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More than dollars: Healthcare utilization among spouses of persons with dementia 不仅仅是金钱:痴呆症患者配偶的医疗保健使用情况。
IF 4.3 2区 医学 Q1 GERIATRICS & GERONTOLOGY Pub Date : 2024-08-29 DOI: 10.1111/jgs.19174
Molly J. Horstman MD, MS
<p>Being the spouse of a person with dementia can be a significant source of strain and can negatively impact one's health.<span><sup>1</sup></span> Although not all spouses serve as the primary caregiver, many spouses provide physical or emotional support to the person with dementia. Studies have shown that spouses of persons with dementia are more likely to have depression, anxiety, and sleep disturbances compared with spouses of persons who do not have dementia.<span><sup>2-4</sup></span> Identifying opportunities to improve health among spouses of persons with dementia is essential. In the United States, families provide most of the long-term care to persons with dementia.<span><sup>1</sup></span> Family members need to maintain sufficient health to fulfill caregiving roles and responsibilities to sustain this system. Spouses of a person with dementia may have less time and fewer financial resources to participate in recommended health behaviors and receive healthcare services, which, over time, may impact their ability to care for the person with dementia.<span><sup>5</sup></span></p><p>In this issue, <i>Ingraham</i> et al. present the results of a matched study examining Medicare Fee-for-Service expenditures for spouses of persons living with dementia compared with spouses of persons without dementia in the 5 years after the person with dementia was diagnosed with dementia.<span><sup>6</sup></span> Using the Health and Retirement Study with linked Medicare Claims, the authors measured three categories of health utilization costs: (1) inpatient or hospital expenditures; (2) outpatient or ambulatory expenditures, which included emergency room visits if a hospitalization did not follow the visit; and (3) skilled nursing facility, hospice, and home health expenditures. In the adjusted analysis, there was no difference in total Medicare expenditures between spouses of persons with dementia and spouses of persons without dementia in the 5 years after dementia was diagnosed. However, in Year 5, there was an increase in total Medicare expenditures among spouses of persons living with dementia driven by an increase in inpatient expenditures, with a total difference of $2748 (95% CI $321–$5447).</p><p>The results of this study differ from prior matched studies examining healthcare expenditures among spouses of persons living with dementia.<span><sup>3, 4, 7, 8</sup></span> As the authors note, prior studies had relied on claims data to identify persons with dementia, while the methods used by <i>Ingraham</i> et al. for identifying incident diagnoses of dementia from the Health and Retirement Study identified adults at an earlier stage of the disease. However, several other differences existed between this study and prior published studies. These include the methods by which spouses were identified, the type of insurance the spouse had, and the types of expenditures included in the total expenditures.<span><sup>3, 4, 7, 8</sup></span> In addition, <i>
作为痴呆症患者的配偶可能会承受巨大的压力,并对患者的健康产生负面影响。1 尽管并非所有的配偶都是主要的照顾者,但许多配偶都会为痴呆症患者提供身体或情感上的支持。研究表明,与非痴呆症患者的配偶相比,痴呆症患者的配偶更容易患抑郁症、焦虑症和睡眠障碍。在美国,大部分痴呆症患者的长期护理都是由家庭提供的。1 家庭成员需要保持足够的健康,以履行护理角色和责任,从而维持这一系统。痴呆症患者的配偶参与建议的健康行为和接受医疗保健服务的时间和财力可能较少,随着时间的推移,这可能会影响他们照顾痴呆症患者的能力。5 在本期杂志中,Ingraham 等人介绍了一项配对研究的结果,该研究对痴呆症患者的配偶与非痴呆症患者的配偶在痴呆症患者被诊断出患有痴呆症后 5 年内的医疗保险付费服务支出进行了比较。作者利用健康与退休研究(Health and Retirement Study)和关联的医疗保险索赔(Medicare Claims),测算了三类医疗利用成本:(1)住院病人或医院支出;(2)门诊病人或非住院病人支出,其中包括急诊就诊(如果就诊后没有住院);以及(3)专业护理机构、临终关怀和家庭医疗支出。在调整后的分析中,痴呆症患者的配偶与非痴呆症患者的配偶在痴呆症确诊后 5 年内的医疗保险总支出没有差异。然而,在第 5 年,痴呆症患者配偶的医疗保险总支出因住院费用的增加而增加,总差额为 2748 美元(95% CI 为 321 美元至 5447 美元)、4、7、8 正如作者所指出的,之前的研究依赖于索赔数据来识别痴呆症患者,而 Ingraham 等人从健康与退休研究(Health and Retirement Study)中使用的识别痴呆症事件诊断的方法则识别了处于疾病早期阶段的成年人。不过,这项研究与之前发表的研究还存在其他一些差异。3, 4, 7, 8 此外,Ingraham 等人还根据配偶是否需要帮助进行日常生活活动和工具性日常生活活动对配偶进行了匹配,而之前的研究并没有这样做。无论如何,Ingraham 等人的研究让我们进一步了解到,痴呆症患者配偶的医疗保健支出至少与非痴呆症患者配偶的医疗保健支出相同,某些类型的医疗保健支出可能更高。在一项针对患有多种慢性疾病的老年人的研究中,我们预计两组人都会有医疗保健支出。然而,两组之间相似的医疗支出并不意味着这两组接受了同等的医疗服务。9 在 20 年前发表的一项研究中,痴呆症患者的配偶与非痴呆症患者的配偶相比,去急诊室就诊的次数更多。4 目前的研究并未涉及这种情况是否仍然存在,但这确实提出了一个问题,即在所接受的医疗服务中是否存在未反映在总支出中的有意义的差异。了解两组患者在接受护理方面的差异可能会为干预措施提供启示,从而改善痴呆症患者配偶的健康状况。这与之前有关痴呆症患者照护者的文献一致,当照护者的损伤程度更严重、照护时间更长时,他们更有可能住院过夜。住院老年人常见的功能和认知能力下降可能会影响配偶履行护理责任的能力。
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引用次数: 0
Many studies, but little certainty about the effects of statin discontinuation on outcomes 研究很多,但停用他汀类药物对结果的影响却不确定。
IF 4.3 2区 医学 Q1 GERIATRICS & GERONTOLOGY Pub Date : 2024-08-29 DOI: 10.1111/jgs.19157
Michelle C. Odden PhD, Chintan V. Dave PharmD, PhD
<p>In this issue of the <i>Journal of the American Geriatrics Society</i>, Piexoto et al. conducted a systematic review of studies of statin discontinuation on clinical outcomes.<span><sup>1</sup></span> They identified only one randomized trial of statin discontinuation, conducted in people near the end of life, which found no difference in 60-day mortality or 1-year cardiovascular mortality among people who discontinued statins compared with those who continued statins. In contrast, among 35 nonrandomized studies among people not near the end of life, statin discontinuation was associated with a higher risk of all-cause mortality, cardiovascular mortality, and cardiovascular events. However, the authors noted concerns around bias of confounding by indication, along with concerns about imprecision, inconsistency, and heterogeneity. Together, the findings from observational studies were evaluated as having a high degree of uncertainty and bias, leaving providers and their patients with little useful information outside of the end-of-life setting.</p><p>There is discordance among the major Northern American and European guidelines on the evaluation of the benefit of statins in older adults, especially for primary prevention.<span><sup>2</sup></span> This is compounded by the challenge of accurate prediction of cardiovascular events in older adults, as a risk-based prevention strategy is the cornerstone of many of the guideline recommendations. Adding to the complexity, there is also insufficient evidence to capture potential harms of statin use due to the limited representation of older adults in large randomized statin trials. Further, limited evidence on statins and patient-centered outcomes such as frailty or statin-associated physical or cognitive changes exists, although one modestly sized trial demonstrated worsening decline in energy and exertional fatigue among persons randomized to statins.<span><sup>3</sup></span> Taken collectively, these factors have contributed to a growing interest in medication discontinuation or dose reduction, otherwise referred to as deprescribing, of statins in older adults.</p><p>Piexoto aimed to address this evidence gap by synthesizing the evidence for statin discontinuation, but their systematic review only highlights the challenges in estimating medication effects in observational studies.<span><sup>1</sup></span> Despite recent advancements in observational research methodologies, the majority of studies included in the review were assessed to have a serious risk of bias. The primary limitation of observational studies, in contrast to randomized trials, is that of confounding, or which occurs when the populations who discontinue statins are systematically different than those who continue statins. This limitation is especially challenging for studies of medication deprescribing and mortality, as limited life expectancy is a common reason for medication review and deprescribing.<span><sup>4</sup></span> The
在本期《美国老年医学会杂志》上,Piexoto 等人对停用他汀类药物对临床结果的影响进行了系统回顾。1 他们发现只有一项停用他汀类药物的随机试验是在临近生命终点的人群中进行的,结果发现停用他汀类药物的人群与继续服用他汀类药物的人群在 60 天死亡率或 1 年心血管死亡率方面没有差异。相比之下,在 35 项针对非临终人群的非随机研究中,他汀类药物的停用与较高的全因死亡率、心血管死亡率和心血管事件风险有关。不过,作者也指出了适应症混杂偏差的问题,以及不精确、不一致和异质性的问题。在评估他汀类药物对老年人的益处,尤其是对一级预防的益处方面,北美和欧洲的主要指南之间存在分歧2 。更复杂的是,由于大型随机他汀试验中老年人的比例有限,因此也没有足够的证据来说明使用他汀类药物的潜在危害。此外,有关他汀类药物和以患者为中心的结果(如虚弱或与他汀类药物相关的身体或认知变化)的证据也很有限,尽管有一项规模不大的试验表明,在随机服用他汀类药物的人群中,体力下降和劳累性疲劳的情况会恶化。Piexoto 旨在通过综合他汀类药物停药的证据来填补这一证据空白,但他们的系统综述只强调了在观察性研究中估计药物效果的挑战。与随机试验相比,观察性研究的主要局限性在于混杂因素,即停用他汀类药物的人群与继续服用他汀类药物的人群存在系统性差异。这一局限性对于药物停用和死亡率研究尤其具有挑战性,因为预期寿命有限是药物审查和停用的常见原因。ACC/AHA 指南指出:"当功能衰退(身体或认知能力)、多病症、虚弱或预期寿命缩短限制了他汀类药物治疗的潜在益处时,停止他汀类药物治疗可能是合理的。这很难在电子健康记录中捕捉到,因此也很难在统计模型中加以控制,因为许多为老年人提供护理的医护人员都是凭临床直觉来预测存活期的。7, 8 除了内部效度问题外,所纳入的研究还突显了在了解多病或体弱患者的他汀类药物去处方情况或其对以患者为中心的终点的后续影响方面存在的重大研究空白。此外,虽然这些研究主要集中在描述他汀类药物停药对心血管造成的风险,但其潜在的益处,如预防不良反应(如肌病、糖尿病)或改善生活质量,仍未得到研究。证据上的不确定性很可能会持续存在,包括一级预防与二级预防、对认知和身体机能等老年病特异性终点的影响,以及对不同程度的多病症、虚弱和通常被排除在试验之外的疾病(如痴呆症和严重慢性肾病)的临床人群的适用性。因此,对于此类试验证据有限的研究问题,研究人员转而采用其他现代方法来更好地估计因果效应。这些强大的工具可以解决观察性研究的一些常见局限性,但应在更广泛的证据范围内进行解释。
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引用次数: 0
Gait performance in older adults across the cognitive spectrum: Results from the GAIT cohort 不同认知能力的老年人的步态表现:GAIT队列的结果。
IF 4.3 2区 医学 Q1 GERIATRICS & GERONTOLOGY Pub Date : 2024-08-29 DOI: 10.1111/jgs.19162
Pauline Ali MD, MSc, Pauline Renaud MD, Manuel Montero-Odasso MD, FRCPC, PhD, AGSF, FGSA, Jennifer Gautier MS, Mickaël Dinomais MD, PhD, Cédric Annweiler MD, PhD

