Coming Home: Health Status and Homelessness Risk of Older Pre-release Prisoners

Older adults comprise an increasing proportion of the prison and homeless populations. While older age is associated with adverse post-release health events and incarceration is a risk factor for homelessness, the health status and homelessness risk of older pre-release prisoners are unknown. Moreover, most post-release services are geared towards veterans; it is unknown whether the needs of non-veterans differ from those of veterans. To assess health status and risk of homelessness of older pre-release prisoners, and to compare veterans with non-veterans. Cross-sectional study of 360 prisoners (≥55 years of age) within 2 years of release from prison using data from the 2004 Survey of Inmates in State and Federal Correctional Facilities. Veteran status, health status (based on self-report), and risk of homelessness (homelessness before arrest). Mean age was 61 years; 93.8% were men and 56.5% were white. Nearly 40% were veterans, of whom 77.2% reported likely VA service eligibility. Veterans were more likely to be white and to have obtained a high school diploma or GED. Overall, 79.1% reported a medical condition and 13.6% reported a serious mental illness. There was little difference in health status between veterans and non-veterans. Although 1 in 12 prisoners reported a risk factor for homelessness, the risk factors did not differ according to veteran status. Older pre-release prisoners had a high burden of medical and mental illness and were at risk for post-release homelessness regardless of veteran status. Reentry programs linking pre-release older prisoners to medical and psychiatric services and to homelessness prevention programs are needed for both veterans and non-veterans

Desire for predictive testing for Alzheimer's disease and impact on advance care planning: a cross-sectional study.

BackgroundIt is unknown whether older adults in the United States would be willing to take a test predictive of future Alzheimer's disease, or whether testing would change behavior. Using a nationally representative sample, we explored who would take a free and definitive test predictive of Alzheimer's disease, and examined how using such a test may impact advance care planning.MethodsA cross-sectional study within the 2012 Health and Retirement Study of adults aged 65 years or older asked questions about a test predictive of Alzheimer's disease (N = 874). Subjects were asked whether they would want to take a hypothetical free and definitive test predictive of future Alzheimer's disease. Then, imagining they knew they would develop Alzheimer's disease, subjects rated the chance of completing advance care planning activities from 0 to 100. We classified a score > 50 as being likely to complete that activity. We evaluated characteristics associated with willingness to take a test for Alzheimer's disease, and how such a test would impact completing an advance directive and discussing health plans with loved ones.ResultsOverall, 75% (N = 648) of the sample would take a free and definitive test predictive of Alzheimer's disease. Older adults willing to take the test had similar race and educational levels to those who would not, but were more likely to be ≤75 years old (odds ratio 0.71 (95% CI 0.53-0.94)). Imagining they knew they would develop Alzheimer's, 81% would be likely to complete an advance directive, although only 15% had done so already.ConclusionsIn this nationally representative sample, 75% of older adults would take a free and definitive test predictive of Alzheimer's disease. Many participants expressed intent to increase activities of advance care planning with this knowledge. This confirms high public interest in predictive testing for Alzheimer's disease and suggests this may be an opportunity to engage patients in advance care planning discussions

Loneliness in Older Persons: A Predictor of Functional Decline and Death

BackgroundLoneliness is a common source of distress, suffering, and impaired quality of life in older persons. We examined the relationship between loneliness, functional decline, and death in adults older than 60 years in the United States.MethodsThis is a longitudinal cohort study of 1604 participants in the psychosocial module of the Health and Retirement Study, a nationally representative study of older persons. Baseline assessment was in 2002 and follow-up assessments occurred every 2 years until 2008. Subjects were asked if they (1) feel left out, (2) feel isolated, or (3) lack companionship. Subjects were categorized as not lonely if they responded hardly ever to all 3 questions and lonely if they responded some of the time or often to any of the 3 questions. The primary outcomes were time to death over 6 years and functional decline over 6 years on the following 4 measures: difficulty on an increased number of activities of daily living (ADL), difficulty in an increased number of upper extremity tasks, decline in mobility, or increased difficulty in stair climbing. Multivariate analyses adjusted for demographic variables, socioeconomic status, living situation, depression, and various medical conditions.ResultsThe mean age of subjects was 71 years. Fifty-nine percent were women; 81% were white, 11%, black, and 6%, Hispanic; and 18% lived alone. Among the elderly participants, 43% reported feeling lonely. Loneliness was associated with all outcome measures. Lonely subjects were more likely to experience decline in ADL (24.8% vs 12.5%; adjusted risk ratio [RR], 1.59; 95% CI, 1.23-2.07); develop difficulties with upper extremity tasks (41.5% vs 28.3%; adjusted RR, 1.28; 95% CI, 1.08-1.52); experience decline in mobility (38.1% vs 29.4%; adjusted RR, 1.18; 95% CI, 0.99-1.41); or experience difficulty in climbing (40.8% vs 27.9%; adjusted RR, 1.31; 95% CI, 1.10-1.57). Loneliness was associated with an increased risk of death (22.8% vs 14.2%; adjusted HR, 1.45; 95% CI, 1.11-1.88).ConclusionAmong participants who were older than 60 years, loneliness was a predictor of functional decline and death

