Geriatric conditions are similar in prevalence to chronic diseases in older adults and in some cases are as strongly associated with disability. The findings suggest that geriatric conditions, although not a target of current models of health care, are important to the health and function of older adults and should be addressed in their care.
Different models of frailty, based on different theoretical constructs, capture different groups of older adults. The different models may represent different frailty pathways or trajectories to adverse outcomes such as disability and death.
Clinical trial evidence guiding treatment of complex, older adults could be improved by eliminating upper age limits for study inclusion, by reducing the use of eligibility criteria that disproportionately affect multimorbid older patients, by evaluating outcomes that are highly relevant to older individuals, and by encouraging adherence to recommended analytic methods for evaluating differential treatment effects by age.
Five common conditions (3 chronic diseases, 2 geriatric syndromes) often co-occur in older adults, suggesting that coordinated management of comorbid conditions, both diseases and geriatric syndromes, is important. Care guidelines and quality indicators, rather than considering one condition at a time, should be developed to address comprehensive and coordinated management of co-occurring diseases and geriatric syndromes.
Objectives To empirically define multimorbidity “classes” based on patterns of disease co-occurrence among older Americans and to examine how class membership predicts healthcare utilization. Design Retrospective cohort study Setting Nationally representative sample of Medicare beneficiaries in file years 1999–2007 Participants 14,052 participants age ≥65 years in the Medicare Beneficiary Survey who had data available for at least 1 year after index interview Measurement Surveys (self-report) assessed chronic conditions; latent class analysis (LCA) was used to define multimorbidity classes based on the presence/absence of 13 conditions. All participants were assigned to a best-fit class. Primary outcomes were hospitalizations and emergency department visits over one year. Results Our primary LCA identified six classes. The largest portion of participants (32.7%) was assigned to the ‘Minimal Disease’ Class, in which most persons had ≤ 1 of the conditions. The other five classes represented various degrees and patterns of multimorbidity. Utilization rates were higher in classes with greater morbidity, compared to the Minimal Disease Class. However, many individuals could not be assigned to a particular class with confidence (sample misclassification error estimate = 0.36). Number of conditions predicted the outcomes at least as well as class membership. Conclusions Although recognition of general patterns of disease co-occurrence is useful for policy planning, the heterogeneity of persons with significant multimorbidity (≥3 conditions) defies neat classification. A simple count of conditions may be preferable for predicting utilization.
Background Some patients with diabetes may have health status characteristics that could make diabetes self-management (DSM) difficult and lead to inadequate glycemic control, or limit the benefit of some diabetes management interventions. Objective To investigate how many older and middle-aged adults with diabetes have such health status characteristics. Design Secondary data analysis of a nationally representative health interview survey, the Health and Retirement Study, and its diabetes mail-out survey. Setting/Participants Americans aged 51 and older with diabetes (n = 3506 representing 13.6 million people); aged 56 and older in diabetes survey (n = 1132, representing 9.9 million). Measurements Number of adults with diabetes and (a) relatively good health; (b) health status that could make DSM difficult (eg, comorbidities, impaired instrumental activities of daily living; and (c) characteristics like advanced dementia and activities of daily living dependency that could limit benefit of some diabetes management. Health and Retirement Study measures included demographics. Diabetes Survey included self-measured HbA1c. Results Nearly 22% of adults ≥51 with diabetes (about 3 million people) have health characteristics that could make DSM difficult. Another 10% (1.4 million) may receive limited benefit from some diabetes management. Mail-out respondents with health characteristics that could make DSM difficult had significantly higher mean HbA1c compared with people with relatively good health (7.6% vs. 7.3%, P < 0.04.). Conclusions Some middle-aged as well as older adults with diabetes have health status characteristics that might make DSM difficult or of limited benefit. Current diabetes quality measures, including measures of glycemic control, may not reflect what is possible or optimal for all patient groups.