Background

Gait performance can provide valuable insights into cognitive functioning in older adult and may be used to screen for cognitive impairment. However, the optimal test condition and spatiotemporal parameter for accuracy have not yet been determined. This study aims to determine the gait measure with the highest accuracy identifying cognitive decline.

Methods

A total of 711 participants were recruited, including 332 cognitively healthy individuals, 264 with mild cognitive impairment (MCI), and 115 with dementia, with a mean age of 72 years (interquartile range 69–76), and 43% (n = 307) of women. The participants underwent gait assessment in three different conditions, including a single task and dual tasks of counting backward by ones and naming animals.

Results

Gait performance was deteriorated as cognitive impairment progressed. The gait test performed during naming animals condition was the most accurate in differentiating between cognitive groups. Specifically, the naming animals gait speed was more accurate in discriminating control participants from those with cognitive impairment (area under the curve [AUC] = 76.9% for MCI and 99.7% for people with dementia with control group as reference). The coefficient of stride length variability while naming animals was the most effective parameter in discriminating between MCI and dementia groups (AUC = 96.7%).

Conclusions

The naming animals dual-task gait test can be a valuable assessment for screening cognitive impairment in older adults, regardless of their cognitive abilities. The test is useful in clinical settings for subjects with a range of cognitive profiles.

