies have documented the tremendous healthcare-related costs of living with dementia, particularly toward the end of life. Dementia is a progressive neurodegenerative disease, which, for some, includes a prolonged pre-clinical phase. However, health services research to date has seldom considered the time before incident dementia. This study documents that health care utilization and costs are significantly elevated in the years before incident dementia relative to a demographically-similar comparison group without dementia.

Declines in Wealth Among US Older Adults at Risk of Dementia.

This case-control study uses Health and Retirement Study data to examine the trajectories of wealth among US older adults at risk of dementia.

Postdischarge Caregiver Burden Among Family Caregivers of Older Trauma Patients.

Importance: Caregiver burden, characterized by psychological distress and physical morbidity, affects more than 50 million family caregivers of older adults in the United States. Risk factors for caregiver burden among caregivers of older trauma patients have not been well characterized. Objective: To characterize postdischarge caregiver burden among caregivers of older trauma patients and identify targets that can inform interventions to improve their experience. Design, Setting, and Participants: This study used a repeated cross-sectional design. Participants were family caregivers for adults 65 years or older with traumatic injury who were discharged from 1 of 2 level I trauma centers. Telephone interviews were conducted at 1 month and 3 months postdischarge with family caregivers (identified by the patient as family or friends who provided unpaid care). Admissions occurred between December 2019 and May 2021, and data were analyzed from June 2021 to May 2022. Exposure: Hospital admission for geriatric trauma. Main Outcome and Measures: High caregiver burden was defined by a score of 17 or higher on the 12-item Zarit Burden Interview. Caregiver self-efficacy and preparedness for caregiving were assessed via the Revised Scale for Caregiving Self-Efficacy and Preparedness for Caregiving Scale, respectively. Associations between caregiver self-efficacy, preparedness for caregiving, and caregiver burden were tested via mixed-effect logistic regression. Results: There were 154 family caregivers enrolled in the study. Their mean (SD) age was 60.6 (13.0) years (range, 18-92 years), 108 of 154 were female (70.6%). The proportion of caregivers experiencing high burden (Zarit Burden Interview score ≥17) was unchanged over time (1 month, 38 caregivers [30.9%]; 3 months, 37 caregivers [31.4%]). Participants with lower caregiver self-efficacy and preparedness for caregiving were more likely to experience greater caregiver burden (odds ratio [OR], 7.79; 95% CI, 2.54-23.82; P < .001; and OR, 5.76; 95% CI, 1.86-17.88; P = .003, respectively). Conclusion and Relevance: This study found that nearly a third of family caregivers of older trauma patients experience high caregiver burden up to 3 months after the patients' discharge. Targeted interventions to increase caregiver self-efficacy and preparedness may reduce caregiver burden in geriatric trauma.

Heart failure with comorbid dementia: Association with clinical characteristics and outcomes.

BACKGROUND: Heart failure (HF) and dementia both have profound effects on function and mortality in older persons. However, we have limited knowledge about the impact of co-occurring HF and dementia. Our goal was to understand how often persons with HF have dementia and the impact of their co-occurrence. METHODS: Retrospective analysis of participants (age > 65) in the 2015 wave of the nationally representative Health and Aging Trends Study (NHATS) with linkage to Medicare claims. 912 participants with HF (45% older than 80, 51% women) using Medicare claims. We used the validated NHATS dementia algorithm to identify those with probable dementia. Outcomes of interest included the need for help with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) at baseline, functional decline, hospitalization over 1 year, and mortality over 2-years. Baseline functional status, functional decline, and hospitalization were compared using adjusted logistic regression, mortality was analyzed using adjusted Cox regression models adjusted for demographics, socio-economic status, baseline health, and baseline functional status. RESULTS: 200 (21%) of the participants with HF also had dementia. For each I/ADL, patients with both HF and dementia were more likely to need help than those with HF without dementia. 71.8% of participants with HF and dementia needed help with medications versus 16.6% with HF without dementia (p < 0.001). Having HF and dementia was associated with an increased risk of requiring help with additional ADLs after one year (aOR = 2.69, 95% CI 1.53, 4.73). Participants with HF and dementia had an increased risk of being hospitalized within one year (aOR = 2.02 95% CI 1.16, 3.54), or dying within two years (aHR = 1.52 95% CI 1.03, 2.26). CONCLUSIONS: One-fifth of persons over age 65 with HF also have comorbid dementia. Co-occurring HF and dementia markedly increase functional impairment and subsequent ADL decline, hospitalization, and death. These results highlight the need for physician awareness for signs of dementia, and appropriate adjustments in the management of HF.

