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Approximately 20% of older persons with dementia have atrial fibrillation (AF). Nearly all have stroke risks that exceed the guideline-recommended threshold for anticoagulation. Although individuals with dementia develop profound impairments and die from the disease, little evidence exists to guide anticoagulant discontinuation, and almost one-third of nursing home residents with advanced dementia and AF remain anticoagulated in the last 6 months of life. We aimed to quantify the benefits and harms of anticoagulation in this population.Using Minimum Data Set and Medicare claims, we conducted a retrospective cohort study with 14,877 long-stay nursing home residents aged ≥66 between 2013 and 2018 who had advanced dementia and AF. We excluded individuals with venous thromboembolism and valvular heart disease. We measured anticoagulant exposure quarterly, using Medicare Part D claims. The primary outcome was all-cause mortality; secondary outcomes were ischemic stroke and serious bleeding. We performed survival analyses with multivariable adjustment and inverse probability of treatment (IPT) weighting.In the study sample, 72.0% were female, 82.7% were aged ≥80 years, and 13.5% were nonwhite. Mean CHAPersons with advanced dementia and AF derive clinically modest life prolongation from anticoagulation, at the cost of elevated risk of bleeding. The relevance of this benefit is unclear in a group with high dementia-related mortality and for whom the primary goal is often comfort.

Background After hospitalization for acute myocardial infarction (AMI), older adults may be at increased risk for falls due to deconditioning, new medications, and worsening health status. Our primary objective was to identify risk factors for falls after AMI hospitalization among adults over age 75. Methods We used data from the Comprehensive Evaluation of Risk Factors in Older Patients with AMI (SILVER-AMI) study, a prospective cohort study of 3041 adults age 75 and older hospitalized with AMI at 94 community and academic medical centers across the United States. In-person interviews and physical assessments, as well as medical record review, were performed to collect demographic, clinical, functional, and psychosocial data. Falls were self-reported in telephone interviews and medically serious falls (those associated with emergency department use or hospitalization) were determined by medical record adjudication. Backward selection was used to identify predictors of fall risk in logistic regression analysis. Results A total of 554 (21.6%) participants reported a fall and 191 (6.4%) had a medically serious fall within 6 months of discharge. Factors independently associated with self-reported falls included impaired mobility, prior fall history, longer hospital stay, visual impairment, and weak grip. Factors independently associated with medically serious falls included older age, polypharmacy, impaired functional mobility, prior fall history, and living alone. Conclusions Among older patients hospitalized for AMI, falls are common in the 6 months following discharge and associated with demographic, functional, and clinical factors that are readily identifiable. Fall risk should be considered in post-AMI clinical decision-making and interventions to prevent falls should be evaluated.

After hospitalization for acute myocardial infarction (AMI), older adults may be at increased risk for falls due to deconditioning, new medications, and worsening health status. Our primary objective was to identify risk factors for falls after AMI hospitalization among adults over age 75.We used data from the Comprehensive Evaluation of Risk Factors in Older Patients with AMI (SILVER-AMI) study, a prospective cohort study of 3041 adults age 75 and older hospitalized with AMI at 94 community and academic medical centers across the United States. In-person interviews and physical assessments, as well as medical record review, were performed to collect demographic, clinical, functional, and psychosocial data. Falls were self-reported in telephone interviews and medically serious falls (those associated with emergency department use or hospitalization) were determined by medical record adjudication. Backward selection was used to identify predictors of fall risk in logistic regression analysis.A total of 554 (21.6%) participants reported a fall and 191 (6.4%) had a medically serious fall within 6 months of discharge. Factors independently associated with self-reported falls included impaired mobility, prior fall history, longer hospital stay, visual impairment, and weak grip. Factors independently associated with medically serious falls included older age, polypharmacy, impaired functional mobility, prior fall history, and living alone.Among older patients hospitalized for AMI, falls are common in the 6 months following discharge and associated with demographic, functional, and clinical factors that are readily identifiable. Fall risk should be considered in post-AMI clinical decision-making and interventions to prevent falls should be evaluated.

Caring for older adults with multiple chronic conditions (MCCs) is challenging. The American Geriatrics Society (AGS) previously developed The AGS Guiding Principles for the Care of Older Adults With Multimorbidity using a systematic review of the literature and consensus. The objective of the current work was to translate these principles into a framework of Actions and accompanying Action Steps for decision making for clinicians who provide both primary and specialty care to older people with MCCs. A work group of geriatricians, cardiologists, and generalists: (1) articulated the core MCC Actions and the Action Steps needed to carry out the Actions; (2) provided decisional tips and communication scripts for implementing the Actions and Action Steps, using commonly encountered situations: (3) performed a scoping review to identify evidence-based, validated tools for carrying out the MCC Actions and Action Steps; and (4) identified potential barriers to, and mitigating factors for, implementing the MCC Actions. The recommended MCC Actions include: (1) identify and communicate patients' health priorities and health trajectory; (2) stop, start, or continue care based on health priorities, potential benefit vs harm and burden, and health trajectory; and (3) align decisions and care among patients, caregivers, and other clinicians with patients' health priorities and health trajectory. The tips and scripts for carrying out these Actions are included in the full MCC Action Framework available in the supplement (www.GeriatricsCareOnline.org). J Am Geriatr Soc 67:665-673, 2019.