背景:步态表现可为了解老年人的认知功能提供有价值的信息,并可用于筛查认知障碍。然而,目前尚未确定准确性的最佳测试条件和时空参数。本研究旨在确定识别认知功能下降准确性最高的步态测量方法:共招募了 711 名参与者,其中包括 332 名认知能力健康者、264 名轻度认知障碍(MCI)患者和 115 名痴呆症患者,他们的平均年龄为 72 岁(四分位间范围为 69-76),女性占 43% (n = 307)。参与者在三种不同的条件下进行了步态评估,包括单一任务和倒数 1 和命名动物的双重任务:结果:随着认知障碍程度的加深,步态表现越来越差。在命名动物的条件下进行的步态测试在区分认知障碍组别方面最为准确。具体来说,命名动物步态速度在区分对照组和认知障碍组时更为准确(以对照组为参照,MCI 患者的曲线下面积[AUC] = 76.9%,痴呆症患者的曲线下面积[AUC] = 99.7%)。命名动物时的步长变异系数是区分 MCI 组和痴呆组的最有效参数(AUC = 96.7%):命名动物双任务步态测试是筛查老年人认知障碍的一项重要评估,无论其认知能力如何。在临床环境中,该测试对不同认知能力的受试者都很有用。
{"title":"Gait performance in older adults across the cognitive spectrum: Results from the GAIT cohort","authors":"Pauline Ali MD, MSc,&nbsp;Pauline Renaud MD,&nbsp;Manuel Montero-Odasso MD, FRCPC, PhD, AGSF, FGSA,&nbsp;Jennifer Gautier MS,&nbsp;Mickaël Dinomais MD, PhD,&nbsp;Cédric Annweiler MD, PhD","doi":"10.1111/jgs.19162","DOIUrl":"10.1111/jgs.19162","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Gait performance can provide valuable insights into cognitive functioning in older adult and may be used to screen for cognitive impairment. However, the optimal test condition and spatiotemporal parameter for accuracy have not yet been determined. This study aims to determine the gait measure with the highest accuracy identifying cognitive decline.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>A total of 711 participants were recruited, including 332 cognitively healthy individuals, 264 with mild cognitive impairment (MCI), and 115 with dementia, with a mean age of 72 years (interquartile range 69–76), and 43% (<i>n</i> = 307) of women. The participants underwent gait assessment in three different conditions, including a single task and dual tasks of counting backward by ones and naming animals.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Gait performance was deteriorated as cognitive impairment progressed. The gait test performed during naming animals condition was the most accurate in differentiating between cognitive groups. Specifically, the naming animals gait speed was more accurate in discriminating control participants from those with cognitive impairment (area under the curve [AUC] = 76.9% for MCI and 99.7% for people with dementia with control group as reference). The coefficient of stride length variability while naming animals was the most effective parameter in discriminating between MCI and dementia groups (AUC = 96.7%).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>The naming animals dual-task gait test can be a valuable assessment for screening cognitive impairment in older adults, regardless of their cognitive abilities. The test is useful in clinical settings for subjects with a range of cognitive profiles.</p>\u0000 </section>\u0000 </div>","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"72 11","pages":"3437-3447"},"PeriodicalIF":4.3,"publicationDate":"2024-08-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.19162","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142116612","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Anxiety and aging: A marker of brain changes and potential treatment target to promote brain health 焦虑与衰老:大脑变化的标志和促进大脑健康的潜在治疗目标。
IF 4.3 2区 医学 Q1 GERIATRICS & GERONTOLOGY Pub Date : 2024-08-29 DOI: 10.1111/jgs.19168
Jordan F. Karp MD, Eric J. Lenze MD
<p>Almost 7 million Americans have Alzheimer's dementia. Approximately 20% of middle-aged women and 10% of middle-aged men will eventually develop Alzheimer's dementia in their lifetime, usually occurring after age 65.<span><sup>1</sup></span> Given the aging of the population, absent incident prevention or efforts that slow the course of the illness there will be close to 14 million Americans living with the disease by 2060.<span><sup>1</sup></span> Although new treatments exist, there is no currently available scalable cure that is cost-effective (accounting for Quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios, and costs), nor will one likely be launched within the next decade. Thus, there needs to be a greater focus on modifiable risk factors (12 of which account for 40% of worldwide dementias)<span><sup>2</sup></span> to prevent new cases in the United States and across the globe.</p><p>Anxiety disorders are common: they have a lifetime prevalence of approximately 34% in the United States<span><sup>3</sup></span> and are the second most common neuropsychiatric disease after depression.<span><sup>4</sup></span> Anxiety is linked with higher rates of both depression<span><sup>5</sup></span> and addiction<span><sup>6</sup></span>; reflects a state of both psychic and physical stress<span><sup>7</sup></span>; and is linked with pro-inflammatory<span><sup>8</sup></span> states, cognitive impairment,<span><sup>9</sup></span> cardiovascular disease,<span><sup>10</sup></span> and all-cause mortality.<span><sup>11</sup></span> It is also treatable. Elucidating the interaction between having anxiety in late-life and rates of incident dementia may add to the list of modifiable risk factors for cognitive decline and neurodegenerative diseases.</p><p>This issue of the journal includes a study by Khaing and colleagues entitled “The effect of anxiety on all-cause dementia: a longitudinal analysis from the Hunter Community Study.”<span><sup>12</sup></span> Their communication describes the association of chronic versus resolved versus new onset anxiety on subsequent diagnosis of dementia. The investigators hypothesized that both the (1) chronicity of anxiety and (2) age of exposure to anxiety would be linked with all-cause dementia risk. The sample (<i>n</i> = 2132, mean age = 76) was an existing cohort of community-dwelling Australians who were recruited between 2004 and 2007. Wave 2 and Wave 3 assessments were completed at 5-year intervals after Wave 1. The natural history of anxiety was categorized as (1) Chronic Anxiety (present at Wave 1 and Wave 2); (2) Resolved Anxiety (present only at Wave 1); and (3) New Anxiety (present only at Wave 2). The primary outcome was incident all-cause dementia up to 13 years after Wave 1. Sixty-four participants (3%) were diagnosed with dementia with the average onset at year 10. Chronic Anxiety (HR = 2.80) and New Anxiety (HR = 3.20) at Wave 2 were both associated with increased risk of all-cau
近 700 万美国人患有阿尔茨海默氏痴呆症。大约 20% 的中年女性和 10% 的中年男性在其一生中将最终患上阿尔茨海默氏症痴呆症,通常发生在 65 岁之后。1 鉴于人口老龄化,如果不采取预防措施或延缓病程,到 2060 年,将有近 1400 万美国人罹患此病。1 尽管存在新的治疗方法,但目前还没有可推广的、具有成本效益(考虑质量调整生命年(QALYs)、增量成本效益比和成本)的治疗方法,也不可能在未来十年内推出。焦虑症很常见:在美国,焦虑症的终生患病率约为 34%3 ,是仅次于抑郁症的第二大常见神经精神疾病4。焦虑症与抑郁症5 和成瘾症6 的高发率有关;反映了一种心理和生理压力状态7 ;与促炎症8 状态、认知障碍9 、心血管疾病10 和全因死亡率11 有关。本期杂志刊登了 Khaing 及其同事的一项研究,题为 "焦虑对全因痴呆症的影响:亨特社区研究的纵向分析 "12 。他们的研究报告描述了慢性焦虑、缓解焦虑和新发焦虑对痴呆症后续诊断的影响。研究者假设:(1) 焦虑的长期性和 (2) 接触焦虑的年龄都与全因痴呆症风险有关。样本(n = 2132,平均年龄 = 76)是2004年至2007年间招募的居住在社区的澳大利亚人的现有队列。第二波和第三波评估是在第一波评估后每隔 5 年完成的。焦虑的自然史分为:(1) 慢性焦虑(在第 1 波和第 2 波均存在);(2) 已解决的焦虑(仅在第 1 波存在);(3) 新焦虑(仅在第 2 波存在)。64 名参与者(3%)被诊断出患有痴呆症,平均发病时间为第 10 年。第 2 波的慢性焦虑(HR = 2.80)和新焦虑(HR = 3.20)都与全因痴呆症风险的增加有关。已解决的焦虑与全因痴呆风险的增加无关。当按年龄进行分层分析时,60-70 岁同时患有慢性焦虑症(HR = 4.58)和新焦虑症(HR = 7.21)的人群患痴呆症的风险更高。作者以平和谨慎的态度解释和描述了这些观察结果。敏感性分析考虑了(1)从基线开始的前5年中被删减的参与者;(2)缺失数据,使用多重归因和观察病例分析,结果显示与主要分析结果类似,尽管缺失数据敏感性分析的效应大小有所减弱(但仍然显著)。这种方法加强了主要观察结果的严谨性和稳定性,作者还深思熟虑地描述了该研究在方法上的五大局限性。也许最大的问题是:全因痴呆诊断前几年的焦虑代表了什么?它是神经退行性疾病的前兆(指即将出现认知功能衰退和随后的神经精神变化的早期行为标记),还是与神经退行性疾病的发展或加速以及认知和行为变化有机理联系的真正风险因素?像这样的队列研究可以建立关联,但无法区分前驱症状和风险因素。正如 Geoffroy 和 Scott 雄辩地描述的那样:"'前驱症状'与'风险综合征'的主要区别在于,前者主要是预测所研究精神障碍的发作,而后者主要是预测某人首次发病的总体可能性(与无障碍或其他障碍相比)、不管是前驱症状还是风险因素的难题,Khaing 等人的研究为焦虑、神经变性和痴呆之间的新兴科学联系增添了新的内容。
{"title":"Anxiety and aging: A marker of brain changes and potential treatment target to promote brain health","authors":"Jordan F. Karp MD,&nbsp;Eric J. Lenze MD","doi":"10.1111/jgs.19168","DOIUrl":"10.1111/jgs.19168","url":null,"abstract":"&lt;p&gt;Almost 7 million Americans have Alzheimer's dementia. Approximately 20% of middle-aged women and 10% of middle-aged men will eventually develop Alzheimer's dementia in their lifetime, usually occurring after age 65.&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; Given the aging of the population, absent incident prevention or efforts that slow the course of the illness there will be close to 14 million Americans living with the disease by 2060.&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; Although new treatments exist, there is no currently available scalable cure that is cost-effective (accounting for Quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios, and costs), nor will one likely be launched within the next decade. Thus, there needs to be a greater focus on modifiable risk factors (12 of which account for 40% of worldwide dementias)&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; to prevent new cases in the United States and across the globe.&lt;/p&gt;&lt;p&gt;Anxiety disorders are common: they have a lifetime prevalence of approximately 34% in the United States&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; and are the second most common neuropsychiatric disease after depression.&lt;span&gt;&lt;sup&gt;4&lt;/sup&gt;&lt;/span&gt; Anxiety is linked with higher rates of both depression&lt;span&gt;&lt;sup&gt;5&lt;/sup&gt;&lt;/span&gt; and addiction&lt;span&gt;&lt;sup&gt;6&lt;/sup&gt;&lt;/span&gt;; reflects a state of both psychic and physical stress&lt;span&gt;&lt;sup&gt;7&lt;/sup&gt;&lt;/span&gt;; and is linked with pro-inflammatory&lt;span&gt;&lt;sup&gt;8&lt;/sup&gt;&lt;/span&gt; states, cognitive impairment,&lt;span&gt;&lt;sup&gt;9&lt;/sup&gt;&lt;/span&gt; cardiovascular disease,&lt;span&gt;&lt;sup&gt;10&lt;/sup&gt;&lt;/span&gt; and all-cause mortality.&lt;span&gt;&lt;sup&gt;11&lt;/sup&gt;&lt;/span&gt; It is also treatable. Elucidating the interaction between having anxiety in late-life and rates of incident dementia may add to the list of modifiable risk factors for cognitive decline and neurodegenerative diseases.&lt;/p&gt;&lt;p&gt;This issue of the journal includes a study by Khaing and colleagues entitled “The effect of anxiety on all-cause dementia: a longitudinal analysis from the Hunter Community Study.”&lt;span&gt;&lt;sup&gt;12&lt;/sup&gt;&lt;/span&gt; Their communication describes the association of chronic versus resolved versus new onset anxiety on subsequent diagnosis of dementia. The investigators hypothesized that both the (1) chronicity of anxiety and (2) age of exposure to anxiety would be linked with all-cause dementia risk. The sample (&lt;i&gt;n&lt;/i&gt; = 2132, mean age = 76) was an existing cohort of community-dwelling Australians who were recruited between 2004 and 2007. Wave 2 and Wave 3 assessments were completed at 5-year intervals after Wave 1. The natural history of anxiety was categorized as (1) Chronic Anxiety (present at Wave 1 and Wave 2); (2) Resolved Anxiety (present only at Wave 1); and (3) New Anxiety (present only at Wave 2). The primary outcome was incident all-cause dementia up to 13 years after Wave 1. Sixty-four participants (3%) were diagnosed with dementia with the average onset at year 10. Chronic Anxiety (HR = 2.80) and New Anxiety (HR = 3.20) at Wave 2 were both associated with increased risk of all-cau","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"72 11","pages":"3294-3295"},"PeriodicalIF":4.3,"publicationDate":"2024-08-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.19168","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142116609","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Racial and ethnic differences in unmet needs among older adults receiving publicly-funded home and community-based services 接受政府资助的家庭和社区服务的老年人在未满足需求方面的种族和民族差异。
IF 4.3 2区 医学 Q1 GERIATRICS & GERONTOLOGY Pub Date : 2024-08-29 DOI: 10.1111/jgs.19153
Chanee D. Fabius PhD, MA, Romil Parikh MBBS, MPH, Jack M. Wolf BA, Stephanie Giordano DLP, MEEP, Shekinah Fashaw-Walters PhD, Eric Jutkowitz PhD, Tetyana Shippee PhD, FGSA