Paid Care for People with Functional Impairment and Serious Illness: Results from the Health and Retirement Study.

BACKGROUND: Paid caregivers (e.g., home health aides) care for individuals living at home with functional impairment and serious illnesses (health conditions with high risk of mortality that impact function and quality of life). OBJECTIVE: To characterize those who receive paid care and identify factors associated with receipt of paid care in the context of serious illness and socioeconomic status. DESIGN: Retrospective cohort study. PARTICIPANTS: Community-dwelling participants ≥ 65 years enrolled in the Health and Retirement Study (HRS) between 1998 and 2018 with new-onset functional impairment (e.g., bathing, dressing) and linked fee-for-service Medicare claims (n = 2521). MAIN MEASURES: Dementia was identified using HRS responses and non-dementia serious illness (e.g., advanced cancer, end-stage renal disease) was identified using Medicare claims. Paid care support was identified using HRS survey report of paid help with functional tasks. KEY RESULTS: While about 27% of the sample received paid care, those with both dementia and non-dementia serious illnesses in addition to functional impairment received the most paid care (41.7% received ≥ 40 h of paid care per week). In multivariable models, those with Medicaid were more likely to receive any paid care (p < 0.001), but those in the highest income quartile received more hours of paid care (p = 0.05) when paid care was present. Those with non-dementia serious illness were more likely to receive any paid care (p < 0.001), but those with dementia received more hours of care (p < 0.001) when paid care was present. CONCLUSIONS: Paid caregivers play a significant role in meeting the care needs of those with functional impairment and serious illness and high paid care hours are common among those with dementia in particular. Future work should explore how paid caregivers can collaborate with families and healthcare teams to improve the health and well-being of the seriously ill throughout the income spectrum.

Caring for aging parents in the last years of life.

BACKGROUND: Adult children provide a large portion of end-of-life caregiving for older adults and make up the majority of caregivers for adults with dementia. Yet research has been limited to the hours of care that primary caregivers provide, neglecting the other ways adult children provide caregiving support. This study aims to describe the caregiving support adult children provide to their parents at the end of life and characterize differences by race and ethnicity and dementia status. METHODS: We conducted a retrospective study using survey responses from the Health and Retirement Study between 2002 and 2018. The sample population (n = 8040) included decedents aged 65 with at least one living adult child at their time of death. Caregiving support was defined as providing financial support, providing help with basic or instrumental activities of daily living (ADLs or IADLs), or coresiding with the care recipient. Respondents were stratified by self-identified race and ethnicity as Hispanic, non-Hispanic White, or non-Hispanic Black. Respondents were further stratified by dementia and marital status. RESULTS: Black and Hispanic respondents without dementia were more likely to report receiving financial help from (28.0% and 25.9%) or coresiding with their adult children (38.9% and 49.7%) compared to White respondents (15.0% receiving financial help and 23.3% coresiding) (p < 0.05). Among respondents with dementia, 47.1% of both Black and Hispanic respondents reported coresiding with their adult children, compared to only 24.6% of White respondents (p < 0.05). Notably, married Black and Hispanic respondents reported significantly higher rates of all support types compared to married White respondents (p < 0.05). CONCLUSIONS: The majority of older adults at the end of life receive some form of care and support from their adult children, with Black and Hispanic older adults receiving particularly high rates of care and support from their adult children regardless of dementia or marital status.

Complex Care Needs at the End of Life for Seriously Ill Adults With Multiple Chronic Conditions.

Understanding the complex care needs of seriously ill adults with multiple chronic conditions with and without cancer is critical for the delivery of high-quality serious illness and palliative care at the end of life. The objective of this secondary data analysis of a multisite randomized clinical trial in palliative care was to elucidate the clinical profile and complex care needs of seriously ill adults with multiple chronic conditions and to highlight key differences among those with and without cancer at the end of life. Of the 213 (74.2%) older adults who met criteria for multiple chronic conditions (eg, 2 or more chronic conditions requiring regular care with limitations of daily living), 49% had a diagnosis of cancer. Hospice enrollment was operationalized as an indicator for severity of illness and allowed for the capture of complex care needs of those deemed to be nearing the end of life. Individuals with cancer had complex symptomatology with a higher prevalence of nausea, drowsiness, and poor appetite and end of life and lower hospice enrollment. Individuals with multiple chronic conditions without cancer had lower functional status, greater number of medications, and higher hospice enrollment. The care of seriously ill older adults with multiple chronic conditions requires tailored approaches to improve outcomes and quality of care across health care settings, particularly at the end of life.

The heterogeneity of the homebound: A latent class analysis of a national sample of homebound older adults.