Objectives Patient Health Priorities Identification (PHPI) is a values-based process in which trained facilitators assist older adults with multiple chronic conditions identify their health priorities. The purpose of this study was to evaluate patients' perceptions of PHPI. Design Qualitative study using thematic analysis. Setting In-depth semistructured telephone and in-person interviews. Participants Twenty-two older adults who participated in the PHPI process. Measurements Open-ended questions about patient perceptions of the PHPI process, perceived benefits of the process, enablers and barriers to PHPI, and recommendations for process enhancement. Results Patient interviews ranged from 9 to 63 minutes (median = 20 min; interquartile range = 15-26). The mean age was 80 years (standard deviation = 7.96), 64% were female, and all patients identified themselves as white. Of the sample, 73% reported no caregiver involvement in their healthcare; 36% lived alone. Most patients felt able to complete the PHPI process with ease. Perceived benefits included increased knowledge and insight into disease processes and treatment options, patient activation, and enhanced communication with family and clinicians. Patients identified several factors that were both enablers and barriers to PHPI including facilitator characteristics, patient demographic and clinical characteristics, social support, relationships between the patient and their primary care provider, and the changing health priorities of the patient. Recommendations for process enhancement included more frequent and flexible facilitator contacts, selection of patients for participation based on specific patient characteristics, clarification of process aims and expectations, involvement of family, written reminders of established health priorities, short duration between facilitation and primary care provider follow-up, and the inclusion of health-related tasks in facilitation visits. Conclusions Patients found the PHPI process valuable in identifying actionable health priorities and healthcare goals leading to enhanced knowledge, activation, and communication regarding their treatment options and preferences. PHPI may be useful for aligning the healthcare that patients receive with their values-based priorities.

Objectives To develop a values‐based, clinically feasible process to help older adults identify health priorities that can guide clinical decision‐making. Design Prospective development and feasibility study. Setting Primary care practice in Connecticut. Participants Older adults with 3 or more conditions or taking 10 or more medications (N=64). Intervention The development team of patients, caregivers, and clinicians used a user‐centered design framework—ideate → prototype → test →redesign—to develop and refine the value‐based patient priorities care process and medical record template with trained clinician facilitators. Measurements We used descriptive statistics of quantitative measures (percentage accepted invitation and completed template, duration of process) and qualitative analysis of barriers and enablers (challenges and solutions identified, facilitator perceptions). Results We developed and refined a process for identifying patient health priorities that was typically completed in 35 to 45 minutes over 2 sessions; 64 patients completed the process. Qualitative analyses were used to elucidate the characteristics and training needed for the patient priorities facilitators, as well as perceived benefits and challenges of the process. Refinements based on our experience and feedback include streamlining the process for greater feasibility, balancing fidelity to the process while customizing to individuals, encouraging patients to share their priorities with their clinicians, and simplifying the template transmitted to clinicians. Conclusion Trained facilitators conducted this process in a busy primary care practice, suggesting that patient priorities identification is feasible and acceptable, although testing in additional settings is necessary. We hope to show that clinicians can align care with patients' health priorities.

Older adults with multiple chronic conditions (MCCs) receive care that is fragmented and burdensome, lacks evidence, and most importantly is not focused on what matters most to them. An implementation feasibility study of Patient Priorities Care (PPC), a new approach to care that is based on health outcome goals and healthcare preferences, was conducted. This study took place at 1 primary care and 1 cardiology practice in Connecticut and involved 9 primary care providers (PCPs), 5 cardiologists, and 119 older adults with MCCs. PPC was implemented using methods based on a practice change framework and continuous plan-do-study-act (PDSA) cycles. Core elements included leadership support, clinical champions, priorities facilitators, training, electronic health record (EHR) support, workflow development and continuous modification, and collaborative learning. PPC processes for clinic workflow and decision-making were developed, and clinicians were trained. After 10 months, 119 older adults enrolled and had priorities identified; 92 (77%) returned to their PCP after priorities identification. In 56 (46%) of these visits, clinicians documented patient priorities discussions. Workflow challenges identified and solved included patient enrollment lags, EHR documentation of priorities discussions, and interprofessional communication. Time for clinicians to provide PPC remains a challenge, as does decision-making, including clinicians' perceptions that they are already doing so; clinicians' concerns about guidelines, metrics, and unrealistic priorities; and differences between PCPs and patients and between PCPs and cardiologists about treatment decisions. PDSA cycles and continuing collaborative learning with national experts and peers are taking place to address workflow and clinical decision-making challenges. Translating disease-based to priorities-aligned decision-making appears challenging but feasible to implement in a clinical setting.

OBJECTIVES: To examine patterns and perceived benefits of seven major complementary health approaches (CHA) among older adults in the United States. METHODS: Data from the 2012 National Health Interview Survey (NHIS), which represents non-institutionalized adults aged 65 or older (n = 7,116 unweighted), were used. We elicited seven most common CHA used in older adults, which are acupuncture, herbal therapies, chiropractic, massage, meditation, Tai Chi, and yoga. Survey participants were asked to self-report perceived benefits (eg, maintaining health and stress reduction) in their CHA used. We estimated prevalence and perceived benefits of CHA use. We also investigated socio-demographic and clinical factors associated with the use of any of these seven CHA. RESULTS: Overall, 29.2% of older adults used any of seven CHA in the past year. Most commonly used CHA included herbal therapies (18.1%), chiropractic (8.4%), and massage (5.7%). More than 60% of older CHA users reported that CHA were important for maintaining health and well-being. Other perceived benefits included improving overall health and feeling better (52.3%), giving a better sense of control over health (27.4%), and making it easier to cope with health problems (24.7%). Older adults with higher education and income levels, ≥2 chronic conditions, and functional limitations had greater odds of using CHA (p < .01, respectively). CONCLUSION: A substantial number of older CHA users reported CHA-related benefits. CHA may play a crucial role in improving health status among older adults. At the population level, further research on the effects of CHA use on bio-psycho-social outcomes is needed to promote healthy aging in older adults.

