Gail McAvay

Background/Objectives: The benefit or harm of a single medication recommended for one specific condition can be difficult to determine in individuals with multiple chronic conditions and polypharmacy. There is limited information on the associations between guideline‐recommended medications and physical function in older adults with multiple chronic conditions. The objective of this study was to estimate the beneficial or harmful associations between guideline‐recommended medications and decline in physical function in older adults with multiple chronic conditions. Design: Prospective observational cohort. Setting: National. Participants: Community‐dwelling adults aged 65 and older from the Medicare Current Beneficiary Survey study (N = 3,273). Participants with atrial fibrillation, coronary artery disease, depression, diabetes mellitus, or heart failure were included. Measurements: Self‐reported decline in physical function; guideline‐recommended medications; polypharmacy (taking <7 vs ≥7 concomitant medications); chronic conditions; and sociodemographic, behavioral, and health risk factors. Results: The risk of decline in function in the overall sample was highest in participants with heart failure (35.4%, 95% confidence interval ( CI ) = 26.3–44.5) and lowest for those with atrial fibrillation (20.6%, 95% CI = 14.9–26.2). In the overall sample, none of the six guideline‐recommended medications was associated with decline in physical function across the five study conditions, although in the group with low polypharmacy exposure, there was lower risk of decline in those with heart failure taking renin angiotensin system blockers (hazard ratio ( HR ) = 0.40, 95% CI = 0.16–0.99) and greater risk of decline in physical function for participants with diabetes mellitus taking statins ( HR = 2.27, 95% CI = 1.39–3.69). Conclusions: In older adults with multiple chronic conditions, guideline‐recommended medications for atrial fibrillation, coronary artery disease, depression, diabetes mellitus, and heart failure were largely not associated with self‐reported decline in physical function, although there were associations for some medications in those with less polypharmacy.

Objectives: To determine empirically the diseases contributing most commonly and strongly to death in older adults, accounting for coexisting diseases. Design: Longitudinal. Setting: United States. Participants: Twenty‐two thousand eight hundred ninety M edicare C urrent B eneficiary S urvey participants, a national representative sample of Medicare beneficiaries, enrolled during 2002 to 2006. Measurements: Information on chronic and acute diseases was ascertained from M edicare claims data. Diseases contributing to death during follow‐up were identified empirically using regression models for all diseases with a frequency of 1% or greater and hazard ratio for death of greater than 1. The additive contributions of these diseases, adjusting for coexisting diseases, were calculated using a longitudinal extension of average attributable fraction; 95% confidence intervals were estimated from bootstrapping. Results: Fifteen diseases and acute events contributed significantly to death, together accounting for nearly 70% of death. Heart failure (20.0%), dementia (13.6%), chronic lower respiratory disease (12.4%), and pneumonia (5.3%) made the largest contributions to death. Cancer, including lung, colorectal, lymphoma, and head and neck, together contributed to 5.6% of death. Other diseases and events included acute kidney injury, stroke, septicemia, liver disease, myocardial infarction, and unintentional injuries. Conclusion: The use of methods that focus on determining a single underlying cause may lead to underestimation of the extent of the contribution of some diseases such as dementia and respiratory disease to death in older adults and overestimation of the contribution of other diseases. Current conceptualization of a single underlying cause may not account adequately for the contribution to death of coexisting diseases that older adults experience.

OBJECTIVES: 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. DESIGN: Cross‐sectional. SETTING: The Cardiovascular Health Study (CHS) and the Health, Aging and Body Composition Study (Health ABC). PARTICIPANTS: Five thousand six hundred fifty‐four CHS members and 2,706 Health ABC members. MEASUREMENTS: 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 (ADLs and IADLs), and death. Disease‐related symptoms and impairments included HF symptoms and ejection fraction (EF) for HF, Dyspnea Scale and forced expiratory volume in 1 second for COPD, joint pain for osteoarthritis, and executive function for cognitive impairment. RESULTS: The diseases were associated with the universal health outcomes ( P <.001) except osteoarthritis with death (both cohorts) and cognitive impairment with self‐rated health (Health ABC). Symptoms and impairments accounted for 30% or more of each disease's effect on the universal health outcomes. In CHS, for example, HF was associated with one fewer (0.918) ADL and IADL performed without difficulty than no HF; HF symptoms accounted for 27% of this effect and EF for only 5%. The hazard ratio for death with HF was 6.5 (95% confidence interval=4.7–8.9) with EF accounting for 40% and HF symptoms for only 14%. CONCLUSION: Disease‐related symptoms and impairments accounted for much of the significant associations between the four 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 and impairments that contribute most strongly to the effect of the disease on the universal health outcomes.

