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1.  Risk as Feelings in the Effect of Patient Outcomes on Physicians' Subsequent Treatment Decisions: A Randomized Trial and Manipulation Validation 
Social science & medicine (1982)  2012;75(2):367-376.
The present study tested predictions derived from the Risk as Feelings hypothesis about the effects of prior patients' negative treatment outcomes on physicians' subsequent treatment decisions. Two experiments at The University of Chicago, U.S.A., utilized a computer simulation of an abdominal aortic aneurysm (AAA) patient with enhanced realism to present participants with one of three experimental conditions: AAA rupture causing a watchful waiting death (WWD), perioperative death (PD), or a successful operation (SO), as well as the statistical treatment guidelines for AAA. Experiment 1 tested effects of these simulated outcomes on (n=76) laboratory participants' (university student sample) self-reported emotions, and their ratings of valence and arousal of the AAA rupture simulation and other emotion inducing picture stimuli. Experiment 2 tested two hypotheses: 1) that experiencing a patient WWD in the practice trial's experimental condition would lead physicians to choose surgery earlier, and 2) experiencing a patient PD would lead physicians to choose surgery later with the next patient. Experiment 2 presented (n=132) physicians (surgeons and geriatricians) with the same experimental manipulation and a second simulated AAA patient. Physicians then chose to either go to surgery or continue watchful waiting. The results of Experiment 1 demonstrated that the WWD experimental condition significantly increased anxiety, and was rated similarly to other negative and arousing pictures. The results of Experiment 2 demonstrated that, after controlling for demographics, baseline anxiety, intolerance for uncertainty, risk attitudes, and the influence of simulation characteristics, the WWD experimental condition significantly expedited decisions to choose surgery for the next patient. The results support the Risk as Feelings hypothesis on physicians' treatment decisions in a realistic AAA patient computer simulation. Bad outcomes affected emotions and decisions, even with statistical AAA rupture risk guidance present. These results suggest that bad patient outcomes cause physicians to experience anxiety and regret that influences their subsequent treatment decision-making for the next patient.
PMCID: PMC4030752  PMID: 22571890
2.  The influence of stress, depression, and anxiety on PSA screening rates in a nationally-representative sample 
Medical care  2012;50(12):1037-1044.
Prostate-specific antigen (PSA) testing for prostate cancer (PCa) is controversial, with concerning rates of both over- and under-screening. The reasons for the observed rates of screening are unknown, and few studies have examined the relationship of psychological health to PSA screening rates. Understanding this relationship can help guide interventions to improve informed-decision making (IDM) for screening.
A nationally-representative sample of men 57–85 years old without PCa (N=1,169) from the National Social life, Health and Aging Project (NSHAP) was analyzed. The independent relationship of validated psychological health scales measuring stress, anxiety, and depression to PSA testing rates was assessed using multvariable logistic regression analyses.
PSA screening rates were significantly lower for men with higher perceived stress (OR=0.76, p=0.006), but not for higher depressive symptoms (OR=0.89, p=0.22) when accounting for stress. Anxiety influences PSA screening through an interaction with number of doctor visits (p=0.02). Among the men who visited the doctor 1 time, those with higher anxiety were less likely to be screened (OR=0.65, p=0.04). Conversely, among those who visited the doctor 10+ times with higher anxiety were more likely to be screened (OR=1.71, p=0.04).
Perceived stress significantly lowers PSA screening likelihood, and it appears to partly mediate the negative relationship of depression with screening likelihood. Anxiety affects PSA screening rates differently for men with different numbers of doctor visits. Interventions to influence PSA screening rates should recognize the role of the patients’ psychological state to improve their likelihood of making informed decisions and improve screening appropriateness.
PMCID: PMC3494796  PMID: 22955835
prostate cancer; screening; stress; anxiety; depression
3.  The Effect of Specialty and Recent Experience on Perioperative Decision Making for Abdominal Aortic Aneurysm Repair 
We hypothesized that recent experience and specialty choice would affect physician compliance with evidence-based guidelines.
In a series of computer-simulated encounters, participants weighed the risk of spontaneous abdominal aortic aneurysm (AAA) rupture against the risk of perioperative death to determine timing for elective repair. Guideline recommendations and statistical information on the risks of rupture and surgical death were provided.
Setting and Participants
Physicians at the annual meetings of the American Geriatrics Society, American College of Surgeons, and American Society of Anesthesiologists.
Before the actual simulation, each participant was randomly exposed to one of three experiences: death during watchful waiting (WWD), perioperative death (PD), or successful outcome (SO).
Compliance with recommended guidelines for AAA treatment.
Against guideline recommendations, 67% of geriatricians, 74% of anesthesiologists, and 77% of surgeons, chose surgery when the rupture risk was lower than the risk of perioperative death(p<0.05). Surgeons exposed to the WWD experience chose surgery significantly earlier than if they were exposed to a PD or SO experience (p<0.001). Anesthesiologist choices did not differ with recent experience.