Objectives To compare the accuracy of and factors affecting the accuracy of self‐reported fall‐related injuries (SFRIs) with those of administratively obtained FRIs (AFRIs). Design Retrospective observational study Setting United States Participants Fee‐for‐service Medicare beneficiaries aged 65 and older (N=47,215). Measurements We used 24‐month self‐report recall data from 2000–2012 Health and Retirement Study data to identify SFRIs and linked inpatient, outpatient, and ambulatory Medicare data to identify AFRIs. Sensitivity and specificity were assessed, with AFRIs defined using the University of California at Los Angeles/RAND algorithm as the criterion standard. Logistic regression models were used to identify sociodemographic and health predictors of sensitivity. Results Overall sensitivity and specificity were 28% and 92%. Sensitivity was greater for the oldest adults (38%), women (34%), those with more functional limitations (47%), and those with a prior fall (38%). In adjusted results, several participant factors (being female, being white, poor functional status, depression, prior falls) were modestly associated with better sensitivity and specificity. Injury severity (requiring hospital care) most substantively improved SFRI sensitivity (73%). Conclusion An overwhelming 72% of individuals who received Medicare‐reimbursed health care for FRIs failed to report a fall injury when asked. Future efforts to address underreporting in primary care of nonwhite and healthier older adults are critical to improve preventive efforts. Redesigned questions—for example, that address stigma of attributing injury to falling—may improve sensitivity.

Background/Objectives Timely administration of antiischemic therapies improves outcomes in individuals with acute myocardial infarction (AMI). Prior literature on delays in AMI care has largely focused on in-hospital delay (“door to balloon” time). Our objective was to identify factors associated with prehospital delay in a contemporary national cohort of older adults with AMI. Design Cross-sectional analysis of data from the ComprehenSIVe Evaluation of Risk Factors in Older Patients with Acute Myocardial Infarction (SILVER-AMI) study, an observational study of older adults hospitalized for AMI. Setting U.S. academic and community hospitals (N = 94). Participants Individuals aged 75 and older hospitalized for AMI (N = 2,500). Measurements Prehospital delay was defined as symptom duration of 6 hours or longer before hospital presentation and was obtained according to participant or caregiver report during AMI hospitalization. Potential predictors of delay from demographic, clinical presentation, comorbid conditions, function, and social support domains were obtained through in-person assessment during the index hospitalization and medical record abstraction. Results Nonwhite race (adjusted odds ratio (aOR) = 1.54, P = .002), atypical symptoms (aOR = 1.41, P = .001), and heart failure (HF) (aOR = 1.35, P = .006 for HF) were significantly associated with delay. Conclusion In contrast with younger AMI populations, female sex and diabetes mellitus were not associated with delay in this older cohort, but factors from other domains (nonwhite race, atypical symptoms, and HF) were significantly associated with delay. These results can be used to customize future public health efforts to encourage early presentation for older adults with AMI.

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

Background/objectives Aligning healthcare decisions with patients' priorities may improve care for older adults with multiple chronic conditions (MCCs). We conducted a pilot study to assess the feasibility of identifying patient priorities in routine geriatrics care and to compare clinicians' recommendations for patients who did or did not have their priorities identified. Design Retrospective chart review. Setting Veterans Administration Medical Center Geriatrics Clinic. Participants Older adults with MCCs receiving Patient Priorities Care (PPC; n = 35) were matched with patients receiving usual care (UC; n = 35). Both PPC and UC patients were cared for by three primary care providers (PCPs) in an ambulatory geriatric clinic. Intervention In the PPC group, a clinician facilitator met with each patient to identify their healthcare priorities and transmitted patients' priorities in the electronic health record (EHR). Trained PCPs then sought to align healthcare decisions with patients' priorities. In the UC group, patients received usual care from the same PCPs. Measurements We matched patients by clinician seen, patient's age, number of active conditions, medications, hospitalizations, functional status, and prior hospitalizations. EHRs were reviewed to identify care decisions including medications added or stopped, referrals and consults added or avoided, referrals to community services and supports, self-management activities added or avoided, and total number of changes to care. Mean differences in recommended care between PPC and UC patients from the same PCPs were examined. Results Clinician facilitators could identify patient priorities during routine clinic encounters. Compared with patients in the UC group, those in the PPC group had, on average, fewer medications added (P = .05), more referrals to community services and supports (P = .03), and more priorities-aligned self-management tasks added (P = .005). Conclusion These findings support the feasibility of identifying and documenting patient priorities during routine encounters. Results also suggest that clinicians use patient priorities in recommending care.

Objective To understand how older persons with multiple chronic conditions (MCC) approach decisions about cancer screening. Materials and Methods We conducted interviews with adults > 65 years old with at least two chronic conditions who were taking ≥ five medications daily. Patients were first asked how age and multimorbidity influence their cancer screening decisions. After showing them an educational prompt that explained the relationship between life expectancy and the benefits of cancer screening, respondents were then asked about screening in the context of specific health scenarios. Using grounded theory, three independent readers coded responses for salient themes. Sample size was determined by thematic saturation. Results Most respondents (26 of 28) initially indicated that their overall health or medical conditions do not influence their cancer screening decisions. After viewing the educational prompt, respondents described two broad approaches to cancer screening in the setting of increasing age or multi-morbidity. The first was a “benefits versus harms” approach in which participants weighed direct health benefits (e.g. reducing cancer incidence or mortality) and harms (e.g. complications or inconvenience). The second was a heuristic approach. Some heuristics favored screening, such as a persistent belief in unspecified benefits from screening, value of knowledge about cancer status, and not wanting to “give up”, whereas other heuristics discouraged screening, such as fatalism or a reluctance to learn about their cancer status. Conclusions When considering cancer screening, some older persons with MCC employ heuristics which circumvent the traditional quantitative comparison of risks and benefits, providing an important challenge to informed decision making.

