75 research outputs found
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Geriatric Syndromes: Clinical, Research, and Policy Implications of a Core Geriatric Concept
Geriatricians have embraced the term “geriatric syndrome,” using it extensively to highlight the unique features of common health conditions in older people. 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, although 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
Patient Priorities-Aligned Care For Older adults With Multiple Conditions: a Nonrandomized Controlled Trial
IMPORTANCE: Older adults with multiple conditions receive health care that may be burdensome, of uncertain benefit, and not focused on what matters to them. Identifying and aligning care with patients\u27 health priorities may improve outcomes.
OBJECTIVE: to assess the association of receiving patient priorities care (PPC) vs usual care (UC) with relevant clinical outcomes.
DESIGN, SETTING, AND PARTICIPANTS: In this nonrandomized controlled trial with propensity adjustment, enrollment occurred between August 21, 2020, and May 14, 2021, with follow-up continuing through February 26, 2022. Patients who were aged 65 years or older and with 3 or more chronic conditions were enrolled at 1 PPC and 1 UC site within the Cleveland Clinic primary care multisite practice. Data analysis was performed from March 2022 to August 2023.
INTERVENTION: Health professionals at the PPC site guided patients through identification of values, health outcome goals, health care preferences, and top priority (ie, health problem they most wanted to focus on because it impeded their health outcome goal). Primary clinicians followed PPC decisional strategies (eg, use patients\u27 health priorities as focus of communication and decision-making) to decide with patients what care to stop, start, or continue.
MAIN OUTCOMES AND MEASURES: Main outcomes included perceived treatment burden, Patient-Reported Outcomes Measurement Information System (PROMIS) social roles and activities, CollaboRATE survey scores, the number of nonhealthy days (based on healthy days at home), and shared prescribing decision quality measures. Follow-up was at 9 months for patient-reported outcomes and 365 days for nonhealthy days.
RESULTS: A total of 264 individuals participated, 129 in the PPC group (mean [SD] age, 75.3 [6.1] years; 66 women [48.9%]) and 135 in the UC group (mean [SD] age, 75.6 [6.5] years; 55 women [42.6%]). Characteristics between sites were balanced after propensity score weighting. At follow-up, there was no statistically significant difference in perceived treatment burden score between groups in multivariate models (difference, -5.2 points; 95% CI, -10.9 to -0.50 points; P = .07). PPC participants were almost 2.5 times more likely than UC participants to endorse shared prescribing decision-making (adjusted odds ratio, 2.40; 95% CI, 0.90 to 6.40; P = .07), and participants in the PPC group experienced 4.6 fewer nonhealthy days (95% CI, -12.9 to -3.6 days; P = .27) compared with the UC participants. These differences were not statistically significant. CollaboRATE and PROMIS Social Roles and Activities scores were similar in the 2 groups at follow-up.
CONCLUSIONS AND RELEVANCE: This nonrandomized trial of priorities-aligned care showed no benefit for social roles or CollaboRATE. While the findings for perceived treatment burden and shared prescribing decision-making were not statistically significant, point estimates for the findings suggested that PPC may hold promise for improving these outcomes. Randomized trials with larger samples are needed to determine the effectiveness of priorities-aligned care.
TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04510948
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Anti-Hypertensive Medications and Cardiovascular Events in Older Adults with Multiple Chronic Conditions
Importance Randomized trials of anti-hypertensive treatment demonstrating reduced risk of cardiovascular events in older adults included participants with less comorbidity than clinical populations. Whether these results generalize to all older adults, most of whom have multiple chronic conditions, is uncertain. Objective: To determine the association between anti-hypertensive medications and CV events and mortality in a nationally representative population of older adults. Design: Competing risk analysis with propensity score adjustment and matching in the Medicare Current Beneficiary Survey cohort over three-year follow-up through 2010. Participants and Setting 4,961 community-living participants with hypertension. Exposure Anti-hypertensive medication intensity, based on standardized daily dose for each anti-hypertensive medication class participants used. Main Outcomes and Measures Cardiovascular events (myocardial infarction, unstable angina, cardiac revascularization, stroke, and hospitalizations for heart failure) and mortality. Results: Of 4,961 participants, 14.1% received no anti-hypertensives; 54.6% received moderate, and 31.3% received high, anti-hypertensive intensity. During follow-up, 1,247 participants (25.1%) experienced cardiovascular events; 837 participants (16.9%) died. Of deaths, 430 (51.4%) occurred in participants who experienced cardiovascular events during follow-up. In the propensity score adjusted cohort, after adjusting for propensity score and other covariates, neither moderate (adjusted hazard ratio, 1.08 [95% CI, 0.89–1.32]) nor high (1.16 [0.94–1.43]) anti-hypertensive intensity was associated with experiencing cardiovascular events. The hazard ratio for death among all participants was 0.79 [0.65–0.97] in the moderate, and 0.72 [0.58–0.91] in the high intensity groups compared with those receiving no anti-hypertensives. Among participants who experienced cardiovascular events, the hazard ratio for death was 0.65 [0.48–0.87] and 0.58 [0.42–0.80] in the moderate and high intensity groups, respectively. Results were similar in the propensity score-matched subcohort. Conclusions and Relevance In this nationally representative cohort of older adults, anti-hypertensive treatment was associated with reduced mortality but not cardiovascular events. Whether RCT results generalize to older adults with multiple chronic conditions remains uncertain
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Potential Therapeutic Competition in Community-Living Older Adults in the U.S.: Use of Medications That May Adversely Affect a Coexisting Condition
OBJECTIVE: The 75% of older adults with multiple chronic conditions are at risk of therapeutic competition (i.e. treatment for
one condition may adversely affect a coexisting condition). The objective was to determine the prevalence of potential
therapeutic competition in community-living older adults.
METHODS: Cross-sectional descriptive study of a representative sample of 5,815 community-living adults 65 and older in the
U.S, enrolled 2007–2009. The 14 most common chronic conditions treated with at least one medication were ascertained
from Medicare claims. Medication classes recommended in national disease guidelines for these conditions and used by
≥2% of participants were identified from in-person interviews conducted 2008–2010. Criteria for potential therapeutic
competition included: 1) well-acknowledged adverse medication effect; 2) mention in disease guidelines; or 3) report in a
systematic review or two studies published since 2000. Outcomes included prevalence of situations of potential therapeutic
competition and frequency of use of the medication in individuals with and without the competing condition.
RESULTS: Of 27 medication classes, 15 (55.5%) recommended for one study condition may adversely affect other study
conditions. Among 91 possible pairs of study chronic conditions, 25 (27.5%) have at least one potential therapeutic
competition. Among participants, 1,313 (22.6%) received at least one medication that may worsen a coexisting condition;
753 (13%) had multiple pairs of such competing conditions. For example, among 846 participants with hypertension and
COPD, 16.2% used a nonselective beta-blocker. In only 6 of 37 cases (16.2%) of potential therapeutic competition were
those with the competing condition less likely to receive the medication than those without the competing condition.
CONCLUSIONS: One fifth of older Americans receive medications that may adversely affect coexisting conditions. Determining
clinical outcomes in these situations is a research and clinical priority. Effects on coexisting conditions should be considered
when prescribing medications.This is the publisher’s final pdf. The published article is copyrighted by the author(s) and published by the Public Library of Science. The published article can be found at: https://doi.org/10.1371/journal.pone.008944
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Anti-Hypertensive Medications and Cardiovascular Events in Older Adults with Multiple Chronic Conditions
Importance
Randomized trials of anti-hypertensive treatment demonstrating reduced risk of cardiovascular events in older adults included participants with less comorbidity than clinical populations. Whether these results generalize to all older adults, most of whom have multiple chronic conditions, is uncertain.
Objective
To determine the association between anti-hypertensive medications and CV events and mortality in a nationally representative population of older adults.
Design
Competing risk analysis with propensity score adjustment and matching in the Medicare Current Beneficiary Survey cohort over three-year follow-up through 2010.
Participants and Setting
4,961 community-living participants with hypertension.
Exposure
Anti-hypertensive medication intensity, based on standardized daily dose for each anti-hypertensive medication class participants used.
Main Outcomes and Measures
Cardiovascular events (myocardial infarction, unstable angina, cardiac revascularization, stroke, and hospitalizations for heart failure) and mortality.