Geriatrician decisions more closely followed guideline recommendations for AAA management than those of two other specialties typically involved in AAA care. Surgeons were most affected by a prior WWD, geriatricians next, and anesthesiologists least. Geriatricians referring patients for AAA surgery should be aware of specialty-specific differences in perioperative decision behavior.
PMCID: PMC3470744  PMID: 23016733
Decision Making; Abdominal Aortic Aneurysm; Simulation; Guidelines
5.  Geriatric Oncology Research to Improve Clinical Care 
Nature reviews. Clinical oncology  2012;9(10):571-578.
The incidence of cancer increases with advanced age. The Cancer and Aging Research Group (CARG), in partnership with the National Institute on Aging and National Cancer Institute, held a conference in September of 2010 which summarized the gaps in knowledge in geriatric oncology and recommendations to close these gaps. One recommendation was that the comprehensive geriatric assessment (CGA) should be incorporated within geriatric oncology research. The information from the CGA can be used to stratify patients into risk categories to better predict their tolerance of cancer treatment. CGA can also be used to follow functional consequences from treatment. Other recommendations were to design trials for older adults with study endpoints that address the needs of the older and/or vulnerable adult with cancer and to build better infrastructure to accommodate the needs of older adults to improve their representation in trials. In this review, we utilize a case-based approach to highlight gaps in knowledge regarding the care of older adults with cancer, discuss our current state of knowledge regarding best practice patterns, and identify opportunities for research in geriatric oncology. More evidence regarding the treatment of older patients with cancer is urgently needed given the rapid aging of the population.
PMCID: PMC3738437  PMID: 22825377
6.  Interventions to Improve Decision Making and Reduce Racial and Ethnic Disparities in the Management of Prostate Cancer: A Systematic Review 
Journal of General Internal Medicine  2012;27(8):1068-1078.
Ethnic minorities are disproportionately impacted by prostate cancer (PCa) and are at risk for not receiving informed decision making (IDM). We conducted a systematic literature review on interventions to improve: (1) IDM about PCa in screening-eligible minority men, and (2) quality of life (QOL) in minority PCa survivors.
MeSH headings for PCa, ethnic minorities, and interventions were searched in MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO.
We identified U.S.-based, English-language articles (1985 – 2010) on interventions to improve PCa IDM and QOL that included 50 % or more minority patients or analyses stratified by race/ethnicity.
Articles (n = 19) were evaluated and scored for quality using a Downs and Black (DB) system. Interventions were organized by those enhancing 1) IDM about PCa screening and 2) improving QOL and symptom among PCa survivors. Outcomes were reported by intervention type (educational seminar, printed material, telephone-based, video and web-based).
Fourteen studies evaluated interventions for enhancing IDM about PCa screening and five evaluated programs to improve outcomes for PCa survivors. Knowledge scores were statistically significantly increased in 12 of 13 screening studies that measured knowledge, with ranges of effect varying across intervention types: educational programs (13 % – 48 % increase), print (11 % – 18 %), videotape/DVD (16 %), and web-based (7 % – 20 %). In the final screening study, an intervention to improve decision-making about screening increased decisional self-efficacy by 9 %. Five cognitive-behavioral interventions improved QOL among minority men being treated for localized PCa through enhancing problem solving and coping skills.
Weak study designs, small sample sizes, selection biases, and variation in follow-up intervals across studies.
Educational programs were the most effective intervention for improving knowledge among screening-eligible minority men. Cognitive behavioral strategies improved QOL for minority men treated for localized PCa.
PMCID: PMC3403148  PMID: 22798216
prostate cancer; interventions; informed decision making; disparities; African American
7.  Remaining Life Expectancy Measurement and PSA Screening of Older Men 
Journal of geriatric oncology  2012;3(3):196-204.
Guidelines recommend informed decision-making regarding prostate specific antigen (PSA) screening for men with at least 10 years of remaining life expectancy (RLE). Comorbidity measures have been used to judge RLE in previous studies, but assessments based on other common RLE measures are unknown. We assessed whether screening rates varied based on four clinically relevant RLE measures, including comorbidities, in a nationally-representative, community-based sample.
Using the National Social Life, Health and Aging Project (NSHAP), we selected men over 65 without prostate cancer (n=709). They were stratified into three RLE categories (0–7 years, 8–12 years, and 13+ years) based on validated measures of comorbidities, self-rated health status, functional status, and physical performance. The independent relationship of each RLE measure and a combined measure to screening was determined using multivariable logistic regressions.