Objective: To ascertain perspectives of multiple stakeholders on contributors to inappropriate care for older adults with multiple chronic conditions. Method: Perspectives of 36 purposively sampled patients, clinicians, health systems, and payers were elicited. Data analysis followed a constant comparative method. Results: Structural factors triggering burden and fragmentation include disease-based quality metrics and need to interact with multiple clinicians. The key cultural barrier identified is the assumption that “physicians know best.” Inappropriate decision making may result from inattention to trade-offs and adherence to multiple disease guidelines. Stakeholders recommended changes in culture, structure, and decision making. Care options and quality metrics should reflect a focus on patients’ priorities. Clinician–patient partnerships should reflect patients knowing their health goals and clinicians knowing how to achieve them. Access to specialty expertise should not require visits. Discussion: Stakeholders’ recommendations suggest health care redesigns that incorporate patients’ health priorities into care decisions and realign relationships across patients and clinicians.

Objectives To prioritize research topics relevant to the care of the growing population of older adults with multiple chronic conditions (MCCs). Design Survey of experts in MCC practice, research, and policy. Topics were derived from white papers, funding announcements, or funded research projects relating to older adults with MCCs. Setting Survey conducted through the Health Care Systems Research Network (HCSRN) and Claude D. Pepper Older Americans Independence Centers (OAICs) Advancing Geriatrics Infrastructure and Network Growth Initiative, a joint endeavor of the HCSRN and OAICs. Participants Individuals affiliated with the HCSRN or OAICs and national MCC experts, including individuals affiliated with funding agencies having MCC-related grant portfolios. Measurements A “top box” methodology was used, counting the number of respondents selecting the top response on a 5-point Likert scale and dividing by the total number of responses to calculate a top box percentage for each of 37 topics. Results The highest-ranked research topics relevant to the health and healthcare of older adults with MCCs were health-related quality of life in older adults with MCCs; development of assessment tools (to assess, e.g., symptom burden, quality of life, function); interactions between medications, disease processes, and health outcomes; disability; implementation of novel (and scalable) models of care; association between clusters of chronic conditions and clinical, financial, and social outcomes; role of caregivers; symptom burden; shared decision-making to enhance care planning; and tools to improve clinical decision-making. Conclusion Study findings serve to inform the development of a comprehensive research agenda to address the challenges relating to the care of this “high-need, high-cost” population and the healthcare delivery systems responsible for serving it.

Objectives Men treated with androgen deprivation therapy (ADT) or radiation therapy (RT) for prostate cancer have an increased risk for fractures. Given uncertainty as to whether specific clinical factors can identify men at increased risk, we sought to develop a prognostic index for risk of fracture in this population. Materials and methods We used the Surveillance, Epidemiology, and End Results-Medicare database to identify men who received ADT or RT after being diagnosed with localized prostate cancer in 2007–2009. Cox proportional hazards models tested the association of potential risk factors with fracture. In a derivation group, hazard ratios were used to assign points for factors independently related to fracture. The prognostic index was then applied to a validation group. Results The sample of 5824 men had a median age of 73.0 years; 82.9% were white and 8.6% had a fracture within 2 years of treatment for prostate cancer. The Cox model identified 8 variables (age, race, hormone treatment, Elixhauser score, anxiety, Parkinson's, fall-inducing medications and disability status) independently associated with fracture. In the derivation cohort, 4.3% of the sample experienced a fracture in the low-risk group, 8.9% in the intermediate group, and 19.2% in the high-risk group (C statistic, 0.749). The index was applied to the validation cohort (C statistic, 0.782). Conclusion The prognostic index can help to identify patients at increased risk for fracture. This underscores the importance of identifying risk factors for fracture, given the substantial variation in fracture risk in men treated with ADT or RT.

Objectives: To determine how well universal health outcome priorities represent individuals' preferences in specific clinical situations. Design: Observational cohort study. Setting: Community. Participants: Community-dwelling adults aged 65 and older (N = 357). Measurements: Participants used three tools assessing universal health outcome priorities related to two common trade-offs: quality versus quantity of life and future health versus present inconveniences and burdens of treatment. The tools' ability to identify participants who were unwilling to take a medication that reduced the risk of myocardial infarction but caused dizziness and fatigue was analyzed. Results: There were consistent and significant associations between unwillingness to take the medication and prioritizing quality of life or future health for all three tools in the expected direction (P < .05). Despite these associations, the positive (PPV) and negative predictive values for the tools were generally modest (0.49–0.83). The tool with the most specific statements resembling the medication scenario had the best specificity (0.97) and PPV (0.83). Conclusion: Universal health outcome priorities only modestly identified older persons who would be unwilling to take a medication for primary prevention of myocardial infarction that causes adverse effects. Although tools that are the most general in their assessment of priorities have the benefit of being applicable across the widest range of scenarios, tools with greater specificity may be necessary to inform individual treatment decisions.