BACKGROUND: Homebound status is a final common pathway for people with a variety of diseases and conditions. There are 7 million homebound older adults in the United States. Despite concerns regarding their high healthcare costs and utilization and limited access to care, the unique subsets within the homebound population are understudied. Better understanding of distinct homebound groups may enable more targeted and tailored approaches to care delivery. Therefore, in a nationally representative sample of homebound older adults we used latent class analysis (LCA) to examine distinct homebound subgroups based on clinical and sociodemographic characteristics. MATERIALS AND METHODS: Using data from the National Health and Aging Trends Study (NHATS) 2011-2019, we identified 901 newly homebound persons (defined as never/rarely leaving home or leaving home only with assistance and/or difficulty). Sociodemographic, caregiving context, health and function, and geographic covariates were derived from NHATS via self-report. LCA was used to identify the existence of distinct subgroups within the homebound population. Indices of model fit were compared for models testing 1-5 latent classes. Association between latent class membership and 1 year mortality was examined using a logistic regression. RESULTS: We identified four classes of homebound individuals differentiated by their health, function, sociodemographic characteristics, and caregiving context: (i) Resource constrained (n = 264); (ii) Multimorbid/high symptom burden (n = 216); (iii) Dementia/functionally impaired (n = 307); (iv) Older/assisted living (n = 114). One year mortality was highest among the older/assisted living subgroup (32.4%) and lowest among the resource constrained (8.2%). CONCLUSIONS: This study identifies subgroups of homebound older adults characterized by distinct sociodemographic and clinical characteristics. These findings will support policymakers, payers, and providers in targeting and tailoring care to the needs of this growing population.

Examining annual transitions in healthcare spending among U.S. medicare beneficiaries using multistate Markov models: Analysis of medicare current beneficiary survey data, 2003-2019.

Many studies have examined factors associated with individuals of high or low healthcare spending in a given year. However, few have studied how healthcare spending changes over multiple years and which factors are associated with the changes. In this study, we examined the dynamic patterns of healthcare spending over a three-year period, among a nationally representative cohort of Medicare beneficiaries in the U.S. and identified factors associated with these patterns. We extracted data for 30,729 participants from the national Medicare Current Beneficiary Survey (MCBS), for the period 2003-2019. Using multistate Markov (MSM) models, we estimated the probabilities of year-to-year transitions in healthcare spending categorized as three states (low (L), medium (M) and high (H)), or to the terminal state, death. The participants, 13,554 (44.1%), 13,715 (44.6%) and 3,460 (11.3%) were in the low, medium and high spending states at baseline, respectively. The majority of participants remained in the same spending category from one year to the next (L-to-L: 76.8%; M-to-M: 71.7%; H-to-H: 56.6 %). Transitions from the low to high spending state were significantly associated with older age (75-84, ≥85 years), residing in a long-term care facility, greater assistance with activities of daily living, enrollment in fee-for-service Medicare, not receiving a flu shot, and presence of specific medical conditions, including cancer, dementia, and heart disease. Using data from a large population-based longitudinal survey, we have demonstrated that MSM modelling is a flexible framework and useful tool for examining changes in healthcare spending over time.

The Trauma Dyad: The Role of Informal Caregivers for Older Adults After Traumatic Injury.

OBJECTIVE: To investigate the association between higher injury severity and increased informal caregiving received by injured older adults. SUMMARY OF BACKGROUND DATA: Injured older adults experience high rates of functional decline and disability after hospitalization. Little is known about the scope of caregiving received post-discharge, particularly from informal caregivers such as family. METHODS: We used the National Health and Aging Trends Study 2011 to 2018 linked to Medicare claims to identify adults ≥65 with hospital admission for traumatic injury and a National Health and Aging Trends Study interview within 12 months pre- and post-trauma. Injury severity was assessed using the injury severity score (ISS, low 0-9; moderate 10-15; severe 16-75). Patients reported the types and hours of formal and informal help received and any unmet care needs. Multi variable logistic regression models examined the association between ISS and increase in informal caregiving hours after discharge. RESULTS: We identified 430 trauma patients. Most were female (67.7%), non-Hispanic White (83.4%) and half were frail. The most common mechanism of injury was fall (80.8%) and median injury severity was low (ISS = 9). Those reporting receiving help with any activity increased post-trauma (49.0% to 72.4%, P < 0.01), and unmet needs nearly doubled (22.8% to 43.0%, P < 0.01). Patients had a median of 2 caregivers and most (75.6%) were informal, often family members. Median weekly hours of care received pre- versus post-injury increased from 8 to 14 (P < 0.01). ISS did not independently predict increase in caregiving hours; pre-trauma frailty predicted an increase in hours ≥8 per week. CONCLUSIONS: Injured older adults reported high baseline care needs which increased significantly after hospital discharge and were mostly met by informal caregivers. Injury was associated with increased need for assistance and unmet needs regardless of injury severity. These results can help set expectations for caregivers and facilitate post-acute care transitions.

