Some have recommended against routine screening for colorectal cancer (CRC) among patients ≥75 years of age, while others have suggested that screening colonoscopy (SC) is less beneficial for women than men. We estimated the expected benefits (decreased mortality from CRC) and harms (SC-related mortality) of SC based on sex, age, and comorbidity.
To stratify older patients according to expected benefits and harms of SC based on sex, age, and comorbidity.
Retrospective study using Medicare claims data.
Medicare beneficiaries 67–94 years old with and without CRC.
Life expectancy, CRC- and colonoscopy-attributable mortality rates across strata of sex, age, and comorbidity, pay-off time (i.e. the minimum time until benefits from SC exceeded harms), and life-years saved for every 100,000 SC.
Increasing age and comorbidity were associated with lower CRC-attributable mortality. Due to shorter life expectancy and CRC-attributable mortality, the benefits associated with SC were substantially lower among patients with greater comorbidity. Among men aged 75–79 years with no comorbidity, the number of life-years saved was 459 per 100,000 SC, while men aged 67–69 with ≥3 comorbidities had 81 life-years saved per 100,000 SC. There was no evidence that SC was less effective in women. Among men and women 75–79 with no comorbidity, number of life-years saved was 459 and 509 per 100,000 SC, respectively; among patients with ≥3 comorbidities, there was no benefit for either men or women.
Although the effectiveness of SC was equivalent for men and women, there was substantial variation in SC effectiveness within age groups, arguing against screening recommendations based solely on age.
screening colonoscopy; colorectal cancer screening; medicare
To determine the priority that older adults with coexisting hypertension and fall risk give to optimizing cardiovascular outcomes versus fall- and medication symptom-related outcomes.
One hundred twenty-three cognitively intact persons aged 70 and older with hypertension and fall risk.
Discrete choice task was used to elicit the relative importance placed on reducing the risk of three outcomes: cardiovascular events, serious fall injuries, and medication symptoms. Risk estimates with and without antihypertensive medications were obtained from the literature. Participants chose between 11 pairs of options that displayed lower risks for one or two outcomes and a higher risk for the other outcome(s), versus the reverse. Results were used to calculate relative importance scores for the three outcomes. These scores, which sum to 100, reflect the relative priority participants placed on the difference between the risk estimates of each outcome.
Sixty-two participants (50.4%) placed greater importance on reducing risk of cardiovascular events than reducing risk of the combination of fall injuries and medication symptoms; 61 participants did the converse. A lower percentage of participants with chronic obstructive pulmonary disease (P =.02), unsteadiness (P =.02), functional dependency (P =.04), lower cognition (P =.02) and depressive symptoms (P =.03) prioritized cardiovascular outcomes over fall injuries and medication symptoms than did participants without these characteristics.
Interindividual variability in the face of competing outcomes supports individualizing decision-making to individual priorities. In the current example, this may mean forgoing antihypertensive medications or compromising on blood pressure reduction for some individuals.
competing outcomes; fall injuries; hypertension; patient priorities
A quantitative framework to assess harms and benefits of candidate medications in the context of drugs that a patient is already taking is proposed.
Probabilities of harms and benefits of a given medication are averaged to yield a utility value. The utility values of all medications under consideration are combined as a geometric mean to yield an overall measure of favorability. The grouping of medications yielding the highest favorability value is chosen.
Five examples of choosing between widely used candidate medications demonstrate the feasibility of the proposed framework.
The framework proposed provides a simple method for considering the trade-offs involved in prescribing multiple medications. It can be adapted to include additional parameters representing severity of condition, prioritization of outcomes, patient preferences, dosages, and medication interactions. Inconsistent reporting in the medical literature of data about benefits and harms of medications, dosages, and interactions constitutes its primary limitation.
adverse effect; utility function; aging; trade-offs; multiple medications
Falling is a common and morbid condition among elderly persons. Effective strategies to prevent falls have been identified but are underutilized.
Using a nonrandomized design, we compared rates of injuries from falls in a region of Connecticut where clinicians had been exposed to interventions to change clinical practice (intervention region) and in a region where clinicians had not been exposed to such interventions (usual-care region). The interventions encouraged primary care clinicians and staff members involved in home care, outpatient rehabilitation, and senior centers to adopt effective risk assessments and strategies for the prevention of falls (e.g., medication reduction and balance and gait training). The outcomes were rates of serious fall-related injuries (hip and other fractures, head injuries, and joint dislocations) and fall-related use of medical services per 1000 person-years among persons who were 70 years of age or older. The interventions occurred from 2001 to 2004, and the evaluations took place from 2004 to 2006.