Self-rated health (OR = 6.82; p < 0.01) most closely correlated with RLE-based screening, while the comorbidity index correlated the least (OR = 1.50; p = 0.09). The relationship of RLE to PSA screening significantly strengthened when controlling for the number of doctor visits, particularly for comorbidities (OR= 43.6; p < 0.001). Men who had consistent estimates of less than 7 years RLE by all four measures had an adjusted PSA screening rate of 43.3%.
Regardless of the RLE measure used, men who were estimated to have limited RLE had significant PSA screening rates. However, different RLE measures have different correlations with PSA screening. Specific estimates of over-screening should therefore carefully consider the RLE measure used.
PMCID: PMC3388723  PMID: 22773938
prostate cancer; older adults; screening; PSA; remaining life expectancy; comorbidity
8.  Biological, Clinical, and Psychosocial Correlates at the Interface of Cancer and Aging Research 
In September 2010, the Cancer and Aging Research Group, in collaboration with the National Cancer Institute and the National Institute on Aging, conducted the first of three planned conferences to discuss research methodology to generate the highest quality research in older adults with cancer and then disseminate these findings among those working in the fields of cancer and aging. Conference speakers discussed the current level of research evidence in geriatric oncology, outlined the current knowledge gaps, and put forth principles for research designs and strategies that would address these gaps within the next 10 years. It was agreed that future oncology research trials that enroll older adults should include: 1) improved standardized geriatric assessment of older oncology patients, 2) substantially enhanced biological assessment of older oncology patients, 3) specific trials for the most vulnerable and/or those older than 75 years, and 4) research infrastructure that specifically targets older adults and substantially strengthened geriatrics and oncology research collaborations. This initial conference laid the foundation for the next two meetings, which will address the research designs and collaborations needed to enhance therapeutic and intervention trials in older adults with cancer.
PMCID: PMC3328422  PMID: 22457474
9.  Persistent Pain and Frailty: A Case For Homeostenosis 
Persistent pain is associated with poorer health outcomes and may lead to increased vulnerability and diminished physiologic reserve, ultimately precipitating frailty. To test for the existence of this process, we compared the association of self-reported moderate to severe pain with the presence of frailty.
Cross-sectional analysis of the Canadian Study of Health and Aging-Wave 2.
Community dwellers
Representative sample of persons age 65 and older in Canada.
Pain (exposure) was categorized as no or very mild pain versus moderate or greater pain. Frailty (outcome) was operationalized as the accumulation of 33 possible self-reported health attitudes, illnesses, and functional abilities, subsequently divided into tertiles (i.e. not frail, pre-frail, and frail). Multivariable logistic regression assessed for the association of pain with frailty.
Of participants who reported moderate or greater pain (35.5% or 1,765 out of 4,968), 16.2% were not frail, 34.1% were pre-frail, and 49.8%were frail. For persons with moderate or greater pain compared to those with mild or no pain, the odds of being pre-frail compared to not frail were higher by a factor of 2.52 (95% confidence interval (CI)=2.13-2.99; p<0.05). For persons with moderate or greater pain compared to those with mild or no pain, the odds of being frail compared to not frail was higher by a factor of 5.52 (CI=4.49-6.64; p<0.05).
Moderate or higher pain was independently associated with the presence of frailty. While we cannot ascertain causality in a cross-sectional analysis, interventions to improve pain management may help prevent or ameliorate frailty.
PMCID: PMC3258356  PMID: 22150394
Pain; frailty; older adults; homeostenosis
10.  Association of Cancer With Geriatric Syndromes in Older Medicare Beneficiaries 
Journal of Clinical Oncology  2011;29(11):1458-1464.
To identify whether a history of cancer is associated with specific geriatric syndromes in older patients.
Patients and Methods
Using the 2003 Medicare Current Beneficiary Survey, we analyzed a national sample of 12,480 community-based elders. Differences in prevalence of geriatric syndromes between those with and without cancer were estimated. Multivariable logistic regressions were used to evaluate whether cancer was independently associated with geriatric syndromes.
Two thousand three hundred forty-nine (18%) reported a history of cancer. Among those with cancer, 60.3% reported one or more geriatric syndromes as compared with 53.2% of those without cancer (P < .001). Those with cancer overall had a statistically significantly higher prevalence of hearing trouble, urinary incontinence, falls, depression, and osteoporosis than those without cancer. Adjusting for possible confounders, those with a history of cancer were more likely to experience depression (adjusted odds ratio [OR], 1.15; 95% CI, 1.02 to 1.30; P = .023), falls (adjusted OR, 1.17; 95% CI, 1.04 to 1.32; P = .010), osteoporosis (adjusted OR, 1.21; 95% CI, 1.06 to 1.38; P = .004), hearing trouble (adjusted OR, 1.28; 95% CI, 1.08 to 1.52; P = .005), and urinary incontinence (adjusted OR, 1.42; 95% CI, 1.20 to 1.69; P < .001). Analysis of specific cancer subtypes showed that lung cancer was associated with vision, hearing, and eating trouble; prostate cancer was associated with incontinence and falls; cervical/uterine cancer was associated with falls and osteoporosis; and colon cancer was associated with depression and osteoporosis.