Prevalence of unpaid caregiving, pain, and depression in older seriously ill patients undergoing elective surgery.

INTRODUCTION: Serious illness is a life-limiting condition negatively impacting daily function, quality of life, or excessively straining caregivers. Over 1 million older seriously ill adults undergo major surgery annually, and national guidelines recommend that palliative care be available to all seriously ill patients. However, the palliative care needs of elective surgical patients are incompletely described. Understanding baseline caregiving needs and symptom burden among seriously ill older surgical patients could inform interventions to improve outcomes. METHODS: Using Health and Retirement Study data (2008-2018) linked to Medicare claims, we identified patients ≥66 years who met an established serious illness definition from administrative data and underwent major elective surgery using Agency for Healthcare Research and Quality (AHRQ) criteria. Descriptive analyses were performed for preoperative patient characteristics, including: unpaid caregiving (no or yes); pain (none/mild or moderate/severe); and depression (no, CES-D < 3, or yes, CES-D ≥ 3). Multivariable regression was performed to examine the association between unpaid caregiving, pain, depression, and in-hospital outcomes, including hospital days (days admitted between discharge date and one-year post-discharge), in-hospital complications (no or yes), and discharge destination (home or non-home). RESULTS: Of the 1343 patients, 55.0% were female and 81.6% were non-Hispanic White. Mean age was 78.0 (SD 6.8); 86.9% had ≥2 comorbidities. Before admission, 27.3% of patients received unpaid caregiving. Pre-admission pain and depression were 42.6% and 32.8%, respectively. Baseline depression was significantly associated with non-home discharge (OR 1.6, 95% CI 1.2-2.1, p = 0.003), while baseline pain and unpaid caregiving needs were not associated with in-hospital or post-acute outcomes in multivariable analysis. CONCLUSIONS: Prior to elective surgery, older adults with serious illnesses have high unpaid caregiving needs and a prevalence of pain and depression. Baseline depression alone was associated with discharge destinations. These findings highlight opportunities for targeted palliative care interventions throughout the surgical encounter.

Frequency and implications of coexistent manifestations of serious illness in older adults with dementia.

BACKGROUND: In older adults, serious illness comprises three manifestations: dementia, activity of daily living (ADL) impairment, and other advanced medical conditions (AMC; e.g., end-stage renal disease). Little is known about how dementia and other manifestations of serious illness co-occur. We aim to describe the prevalence of persons with dementia (PWD) who are living with additional manifestations of serious illness, and the implications on healthcare utilization, Medicare costs, caregiving hours and out-of-pocket expenses. METHODS: In this cross-sectional study, we use data from the 2016 Health and Retirement Study (HRS) linked to Medicare fee-for-service claims. We limited inclusion to adults >65 years. Dementia was determined using validated methodology that incorporates functional and cognitive test scores from HRS. We classified PWD as having dementia alone, dementia and an AMC (irrespective of ADL impairment) or dementia and ADL impairment (without an AMC). Healthcare utilization and Medicare costs were measured in claims, caregiving hours and out-of-pocket expenses were self-reported. RESULTS: Most PWD (67%) met criteria for another manifestation of serious illness (24% advanced medical condition, 44% ADL impairment). PWD and an AMC had the highest proportion of hospital use and the highest median total Medicare costs ($17,900 vs. $8962 dementia + ADL impairment vs. $4376 dementia alone). Mean total hours of caregiving per month were similar for PWD and an AMC and PWD and ADL impairment (142.9 and 141.9 h, respectively), while mean hours were much lower for PWD alone (47.7 h). Median out-of-pocket costs were highest for PWD and ADL impairment ($13,261) followed by PWD and an AMC ($10,837) and PWD alone ($7017). CONCLUSIONS: PWD commonly face another manifestation of serious illness. Dementia and ADL impairment was associated with the highest costs for PWD and families while dementia and an AMC was associated with the highest costs for Medicare.

The burden of pre-admission pain, depression, and caregiving on palliative care needs for seriously ill trauma patients.

