Context To better target services to those who may benefit, many guidelines recommend incorporating life expectancy into clinical decisions. Objectives We conducted a systematic review to help physicians assess the quality and limitations of prognostic indices for mortality in older adults. Data Sources We searched MEDLINE, EMBASE, Cochrane, and Google Scholar through November 2011. Study Selection We included indices if they were validated and predicted absolute risk of mortality in patients whose average age was ≥ 60. We excluded indices that estimated ICU, disease-specific, or in-hospital mortality. Data Extraction For each prognostic index, we extracted data on clinical setting, potential for bias, generalizability, and accuracy. Results We reviewed 21,593 titles to identify 16 indices that predict risk of mortality from 6-months to 5 years for older adults in a variety of clinical settings: the community (six indices), the nursing home (two indices), and the hospital (eight indices). At least 1 measure of transportability was tested for all but 3 indices. By our measures, no study was free from potential bias. While 13 indices had c-statistics ≥ 0.70, none of the indices had c-statistics ≥ 0.90. Only two indices were independently validated by investigators who were not involved in the index’s development. Conclusion We identified several indices for predicting overall mortality in different patient groups; future studies need to independently test their accuracy in heterogeneous populations and their ability to improve clinical outcomes before their widespread use can be recommended.

Background/Objectives Physical distancing during the COVID‐19 pandemic may have unintended, detrimental effects on social isolation and loneliness among older adults. Our objectives were to investigate 1) experiences of social isolation and loneliness during shelter‐in‐place orders and 2) unmet health needs related to changes in social interactions. Design Mixed‐methods, longitudinal phone‐based survey administered every 2 weeks. Setting Two community sites and an academic geriatrics outpatient clinical practice. Participants 151 community‐dwelling older adults. Measurements We measured social isolation using a 6‐item modified Duke Social Support Index, social interaction sub‐scale, which included assessments of video‐based and internet‐based socializing. Measures of loneliness included self‐reported worsened loneliness due to the COVID‐19 pandemic, and loneliness severity based on the 3‐item UCLA loneliness scale. Participants were invited to share open‐ended comments about their social experiences. Results Participants were on average 75 years old (SD = 10), 50% had hearing or vision impairment, 64% lived alone, and 26% difficulty bathing. Participants reported social isolation in 40% of interviews, 76% reported minimal video‐based socializing, and 42% minimal internet‐based socializing. Socially isolated participants reported difficulty finding help with functional needs, including bathing (20% vs 55%, p = .04). Over half (54%) of participants reported worsened loneliness due to COVID‐19, which was associated with worsened depression (62% vs 9%, p < .001) and anxiety (57% vs 9%, p < .001). Rates of loneliness improved on average by time since shelter‐in‐place orders (4–6 weeks: 46% vs 13–15 weeks: 27%, p = .009), however, loneliness persisted or worsened for a subgroup of participants. Open‐ended responses revealed challenges faced by the subgroup experiencing persistent loneliness, including poor emotional coping and discomfort with new technologies. Conclusions Many older adults are adjusting to COVID‐19 restrictions since the start of shelter‐in‐place orders. Additional steps are critically needed to address the psychological suffering and unmet medical needs of those with persistent loneliness or barriers to technology‐based social interaction.

Background Advance care planning is increasingly common, but whether it influences end-of-life quality of care remains controversial. Design Medicare data and survey data from the Health and Retirement Study were combined to determine whether advance care planning was associated with quality metrics. Setting The nationally representative Health and Retirement Study. Participants 4394 decedent subjects (mean age 82.6 years at death, 55% women). Measurements Advance care planning was defined as having an advance directive, durable power of attorney or having discussed preferences for end-of-life care with a next-of-kin. Outcomes included previously reported quality metrics observed during the last month of life (rates of hospital admission, in-hospital death, >14 days in the hospital, intensive care unit admission, >1 emergency department visit, hospice admission, and length of hospice ≤3 days). Results Seventy-six percent of subjects engaged in advance care planning. Ninety-two percent of advance directives stated a preference to prioritize comfort. After adjustment, subjects who engaged in advance care planning were less likely to die in a hospital (adjusted RR 0.87, 95% CI 0.80-0.94), more likely to be enrolled in hospice (aRR 1.68, 1.43-1.97), and less likely to receive hospice for ≤3 days before death (aRR 0.88, 0.85-0.91). Having an advance directive, a durable-power-of-attorney or an advance care planning discussion were each independently associated with a significant increase in hospice use (p<0.01 for all). Conclusion Advance care planning was associated with improved quality of care at the end of life, including less in-hospital death and increased use of hospice. Having an advance directive, assigning a durable power of attorney and conducting advance care planning discussions are all important elements of advance care planning.