Syncopal episodes are common among older adults; etiologies range from benign to life threatening. We determined the frequency, yield, and costs of tests obtained to evaluate older persons with syncope. We also calculated the cost per test yield and determined whether the San Francisco syncope rule (SFSR) improved test yield. Review of 2106 consecutive patients 65 years or older admitted following a syncopal episode. Electrocardiograms (in 99% of admissions), telemetry (in 95%), cardiac enzyme tests (in 95%), and head computed tomographic (CT) scans (in 63%) were the most frequently obtained tests. Results from cardiac enzymes tests, CT scans, echocardiography, carotid ultrasonography, and electroencephalography all affected diagnosis or management in less than 5% of cases and helped determine the etiology of syncope less than 2% of the time. Postural blood pressure (BP) recording, performed in only 38% of episodes, had the highest yield with respect to affecting diagnosis (18%-26%) or management (25%-30%) and determining etiology of the syncopal episode (15%-21%). The cost per test affecting diagnosis or management was highest for electroencephalography ($32 973), CT scans ($24 881), and cardiac enzymes test ($22 397) and lowest for postural BP recording ($17-$20). The yields and costs for cardiac tests were better among patients meeting, vs those not meeting, the SFSR. For example, the cost per cardiac enzymes test affecting diagnosis or management was $10 331 in those meeting, vs $111 518 in those not meeting, the SFSR. Many unnecessary tests are obtained to evaluate syncope. Selecting tests based on history and examination and prioritizing less expensive and higher yield tests would ensure a more informed and cost-effective approach to evaluating older patients with syncope.

OBJECTIVES: To determine whether specific subsets of symptoms from the Geriatric Depression Scale (GDS), assessed at hospital admission, were associated with the incidence of delirium. DESIGN: Secondary analysis of a prospective cohort study of patients from the Delirium Prevention Trial. SETTING: General medicine service at Yale New Haven Hospital, March 25, 1995, through March 18, 1998. PARTICIPANTS: Four hundred sixteen patients aged 70 and older who were at intermediate or high risk for delirium and were not taking antidepressants at hospital admission. MEASUREMENTS: Depressive symptoms were assessed GDS, and daily assessments of delirium were obtained using the Confusion Assessment Method. RESULTS: Of the 416 patients in the analysis sample, 36 (8.6%) developed delirium within the first 5 days of hospitalization. Patients who developed delirium reported 5.7 depressive symptoms on average, whereas patients without delirium reported an average of 4.2 symptoms. Using a Cox proportional hazards model, it was found that depressive symptoms assessing dysphoric mood and hopelessness were predictive of incident delirium, controlling for measures of physical and mental health. In contrast, symptoms of withdrawal, apathy, and vigor were not significantly associated with delirium. CONCLUSION: These findings suggest that assessing symptoms of dysphoric mood and hopelessness could help identify patients at risk for incident delirium. Future studies should evaluate whether nonpharmacological treatment for these symptoms reduces the risk of delirium.

OBJECTIVES: To compare 1‐year institutionalization and mortality rates of patients who were delirious at discharge, patients whose delirium resolved by discharge, and patients who were never delirious in the hospital. DESIGN: Secondary analysis of prospective cohort data from the Delirium Prevention Trial. SETTING: General medicine service at Yale New Haven Hospital, March 25, 1995, through March 18, 1998, with follow‐up interviews completed in 2000. PARTICIPANTS: Four hundred thirty‐three patients aged 70 and older who were not delirious at admission. MEASUREMENTS: Patients underwent daily assessments of delirium from admission to discharge using the Confusion Assessment Method. Nursing home placement and mortality were determined at 1‐year follow up. RESULTS: Of the 433 study patients, 24 (5.5%) had delirium at discharge, 31 (7.2%) had delirium that resolved during hospitalization, and 378 (87.3%) were never delirious. After 1 year of follow‐up, 20 of 24 (83.3%) patients discharged with delirium, 21 of 31 (67.7%) patients whose delirium resolved, and 157 of 378 (41.5%) patients who were never delirious were admitted to a nursing home or died. Compared with patients who were never delirious, patients with delirium at discharge had a multivariable adjusted hazard ratio (HR) of 2.64 (95% confidence interval (CI)=1.60–4.35) for nursing home placement or mortality, whereas resolved cases had a HR of 1.53 (95% CI=0.96–2.43). CONCLUSION: Delirium at discharge is associated with a high rate of nursing home placement and mortality over a 1‐year follow‐up period. Interventions to increase detection of delirium and improvements in transitional care may help reduce these negative outcomes.