Background

Unmet need for home and community-based services (HCBS) may disparately impact older adults from racial and ethnic minoritized groups. We examined racial and ethnic differences in unmet need for HCBS among consumers ≥65 years using publicly funded HCBS.

Methods

We analyzed the National Core Indicators-Aging and Disability survey data (2015–2019) from 21,739 community-dwelling HCBS consumers aged ≥65 years in 23 participating states. Outcome measures included self-reported unmet need in six service types (i.e., personal care, homemaker/chore, delivered meals, adult day services, transportation, and caregiver support). Racial and ethnic groups included non-Hispanic Black, Asian, non-Hispanic White, Hispanic, and multiracial groups. Logistic regression models examined associations between race and ethnicity and unmet need, adjusting for sociodemographic, health, and HCBS program (i.e., Medicaid, Older Americans Act [OAA], Program for All-Inclusive Care for the Elderly [PACE]) characteristics, and use of specific service types.

Results

Among 21,739 respondents, 23.3% were Black, 3.4% were Asian, 10.8% were Hispanic, 58.8% were non-Hispanic White, and 3.7% were multiracial or identified with other races/ethnicities. Asian and Black consumers had higher odds of reporting unmet need in personal care than White consumers (adjusted odds ratio [aOR], 1.45, p value < 0.01; and aOR, 1.25, p < 0.001, respectively). Asian and Black consumers had significantly higher odds of unmet need in adult day services versus White consumers (aOR, 1.94, p < 0.001 and aOR, 1.39, p < 0.001, respectively). Black consumers had higher odds of unmet need versus non-Hispanic White consumers in meal delivery and caregiver support services (aOR, 1.29; p < 0.01; and aOR 1.26, p < 0.05, respectively). Race and ethnicity were not significantly associated with experiencing unmet need for homemaker/chore or transportation services.

Conclusions

Future research should identify driving forces in disparities in unmet need to develop culturally appropriate solutions.

