Advance care planning should take into account patients' attitudes toward the burden of treatment, the possible outcomes, and their likelihood. The likelihood of adverse functional and cognitive outcomes of treatment requires explicit consideration.

Background/Objectives Polypharmacy is receiving increased attention as a potential problem for older persons, who frequently have multiple chronic conditions. The purpose of this study was to summarize evidence regarding the health outcomes associated with polypharmacy, defined as number of prescribed medications,among older community-dwelling persons. Design Systematic review of MEDLINE (OvidSP 1946 to May Week 3 2014). Setting Community Participants Observational studies examining health outcomes according to the number of prescription medications taken. Measurements Association of number of medications with health outcomes. Because of the importance of comorbidity as a potential confounder of the relationship between polypharmacy and health outcomes, articles were assessed regarding the quality of their adjustment for confounding. Results Of the total of 50 studies identified, the majority studies that were rated as “good” in terms of their adjustment for comorbidity demonstrated relationships between polypharmacy and a range of outcomes, including falls/fall outcomes/fall risk factors; adverse drug events, hospitalization, mortality, and measures of function and cognition. However, a number of these studies failed to demonstrate associations, as did a substantial proportion of those studies rated as “fair” or “poor.” Conclusions Data are mixed regarding the relationship between polypharmacy, considered in terms of number of medications, and adverse outcomes among community-dwelling older persons. Because of the challenge of confounding, randomized controlled trials of medication discontinuation may provide more definitive evidence regarding this relationship.

We evaluated Toll-like receptor (TLR) function in primary human dendritic cells from 104 young (age 21–30) and older (≥ 65 years) individuals. We used multicolor flow cytometry and intracellular cytokine staining of myeloid (mDC) and plasmacytoid (pDC) DCs and found substantial decreases in older, compared to young individuals in TNF-α, IL-6 and/or IL-12 (p40) production in mDCs and in TNF-α and IFN-α production in pDCs in response to TLR1/2, TLR2/6, TLR3, TLR5, and TLR8 engagement in mDCs and TLR7 and TLR9 in pDCs. These differences were highly significant after adjustment for heterogeneity between young and older groups (e.g. gender, race, body mass index [BMI], number of comorbid medical conditions) using mixed effect statistical modeling. Studies of surface and intracellular expression of TLR proteins, and of TLR gene expression in purified mDCs and pDCs revealed potential contributions for both transcriptional and post-transcriptional mechanisms in these age-associated effects. Moreover, intracellular cytokine production in the absence of TLR ligand stimulation was elevated in cells from older, compared to young individuals, suggesting a dysregulation of cytokine production that may limit further activation by TLR engagement. Our results provide evidence for immunosenescence in dendritic cells; notably, defects in cytokine production were strongly associated with poor antibody response to influenza immunization, a functional consequence of impaired TLR function in the aging innate immune response.

Background Despite the fact that 80% of patients with heart failure are over age 65, recognition of cognitive impairment by physicians in this population has received relatively little attention. The purpose of our study was to evaluate physician documentation (as a measure of recognition) of cognitive impairment at time of discharge in a cohort of older adults hospitalized for heart failure. Methods We performed a prospective cohort study of older adults hospitalized with a primary diagnosis of heart failure. Cognitive status was evaluated with the Folstein Mini-Mental State Examination (MMSE) at the time of hospitalization. A score of 21–24 was used to indicate mild cognitive impairment, and a score of ≤20 to indicate moderate to severe impairment. To evaluate physician documentation of cognitive impairment, we used a standardized form with a targeted keyword strategy to review hospital discharge summaries. We calculated the proportion of patients with cognitive impairment documented as such by physicians, and compared characteristics between groups with and without documented cognitive impairment. We then analyzed the association of cognitive impairment, and documentation of cognitive impairment, with 6-month mortality or readmission using Cox proportional hazards regression. Results A total of 282 patients completed the cognitive assessment. Their mean age was 80 years of age, 18.8% were nonwhite, and 53.2% were female. Cognitive impairment was present in 132/282 patients (46.8% overall; 25.2% mild, 21.6% moderate-severe). Among those with cognitive impairment, 30/132 (22.7%) were documented as such by physicians. Compared with patients whose cognitive impairment was documented by physicians, those whose impairment was not documented were younger (81.3 years vs. 85.2 years, P<0.05) and had less severe impairment (median MMSE score 22.0 vs. 18.0, P<0.01). After multivariable adjustment, patients whose cognitive impairment was not documented were significantly more likely to experience 6-month mortality or hospital readmission than patients without cognitive impairment. Conclusions Cognitive impairment is common in older adults hospitalized for heart failure, yet frequently not documented by physicians. Implementation of strategies to improve recognition and documentation of cognitive impairment may improve the care of these patients, particularly at the time of hospital discharge.

Objective-To develop and test a simple tool to elicit the preferences of older persons based on prioritization of universal health outcomes.Methods-Persons age ≥ 65 participating in a larger study were asked to rank 4 outcomes on a visual analogue scale: 1) maintaining independence, 2) staying alive, 3) reducing/eliminating pain, 4) reducing/eliminating other symptoms.Results-Interviewers rated 73% of the 81 participants as having good to excellent understanding, and cognitive interviews demonstrated the tool captured how participants thought about trade-offs. Test-retest reliability was fair to poor for ranking most of the outcomes as either most or least important (kappa .28-1.0). Patient characteristics associated with ranking "keeping you alive" as most important have been shown to be associated with a preference for lifesustaining treatment, a related construct. There was substantial variability in the outcome ranked as most important.Conclusions-The task of ranking 4 universal health outcomes was well understood, captured what was important when considering trade-offs, and demonstrated content validity. However, test-retest reliability was fair to poor.