Before the interventions, the adjusted rates of serious fall-related injuries (per 1000 person-years) were 31.2 in the usual-care region and 31.9 in the intervention region. During the evaluation period, the adjusted rates were 31.4 and 28.6, respectively (adjusted rate ratio, 0.91; 95% Bayesian credibility interval, 0.88 to 0.94). Between the preintervention period and the evaluation period, the rate of fall-related use of medical services increased from 68.1 to 83.3 per 1000 person-years in the usual-care region and from 70.7 to 74.2 in the intervention region (adjusted rate ratio, 0.89; 95% credibility interval, 0.86 to 0.92). The percentages of clinicians who received intervention visits ranged from 62% (131 of 212 primary care offices) to 100% (26 of 26 home care agencies).
Dissemination of evidence about fall prevention, coupled with interventions to change clinical practice, may reduce fall-related injuries in elderly persons.
Quality-assurance initiatives encourage adherence to evidenced-based guidelines based on a consideration of treatment benefit. The objective of this study was to examine older persons’ willingness to take medication for primary cardiovascular disease prevention according to benefits and harms.
In-person interviews were performed with 356 community-living older persons. Participants were asked about their willingness to take medication for primary prevention of myocardial infarction (MI) with varying benefits in terms of absolute 5-year risk reduction and varying harms in terms of type and severity of adverse effects.
A majority (88%) would take medication providing an absolute benefit of six fewer persons with MI out of 100, approximating the average risk reduction of currently available medications. Of participants who would not take it, 17% changed their preference if the absolute benefit was increased to ten fewer persons with MI, and, of participants who would take it, 82% remained willing if the absolute benefit was decreased to three fewer persons with MI. In contrast, large proportions (48% – 69%) were unwilling or uncertain about taking medication with average benefit causing mild fatigue, nausea, or fuzzy thinking, and only 3% would take medication with adverse effects severe enough to affect functioning.
Older persons’ willingness to take medication for primary cardiovascular prevention is relatively insensitive to its benefit but highly sensitive to its adverse effects. These results suggest that clinical guidelines and decisions about prescribing these medications to older persons need to place emphasis on both benefits and harms.
To determine the extent to which disease-related symptoms and impairments, which constitute measures of disease severity or targets of therapy, account for the associations between chronic diseases and universal health outcomes.
Cardiovascular Health Study (CHS) and Health ABC.
5,654 CHS, and 2,706 Health ABC, members.
Diseases included heart failure (HF), chronic obstructive pulmonary disease (COPD), osteoarthritis, and cognitive impairment. The universal health outcomes included self-rated health, basic and instrumental activities of daily living (BADLs-IADLs), and death. Disease-related symptoms/impairments included HF symptoms and ejection fraction (EF) for HF; Dyspnea Scale and FEV1 for COPD; joint pain for osteoarthritis, and executive function for cognitive impairment.
The diseases were associated with the universal health outcomes (p<0.001) except osteoarthritis with death (both cohorts) and cognitive impairment with self-rated health (Health ABC). Symptoms/impairments accounted for ≥30% of each disease’s effect on the universal health outcomes. In CHS, for example, HF, compared with no HF, was associated with one fewer (0.918) BADLs-IADL performed without difficulty; 27% of this effect was accounted for by HF symptoms, only 5% by EF. The hazard ratio for death with HF was 6.5 (95% CI, 4.7, 8.9) with 40% accounted for by EF and only 14% by HF symptoms.
Disease-related symptoms/impairments accounted for much of the significant associations between the 4 chronic diseases and the universal health outcomes. Results support considering universal health outcomes as common metrics across diseases in clinical decision-making, perhaps by targeting the disease-related symptoms/impairments that contribute most strongly to the effect of the disease on the universal health outcomes.
chronic diseases; universal health outcomes; patient-reported outcomes; clinical decision-making
Clinicians are caring for an increasing number of older patients with multiple diseases, in the face of uncertainty concerning the benefits and harms associated with guideline-directed interventions. Understanding how primary care clinicians approach treatment decision-making for these patients is critical to the design of improving the decision-making process.
Focus groups were conducted with study with forty primary care clinicians (physicians, nurse-practitioners, physician assistants) in academic, community, and VA-affiliated primary care practices. Participants were given open-ended questions about their approach to treatment decision-making for older persons with multiple medical conditions. Responses were organized into themes using qualitative content analysis.