INTRODUCTION: Increasing numbers of individuals admitted to hospitals for trauma are older adults, many of whom also have underlying serious illnesses. Older adults with serious illness benefit from palliative care, but the palliative care needs of seriously ill older adults with trauma have not been elucidated. We hypothesize that older adults with serious illness have a high prevalence of pain, depression, and unpaid caregiving hours before trauma admission. METHODS: Using Health and Retirement Study data (2008-2018) linked to Medicare claims, we identified patients 66 years or older who met an established definition of serious illness in surgery and were admitted with trauma. Descriptive analyses were performed for baseline patient characteristics, pre-admission pain (dichotomized as none/mild vs. moderate/severe), depression (dichotomized as no, Center for Epidemiologic Studies Depression scale [CES-D] < 3 vs. yes, CES-D ≥ 3), and unpaid caregiving hours (dichotomized as low (<30 h/month), high (≥30 h/month)). RESULTS: We identified 1741 patients, 67.4% were female and 86.8% White. Mean age was 83 (SD 7.5), and 60.3% had ≥4 comorbidities. The majority (62.9%) were admitted due to falls, 33.5% had isolated hip fracture. The prevalence of baseline moderate/severe pain and depression were 38.1% and 42.6%, respectively. Among the cohort, 42.2% had unpaid caregiving, of those 27.7% had ≥30 h/week of unpaid caregiving hours. CONCLUSIONS: Prior to trauma admission, older adults with serious illness have a high prevalence of pain, depression, and unpaid caregiving hours. These findings may inform targeted palliative care interventions to reduce symptom burden and post-discharge healthcare utilization.

Multiple Chronic Conditions among Seriously Ill Adults Receiving Palliative Care.

The objective of this study was to characterize multiple chronic conditions (MCCs) among seriously ill adults receiving palliative care at the end of life. A latent class analysis was conducted to identify latent subgroups of seriously ill older adults based on a baseline Charlson comorbidity index (CCI) measurement, a measure of comorbidity burden, and mortality risk. The three latent subgroups were: (1) low to moderate CCI with MCC, (2) high CCI with MCC, and (3) high CCI and metastatic cancer. The "low to moderate CCI and MCC" subgroup included older adults with chronic obstructive pulmonary disease (COPD), cardiovascular disease, congestive heart failure, myocardial infarction, dementia, diabetes, and lymphoma. A "high CCI and MCC" subgroup included individuals with severe illness including liver or renal disease among other MCCs. A "high CCI and metastatic cancer" included all participants with metastatic cancer. This study sheds light on the MCC profile of seriously ill adults receiving palliative care.

Virtual Geritalk: Does Intensive Virtual Communication Skills Training Improve Use of Serious Illness Communication Skills?

Background: The COVID-19 pandemic presented a unique opportunity to adapt in-person communication skills training to a virtual format. Objective: Examine use of serious illness communication skills by learners after participating in an intensive virtual communication skills training. Design: Prospective cohort study. Setting/Subjects: Icahn School of Medicine at Mount Sinai, Clinical Fellows. Measurements: Family Meeting Communication Assessment Tool (FAMCAT) assessed fundamental and advanced communication skills. Results: As compared to a historical benchmark obtained after a prior in-person course, the virtual course showed equivalent or better use of communication skills across fundamental skills and advanced skills. Conclusions: Our findings suggest that a virtual communication skills training is associated with the use of serious illness communication skills in the clinical setting by learners.

The devil's in the details: Variation in estimates of late-life activity limitations across national cohort studies.

BACKGROUND: Assessing activity limitations is central to aging research. However, assessments of activity limitations vary, and this may have implications for the populations identified. We aim to compare measures of activities of daily living (ADLs) and their resulting prevalence and mortality across three nationally-representative cohort studies: the National Health and Aging Trends Study (NHATS), the Health and Retirement Survey (HRS), and the Medicare Current Beneficiary Survey (MCBS). METHODS: We compared the phrasing and context of questions around help and difficulty with six self-care activities: eating, bathing, toileting, dressing, walking inside, and transferring. We then compared the prevalence and 1-year mortality for difficulty and help with eating and dressing. RESULTS: NHATS, HRS, and MCBS varied widely in phrasing and framing of questions around activity limitations, impacting the proportion of the population found to experience difficulty or receive help. For example, in NHATS 12.4% [95% confidence interval (CI) 11.5%-13.4%] of the cohort received help with dressing, while in HRS this figure was 6.4% [95% CI 5.7%-7.2%] and MCBS 5.3% [95% CI 4.7%-5.8%]. When combined with variation in sampling frame and survey approach of each survey, such differences resulted in large variation in estimates of the older population of older adults with ADL disability. CONCLUSIONS: In order to take late-life activity limitations seriously, we must clearly define the measures we use. Further, researchers and clinicians seeking to understand the experience of older adults with activity limitations should be careful to interpret findings in light of the framing of the question asked.