Rationale: Aging is associated with reduced FEV 1 to FVC ratio (FEV 1 /FVC), hyperinflation, and alveolar enlargement, but little is known about how age affects small airways. Objectives: To determine if chest computed tomography (CT)assessed functional small airway would increase with age, even among asymptomatic individuals. Methods: We used parametric response mapping analysis of paired inspiratory/expiratory CTs to identify functional small airway abnormality (PRM FSA) and emphysema (PRM EMPH) in the SPIROMICS (Subpopulations and Intermediate Outcome Measures in COPD Study) cohort. Using adjusted linear regression models, we analyzed associations between PRM FSA and age in subjects with or without airflow obstruction. We subdivided participants with normal spirometry based on respiratory-related impairment (6-minute-walk distance ,350 m, modified Medical Research Council >2, chronic bronchitis, St. George's Respiratory Questionnaire .25, respiratory events requiring treatment [antibiotics and/or steroids or hospitalization] in the year before enrollment). Measurements and Main Results: Among 580 never-and eversmokers without obstruction or respiratory impairment, PRM FSA increased 2.7% per decade, ranging from 3.6% (ages 40-50 yr) to 12.7% (ages 70-80 yr). PRM EMPH increased nonsignificantly (0.1% [ages 40-50 yr] to 0.4% [ages 70-80 yr]; P = 0.34). Associations were similar among nonobstructed individuals with respiratory-related impairment. Increasing PRM FSA in subjects without airflow obstruction was associated with increased FVC (P = 0.004) but unchanged FEV 1 (P = 0.94), yielding lower FEV 1 /FVC ratios (P , 0.001). Although emphysema was also significantly associated with lower FEV 1 /FVC (P = 0.04), its contribution relative to PRM FSA in those without airflow obstruction was limited by its low burden. Conclusions: In never-and ever-smokers without airflow obstruction, aging is associated with increased FVC and CT-defined functional small airway abnormality regardless of respiratory symptoms.
Rationale: Survivors of critical illness suffer significant limitations and disabilities. Objectives: Ascertain whether severe sepsis is associated with increased risk of so-called geriatric conditions (injurious falls, low body mass index [BMI], incontinence, vision loss, hearing loss, and chronic pain) and whether this association is measured consistently across three different study designs. Methods: Patients with severe sepsis were identified in the Health and Retirement Study, a nationally representative cohort interviewed every 2 years, 1998 to 2006, and in linked Medicare claims. Three comparators were used to assess an association of severe sepsis with geriatric conditions in survivors: the prevalence in the United States population aged 65 years and older, survivors' own pre-sepsis levels assessed before hospitalization, or survivors' own pre-sepsis trajectory. Measurements and Main Results: Six hundred twenty-three severe sepsis hospitalizations were followed a median of 0.92 years. When compared with the 65 years and older population, surviving severe sepsis was associated with increased rates of low BMI, injurious falls, incontinence, and vision loss. Results were similar when comparing survivors to their own pre-sepsis levels. The association of low BMI and severe sepsis persisted when controlling for patients' pre-sepsis trajectories, but there was no association of severe sepsis with injurious falls, incontinence, vision loss, hearing loss, and chronic pain after such controls. Conclusions: Geriatric conditions are common after severe sepsis. However, severe sepsis is associated with increased rates of only a subset of geriatric conditions, not all. In studying outcomes after acute illness, failing to measure and control for both preillness levels and trajectories may result in erroneous conclusions.Keywords: severe sepsis; long-term outcomes; geriatric conditions; cohort studies; trajectory bias A substantial body of research has demonstrated that survivors of critical illness face extensive physical, psychological, cognitive, and social deficits in the aftermath of their critical illness (1). For example, survivors of acute respiratory distress syndrome (ARDS) have prolonged 6-minute walk times, executive dysfunction, other neuropsychiatric deficits, and diminished ability to return to work (2-13). Numerous studies have found quality of life among survivors of critical illness (14, 15), severe sepsis (16,17), and ARDS (4-8, 13, 18) to be abnormally low.Patients surviving critical illness have limitations and disabilities somewhat characteristic of an older adult population. Rubenfeld recently postulated a "progeric hypothesis" that the sequelae of critical illness mirror accelerated aging (19). This hypothesis suggests that severe sepsis may be associated with the development of so-called geriatric conditions (15,20,21). These are conditions common among older adults, multifactorial in etiology, and associated with disability, often contributing to decreased quality of life (20-23). The followin...
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