Participants were concerned about their patients’ ability to adhere to complex regimens deriving from guideline-directed care. There was variability in beliefs regarding and approaches to balancing the benefits and harms of guideline-directed care. There was also variability in how they involved patients in the process of decision making, with clinicians describing conflicts between their own and their patients’ goals. Participants listed a number of barriers to making good treatment decisions, including lack of outcome data, the role of specialists, patient and family expectations, and insufficient time and reimbursement.
The experiences of practicing clinicians suggest that they struggle with the uncertainties of applying disease-specific guidelines to their older patients with multiple conditions. To improve decision making, they need more data, alternative guidelines, approaches to reconciling their own and their patients’ priorities, the support of their subspecialist colleagues, and an altered reimbursement system.
To examine the ways in which older persons with multiple conditions think about potentially competing outcomes, in order to gain insight into how processes to elicit values regarding these outcomes can be grounded in the patient's perspective.
Qualitative study consisting of purposefully sampled focus groups.
Persons age ≥ 65 years taking ≥ 5 medications.
Participants were asked their perceptions about whether their illnesses or treatment interacted with each other, goals of their treatment, and decisions to change or stop treatment.
Although participants were largely unaware that treatment of one condition could worsen another, many had experience with adverse medication effects as a competing outcome. Participants initially discussed their conditions in terms of disease-specific outcomes, such as achieving a target blood pressure or lipid level. In the context of decision-making, participants shifted their discussion from disease-specific to global, cross-disease health outcomes, such as survival, preservation of physical function, and relief of symptoms. Despite having some misconceptions regarding the likelihood of these outcomes, they weighed the outcomes against one another in order to consider what was most important to them. Their preference was for the treatment that would achieve the most desired outcome.
Because of their experience with adverse medication effects, older persons with multiple morbidities can understand the concept of competing outcomes. The task of prioritizing global, cross-disease outcomes can help to clarify what is most important to seniors who are faced with complex healthcare decisions.
Decision-making; chronic disease; multiple morbidity
Antihypertensive drugs are prescribed commonly in older adults for their beneficial cardiovascular and cerebrovascular effects, but few studies have assessed antihypertensive drugs’ adverse effects on non-cardiovascular outcomes in routine clinical practice.
To evaluate, among older adults, the association between antihypertensive medication use and physical performance, cognition, and mood.
Design and Setting
Prospective cohort study in a Veterans Affairs primary care clinic, with patients enrolled in 2000–2001 and assessed for medication use, comorbidities, health behaviors, and other characteristics; and followed-up 1 year later.
544 community-dwelling hypertensive men over age 65 years.
Timed chair stands; Trail Making Test part B; and Centers for Epidemiologic Studies Depression (CES-D) scores.
Participants had a mean age of 74.4 ± 5.2 years and took a mean of 2.3 ± 1.2 antihypertensive medications at baseline. After adjustment for age, comorbidities, level of blood pressure, and other confounders, each 1-unit increase in antihypertensive medication “intensity” was associated with a 0.11-second (95% confidence interval, 0.05–0.16) increase in the time required to complete the timed chair stands. No significant relationship was found between antihypertensive medication intensity and outcomes for Trail Making B or CES-D scores.
A higher cumulative exposure to antihypertensive medications in community-living older men was associated with adverse effects on physical performance, but not on the cognitive or depression measures available in this study. Clinicians should consider non-cardiovascular related adverse effects when treating older males taking multiple antihypertensive medications.
aged; drugs; antihypertensives; adverse effects; polypharmacy; ambulatory care
Geriatricians have embraced the term “geriatric syndrome”, using it extensively to highlight the unique features of common health conditions in the elderly. Geriatric syndromes, such as delirium, falls, incontinence and frailty, are highly prevalent, multifactorial, and associated with substantial morbidity and poor outcomes. Nevertheless, this central geriatric concept has remained poorly defined. This article reviews criteria for defining geriatric syndromes, and proposes a balanced approach of developing preliminary criteria based on peer-reviewed evidence. Based on a review of the literature, four shared risk factors—older age, baseline cognitive impairment, baseline functional impairment, and impaired mobility—were identified across five common geriatric syndromes (pressure ulcers, incontinence, falls, functional decline, and delirium). Understanding basic mechanisms involved in geriatric syndromes will be critical to advancing research and developing targeted therapeutic options. However, given the complexity of these multifactorial conditions, attempts to define relevant mechanisms will need to incorporate more complex models, including a focus on synergistic interactions between different risk factors. Finally, major barriers have been identified in translating research advances, such as preventive strategies of proven effectiveness for delirium and falls, into clinical practice and policy initiatives. National strategic initiatives are required to overcome barriers and to achieve clinical, research, and policy advances that will improve quality of life for older persons.