Background: Many older adults with hypertension receive multiple antihypertensives. It is unclear whether treatment with several antihypertensive classes results in greater cardiovascular benefits than fewer antihypertensive classes. Objectives: We investigated (a) the longitudinal associations between treatment with ≥ 3 versus 1-2 classes and death and major adverse cardiovascular events (MACE) and (b) whether these associations varied by the presence of mobility disability. Methods: We included 6,011 treated hypertensive adults ≥65 from the Medical Expenditure Panel Survey (MEPS), a nationally representative community sample. Times to MACE and death were compared between those receiving ≥3 versus 1-2 classes using multivariable proportional hazards regression. We used inverse probability of treatment weighting to account for indication and contraindication bias. Results: There were no significant differences in the risk of mortality (hazard ratio [HR] = 0.96, p = .769) or MACE (HR = 1.10, p = .574) between the exposure groups, and there were no significant exposure × mobility disability interactions. Discussion: We found no benefit of ≥3 versus 1-2 antihypertensive classes in reducing mortality and cardiovascular events in a representative cohort of older adults, raising concern about the added benefit of additional antihypertensives in the real world.

OBJECTIVES: To evaluate the association between the treatment region (TR) or usual care region (UCR) of the Connecticut Collaboration for Fall Prevention (CCFP), a clinical intervention for prevention of falls, and the rate of hospitalization for fall-related traumatic brain injury (FR-TBI) in persons aged 70 and older and to describe the Medicare charges for FR-TBI hospitalizations. DESIGN: Using a quasi-experimental design, rates of hospitalization for FR-TBI were recorded over an 8-year period (2000-2007) in two distinct geographic regions (TR and UCR) chosen for their similarity in characteristics associated with occurrence of falls. SETTING: Two geographical regions in Connecticut. PARTICIPANTS: More than 200,000 persons aged 70 and older. INTERVENTION: Clinicians in the TR translated research protocols from the Yale Frailty and Injuries: Cooperative Studies of Intervention Techniques, a successful fall-prevention randomized clinical trial, into discipline- and site-specific fall-prevention procedures for integration into their clinical practices. MEASUREMENTS: Rate of hospitalization for FR-TBI in persons aged 70 and older. RESULTS: Connecticut Collaboration for Fall Prevention's TR exhibited lower rates of hospitalization for FR-TBI than the UCR (risk ratio = 0.84, 95% credible interval = 0.72-0.99). CONCLUSION: The significantly lower rate of hospitalization for FR-TBI in CCFP's TR suggests that the engagement of practicing clinicians in the implementation of evidence-based fall-prevention practices may reduce hospitalizations for FR-TBI. Language: en

Objectives To evaluate the associations between a broad array of cardiorespiratory and noncardiorespiratory impairments and dyspnea in older persons. Design Cross-sectional. Setting Cardiovascular Health Study. Participants Community-dwelling persons (N = 4,413; mean age 72.6, 57.1% female, 4.5% African American, 27.2%

Objectives To determine how often hospitalized older adults principally diagnosed with pneumonia, chronic obstructive pulmonary disease (COPD), or heart failure (HF) are concurrently treated for two or more of these acute cardiopulmonary conditions. Design Retrospective cohort study. Setting 368 U.S. hospitals in the Premier research database. Participants Individuals aged 65 and older principally hospitalized with pneumonia, COPD, or HF in 2009 or 2010. Measurements Proportion of diagnosed episodes of pneumonia, COPD, or HF concurrently treated for two or more of these acute cardiopulmonary conditions during the first 2 hospital days. Results Of 91,709 diagnosed pneumonia hospitalizations, 32% received treatment for two or more acute cardiopulmonary conditions (18% for HF, 18% for COPD, 4% for both). Of 41,052 diagnosed COPD hospitalizations, 19% received treatment for two or more acute cardiopulmonary conditions (all of which involved additional HF treatment). Of 118,061 diagnosed HF hospitalizations, 38% received treatment for two or more acute cardiopulmonary conditions (34% for pneumonia, 9% for COPD, 5% for both). Conclusion Hospitalized older adults diagnosed with pneumonia, COPD, or HF are frequently treated for two or more acute cardiopulmonary conditions, suggesting that clinical syndromes often fall between traditional diagnostic categories. Research is needed to evaluate the risks and benefits of real-world treatment for the many older adults whose presentations elicit diagnostic uncertainty or concern about coexisting acute conditions.

Older adults with multiple conditions receive care that is often fragmented, burdensome, and of unclear benefit. An advisory group of patients, caregivers, clinicians, health system engineers, health care system leaders, payers, and others identified three modifiable contributors to this fragmented, burdensome care: decision making and care focused on diseases, not patients; inadequate delineation of roles and responsibilities and accountability among clinicians; and lack of attention to what matters to patients and caregivers (ie, their health outcome goals and care preferences). The advisory group identified patient priority-directed care as a feasible, sustainable approach to addressing these modifiable factors.

Persons with multiple chronic conditions receive multiple guideline-recommended medications to improve outcomes such as mortality. Our objective was to estimate the longitudinal average attributable fraction for 3-year survival of medications for cardiovascular conditions in persons with multiple chronic conditions and to determine whether heterogeneity occurred by age.Medicare Current Beneficiary Survey participants (N = 8,578) with two or more chronic conditions, enrolled from 2005 to 2009 with follow-up through 2011, were analyzed. We calculated the longitudinal extension of the average attributable fraction for oral medications (beta blockers, renin-angiotensin system blockers, and thiazide diuretics) indicated for cardiovascular conditions (atrial fibrillation, coronary artery disease, heart failure, and hypertension), on survival adjusted for 18 participant characteristics. Models stratified by age (≤80 and80 years) were analyzed to determine heterogeneity of both cardiovascular conditions and medications.Heart failure had the greatest average attributable fraction (39%) for mortality. The fractional contributions of beta blockers, renin-angiotensin system blockers, and thiazides to improve survival were 10.4%, 9.3%, and 7.2% respectively. In age-stratified models, of these medications thiazides had a significant contribution to survival only for those aged 80 years or younger. The effects of the remaining medications were similar in both age strata.Most cardiovascular medications were attributed independently to survival. The two cardiovascular conditions contributing independently to death were heart failure and atrial fibrillation. The medication effects were similar by age except for thiazides that had a significant contribution to survival in persons younger than 80 years.