Elderly patients with cancer experience a higher prevalence of geriatric syndromes than those without cancer. Prospective studies that establish the causal relationships between cancer and geriatric syndromes are necessary.
PMCID: PMC3082984  PMID: 21402608
11.  Obese frailty, physical performance deficits, and falls in older men with biochemical recurrence of prostate cancer on androgen deprivation therapy: a case-control study 
Urology  2011;77(4):934-940.
Early androgen deprivation therapy (ADT) has no proven survival advantage in older men with biochemical recurrence (BCR) of prostate cancer (PCa), and it may contribute to geriatric frailty; we tested this hypothesis.
We conducted a case-control study of men aged 60+ with BCR on ADT (n=63) versus PCa survivors without recurrence (n=71). Frailty prevalence, “obese” frailty, Short Physical Performance Battery (SPPB) scores and falls were compared. An exploratory analysis of frailty biomarkers (CRP, ESR, hemoglobin, albumin, and total cholesterol) was performed. Summary statistics, univariate and multivariate regression analyses were conducted.
More patients on ADT were obese (BMI >30; 46.2% vs. 20.6%; p=0.03). There were no statistical differences in SPPB (p=0.41) or frailty (p=0.20). Using a proposed “obese” frailty criteria, 8.7% in ADT group were frail and 56.5% were “prefrail”, compared with 2.9% and 48.8% of controls (p=0.02). Falls in the last year were higher in ADT group (14.3% vs. 2.8%; p=0.02). In analyses controlling for age, clinical characteristics, and comorbidities, the ADT group trended toward significance for “obese” frailty (p = 0.14) and falls (OR = 4.74, p = 0.11). Comorbidity significantly increased the likelihood of “obese” frailty (p=0.01) and falls (OR 2.02, p = 0.01).
Men with BCR on ADT are frailer using proposed modified “obese” frailty criteria. They may have lower performance status and more falls. A larger, prospective trial is necessary to establish a causal link between ADT use and progression of frailty and disability.
PMCID: PMC3074039  PMID: 21269665
prostate cancer; biochemical recurrence; androgen deprivation therapy; frailty; older adults
12.  Assessment of Insulin Resistance and Impaired Glucose Tolerance in Lean Women with Polycystic Ovary Syndrome 
Journal of Women's Health  2011;20(1):37-43.
To analyze insulin resistance (IR) and determine the need for a 2-hour oral glucose tolerance test (OGTT) for the identification of IR and impaired glucose tolerance (IGT) in lean nondiabetic women with polycystic ovary syndrome (PCOS).
This was a cross-sectional analysis of treatment-naive women with PCOS who enrolled in a university-based clinical trial. Nondiabetic women with PCOS based on the Eunice Kennedy Shriven National Institute of Child Health and Human Development (NICHD) definition, aged 18–43 years and weighing ≤113 kg, were evaluated. Glucose and insulin levels were assessed at times 0, 30, 60, 90, and 120 minutes after a 75-g glucose load. Lean was defined as body mass index (BMI) <25 kg/m2. Multiple linear regression was performed.
A cohort of 78 women was studied. The prevalence of IR was 0% among lean women vs. 21% among nonlean subjects based on fasting insulin I0 and 40%–68% based on two different homeostatic model assessment (HOMA) cutoff points (p < 0.005). All women with IR had a BMI ≥ 28. Controlling for age and race, BMI explained over 57% of the variation in insulin fasting (Io), glucose fasting/Io (Go/Io), the qualitative insulin sensitivity check index (QUICKI), and HOMA and was a highly significant predictor of these outcomes (p < 0.0001). Only 1 of 31 (3%) of the lean PCOS women had IGT based on a 2-hour OGTT, and no lean subjects had IGT based on their fasting blood glucose.
Diabetes mellitus, IGT, and IR are far less common in young lean women with PCOS compared with obese women with PCOS. These data imply that it is unnecessary to routinely perform either IR testing or 2-hour OGTT in lean women with PCOS; however, greater subject accumulation is needed to determine if OGTT is necessary in lean women with PCOS. BMI is highly predictive of both insulin and glucose levels in women with PCOS.
PMCID: PMC3026650  PMID: 21194310
13.  Patient and provider determinants of nephrology referral in older adults with severe chronic kidney disease: a survey of provider decision making 
BMC Nephrology  2011;12:47.