背景:对家庭和社区服务(HCBS)的需求未得到满足可能会对来自少数种族和族裔群体的老年人造成不同程度的影响。我们研究了使用政府资助的家庭和社区服务(HCBS)的年龄≥65 岁的消费者在家庭和社区服务未满足需求方面的种族和民族差异:我们分析了全国核心指标--老龄和残疾调查数据(2015-2019 年),这些数据来自 23 个参与州的 21739 名年龄≥65 岁、居住在社区的 HCBS 消费者。结果测量包括六种服务类型(即个人护理、家政服务/家务、送餐服务、成人日间服务、交通和护理人员支持)中自我报告的未满足需求。种族和民族群体包括非西班牙裔黑人、亚裔、非西班牙裔白人、西班牙裔和多种族群体。逻辑回归模型检验了种族和民族与未满足需求之间的关联,并对社会人口、健康和 HCBS 计划(即 Medicaid、《美国老年人法案》[OAA]、《老年人全包护理计划》[PACE])特征以及特定服务类型的使用情况进行了调整:在 21739 名受访者中,23.3% 为黑人,3.4% 为亚裔,10.8% 为西班牙裔,58.8% 为非西班牙裔白人,3.7% 为多种族或其他种族/民族。与白人消费者相比,亚裔和黑人消费者报告个人护理需求未得到满足的几率更高(调整后的几率比[aOR],1.45,P值 结论):未来的研究应找出未满足需求差异的驱动因素,以制定文化上合适的解决方案。
{"title":"Racial and ethnic differences in unmet needs among older adults receiving publicly-funded home and community-based services","authors":"Chanee D. Fabius PhD, MA,&nbsp;Romil Parikh MBBS, MPH,&nbsp;Jack M. Wolf BA,&nbsp;Stephanie Giordano DLP, MEEP,&nbsp;Shekinah Fashaw-Walters PhD,&nbsp;Eric Jutkowitz PhD,&nbsp;Tetyana Shippee PhD, FGSA","doi":"10.1111/jgs.19153","DOIUrl":"10.1111/jgs.19153","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Unmet need for home and community-based services (HCBS) may disparately impact older adults from racial and ethnic minoritized groups. We examined racial and ethnic differences in unmet need for HCBS among consumers ≥65 years using publicly funded HCBS.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We analyzed the National Core Indicators-Aging and Disability survey data (2015–2019) from 21,739 community-dwelling HCBS consumers aged ≥65 years in 23 participating states. Outcome measures included self-reported unmet need in six service types (i.e., personal care, homemaker/chore, delivered meals, adult day services, transportation, and caregiver support). Racial and ethnic groups included non-Hispanic Black, Asian, non-Hispanic White, Hispanic, and multiracial groups. Logistic regression models examined associations between race and ethnicity and unmet need, adjusting for sociodemographic, health, and HCBS program (i.e., Medicaid, Older Americans Act [OAA], Program for All-Inclusive Care for the Elderly [PACE]) characteristics, and use of specific service types.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Among 21,739 respondents, 23.3% were Black, 3.4% were Asian, 10.8% were Hispanic, 58.8% were non-Hispanic White, and 3.7% were multiracial or identified with other races/ethnicities. Asian and Black consumers had higher odds of reporting unmet need in personal care than White consumers (adjusted odds ratio [aOR], 1.45, <i>p</i> value &lt; 0.01; and aOR, 1.25, <i>p</i> &lt; 0.001, respectively). Asian and Black consumers had significantly higher odds of unmet need in adult day services versus White consumers (aOR, 1.94, <i>p</i> &lt; 0.001 and aOR, 1.39, <i>p</i> &lt; 0.001, respectively). Black consumers had higher odds of unmet need versus non-Hispanic White consumers in meal delivery and caregiver support services (aOR, 1.29; <i>p</i> &lt; 0.01; and aOR 1.26, <i>p</i> &lt; 0.05, respectively). Race and ethnicity were not significantly associated with experiencing unmet need for homemaker/chore or transportation services.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Future research should identify driving forces in disparities in unmet need to develop culturally appropriate solutions.</p>\u0000 </section>\u0000 </div>","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"72 11","pages":"3520-3529"},"PeriodicalIF":4.3,"publicationDate":"2024-08-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142116619","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Comment on: Willingness to take less medication for type 2 diabetes among older patients 发表评论:老年 2 型糖尿病患者减少用药的意愿。
IF 4.3 2区 医学 Q1 GERIATRICS & GERONTOLOGY Pub Date : 2024-08-28 DOI: 10.1111/jgs.19175
Petra Denig PhD, Peter J. C. Stuijt MSc
<p>When people with type 2 diabetes age and their health status deteriorates, reevaluation of their treatment is needed. Medication de-intensification is recommended for older patients with a poor health status when they have low levels of hemoglobin A1c while taking medication. The recently published study of Haider et al. investigated the willingness of older people with diabetes to de-intensify their medication.<span><sup>1</sup></span> Of particular interest, they examined which patient characteristics were associated with such willingness and whether this aligned with the guideline recommendations. A key finding was that the people who may benefit the most from treatment de-intensification according to the guidelines were less likely to be willing to take less diabetes medication.<span><sup>1</sup></span></p><p>As Pilla et al. mentioned in an editorial, the study was limited by its reliance on responses to the question “I would be willing to take less medication for my diabetes” that lacks clinical context.<span><sup>2</sup></span> An alternative question has been posed by Crutzen et al. in a study among older people on diabetes and/or cardiovascular drugs.<span><sup>3</sup></span> This concerns the question from revised Patients Attitudes Towards Deprescribing (rPATD) questionnaire, “If my doctor said it was possible, I would be willing to stop one or more of my regular medicines.”<span><sup>4</sup></span> Crutzen et al. observed that 88% of older patients were willing to stop medication if their doctor said it was possible. This is clearly higher than the 51% willing to take less medication in the study of Haider et al. Although this could indicate that the willingness was higher given the context “that the doctor said it was possible,” an alternative explanation is that the willingness depends on the type of medication. Where the question posed by Haider et al. referred to “less medication for my diabetes,” the medication is not specified in the willingness question of the rPATD.</p><p>Differences regarding attitudes toward specific medication were further explored by Crutzen et al.<span><sup>3</sup></span> In particular, attitudes towards de-intensifying insulin, sulfonylurea, or statins were studied, showing remarkable differences. For example, few of the older people would like their doctor to reduce the dose of their insulin and more than half were reluctant to stop insulin (Table 1). For patients taking sulfonylurea or statins, these percentages were more in favor of de-intensification (Table 1). Furthermore, few people would like to try stopping the insulin or sulfonylurea they were taking to see how they would feel without, whereas more patients would like to try stopping their statin (Table 1). This might be related to experiencing drug-related problems, such as side effects. Very few patients believed they experienced side effects from their insulin or sulfonylurea, but this was clearly different for statins (Table 1). The findin
当 2 型糖尿病患者年龄增长、健康状况恶化时,需要重新评估他们的治疗。对于健康状况较差的老年患者,如果他们在服药期间血红蛋白 A1c 水平较低,则建议减低用药强度。海德尔(Haider)等人最近发表的研究报告调查了老年糖尿病患者是否愿意减低用药强度。1 特别值得关注的是,他们研究了哪些患者特征与减低用药强度的意愿有关,以及这是否与指南建议一致。1 正如皮拉等人在一篇社论中提到的,这项研究的局限性在于它依赖于对 "我愿意减少糖尿病药物用量 "这一问题的回答,而这一问题缺乏临床背景。Crutzen 等人在一项针对服用糖尿病和/或心血管药物的老年人的研究中提出了另一个问题。3 该问题涉及经修订的《患者对减药的态度》(rPATD)问卷中的问题:"如果医生说有可能,我愿意停用一种或多种常规药物"。虽然这可能表明,在 "医生说可以 "的情况下,患者的意愿更高,但另一种解释是,患者的意愿取决于药物的种类。在 Haider 等人提出的问题中提到 "减少糖尿病药物治疗",而 rPATD 的意愿问题中并没有具体说明药物。例如,很少有老年人希望医生减少胰岛素的剂量,一半以上的老年人不愿意停用胰岛素(表 1)。而服用磺脲类药物或他汀类药物的患者则更倾向于减少剂量(表 1)。此外,很少有人愿意尝试停用正在服用的胰岛素或磺脲类药物,以了解停药后的感觉,而更多患者愿意尝试停用他汀类药物(表 1)。这可能与遇到药物相关问题(如副作用)有关。只有极少数患者认为胰岛素或磺脲类药物会给他们带来副作用,但他汀类药物显然不同(表 1)。糖尿病患者是否愿意减低用药强度取决于药物的种类,这一发现并不令人惊讶,因为不同的心血管代谢药物在必要性和顾虑方面也存在差异。降低强度可能包括停药和降低治疗强度。在 Haider 等人的研究中,并不清楚受访者如何理解 "愿意减少服药"。有些人可能认为这意味着停止用药,而另一些人可能认为这也包括减少用药剂量。Crutzen 等人的研究表明,大多数老年患者不确定是否愿意减少一种或多种药物的剂量。3 Pilla 等人和 Haider 等人都承认,定性研究对于深入了解愿意或不愿意减少糖尿病药物治疗的人的信念和观点非常重要、2 以往研究的相关发现包括,一些患者对糖尿病药物治疗的益处抱有不切实际的期望,一些患者对改变治疗目标感到困惑。关于药物减量的共同决策必须包括患者与医护人员关于治疗目标以及继续严格治疗方案的益处和风险的对话。此外,以往的研究还发现了在哪些条件下患者更愿意放弃强化治疗。6, 7 最后,医疗服务提供者可能需要接受更多培训,以进行去势咨询和应用去势原则。最近的研究表明,这种培训可以使糖尿病患者更频繁地停药。
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引用次数: 0
Clinical performance of existing diagnostic criteria for pneumonia in older emergency patients: A prospective cohort study 老年急诊患者肺炎现有诊断标准的临床表现:前瞻性队列研究。
IF 4.3 2区 医学 Q1 GERIATRICS & GERONTOLOGY Pub Date : 2024-08-24 DOI: 10.1111/jgs.19113
Katherine M. Hunold MD, MPH, Lorraine C. Mion PhD, RN, FAAN, Tanya R. Gure MD, Andrew L. Schwaderer MD, Matthew Exline MD, MPH, Courtney Hebert MD, MS, Brent C. Lampert DO, Lauren T. Southerland MD, Julie A. Stephens MS, Edward W. Boyer MD, PhD, Michael Hill RN, Ching-Min B. Chu BS, Carson Reider PhD, Jeffrey M. Caterino MD, MPH