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A B S T R A C T PurposeDespite well-documented racial and ethnic differences in advance care planning (ACP), we know little about why these differences exist. This study tested proposed mediators of racial/ethnic differences in ACP. Patients and MethodsWe studied 312 non-Hispanic white, 83 non-Hispanic black, and 73 Hispanic patients with advanced cancer in the Coping with Cancer study, a federally funded multisite prospective cohort study designed to examine racial/ethnic disparities in ACP and end-of-life care. We assessed the impact of terminal illness acknowledgment, religiousness, and treatment preferences on racial/ethnic differences in ACP. ResultsCompared with white patients, black and Hispanic patients were less likely to have an ACP (white patients, 80%; black patients, 47%; Hispanic patients, 47%) and more likely to want life-prolonging care even if he or she had only a few days left to live (white patients, 14%; black patients, 45%; Hispanic patients, 34%) and to consider religion very important (white patients, 44%; black patients, 88%; Hispanic patients, 73%; all P Ͻ .001, comparison of black or Hispanic patients with white patients). Hispanic patients were less likely and black patients marginally less likely to acknowledge their terminally ill status (white patients, 39% v Hispanic patients, 11%; P Ͻ .001; white v black patients, 27%; P ϭ .05). Racial/ethnic differences in ACP persisted after adjustment for clinical and demographic factors, terminal illness acknowledgment, religiousness, and treatment preferences (has ACP, black v white patients, adjusted relative risk, 0.64 [95% CI, 0.49 to 0.83]; Hispanic v white patients, 0.65 [95% CI, 0.47 to 0.89]). ConclusionAlthough black and Hispanic patients are less likely to consider themselves terminally ill and more likely to want intensive treatment, these factors did not explain observed disparities in ACP.

Context.-The association between environmental tobacco smoke (ETS) exposure and respiratory symptoms has not been well established in adults. Objective.-To study the respiratory health of bartenders before and after legislative prohibition of smoking in all bars and taverns by the state of California. Design.-Cohort of bartenders interviewed before and after smoking prohibition. Setting and Participants.-Bartenders at a random sample of bars and taverns in San Francisco. Main Outcome Measures.-Interviews assessed respiratory symptoms, sensory irritation symptoms, ETS exposure, personal smoking, and recent upper respiratory tract infections. Spirometric assessment included forced expiratory volume in 1 second (FEV 1) and forced vital capacity (FVC) measurements. Results.-Fifty-three of 67 eligible bartenders were interviewed. At baseline, all 53 bartenders reported workplace ETS exposure. After the smoking ban, selfreported ETS exposure at work declined from a median of 28 to 2 hours per week (PϽ.001). Thirty-nine bartenders (74%) initially reported respiratory symptoms. Of those symptomatic at baseline, 23 (59%) no longer had symptoms at follow-up (PϽ.001). Forty-one bartenders (77%) initially reported sensory irritation symptoms. At follow-up, 32 (78%) of these subjects had resolution of symptoms (PϽ.001). After prohibition of workplace smoking, we observed improvement in mean FVC (0.189 L; 95% confidence interval [CI], 0.082-0.296 L; 4.2% change) and, to a lesser extent, mean FEV 1 (0.039 L; 95% CI, −0.030 to 0.107 L; 1.2% change). Complete cessation of workplace ETS exposure (compared with continued exposure) was associated with improved mean FVC (0.287 L; 95% CI, 0.088-0.486; 6.8% change) and mean FEV 1 (0.142 L; 95% CI, 0.020-0.264 L; 4.5% change), after controlling for personal smoking and recent upper respiratory tract infections. Conclusion.-Establishment of smoke-free bars and taverns was associated with a rapid improvement of respiratory health.

IMPORTANCE-Serious illness impairs function and threatens survival. Patients facing serious illness value shared decision making, yet few decision aids address the needs of this population.OBJECTIVE-To perform a systematic review of evidence about decision aids and other exportable tools that promote shared decision making in serious illness, thereby (1) identifying tools relevant to the treatment decisions of seriously ill patients and their caregivers, (2) evaluating the quality of evidence for these tools, and (3) summarizing their effect on outcomes and accessibility for clinicians.

IMPORTANCE Chronic pain is common among the elderly and is associated with cognitive deficits in cross-sectional studies; the population-level association between chronic pain and longitudinal cognition is unknown. OBJECTIVE To determine the population-level association between persistent pain, which may reflect chronic pain, and subsequent cognitive decline. DESIGN, SETTING, AND PARTICIPANTSCohort study with biennial interviews of 10 065 community-dwelling older adults in the nationally representative Health and Retirement Study who were 62 years or older in 2000 and answered pain and cognition questions in both 1998 and 2000. Data analysis was conducted between June 24 and October 31, 2016.EXPOSURES "Persistent pain," defined as a participant reporting that he or she was often troubled with moderate or severe pain in both the 1998 and 2000 interviews. MAIN OUTCOMES AND MEASURESCoprimary outcomes were composite memory score and dementia probability, estimated by combining neuropsychological test results and informant and proxy interviews, which were tracked from 2000 through 2012. Linear mixed-effects models, with random slope and intercept for each participant, were used to estimate the association of persistent pain with slope of the subsequent cognitive trajectory, adjusting for demographic characteristics and comorbidities measures in 2000 and applying sampling weights to represent the 2000 US population. We hypothesized that persistent pain would predict accelerated memory decline and increased probability of dementia. To quantify the impact of persistent pain on functional independence, we combined our primary results with information on the association between memory and ability to manage medications and finances independently. RESULTSOf the 10 065 eligible HRS sample members, 60% were female, and median baseline age was 73 years (interquartile range, 67-78 years). At baseline, persistent pain affected 10.9% of participants and was associated with worse depressive symptoms and more limitations in activities of daily living. After covariate adjustment, persistent pain was associated with 9.2% (95% CI, 2.8%-15.0%) more rapid memory decline compared with those without persistent pain. After 10 years, this accelerated memory decline implied a 15.9% higher relative risk of inability to manage medications and an 11.8% higher relative risk of inability to manage finances independently. Adjusted dementia probability increased 7.7% faster (95% CI, 0.55%-14.2%); after 10 years, this translates to an absolute 2.2% increase in dementia probability for those with persistent pain.CONCLUSIONS AND RELEVANCE Persistent pain was associated with accelerated memory decline and increased probability of dementia.