Although chronic kidney disease (CKD) disproportionately affects older adults, they are less likely to be referred to a nephrologist. Factors that influence the referral decisions of primary care providers (PCPs) specifically for older CKD patients have been incompletely described. Patient factors such as dementia, functional disability, and co-morbidity may complicate the decision to refer an older adult. This study evaluated the role of patient and PCP factors in the referral decisions for older adults with stage 4 CKD.
We administered a two-part survey to study the decisions of practicing PCPs. First, using a blocked factorial design, vignettes systematically varied 6 patient characteristics: age, race, gender, co-morbidity, functional status, and cognitive status. CKD severity, patient preferences, and degree of anemia were held constant. Second, covariates from a standard questionnaire included PCP estimates of life expectancy, demographics, reaction to clinical uncertainty, and risk aversion. The main outcome was the decision to refer to the nephrologist. Random effects logistic regression models tested independent associations of predictor variables with the referral decision.
More than half (62.5%) of all PCP decisions (n = 680) were to refer to a nephrologist. Vignette-based factors that independently decreased referral included older patient age (OR = 0.27; 95% CI, 0.15 to 0.48) and having moderate dementia (OR = 0.14; 95%CI, 0.07 to 0.25). There were no associations between co-morbidity or impaired functional activity with the referral decision. Survey-based PCP factors that significantly increased the referral likelihood include female gender (OR = 7.75; 95%CI, 2.07 to 28.93), non-white race (OR = 30.29; 95%CI, 1.30 to 703.73), those who expect nephrologists to discuss goals of care (OR = 53.13; 95%CI, 2.42 to 1168.00), those with higher levels of anxiety about uncertainty (OR = 1.28; 95%CI, 1.04 to 1.57), and those with greater risk aversion (OR = 3.39; 95%CI, 1.02 to 11.24).
In this decision making study using hypothetical clinical vignettes, we found that the PCP decision to refer older patients with severe CKD to a nephrologist reflects a complex interplay between patient and provider factors. Age, dementia, and several provider characteristics weighed more heavily than co-morbidity and functional status in PCP referral decisions. These results suggest that practice guidelines should develop a more nuanced approach to the referral of older adults with CKD.
PMCID: PMC3192737  PMID: 21943241
14.  The Association Between Noncancer Pain, Cognitive Impairment, and Functional Disability: An Analysis of the Canadian Study of Health and Aging 
Noncancer pain and cognitive impairment affect many older adults and each is associated with functional disability, but their combined impact has yet to be rigorously studied.
This is a cross-sectional analysis of the Canadian Study of Health and Aging. Pain was collapsed from a 5-point to a dichotomous scale (no and very mild vs moderate and greater). Cognitive status was dichotomized from the Modified Mini-Mental State Examination (0–100) to no (>77) or mild-moderate (77–50) impairment. Five Instrumental Activities of Daily Living (IADL) and seven Activities of Daily Living (ADL) were self-rated as “accomplished without any help” (0), “with some help” (1), or “completely unable to do oneself” (2) and then summed to create a composite score of 0–10 and 0–14, respectively. Multivariate linear regression analysis was conducted to determine the associations between self-reported functional status with moderate or greater pain, cognitive impairment, and the interaction of the two.
A total of 5,143 (90.2%) participants were eligible, 1,813 (35.6%) reported pain at a moderate intensity or greater and 727 (14.3%) were cognitively impaired. The median IADL and ADL summary scores increased among the pain and cognition categories in the following order: no pain and cognitively intact (0.63 SD 1.24, 0.23 SD 0.80), pain and cognitively intact (1.18 SD 1.69, 0.57 SD 1.27), no pain and cognitively impaired (1.64 SD 2.22, 0.75 SD 1.57), and pain and cognitively impaired (2.27 SD 2.47, 1.35 SD 2.09), respectively. Multivariate linear regression found IADL summary scores were associated with pain, coefficient .17 (95% confidence interval [CI] 0.07–0.26), p < .01; cognitive impairment, coefficient .67 (95% CI 0.51–0.83), p < .01; and an interaction effect of pain with cognitive impairment, coefficient .24 (95% CI 0.01–0.49), p = .05. ADL summary scores were associated with pain coefficient .10 (95% CI 0.04–0.17), p < .01 and cognitive impairment, coefficient .29 (95% CI 0.19–0.39), p < .01, but had a nonsignificant interaction term, coefficient .12 (95% CI −0.03 to 0.29), p = .12.
Noncancer pain and cognitive impairment are independently associated with IADL and ADL impairment and IADL impairment is even greater when both conditions are present.