Desire for predictive testing for Alzheimer's disease and impact on advance care planning: a cross-sectional study.

BackgroundIt is unknown whether older adults in the United States would be willing to take a test predictive of future Alzheimer's disease, or whether testing would change behavior. Using a nationally representative sample, we explored who would take a free and definitive test predictive of Alzheimer's disease, and examined how using such a test may impact advance care planning.MethodsA cross-sectional study within the 2012 Health and Retirement Study of adults aged 65 years or older asked questions about a test predictive of Alzheimer's disease (N = 874). Subjects were asked whether they would want to take a hypothetical free and definitive test predictive of future Alzheimer's disease. Then, imagining they knew they would develop Alzheimer's disease, subjects rated the chance of completing advance care planning activities from 0 to 100. We classified a score > 50 as being likely to complete that activity. We evaluated characteristics associated with willingness to take a test for Alzheimer's disease, and how such a test would impact completing an advance directive and discussing health plans with loved ones.ResultsOverall, 75% (N = 648) of the sample would take a free and definitive test predictive of Alzheimer's disease. Older adults willing to take the test had similar race and educational levels to those who would not, but were more likely to be ≤75 years old (odds ratio 0.71 (95% CI 0.53-0.94)). Imagining they knew they would develop Alzheimer's, 81% would be likely to complete an advance directive, although only 15% had done so already.ConclusionsIn this nationally representative sample, 75% of older adults would take a free and definitive test predictive of Alzheimer's disease. Many participants expressed intent to increase activities of advance care planning with this knowledge. This confirms high public interest in predictive testing for Alzheimer's disease and suggests this may be an opportunity to engage patients in advance care planning discussions

Loneliness in Older Persons

BACKGROUND: Loneliness is a common source of distress, suffering, and impaired quality of life in older persons. We examined the relationship between loneliness, functional decline and death in adults over age 60 in the United States. METHODS: This is a longitudinal cohort study of 1604 participants in the psychosocial module of the Health and Retirement Study (HRS), a nationally representative study of older persons. Baseline assessment was in 2002 and follow-up occurred every two years until 2008. Subjects were asked if they feel 1) Left Out 2) Isolated or 3) Lack Companionship. Subjects were categorized as not lonely if they responded hardly ever to all three questions and lonely if they responded some of the time or often to any of the three questions. The primary outcomes were time to death over 6 years, and functional decline over 6 years on 4 measures: difficulty on an increased number of activities of daily living (ADL), difficulty in an increased number of upper extremity tasks, decline in mobility, or increased difficulty in stair climbing. Multivariate analyses adjusted for demographic variables, socioeconomic status, living situation, depression, and various medical conditions. RESULTS: The mean age of subjects was 71 years, 59% were women, 81% White, 11% Black, 6% Hispanic, and 18% lived alone. 43% of elders reported feeling lonely. Loneliness was associated with all outcome measures. Lonely subjects were more likely to experience decline in ADLs, (24.8% vs. 12.5%, Adjusted Risk Ratio 1.59, 1.23-2.07); develop difficulties with upper extremity tasks (41.5% vs. 28.3%, ARR 1.28, 1.08-1.52); decline in mobility (38.1% v. 29.4%, ARR 1.18, 0.99-1.41); or difficulty in climbing (40.8% vs. 27.9%, ARR 1.31, 1.10-1.57). Loneliness was associated with an increased risk of death (22.8% vs. 14.2%, AHR 1.45, 1.11-1.88). CONCLUSIONS: Among participants who were older than 60, loneliness was a predictor of functional decline and death

Detained and Distressed: Persistent Distressing Symptoms in a Population of Older Jail Inmates.