Objectives: To determine the extent to which the co-occurrence of chronic obstructive pulmonary disease (COPD) and cognitive impairment affect adverse health outcomes in older adults. Design: Multicenter longitudinal cohort study. Setting: California, Pennsylvania, Maryland, and North Carolina. Participants: Three thousand ninety-three community-dwelling adults aged 65 and older from the Cardiovascular Health Study. Four hundred thirty-one had chronic obstructive pulmonary disease (COPD) at study baseline. Measurements: Follow-up began at the second CHS visit and continued for 3 years. Spirometric criteria for airflow limitation served to establish COPD using the Lambda-Mu-Sigma method, which accounts for age-related changes in lung function. Cognitive impairment was evaluated using the modified Mini-Mental State Examination and claims data. Outcomes were respiratory-related and all-cause hospitalizations and death. Results: Participants with coexisting COPD and cognitive impairment had the highest rates of respiratory-related (adjusted hazard ratio (aHR) = 4.10, 95% confidence interval (CI) = 1.86�9.05) and all-cause hospitalizations (aHR = 1.34, 95% CI = 1.00�1.80) and death (aHR = 2.29, 95% CI = 1.18�4.45). In particular, individuals with both conditions had a 48% higher rate of all-cause hospitalizations (adjusted synergy index (aSI) = 1.48, 95% CI = 0.19�11.31) and a rate of death nearly three times as high (aSI = 2.74, 95% CI = 0.43�17.32) as the sum of risks for each respective outcome associated with having COPD or cognitive impairment alone. Nevertheless, tests for interaction were not statistically significant for the presence of synergism between the two conditions contributing to each of the outcomes. Therefore, it cannot be concluded that the combined effect of COPD and cognitive impairment is greater than additive. Conclusion: Coexisting COPD and cognitive impairment have an additive effect on respiratory-related and all-cause hospitalizations and death. Optimizing outcomes in older adults with COPD and cognitive impairment will require that how to improve concurrent management of both conditions be determined.

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 Medicare Current Beneficiary Survey participants, a national representative sample of Medicare beneficiaries, enrolled during 2002 to 2006. Measurements: Information on chronic and acute diseases was ascertained from Medicare 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 relative effect of five chronic conditions on four representative universal health outcomes. DESIGN: Cross-sectional. SETTING: Cardiovascular Health Study. PARTICIPANTS: Five thousand two hundred and ninety-eight community-living participants aged 65 and older. MEASUREMENTS: Multiple regression and Cox models were used to determine the effect of heart failure (HF), chronic obstructive pulmonary disease (COPD), osteoarthritis, depression, and cognitive impairment on self-rated health, 12 basic and instrumental activities of daily living (ADLs and IADLs), six-item symptom burden scale, and death. RESULTS: Each condition adversely affected self-rated health (P

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

The following article is a summary of the American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons (2010). This article provides additional discussion of the guideline process and the differences between the current guideline and the 2001 version and includes the guidelines' recommendations, algorithm, and acknowledgments. The complete guideline is published on the American Geriatrics Society's Web site ( http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010/).

Deteriorating pulmonary function is associated with adverse clinical outcomes, including less physical activity, pneumonia, cardiovascular events, respiratory failure, and death.1–7 Pulmonary function, assessed according to forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC), gradually declines with aging. Accelerated pulmonary function decline indicates common lung diseases in older adults, such as chronic obstructive pulmonary disease (COPD), which is the fourth leading cause of death globally, with rising mortality rates in women.8–11 Emerging evidence suggests that women may develop faster pulmonary function decline than men because of their greater vulnerability to the effects of environmental exposures associated with systemic inflammation, including cigarette smoking.12–15 High concentrations of systemic inflammatory biomarkers interleukin-6 (IL-6) and C-reactive protein (CRP) have been associated with lower levels of pulmonary function in observational studies,16,17 although little is known about how systemic inflammation is linked to poorer pulmonary function specifically in older women. Prior research studies that have evaluated the relationship between systemic IL-6 and CRP concentrations and pulmonary function in older women have been rare and have limited their assessment to one inflammatory biomarker at a time.18 As an acute phase protein seen during proinflammatory states, the liver produces CRP directly in response to IL-6 activation. Given that IL-6 stimulates the hepatic production of CRP, it is important to understand how combined levels of systemic IL-6 and CRP correlate with pulmonary function in older women. Combined IL-6 and CRP levels may better reflect trends in pulmonary function levels than would levels of each inflammatory biomarker alone. It is uncertain whether higher IL-6 and CRP levels in combination are associated with lower pulmonary function levels. Because IL-6 regulates circulating CRP concentrations, this raises the possibility of whether the combined highest levels of IL-6 and CRP in older women may be associated with the poorest pulmonary function. To the knowledge of the authors, no study has evaluated the association between IL-6 and CRP concentrations and pulmonary function in a population composed of exclusively older women. Understanding how systemic IL-6 and CRP concentrations relate to pulmonary function in older women cross-sectionally would serve as the basis for determining whether, over time, these inflammatory biomarkers may be used adjunctively to monitor deteriorating pulmonary function, assess for clinical responses to treatment, and prognosticate adverse clinical outcomes, including pneumonia and respiratory failure, associated with poor pulmonary function from respiratory diseases. In disabled and higher-functioning older women from two cohorts, this study sought to determine whether higher systemic IL-6 and CRP levels are associated with poorer pulmonary function and, if so, whether the combined highest IL-6 and CRP levels are associated with the poorest pulmonary function. It was hypothesized that similar trends in the relationships between IL-6 and CRP levels and pulmonary function in disabled and higher-functioning older women would be observed.