PMCID: PMC2903783  PMID: 20351073
Noncancer pain; Cognitive impairment; Function; Dementia; Older adult
15.  Management of complications of androgen deprivation therapy in the older man☆ 
Prostate cancer is the most common malignancy in older men. With the aging of the population, the number of older men with prostate cancer will grow rapidly. Androgen deprivation therapy (ADT) is the mainstay of treatment for men with systemic disease and is increasingly utilized as primary therapy or in combination with other therapies for localized disease. Side effects of therapy are multifold and include hot flashes, osteoporosis, and adverse psychological and metabolic effects. Recent research has illustrated that ADT can negatively impact the functional, cognitive, and physical performance of older men. Patients with prostate cancer, despite recurrence of the disease, have a long life expectancy and may be subjected to the side effects of ADT for many years. This review highlights the complications of ADT and approaches to management. We also provide recommendations for assessment and management of ADT complications among the most vulnerable and frail older male patients.
PMCID: PMC3074615  PMID: 18952456
Disability; Geriatric assessment; Prostate cancer; Vulnerable elders; Functional impairment; Androgen deprivation; Quality of life; Complications
16.  Is the Presence of Mild to Moderate Cognitive Impairment Associated with Self-Report of Non-Cancer Pain? A Cross-Sectional Analysis of a Large Population-Based Study 
Research, guidelines and experts in the field suggest that persons with cognitive impairment report pain less often and at a lower intensity than those without cognitive impairment. However, this presupposition is derived from research with important limitations, namely inadequate power and lack of multivariate adjustment.
We conducted a cross-sectional analysis of the Canadian Study of Health and Aging to evaluate the relationship between cognitive status and pain self-report.
Cognitive status was assessed using the Modified Mini Mental State Exam. Pain was assessed using a 5-point verbal descriptor scale. For analysis, responses were dichotomized into “no pain” versus “any pain” and “pain at a moderate intensity or higher” versus “pain not at a moderate intensity or higher.” Additional predictors included demographics, physical function, depression, and co-morbidity. Of 5,703 eligible participants, 306 (5.4%) did not meet inclusion criteria, leaving a total of 5,397, of whom 876 (16.2%) were cognitively impaired.
In the unadjusted analysis, significantly more cognitively intact (n=2,541; 56.2%) than cognitively impaired (n=456; 52.1%, P=0.03) participants reported non-cancer pain. There was no significant difference in the proportion of cognitively intact (n=1,623; 35.9%) and impaired (n=329; 37.6%, P=0.36) participants who reported pain at moderate or higher intensity. In multivariate analyses, cognitively impaired participants did not have lower odds of reporting any non-cancer pain (odds ratio [OR]=0.83 [0.68-1.01], P=0.07) or pain at a moderate or higher intensity (OR= 0.95 [0.78-1.16], P=0.62).
Non-cancer pain was equally prevalent in people with and without cognitive impairment, which contrasts with the currently held opinion that that cognitively impaired persons report non-cancer pain less often and at a lower intensity.
PMCID: PMC2885711  PMID: 20413060
Cognition; cognitive impairment; pain; self-report; Modified Mini-Mental State Examination
17.  Falls and Physical Performance Deficits in Older Patients With Prostate Cancer Undergoing Androgen Deprivation Therapy 
Urology  2008;72(2):422-427.
Men experience a decrease in lean muscle mass and strength during the first year of androgen deprivation therapy (ADT). The prevalence of falls and physical and functional impairment in this population have not been well described.
A total of 50 men aged 70 years and older (median 78) receiving ADT for systemic prostate cancer (80% biochemical recurrence) underwent functional and physical assessments. The functional assessments included Katz’s Activities of Daily Living (ADLs) and Lawton’s Instrumental Activities of Daily Living (IADLs). Patients completed the Vulnerable Elder’s Survey-13, a short screening tool of self-perceived functional and physical performance ability. Physical performance was assessed using the Short Physical Performance Battery. The history of falls was recorded. Of the 50 patients, 40 underwent follow-up assessment with the same instruments 3 months after the initial assessment.
Of the 50 men, 24% had impairment in the ADLs, 42% had impairment in the IADLs, 56% had abnormal Short Physical Performance Battery findings, and 22% reported falls within the previous 3 months. Within the Short Physical Performance Battery, deficits occurred within all subcomponents (balance, walking, and chair stands). On univariate analysis, age, deficits in ADLs and IADLs, and abnormal cognitive and functional screen findings were associated with an increased risk of abnormal physical performance. ADL deficits, the use of an assistive device, and abnormal functional screen findings were associated with an increased risk of falling.
The results of our study have shown that older men with prostate cancer receiving long-term ADT exhibit significant functional and physical impairment and are at risk of falls that is greater than that for similar-aged cohorts. Careful assessment of the functional and physical deficits in older patients receiving ADT is warranted.
PMCID: PMC3032402  PMID: 18561991
18.  Cognitive effects of androgen deprivation therapy in an older cohort of men with prostate cancer 
To determine the baseline prevalence of cognitive impairment in older men treated with ADT and to assess changes in cognitive performance over time.