Distressing symptoms are associated with poor function, acute care use, and mortality in older adults. The number of older jail inmates is increasing rapidly, prompting calls to develop systems of care to meet their healthcare needs, yet little is known about multidimensional symptom burden in this population. This cross-sectional study describes the prevalence and factors associated with distressing symptoms and the overlap between different forms of symptom distress in 125 older jail inmates in an urban county jail. Physical distress was assessed using the Memorial Symptom Assessment Scale. Several other forms of symptom distress were also examined, including psychological (Generalized Anxiety Disorder Scale, Patient Health Questionnaire), existential (Patient Dignity Inventory), and social (Three Item Loneliness Scale). Information was collected on participant sociodemographic characteristics, multimorbidity, serious mental illness (SMI), functional impairment, and behavioral health risk factors through self-report and chart review. Chi-square tests were used to identify factors associated with physical distress. Overlap between forms of distress was evaluated using set theory analysis. Overall, many participants (74%) reported distressing symptoms, including having one or more physical (44%), psychological (37%), existential (54%), or social (45%) symptoms. Physical distress was associated with poor health (multimorbidity, functional impairment, SMI) and low income. Of the 93 participants with any symptom, 49% reported three or more forms of distress. These findings suggest that an optimal model of care for this population would include a geriatrics-palliative care approach that integrates the management of all forms of symptom distress into a comprehensive treatment paradigm stretching from jail to the community

Functional Impairment and Hospital Readmission in Medicare Seniors

IMPORTANCE: Medicare currently penalizes hospitals for high rates of readmission for seniors but does not account for common age-related syndromes such as functional impairment. OBJECTIVES: Given the high prevalence of functional impairments in community-dwelling seniors, we assessed effects of functional impairment on Medicare hospital readmissions. STUDY DESIGN, PARTICIPANTS, AND SETTING: We created a nationally-representative cohort of 7,854 community-dwelling seniors in the Health and Retirement Study (HRS) with 22,289 Medicare hospitalizations from 2000–2010. MAIN OUTCOME AND MEASUREMENTS: Outcome was 30-day readmission, assessed by Medicare claims. Main predictor was functional impairment determined from HRS interview preceding hospitalization, stratified into 5 levels: no functional impairments, difficulty with ≥1 instrumental activity of daily living (IADL), difficulty with ≥1 activity of daily living (ADL), dependency (need for help) in 1–2 ADLs, and dependency in ≥3 ADLs. Adjustment variables included age, race, gender, income, and net worth and comorbid conditions (Elixhauser score from Medicare claims), and prior admission. We performed multivariable logistic regression adjusted for clustering at patient level to characterize the association of functional impairments and readmission. RESULTS: Mean age 79 (±8; 65–105), 58% female, 85% White, 90% reported ≥3 comorbidities, 86% had ≥1 hospitalization in previous year. Overall, 48% had some level of functional impairment prior to admission and 15% experienced a 30-day readmission. We found a progressive increase in adjusted risk of readmission as the degree of functional impairment increased: 13.5% with no functional impairment, 14.3% with ≥ 1 IADL difficulty (OR 1.06; 95% CI 0.94–1.20), 14.4% with ≥1 ADL difficulty (OR 1.08; 0.96–1.21), 16.5% with dependency in 1–2 ADLs (OR 1.26; 1.11–1.44), and 18.2% with dependency in ≥3 ADLs (1.42; 1.20–1.69). Sub-analysis restricted to patients admitted with conditions targeted by Medicare (heart failure, myocardial infarction, and pneumonia) revealed a parallel trend with larger effects for the most-impaired (16.9% readmission rate for no impairment vs. 25.7% for dependency in ≥3 ADLs, OR 1.70; 1.04–2.78). CONCLUSIONS: Functional impairment is associated with increased risk of 30-day, all-cause hospital readmission in Medicare seniors, especially those admitted for heart failure, myocardial infarction or pneumonia. Functional impairment on admission may be an overlooked but highly suitable target for interventions to reduce Medicare hospital readmissions. RELEVANCE: Functional impairment may be an important but under-addressed factor in preventing readmissions for Medicare seniors

Functional impairment and hospital readmission in Medicare seniors.