OBJECTIVES: To test intervention protocols for feasibility, staff adherence, and effectiveness in reducing pneumonia risk factors (impaired oral hygiene, swallowing difficulty) in nursing home residents. DESIGN: Prospective study. SETTING: Two nursing homes. PARTICIPANTS: Fifty-two nursing home residents. INTERVENTION: Thirty residents with impaired oral hygiene were randomly assigned to manual oral brushing plus 0.12% chlorhexidine oral rinse at different frequencies daily. Twenty-two residents with swallowing difficulty were randomly assigned to upright feeding positioning, teaching swallowing techniques, or manual oral brushing. All protocols were administered over 3 months. MEASUREMENTS: Feasibility was assessed monthly and defined as high if the protocol took less than 10 minutes to administer. Adherence was assessed weekly and defined as high if full staff adherence was demonstrated in more than 75% of assessments. Effectiveness for improved oral hygiene (reduction in oral plaque score) and swallowing (reduction in cough during swallowing) was compared at baseline and 3 months. RESULTS: Daily manual oral brushing plus 0.12% chlorhexidine rinse demonstrated high feasibility, high staff adherence, and effectiveness in improving oral hygiene (P

OBJECTIVES: To identify clinical features associated with bacteriuria plus pyuria in noncatheterized nursing home residents with clinically suspected urinary tract infection (UTI). DESIGN: Prospective, observational cohort study from 2005 to 2007. SETTING: Five New Haven, Connecticut area nursing homes. PARTICIPANTS: Five hundred fifty-one nursing home residents each followed for 1 year for the development of clinically suspected UTI. MEASUREMENTS: The combined outcome of bacteriuria (>100,000 colony forming units from urine culture) plus pyuria (>10 white blood cells from urinalysis). RESULTS: After 178,914 person-days of follow-up, 228 participants had 399 episodes of clinically suspected UTI with a urinalysis and urine culture performed; 147 episodes (36.8%) had bacteriuria plus pyuria. The clinical features associated with bacteriuria plus pyuria were dysuria (relative risk (RR)=1.58, 95% confidence interval (CI)=1.10–2.03), change in character of urine (RR=1.42, 95% CI=1.07-1.79), and change in mental status (RR=1.38, 95% CI=1.03–1.74). CONCLUSION: Dysuria, change in character of urine, and change in mental status were significantly associated with the combined outcome of bacteriuria plus pyuria. Absence of these clinical features identified residents at low risk of having bacteriuria plus pyuria (25.5%), whereas presence of dysuria plus one or both of the other clinical features identified residents at high risk of having bacteriuria plus pyuria (63.2%). Diagnostic uncertainty still remains for the vast majority of residents who meet only one clinical feature. If validated in future cohorts, these clinical features with bacteriuria plus pyuria may serve as an evidence-based clinical definition of UTI to assist in management decisions.

Objectives: To examine the ways in which older persons with multiple conditions think about potentially competing outcomes, in order to gain insight into how processes to elicit values regarding these outcomes can be grounded in the patient's perspective.

OBJECTIVES: To determine the priority that older adults with coexisting hypertension and fall risk give to optimizing cardiovascular outcomes versus fall- and medication symptom-related outcomes. DESIGN: Interview. SETTING: Community. PARTICIPANTS: One hundred twenty-three cognitively intact persons aged 70 and older with hypertension and fall risk. MEASUREMENTS: Discrete choice task was used to elicit the relative importance placed on reducing the risk of three outcomes: cardiovascular events, serious fall injuries, and medication symptoms. Risk estimates with and without antihypertensive medications were obtained from the literature. Participants chose between 11 pairs of options that displayed lower risks for one or two outcomes and a higher risk for the other outcome(s), versus the reverse. Results were used to calculate relative importance scores for the three outcomes. These scores, which sum to 100, reflect the relative priority participants placed on the difference between the risk estimates of each outcome. RESULTS: Sixty-two participants (50.4%) placed greater importance on reducing risk of cardiovascular events than reducing risk of the combination of fall injuries and medication symptoms; 61 participants did the converse. A lower percentage of participants with chronic obstructive pulmonary disease (P=.02), unsteadiness (P=.02), functional dependency (P=.04), lower cognition (P=.02) and depressive symptoms (P=.03) prioritized cardiovascular outcomes over fall injuries and medication symptoms than did participants without these characteristics. CONCLUSION: Interindividual variability in the face of competing outcomes supports individualizing decision-making to individual priorities. In the current example, this may mean forgoing antihypertensive medications or compromising on blood pressure reduction for some individuals. Language: en

This study determined the extent to which fall risk assessment and management practices for older patients were implemented in Medicare-certified home health agencies (HHAs) in a defined geographic area in southern New England that had participated in evidence-based fall prevention training between October 2001 and September 2004. The standardized in-service training sessions taught home health nurses and rehabilitation therapists how to conduct assessments for five evidence-based risk factors for falls in older adults--mobility impairments, balance disturbances, multiple medications, postural hypotension, and home environmental hazards--using techniques shown to be efficacious in clinical trials. Twenty-six HHAs participated in these in-service training sessions; 19 of these participated in a survey of nurses and rehabilitation therapists between October 2004 and September 2005. Self-reported assessment and management practices implemented with older patients during home healthcare visits were measured in this survey, and HHA-level measures for each fall risk factor were constructed based on proportions of clinicians reporting assessment and management practices that were recommended in the fall prevention training sessions. For all fall risk factors except postural hypotension, 80% or more of clinicians in all HHAs reported implementing recommended fall risk management practices. Greater variation was found regarding fall risk assessment practices, with fewer than 70% of clinicians in one or more HHAs reporting recommended assessment practices for all risk factors. Results suggest that evidence-based training for home healthcare clinicians can stimulate fall risk assessment and management practices during home health visits. HHA-level comparisons hold the potential to illustrate the extent of diffusion of evidence-based fall prevention practices within and between agencies.