Background

Pneumonia accounts for over half a million older adult emergency department (ED) visits annually, but ED pneumonia diagnosis is inaccurate. Geriatric-specific pneumonia diagnostic criteria exist for other settings; no prospective data exist to determine if application in the older adult ED population is feasible. The objective was to prospectively evaluate the utility of four current diagnostic criteria (Loeb; Modified McGeer; Infectious Disease Society of America/American Thoracic Society; American College of Emergency Physicians) in older adult ED patients.

Methods

This was a prospective, observational cohort study of older adult ED patients ≥65 years of age in two U.S. EDs with suspected pneumonia defined as having chest radiography ordered and treating physician suspicion. The standard we used for defining the presence, absence, or inability to determine a diagnosis of pneumonia diagnosis was expert physician chart adjudication. We report the summary statistics for demographic characteristics and symptoms/exam findings and sensitivity, specificity, and likelihood ratios with 95% confidence intervals of the existing diagnostic criteria. Pre-specified cutoff values of a positive LR >10 and a negative LR <0.3 were considered clinically significant.

Results

Of 135 patients enrolled, 27 had pneumonia by adjudicator review. Typical patient-reported pneumonia symptoms, such as fever (18.5%) and new/worse cough (51.9%), were not consistently present in pneumonia. The IDSA/ATS and ACEP criteria had positive LR >10 and negative LR <0.3; however, all confidence intervals included pre-specified cutoffs.

Conclusions

Older adults presented to the ED with low frequency of typical pneumonia symptoms. Although existing diagnostic definitions had promising test characteristics, they may not perform well enough for clinical application without refinement.

背景:每年有 50 多万老年人因肺炎到急诊科(ED)就诊,但急诊科肺炎诊断并不准确。目前已有针对其他环境的老年肺炎诊断标准,但尚无前瞻性数据来确定在老年人急诊室人群中应用这些标准是否可行。我们的目的是前瞻性地评估目前四种诊断标准(Loeb、修订版 McGeer、美国传染病学会/美国胸科学会、美国急诊医师学会)在老年急诊室患者中的实用性:这是一项前瞻性的观察性队列研究,研究对象是美国两家急诊室中年龄≥65 岁的老年急诊患者,其疑似肺炎的定义是已接受胸片检查且主治医生怀疑其患有肺炎。我们采用专家医师的病历判定标准来界定是否存在肺炎诊断或无法确定肺炎诊断。我们报告了现有诊断标准的人口统计学特征、症状/检查结果、灵敏度、特异性、似然比及 95% 置信区间的汇总统计。预设的临界值为阳性 LR >10 和阴性 LR 结果:在 135 名入选患者中,经评审员审查,27 人患有肺炎。患者报告的典型肺炎症状,如发热(18.5%)和新发/加重的咳嗽(51.9%),在肺炎中并不总是出现。IDSA/ATS 和 ACEP 标准的阳性 LR >10 和阴性 LR 结论:老年人在急诊室出现典型肺炎症状的频率较低。虽然现有的诊断定义具有很好的测试特性,但如果不加以改进,它们可能无法很好地应用于临床。
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引用次数: 0
Individual socioeconomic status, neighborhood disadvantage, and cognitive aging: A longitudinal analysis of the CLSA 个人社会经济地位、邻里劣势和认知老化:对 CLSA 的纵向分析。
IF 4.3 2区 医学 Q1 GERIATRICS & GERONTOLOGY Pub Date : 2024-08-23 DOI: 10.1111/jgs.19155
John R. Best PhD

Background

There are likely many contributors to variation in the rate of cognitive decline in middle and late adulthood, including individual and neighborhood socio-economic factors. This study examines whether individual socio-economic factors, namely income and wealth, correlate with cognitive decline, in part, through neighborhood-level social and material disadvantage.

Methods

Using the three waves of data collection from the Canadian Longitudinal Study on Aging (CLSA), this study included 51,338 participants between the age of 45 and 85 years at baseline (51% female). Individual socio-economic status (SES) was assessed by annual household income and by the current value of savings and investments. Neighborhood disadvantage was measured by area-based material and social deprivation indices. Cognition was measured at each wave using verbal fluency, mental alternations, and delayed word recall. Latent change score models, incorporating direct and indirect pathways, were constructed to estimate the indirect effect of individual SES on cognitive change through area-level disadvantage. Multi-group models were constructed on the basis of age-group (45–64 years; 65–74 years; or 75+ years) to allow for varying estimates across age.

Results

Among 45–64-year-olds, income and wealth had indirect effects on initial cognitive level and on rate of cognitive decline through material disadvantage (standardized indirect effects = 0.01, p < 0.001), but only wealth had an indirect effect through social disadvantage (p = 0.019). Among 65-74-year-olds, income and wealth had indirect effects on initial cognitive level (p < 0.01) but not on rate of cognitive decline (p > 0.05), and among 75+ year-olds, no indirect effects were observed (p > 0.05). Wealth and income had direct effects, independent of neighborhood disadvantage, on cognition in all age groups (p < 0.05).