Methods and results
Thirty-two patients (median age of 71 years, range 51–87) were administrated an extensive neuropsychological testing battery prior to ADT initiation, with 21 (65%) completing post-treatment evaluations 6 months later. At baseline, 45% scored >1.5 standard deviations below the mean on ≥2 neuropsychological measures. Using standardized inferential statistics, no change in cognition was documented following treatment. The Reliable Change Index revealed that, on a case-by-case basis, 38% demonstrated a decline in measures of executive functioning and 48% showed improvement on measures of visuospatial abilities. Within exploratory analyses, patients who scored below expectation at baseline displayed no change in cognition, while patients with average or better scores at baseline displayed improvements in visuospatial planning and timed tests of phonemic fluency.
We found a high prevalence of lower than expected cognitive performance among a sample of patients just starting ADT for prostate cancer. Assessment of baseline cognitive function should be taken into account for future research and to inform clinical management.
PMCID: PMC3028591  PMID: 20656210
Cognition; Androgen deprivation; Prostate; Elderly
19.  The Role of Anxiety in Prostate Carcinoma 
Cancer  2005;104(3):467-478.
Although the impact of anxiety on patients with some types of cancer is well recognized, to the authors knowledge its impact on patients with prostate carcinoma has not been studied as thoroughly. The authors conducted a systematic review of the medical literature for high-quality articles that quantified anxiety levels in men with prostate carcinoma and identified 29 articles. Using the clinical timeline of prostate carcinoma to organize the articles, cross-sectional studies that reflected anxiety prevalence in populations and longitudinal studies that reflected changes in anxiety over time were identified. Anxiety appeared to fluctuate over the clinical timeline in response to stressors and uncertainty (such as at the time of screening and/or biopsy), rising before these times and falling afterward. Although anxiety levels in men age > 55 years who were at risk for prostate carcinoma were modest (10–15%), multiple studies found that these levels were substantially higher in men who presented for screening (> 50%), and “seeking peace of mind” was the motivation cited most frequently for pursuing screening. Most studies demonstrated a significant decrease in anxiety levels after a normal screening or biopsy result, although the proportion of men who remained anxious afterward did not fall to baseline levels (20–36%). Men who presented for prostate-specific antigen monitoring after treatment had elevated anxiety levels at the time of testing (23–33%). Many years after therapy for localized disease, anxiety levels were lower after prostatectomy (23%) compared with the levels after watchful waiting (31%).
PMCID: PMC3010360  PMID: 15959911
prostate carcinoma; anxiety; uncertainty; prostate-specific antigen monitoring; screening; stressors; treatment; watchful waiting; medical decision-making
20.  Patient Anxiety About Prostate Cancer Independently Predicts Early Initiation of Androgen Deprivation Therapy for Biochemical Cancer Recurrence in Older Men: A Prospective Cohort Study 
Journal of Clinical Oncology  2009;27(10):1557-1563.
Androgen deprivation therapy (ADT) is first-line therapy for patients with prostate cancer (PCA) who experience biochemical recurrence (BCR). However, the optimal timing of ADT initiation is uncertain, and earlier ADT initiation can cause toxicities that lower quality of life (QOL). We tested the hypothesis that elevated cancer anxiety leads to earlier ADT initiation for BCR in older men.
Patients and Methods
We conducted a prospective cohort study of older patients with BCR of PCA (n = 67). Patients completed questionnaires at presentation and each follow-up visit until initiation of ADT. PCA-specific anxiety was measured with the Memorial Anxiety Scale for Prostate Cancer (MAX-PC). Other collected data included demographics, clinical information, and general anxiety information. Treating oncologists were surveyed about their recommendations for ADT initiation. The primary outcome was the time to ADT initiation. Univariate, multivariate logistic regression, and time-to-event analyses were conducted to evaluate whether cancer anxiety was a predictor of earlier initiation of ADT.
Thirty-three percent of patients initiated ADT at the first or second clinic visit. Elevated PCA anxiety (MAX-PC > 16) was the most robust predictor in multivariate analyses of early initiation (odds ratio [OR], 9.19; P = .01). PSA also independently correlated with early initiation (OR, 1.31; P = .01). PSA did not correlate with MAX-PC.
Cancer anxiety independently and robustly predicts earlier ADT initiation in older men with BCR. For older patients with PCA, earlier ADT initiation may not change life expectancy and can negatively impact QOL. PCA-specific anxiety is a potential target for a decision-making intervention in this setting.
PMCID: PMC2738613  PMID: 19255325
21.  Older Adults and Chronic Kidney Disease Decision Making by Primary Care Physicians: A Scholarly Review and Research Agenda 
Chronic kidney disease (CKD) is a growing public health concern that overwhelmingly affects older adults. National guidelines have called for earlier referral of CKD patients, but it is unclear how these should apply to older adults.