ImportanceMedicare currently penalizes hospitals for high readmission rates for seniors but does not account for common age-related syndromes, such as functional impairment.ObjectiveTo assess the effects of functional impairment on Medicare hospital readmissions given the high prevalence of functional impairments in community-dwelling seniors.Design, setting, and participantsWe created a nationally representative cohort of 7854 community-dwelling seniors in the Health and Retirement Study, with 22,289 Medicare hospitalizations from January 1, 2000, through December 31, 2010.Main outcomes and measuresOutcome was 30-day readmission assessed by Medicare claims. The main predictor was functional impairment determined from the Health and Retirement Study interview preceding hospitalization, stratified into the following 5 levels: no functional impairments, difficulty with 1 or more instrumental activities of daily living, difficulty with 1 or more activities of daily living (ADL), dependency (need for help) in 1 to 2 ADLs, and dependency in 3 or more ADLs. Adjustment variables included age, race/ethnicity, sex, annual income, net worth, comorbid conditions (Elixhauser score from Medicare claims), and prior admission. We performed multivariable logistic regression to adjust for clustering at the patient level to characterize the association of functional impairments and readmission.ResultsPatients had a mean (SD) age of 78.5 (7.7) years (range, 65-105 years); 58.4% were female, 84.9% were white, 89.6% reported 3 or more comorbidities, and 86.0% had 1 or more hospitalizations in the previous year. Overall, 48.3% had some level of functional impairment before admission, and 15.5% of hospitalizations were followed by readmission within 30 days. We found a progressive increase in the adjusted risk of readmission as the degree of functional impairment increased: 13.5% with no functional impairment, 14.3% with difficulty with 1 or more instrumental activities of daily living (odds ratio [OR], 1.06; 95% CI, 0.94-1.20), 14.4% with difficulty with 1 or more ADL (OR, 1.08; 95% CI, 0.96-1.21), 16.5% with dependency in 1 to 2 ADLs (OR, 1.26; 95% CI, 1.11-1.44), and 18.2% with dependency in 3 or more ADLs (OR, 1.42; 95% CI, 1.20-1.69). Subanalysis restricted to patients admitted with conditions targeted by Medicare (ie, heart failure, myocardial infarction, and pneumonia) revealed a parallel trend with larger effects for the most impaired (16.9% readmission rate for no impairment vs 25.7% for dependency in 3 or more ADLs [OR, 1.70; 95% CI, 1.04-2.78]).Conclusions and relevanceFunctional impairment is associated with increased risk of 30-day all-cause hospital readmission in Medicare seniors, especially those admitted for heart failure, myocardial infarction, or pneumonia. Functional impairment may be an important but underaddressed factor in preventing readmissions for Medicare seniors

Six-Month Emergency Department Use among Older Adults Following Jail Incarceration.

Although the number of older adults who are arrested and subject to incarceration in jail is rising dramatically, little is known about their emergency department (ED) use or the factors associated with that use. This lack of knowledge impairs the ability to design evidence-based approaches to care that would meet the needs of this population. This 6-month longitudinal study aimed to determine the frequency of 6-month ED use among 101 adults aged 55 or older enrolled while in jail and to identify factors associated with that use. The primary outcome was self-reported emergency department use within 6 months from baseline. Additional measures included baseline socio-demographics, physical and mental health conditions, geriatric factors (e.g., recent falls, incontinence, functional impairment, concern about post-release safety), symptoms (pain and other symptoms), and behavioral and social health risk factors (e.g., substance use disorders, recent homelessness). Chi-square tests were used to identify baseline factors associated with ED use over 6 months. Participants (average age 60) reported high rates of multimorbidity (61%), functional impairment (57%), pain (52%), serious mental illness (44%), recent homelessness (54%), and/or substance use disorders (69%). At 6 months, 46% had visited the ED at least once; 21% visited multiple times. Factors associated with ED use included multimorbidity (p = 0.01), functional impairment (p = 0.02), hepatitis C infection (p = 0.01), a recent fall (p = 0.03), pain (p < 0.001), loneliness (p = 0.04), and safety concerns (p = 0.01). In this population of older adults in a county jail, geriatric conditions and distressing symptoms were common and associated with 6-month community ED use. Jail is an important setting to develop geriatric care paradigms aimed at addressing comorbid medical, functional, and behavioral health needs and symptomatology in an effort to improve care and decrease ED use in the growing population of criminal justice-involved older adults