Conclusions

Among middle-aged adults, greater individual SES may mitigate cognitive decline, in part, by allowing individuals to live in more materially and socially advantaged neighborhoods.

背景:造成中晚年认知能力下降率差异的因素可能有很多,其中包括个人和邻里社会经济因素。本研究探讨了个人社会经济因素(即收入和财富)是否在一定程度上通过邻里层面的社会和物质劣势与认知能力下降相关联:本研究利用加拿大老龄化纵向研究(CLSA)的三波数据收集,纳入了基线年龄在 45 岁至 85 岁之间的 51,338 名参与者(51% 为女性)。个人社会经济地位(SES)通过家庭年收入以及储蓄和投资的现值进行评估。邻里劣势通过基于地区的物质和社会贫困指数来衡量。在每个波次中,均使用言语流畅度、思维交替和延迟单词回忆对认知能力进行测量。我们构建了包含直接和间接途径的潜在变化得分模型,以估算个人社会经济地位通过地区层面的不利条件对认知变化的间接影响。根据年龄组(45-64 岁;65-74 岁;或 75 岁以上)构建了多组模型,以便在不同年龄段得出不同的估计结果:在 45-64 岁的人群中,收入和财富对初始认知水平和因物质条件不利而导致的认知能力下降率有间接影响(标准化间接影响 = 0.01,P 0.05),而在 75 岁以上的人群中,没有观察到间接影响(P > 0.05)。在所有年龄组中,财富和收入对认知能力都有直接影响,与邻里劣势无关(p 结论:在所有年龄组中,财富和收入对认知能力都有直接影响,与邻里劣势无关):在中年人中,个人更高的社会经济地位可能会缓解认知能力的下降,部分原因是个人可以生活在物质和社会条件更优越的社区。
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引用次数: 0
Veterans' use of inpatient and outpatient palliative care: The national landscape 退伍军人使用住院和门诊姑息关怀的情况:全国情况。
IF 4.3 2区 医学 Q1 GERIATRICS & GERONTOLOGY Pub Date : 2024-08-23 DOI: 10.1111/jgs.19141
Brystana G. Kaufman PhD, MSPH, Sandra Woolson MS, Catherine Stanwyck BA, Madison Burns BS, Paul Dennis PhD, Jessica Ma MD, Shelli Feder PhD, APRN, Joshua M. Thorpe PhD, S. Nicole Hastings MD, David B. Bekelman MD, Courtney H. Van Houtven PhD

Background

Palliative care improves the quality of life for people with life-limiting conditions, which are common among older adults. Despite the Veterans Health Administration (VA) outpatient palliative care expansion, most research has focused on inpatient palliative care. This study aimed to compare veteran characteristics and hospice use for palliative care users across care settings (inpatient vs. outpatient) and dose (number of palliative care encounters).

Methods

This national cohort included veterans with any VA palliative care encounters from 2014 through 2017. We used VA and Medicare administrative data (2010–2017) to describe veteran demographics, socioeconomic status, life-limiting conditions, frailty, and palliative care utilization. Specialty palliative care encounters were identified using clinic stop codes (353, 351) and current procedural terminology codes (99241–99245).

Results

Of 120,249 unique veterans with specialty palliative care over 4 years, 67.8% had palliative care only in the inpatient setting (n = 81,523) and 32.2% had at least one palliative care encounter in the outpatient setting (n = 38,726), with or without an inpatient palliative care encounter. Outpatient versus inpatient palliative care users were more likely to have cancer and less likely to have high frailty, but sociodemographic factors including rurality and housing instability were similar. Duration of hospice use was similar between inpatient (median = 37 days; IQR = 11, 112) and outpatient (median = 44 days; IQR = 14, 118) palliative care users, and shorter among those with only one palliative care encounter (median = 18 days; IQR = 5, 64).

Conclusions

This national evaluation provides novel insights into the care setting and dose of VA specialty palliative care for veterans. Among veterans with palliative care use, one-third received at least some palliative care in the outpatient care setting. Differences between veterans with inpatient and outpatient use motivate the need for further research to understand how care settings and number of palliative care encounters impact outcomes for veterans and older adults.