Results
Of 4,961 participants, 14.1% received no anti-hypertensives; 54.6% received moderate, and 31.3% received high, anti-hypertensive intensity. During follow-up, 1,247 participants (25.1%) experienced cardiovascular events; 837 participants (16.9%) died. Of deaths, 430 (51.4%) occurred in participants who experienced cardiovascular events during follow-up. In the propensity score adjusted cohort, after adjusting for propensity score and other covariates, neither moderate (adjusted hazard ratio, 1.08 [95% CI, 0.89–1.32]) nor high (1.16 [0.94–1.43]) anti-hypertensive intensity was associated with experiencing cardiovascular events. The hazard ratio for death among all participants was 0.79 [0.65–0.97] in the moderate, and 0.72 [0.58–0.91] in the high intensity groups compared with those receiving no anti-hypertensives. Among participants who experienced cardiovascular events, the hazard ratio for death was 0.65 [0.48–0.87] and 0.58 [0.42–0.80] in the moderate and high intensity groups, respectively. Results were similar in the propensity score-matched subcohort.
Conclusions and Relevance
In this nationally representative cohort of older adults, anti-hypertensive treatment was associated with reduced mortality but not cardiovascular events. Whether RCT results generalize to older adults with multiple chronic conditions remains uncertain
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Effect of β-Blockers on Cardiac and Pulmonary Events and Death in Older Adults With Cardiovascular Disease and Chronic Obstructive Pulmonary Disease
CONTEXT: In older adults with multiple conditions, medications may not impart the same benefits seen in patients who are younger, or without multi-morbidity. Furthermore, medications given for one condition may adversely affect other outcomes. Beta-blocker (β-Blocker) use with coexisting cardiovascular disease (CVD) and chronic obstructive pulmonary disease (COPD) is such a situation.
OBJECTIVE: To determine the effect of β-Blocker use on cardiac and pulmonary outcomes and mortality in older adults with coexisting COPD and CVD.
DESIGN, SETTING, PARTICIPANTS: The 1062 participants were members of the 2004-2007 Medicare Current Beneficiary Survey cohorts, a nationally representative sample of Medicare beneficiaries. Study criteria included age 65+ years plus coexisting CVD and COPD/asthma. Follow-up occurred through 2009. We determined the association between β-Blocker use and the outcomes with propensity score-adjusted and covariate-adjusted Cox proportional hazards.
MAIN OUTCOME MEASURES: The three outcomes were major cardiac and pulmonary events, and all-cause mortality.
RESULTS: Half of the participants used β-Blockers. During follow-up 179 participants experienced a major cardiac event; 389 participants experienced a major pulmonary event; and 255
participants died. Each participant could have experienced any one or more of these events. The hazard ratio for β-blocker use was 1.18 (95% CI, 0.85-1.62) for cardiac events; 0.91 (95% CI, 0.73-1.12) for pulmonary events; and, 0.87 (95% CI, 0.67-1.13) for death.
CONCLUSION: In this population of older adults, β-Blockers did not seem to affect occurrence of cardiac or pulmonary events or death in those with CVD and COPD.Keywords: cardiovascular disease, multiple chronic conditions, coronary artery disease, COPD, chronic obstructive pulmonary disease, cardiac events, beta-blocker, pulmonary events, multimorbidity, CAD, CV
Protocol for a home-based integrated physical therapy program to reduce falls and improve mobility in people with Parkinson’s disease
Background The high incidence of falls associated with Parkinson’s disease (PD) increases the risk of injuries and immobility and compromises quality of life. Although falls education and strengthening programs have shown some benefit in healthy older people, the ability of physical therapy interventions in home settings to reduce falls and improve mobility in people with Parkinson’s has not been convincingly demonstrated.Methods/design 180 community living people with PD will be randomly allocated to receive either a home-based integrated rehabilitation program (progressive resistance strength training, movement strategy training and falls education) or a home-based life skills program (control intervention). Both programs comprise one hour of treatment and one hour of structured homework per week over six weeks of home therapy. Blinded assessments occurring before therapy commences, the week after completion of therapy and 12 months following intervention will establish both the immediate and long-term benefits of home-based rehabilitation. The number of falls, number of repeat falls, falls rate and time to first fall will be the primary measures used to quantify outcome. The economic costs associated with injurious falls, and the costs of running the integrated rehabilitation program from a health system perspective will be established. The effects of intervention on motor and global disability and on quality of life will also be examined. Discussion This study will provide new evidence on the outcomes and cost effectiveness of home-based movement rehabilitation programs for people living with PD
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