Geriatric syndromes; multifactorial; gerontology; policy
Symptoms are a central component of health status; however, little is known about the full range and trajectory of symptoms experienced by persons with chronic diseases other than cancer.
Observational cohort study with interviews performed at least every 4 months for up to 2 years among community-dwelling persons 60 years or older with chronic obstructive pulmonary disease (COPD) or heart failure (HF). Seven symptoms rated as absent, mild, moderate, or severe were assessed at each interview.
Among the 79 participants with COPD, at least 50% reported shortness of breath, physical discomfort, fatigue, and problems with appetite and anxiety. Among the 59 participants with HF, at least 50% reported physical discomfort, fatigue, and problems with appetite at both their initial and final interviews. Both disease-specific and non–disease-specific symptoms increased in severity over time. The prevalence of individual symptoms did not differ according to whether the participants lived or died.
As a potentially modifiable contributor to poor health status, the high symptom burden among older persons with COPD and HF represents a large unmet need for improved symptom assessment and treatment. This need may not be met by current disease management guidelines, which focus on a small number of symptoms except for patients at the end of life.
Medication decision making is complex, particularly for older patients with multiple conditions for whom benefits may be uncertain and health priorities may be variable. While patient input would seem important in the face of this uncertainty and variability, little is known about older patients' views of involvement in medication decision making.
To explore the views of older adults regarding participation in medication decision making.
Fifty-one persons at least 65 years old who consumed at least one medication were recruited from 3 senior centers and 4 physicians' offices.
One-on-one interviews were conducted to uncover participants' perceptions of medication-related decision making through semistructured, open-ended questions. Themes were compared according to the constant comparative method of analysis.
The predominant theme that emerged was the variability in perceptions concerning whether it was possible or desirable for patients to participate in prescribing decisions. For some participants, involvement was limited to sharing information. Physician and system factors that were felt to facilitate or impede patient participation included communication skills, the expanding number of medications available, multiple physicians prescribing for the same patient, and a focus on treating numbers. Perceived lack of knowledge, low self-efficacy, and fear were the patient factors mentioned. Both the presence and absence of trust in the prescribing physician were seen as alternatively impeding and enhancing patient participation. Only 1 participant explicitly mentioned patient preference, a cornerstone of shared decision making.
While evolution to greater patient involvement in medication decision making may be possible, and desirable to some older patients, findings suggest that the transition will be challenging.
medication prescribing; patient participation in decision making; older adults
Falls are common, treatable, and result in considerable morbidity in older adults. However, fall risk factor evaluation and management targeted at high-risk patients is largely neglected in clinical practice.
To identify barriers and facilitators to the implementation of fall risk management by primary care providers.
Qualitative study using a semi-structured interview.
Primary care providers who received an academic outreach visit.
Self-reported facilitators and barriers to evaluating and managing fall risk in older patients.
Physician factors, logistical factors, and patient factors intersect to either facilitate or impede fall risk evaluation and management by primary care providers. Physician factors include awareness, competing risks, appropriateness of referrals, training, and tie-in to familiar activities. Logistical factors include availability of transportation, time requirements of immobile patients, reimbursement, scheduling, family involvement, and utilization of other health care providers. Physicians' perceptions of patient factors include reporting, attitudes toward medication, and positive feedback.
Strategies to improve the adoption of fall risk evaluation and management in primary care should address the specific physician, logistical, and patient barriers perceived by physicians who had received an informative, motivational intervention to assess and manage falls among their patients.
falls; elderly; qualitative research; primary care
To determine primary care physicians' awareness of, and screening practices for, alcohol use disorders (AUDs) among older patients.
Cross-sectional telephone survey of a national sample of primary care physicians.
Physicians randomly sampled from the Masterfile database of the American Medical Association and stratified by specialty as family practice physicians, internal medicine physicians, and either family practice or internal medicine physicians with geriatric certification.
A total of 171 physicians were contacted: 155 (91%) agreed to participate, and responses were analyzed from 150 (50 family practice, 50 internal medicine, 50 with geriatric certification). The median prevalence estimate of AUDs among older patients was 5% for each group of physicians. In contrast to published prevalence rates of AUDs ranging from 5% to 23%, 38% of physicians reported prevalence estimates of less than 5%, and 5% cited estimates of at least 25%. Compared with the other groups, the physicians with geriatric certification were more likely to report no regular screening (42% vs 20% for family practice vs 18% for internal medicine, p=.01), while younger (<40 years) and middle-aged physicians (40–55 years) reported higher annual screening rates relative to older physicians (>55 years) (77% vs 60% vs 44% respectively, p=.03). Among physicians who regularly screened (n=110), 100% asked quantity-frequency questions, 39% also used the CAGE questions, and 15% also cited use of biochemical markers.