背景:姑息关怀改善了患有局限性疾病的人的生活质量,这种疾病在老年人中很常见。尽管退伍军人健康管理局(VA)扩大了门诊姑息关怀的范围,但大多数研究都集中在住院姑息关怀方面。本研究旨在比较退伍军人的特征以及姑息关怀使用者在不同关怀环境(住院病人与门诊病人)和剂量(姑息关怀就诊次数)下的临终关怀使用情况:该全国队列包括2014年至2017年期间接受过退伍军人事务部姑息治疗的退伍军人。我们使用退伍军人事务部和医疗保险管理数据(2010-2017 年)来描述退伍军人的人口统计学特征、社会经济状况、临终状况、虚弱程度和姑息关怀的使用情况。使用诊所停止代码(353、351)和当前程序术语代码(99241-99245)确定了专业姑息治疗就诊情况:在 4 年内接受过专业姑息治疗的 120,249 名退伍军人中,67.8% 的人只在住院环境中接受过姑息治疗(n = 81,523),32.2% 的人在门诊环境中至少接受过一次姑息治疗(n = 38,726),无论是否在住院环境中接受过姑息治疗。门诊姑息关怀使用者与住院姑息关怀使用者相比,患癌症的可能性更大,身体虚弱的可能性更小,但包括农村和住房不稳定在内的社会人口因素却相似。住院病人(中位数=37天;IQR=11-112)和门诊病人(中位数=44天;IQR=14-118)的姑息关怀使用者使用临终关怀服务的时间相似,而只有一次姑息关怀经历的病人使用临终关怀服务的时间较短(中位数=18天;IQR=5-64):这项全国性评估为退伍军人专科姑息关怀的护理环境和剂量提供了新的见解。在使用姑息治疗的退伍军人中,三分之一的人至少在门诊接受了一些姑息治疗。住院和门诊退伍军人之间的差异促使人们需要进一步研究,以了解护理环境和姑息关怀的次数如何影响退伍军人和老年人的治疗效果。
{"title":"Veterans' use of inpatient and outpatient palliative care: The national landscape","authors":"Brystana G. Kaufman PhD, MSPH,&nbsp;Sandra Woolson MS,&nbsp;Catherine Stanwyck BA,&nbsp;Madison Burns BS,&nbsp;Paul Dennis PhD,&nbsp;Jessica Ma MD,&nbsp;Shelli Feder PhD, APRN,&nbsp;Joshua M. Thorpe PhD,&nbsp;S. Nicole Hastings MD,&nbsp;David B. Bekelman MD,&nbsp;Courtney H. Van Houtven PhD","doi":"10.1111/jgs.19141","DOIUrl":"10.1111/jgs.19141","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Palliative care improves the quality of life for people with life-limiting conditions, which are common among older adults. Despite the Veterans Health Administration (VA) outpatient palliative care expansion, most research has focused on inpatient palliative care. This study aimed to compare veteran characteristics and hospice use for palliative care users across care settings (inpatient vs. outpatient) and dose (number of palliative care encounters).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This national cohort included veterans with any VA palliative care encounters from 2014 through 2017. We used VA and Medicare administrative data (2010–2017) to describe veteran demographics, socioeconomic status, life-limiting conditions, frailty, and palliative care utilization. Specialty palliative care encounters were identified using clinic stop codes (353, 351) and current procedural terminology codes (99241–99245).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Of 120,249 unique veterans with specialty palliative care over 4 years, 67.8% had palliative care only in the inpatient setting (<i>n</i> = 81,523) and 32.2% had at least one palliative care encounter in the outpatient setting (<i>n</i> = 38,726), with or without an inpatient palliative care encounter. Outpatient versus inpatient palliative care users were more likely to have cancer and less likely to have high frailty, but sociodemographic factors including rurality and housing instability were similar. Duration of hospice use was similar between inpatient (median = 37 days; IQR = 11, 112) and outpatient (median = 44 days; IQR = 14, 118) palliative care users, and shorter among those with only one palliative care encounter (median = 18 days; IQR = 5, 64).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>This national evaluation provides novel insights into the care setting and dose of VA specialty palliative care for veterans. Among veterans with palliative care use, one-third received at least some palliative care in the outpatient care setting. Differences between veterans with inpatient and outpatient use motivate the need for further research to understand how care settings and number of palliative care encounters impact outcomes for veterans and older adults.</p>\u0000 </section>\u0000 </div>","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"72 11","pages":"3385-3397"},"PeriodicalIF":4.3,"publicationDate":"2024-08-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142047671","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Reply to: Peptic ulcers with ChEIs, NSAIDs 答复消化性溃疡与 ChEIs、NSAIDs。
IF 4.3 2区 医学 Q1 GERIATRICS & GERONTOLOGY Pub Date : 2024-08-22 DOI: 10.1111/jgs.19133
Máté Szilcz PhD, Jonas W. Wastesson PhD, Amaia Calderón-Larrañaga PhD, Daniel Prieto-Alhambra MD, PhD, Pierre-Olivier Blotière PhD, Géric Maura PharmD, PhD, Kristina Johnell PhD
<p>We sincerely thank Professor Montastruc for their letter.<span><sup>1</sup></span> We appreciate that our call for further research on the interaction between non-steroidal anti-inflammatory drugs (NSAIDs) and cholinesterase inhibitors (ChEIs) and their effects on peptic ulcer was noticed.<span><sup>2</sup></span> We value the use of established pharmacovigilance methods for detecting a signal for the drug–drug interaction we identified. Signal detection is an important first step in the process of establishing evidence, which we omitted in our research, where we directly moved to hypothesis testing with pharmacoepidemiologic methods.</p><p>Professor Montastruc investigated the drug–drug interaction using disproportionality analyses, which focuses on the differences in the proportion of adverse event reports in a global pharmacovigilance database. They found that the reporting odds ratios of peptic ulcer for the combination of ChEIs and NSAIDs were three times as high as for NSAIDs alone, an effect estimate that is in line with our findings. Furthermore, they highlighted that their study extends our research, as we compared treatment episodes with no treatment, whereas they compared the combination treatment with NSAIDs alone.</p><p>To quantify the comparison between combination of ChEIs and NSAIDs and NSAIDs alone, similarly to Montastruc, we performed a post hoc analysis on the results obtained from our self-controlled case series study. We found that the incidence rate ratio of peptic ulcer with concomitant use of ChEIs and NSAIDs is 1.74 (95% confidence interval: 1.27–2.38) compared to NSAIDs alone. This is a slightly smaller effect size than reported by Montastruc. This discrepancy could be due to the fact that Montastruc calculated <i>reporting</i> odds ratios, which might overestimate the true risk of adverse effects in pharmacovigilance databases, especially in the case of drug–drug interactions.<span><sup>3</sup></span></p><p>We appreciate that our work has inspired further research on the topic, but there are necessary next steps. Following the detected signal from Montastruc and our pharmacoepidemiologic research, future studies should use big data, for example via federated networks of health data.<span><sup>4</sup></span> Analyzing a large cohort would potentially allow for the examination of subgroups, such as different combinations of chemical substances in ChEIs (e.g., donepezil, rivastigmine, galantamine) and NSAIDs (e.g., diclofenac, naproxen, ibuprofen), and their effects on bleeding or non-bleeding peptic ulcers—analyses we could not perform. Increasing the size of the study population via federated networks would further enhance precision and enable wider generalizability of the results. Ultimately, when enough evidence is gathered, concomitant ChEIs and NSAIDs use should be carefully evaluated and potentially included in guidelines to prevent inappropriate medication use, ensuring better safety and outcomes for patients.<
我们衷心感谢 Montastruc 教授的来信。1 我们很高兴我们关于进一步研究非甾体抗炎药 (NSAID) 和胆碱酯酶抑制剂 (ChEI) 之间的相互作用及其对消化性溃疡的影响的呼吁受到了关注。2 我们重视使用既定的药物警戒方法来检测我们发现的药物相互作用信号。信号检测是建立证据过程中重要的第一步,我们在研究中省略了这一步,直接采用药物流行病学方法进行假设检验。Montastruc 教授采用比例失调分析法对药物间相互作用进行了调查,该方法主要关注全球药物警戒数据库中不良事件报告比例的差异。他们发现,胆碱酯酶抑制剂和非甾体抗炎药联用的消化性溃疡报告几率是单用非甾体抗炎药的三倍,这一效应估计值与我们的研究结果一致。此外,他们还强调,他们的研究扩展了我们的研究,因为我们比较的是治疗发作与不治疗,而他们比较的是联合治疗与单用非甾体抗炎药。为了量化 ChEIs 和非甾体抗炎药联合治疗与单用非甾体抗炎药之间的比较,与 Montastruc 类似,我们对自我对照病例系列研究的结果进行了事后分析。我们发现,与单独使用非甾体抗炎药相比,同时使用抗胆碱酯酶药和非甾体抗炎药的消化性溃疡发病率比为 1.74(95% 置信区间:1.27-2.38)。这比 Montastruc 报告的效应规模略小。这一差异可能是由于 Montastruc 计算的是报告几率比,而这可能会高估药物警戒数据库中不良反应的真实风险,尤其是在药物间相互作用的情况下。根据 Montastruc 和我们的药物流行病学研究检测到的信号,未来的研究应使用大数据,例如通过健康数据的联合网络4、4 分析大型队列有可能对亚组进行研究,例如胆碱酯酶抑制剂(如多奈哌齐、利伐斯的明、加兰他敏)和非甾体抗炎药(如双氯芬酸、萘普生、布洛芬)中不同化学物质的组合及其对出血或不出血消化性溃疡的影响--这些分析我们无法进行。通过联合网络扩大研究人群的规模将进一步提高精确度,并使研究结果具有更广泛的普遍性。最终,当收集到足够的证据时,应仔细评估 ChEIs 和非甾体抗炎药的同时使用,并可能将其纳入指南,以防止用药不当,确保患者获得更好的安全性和治疗效果。MS进行了统计分析,解释了数据,起草并严格修改了手稿。JWW、ACL、POB、GM、DPA 和 KJ 对数据进行了解释,并对手稿进行了严格的修改。KJ获得经费并获取数据。KJ、JWW、ACL和DPA提供指导。KJ 和 MS 是研究和数据完整性的保证人。所有作者均批准了手稿的最终版本。作者声明与本文无实际利益冲突。潜在利益冲突:MS从辉瑞公司、Macanda和Aurealis Therapeutics获得咨询费。资助者在研究设计、数据收集和分析、发表决定或手稿撰写中未发挥任何作用。本研究得到了瑞典健康、工作生活和福利研究委员会(FORTE)和KID-funding的资助。
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引用次数: 0
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