This scholarly review aims to explore the current literature about upstream referral decisions for CKD within the context of decisions about initiation of dialysis and general referral decisions. The authors propose a model for understanding the referral process and discuss future directions for research to guide decision making for older patients with CKD.
While age has been shown to be influential in decisions to refer patients for dialysis and other medical therapies, the role of other patient factors such as competing medical co-morbidities, functional loss, or cognitive impairment in the decision making of physicians has been less well elucidated, particularly for CKD.
More information is needed on the decision-making behavior of physicians for upstream referral decisions like those being advocated for CKD. Exploring the role of geriatric factors like cognitive and functional status may help facilitate more appropriate use of resources and improve patient outcomes.
PMCID: PMC2359471  PMID: 18175190
chronic kidney disease; decision making; older adults
22.  Accelerating protons to therapeutic energies with ultraintense, ultraclean, and ultrashort laser pulses 
Medical physics  2008;35(5):1770-1776.
Proton acceleration by high-intensity laser pulses from ultrathin foils for hadron therapy is discussed. With the improvement of the laser intensity contrast ratio to 10−11 achieved on the Hercules laser at the University of Michigan, it became possible to attain laser-solid interactions at intensities up to 1022 W/cm2 that allows an efficient regime of laser-driven ion acceleration from submicron foils. Particle-in-cell (PIC) computer simulations of proton acceleration in the directed Coulomb explosion regime from ultrathin double-layer (heavy ions/light ions) foils of different thicknesses were performed under the anticipated experimental conditions for the Hercules laser with pulse energies from 3 to 15 J, pulse duration of 30 fs at full width half maximum (FWHM), focused to a spot size of 0.8 μm (FWHM). In this regime heavy ions expand predominantly in the direction of laser pulse propagation enhancing the longitudinal charge separation electric field that accelerates light ions. The dependence of the maximum proton energy on the foil thickness has been found and the laser pulse characteristics have been matched with the thickness of the target to ensure the most efficient acceleration. Moreover, the proton spectrum demonstrates a peaked structure at high energies, which is required for radiation therapy. Two-dimensional PIC simulations show that a 150−500 TW laser pulse is able to accelerate protons up to 100−220 MeV energies.
PMCID: PMC2597229  PMID: 18561651
ion acceleration; laser-plasma interaction; proton therapy
23.  Association of a Cancer Diagnosis With Vulnerability and Frailty in Older Medicare Beneficiaries 
Few studies have evaluated the independent effect of a cancer diagnosis on vulnerability and frailty, which have been associated with adverse health outcomes in older adults.
We used data in the 2003 Medicare Current Beneficiary Survey from a nationally representative sample of 12 480 community-dwelling elders. Multivariable logistic regression models were used to evaluate whether cancer was independently associated with vulnerability and frailty. Measures of vulnerability and frailty included disability, geriatric syndromes, self-rated health, and scores on two assessment tools for elderly cancer patients—the Vulnerable Elders Survey-13 (VES-13) and the Balducci frailty criteria. All statistical tests were two-sided.
Diagnosis of a non-skin cancer was reported by 18.8% of the respondents. Compared with respondents without a cancer history, respondents with a personal history of cancer had a statistically significantly higher prevalence of limitations in activities of daily living (31.9% vs 26.9%), limitations in instrumental activities of daily living (49.5% vs 42.3%), geriatric syndromes (60.8% vs 53.9%), low self-rated health (27.4% vs 20.9%), score of 3 or higher on the VES-13 (45.8% vs 39.5%), and satisfying criteria for frailty as defined by Balducci (79.6% vs 73.4%) (P < .001 for all characteristics). After adjustment for confounders, a cancer diagnosis was found to be associated with low self-rated health (adjusted odds ratio [OR] = 1.46, 95% confidence interval [CI] = 1.30 to 1.64; relative risk [RR] = 1.33), limitations in activities of daily living (adjusted OR = 1.19, 95% CI = 1.06 to 1.33; RR = 1.13), limitations in instrumental activities of daily living (adjusted OR = 1.25, 95% CI = 1.13 to 1.38; RR = 1.13), a geriatric syndrome (adjusted OR = 1.27, 95% CI = 1.15 to 1.41; RR = 1.11), VES-13 score of 3 or higher (adjusted OR = 1.26, 95% CI = 1.13 to 1.41; RR = 1.14), and frailty (adjusted OR = 1.46, 95% CI = 1.29 to 1.65; RR = 1.09) as defined by Balducci criteria.
Diagnosis of a non-skin cancer was associated with increased levels of having disability, having geriatric syndromes, and meeting criteria for vulnerability and frailty.
PMCID: PMC3937788  PMID: 19638506
25.  On Pulmonary Consumption and Infection* 
British Medical Journal  1883;1(1174):1280.
PMCID: PMC2372659  PMID: 20750662

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