Primary care physicians may “underdetect” AUDs among older patients. The development of age-specific screening methods and physician education may facilitate detection of older patients with (or at risk for) these disorders.
alcohol use disorders; older patients; screening
Develop a taxonomy for understanding and classifying goals in the care of persons with dementia.
Qualitative study using open-ended interviews with key informants and the constant comparative method of qualitative data analysis.
The geriatric assessment center at a large academic medical center in Connecticut.
Key informant interviews with 36 subjects: consecutive patients receiving geriatric assessment at the center and their primary family caregivers, case managers, and physicians of patients.
MEASUREMENTS AND MAIN RESULTS
Goals, or desired outcomes, for the patient's care as described by patients, primary family caregivers, case managers, and physicians were the main measurements. Participant interviews were conducted until the point of theoretical saturation, i.e., until further interviews no longer provided new concepts. All participants articulated at least one goal. Specific goals were characterized by a limited number of goal attributes resulting in a taxonomy, or consistent classification system, for reported goals. These attributes include domain (or content), specificity, time frame, and level of challenge.
The findings suggested that patients, primary family caregivers, and clinicians can articulate goals of care and may bring differing perspectives to the goal-setting process. The research identified a taxonomy that may facilitate negotiation of goals by revealing important, and perhaps overlooked, aspects of goals and the goal-setting process.
goals; health care preferences; taxonomy; classification; dementia
To explore how older persons form preferences for site of medical care by examining their perceptions of home care and hospital care.
Qualitative analysis of in-depth interviews using the constant comparative method.
Twenty-nine persons age 65 to 89 years who had been hospitalized with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia and were receiving home care services.
Respondents, who thought of home care only as a means to provide low-intensity and low-frequency services, were initially skeptical about expanded home care services to treat acute illness. Regardless of their opinions about home and hospital, all respondents preferred the site associated with the greatest chance of survival. If the sites offered equal survival, 52% of the respondents preferred treatment at home because of freedom from the constraints of the hospital and the comfort of familiar surroundings. For respondents who preferred the hospital, the home represented a frightening and lonely place to be sick. Respondents' views of the home and hospital were shaped by their social supports, self-reliance, religious beliefs, and past illness experiences.
Because survival appears to be the most important determinant of preference, home treatment of acute illness is a viable alternative only if it provides outcomes equivalent to those of hospitalization. Strongly held perceptions that home care can only be a low-intensity service may limit preferences for home treatment. When expected outcomes at the two sites are similar, the challenge to the health care system will be incorporating patient preference about the process of care into decisions about the appropriate site of care.
patient preference; home care; qualitative research
To identify the factors that predict recovery in activities of daily living (ADLs) among disabled older persons living in the community.
Prospective cohort study with 2-year follow-up.
213 men and women 72 years or older, who reported dependence in one or more ADLs.
MEASUREMENTS AND MAIN RESULTS
All participants underwent a comprehensive home assessment and were followed for recovery of ADL function, defined as requiring no personal assistance in any of the ADLs within 2 years. Fifty-nine participants (28%) recovered independent ADL function. Compared with those older than 85 years, participants aged 85 years or younger were more than 8 times as likely to recover their ADL function (relative risk [RR] 8.4; 95% confidence interval [CI] 2.7, 26). Several factors besides age were associated with ADL recovery in bivariate analysis, including disability in only one ADL, self-efficacy score greater than 75, Folstein Mini-Mental State Examination (MMSE) score of 28 or better, high mobility, score in the best third of timed physical performance, fewer than five medications, and good nutritional status. In multivariable analysis, four factors were independently associated with ADL recovery—age 85 years or younger (adjusted RR 4.1; 95% CI 1.3, 13), MMSE score of 28 or better (RR 1.7; 95% CI 1.2, 2.3), high mobility (RR 1.7; 95% CI 1.0, 2.9), and good nutritional status (RR 1.6; 95% CI 1.0, 2.5).
Once disabled, few persons older than 85 years recover independent ADL function. Intact cognitive function, high mobility, and good nutritional status each improve the likelihood of ADL recovery and may serve as markers of resiliency in this population.
activities of daily living (ADLs); recovery; elderly; prospective cohort study; prognosis