In patients with multiple health conditions, the treatment of one condition may worsen another one. Clinical decision-making should incorporate patients’ priorities when faced with these potentially competing health outcomes.1 The older adult with coexisting hypertension and fall risk represents a common clinical situation for which a method for eliciting patient priorities would be useful. Falls and hypertension are both major causes of disability. The 3-year incidence of all nonfatal cardiovascular events in older adults with hypertension is 16.2%,2 similar to the incidence of serious fall injury in elderly persons with fall risk.3,4 Treatment of hypertension in elderly patients decreases the risk of cardiovascular disease (CVD) outcomes.2,5–7 Although the relationship between antihypertensive medications and fall risk is complex and as yet inadequately studied, most studies adjusting for appropriate confounders have reported a greater risk of falls, fall injuries, or fall risk factors with antihypertensive medications. Conversely, the risk of falls may be decreased if medications are reduced.8 Cardiovascular medications, including antihypertensives, are the drugs most commonly implicated in medication-related symptoms and adverse effects.9 Furthermore, falling and fall risk factors such as postural unsteadiness, weakness, dizziness, and postural hypotension are among the most common adverse effects of medications, including antihypertensive medications.10,11 The co-occurrence of hypertension and fall risk, therefore, can serve as a model for studying health priorities in the face of potentially competing health conditions, although eliciting priorities raises concerns about well-known challenges, including reluctance to articulate feelings about outcomes not yet experienced, the tendency to select all outcomes as equally important, and change in priorities with time and changing health status.12,13 Limited health literacy, the effects of framing and ordering, and inadequate numeracy and communication skills of patients and clinicians further complicate efforts to elicit patient priorities and preferences reliably.14–16 If, as precepts of patient-centered care espouse, clinical decision-making is to incorporate patients’ priorities and individualize therapy to meet these priorities,1 then an approach must be found that addresses these challenges. Conjoint analysis,17 which elicits priorities by asking respondents to make explicit tradeoffs between competing outcomes, is one possible approach that has been applied in several health-related areas. Conjoint analysis has been used successfully in older individuals with visual deficits, limited education, and lack of computer experience.18–20 The aim of the present study was to describe the development and testing of a choice-based conjoint analysis task designed to elicit older individuals’ priorities in the face of competing CVD outcomes, medication-related symptoms, and fall injuries.

OBJECTIVES: To prospectively evaluate nursing home residents with suspected urinary tract infection (UTI) to determine whether they met the McGeer, Loeb, or revised Loeb consensus-based criteria and whether any set of criteria was associated with laboratory evidence of UTI, namely bacteriuria (>100,000 colony forming units) plus pyuria (>10 white blood cells). DESIGN: Prospective cohort study. SETTING: Three New Haven–area nursing homes. PARTICIPANTS: Of 611 residents screened, 457 were eligible, 362 consented, and 340 enrolled. MEASUREMENTS: Participants underwent prospective surveillance from May 2005 to April 2006 for the development of suspected UTI (defined as a participant's physician or nurse clinically suspecting UTI). One hundred participants with suspected UTI and a urinalysis and urine culture performed were included in the analyses. RESULTS: Participants were identified who met the criteria of McGeer, Loeb, revised Loeb, and laboratory evidence of UTI. Using laboratory evidence of UTI as the outcome, the McGeer criteria demonstrated 30% sensitivity, 82% specificity, 57% positive predictive value (PPV), and 61% negative predictive value (NPV); the Loeb criteria showed 19% sensitivity, 89% specificity, 57% PPV, and 59% NPV; and the revised Loeb criteria demonstrated 30% sensitivity, 79% specificity, 52% PPV, and 60% NPV. CONCLUSION: All of the consensus-based criteria have similar test characteristics. The diagnostic accuracy of UTI criteria in nursing home residents could be improved, and the data suggest that evidence-based clinical criteria associated with laboratory evidence of UTI need to be identified and validated.

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.

OBJECTIVES: To determine the relationship between hydroxymethyl glutaryl coenzyme A reductase inhibitor (statin) use and proximal muscle strength, cognition, and depression in older adults. DESIGN: Observational cohort study. SETTING: Outpatient primary care clinics. PARTICIPANTS: Seven hundred fifty-six communitydwelling veterans aged 65 and older. MEASUREMENTS: Timed chair stands (a measure of proximal muscle strength), Trail Making Test Part B (a measure of cognition), and the Center for Epidemiologic Studies Depression Scale score were measured at baseline and 1-year follow-up. Participants were assessed for statin prescriptions (and indications for or contraindications to their use), concomitant medication use, comorbidities, and other potential confounders. RESULTS: Statin users (n 5315) took a mean 6.6 medications, versus 4.6 for nonusers (n 5441), and had a median duration of statin use of 727 days. Statin users were more likely to be white and had (as expected) more cardiac, cerebrovascular, and peripheral vascular disease. Based on multivariable models adjusting for pertinent covariates, statin users performed modestly better than nonusers for timed chair stands (� 0.5 seconds; P 5.04), Trail Making Test Part B (� 7.7 seconds; P 5.08), and depression scores (� 0.2 points;P 5.49) at follow-up.Of potentially high-risk participants (based on age, comorbidity, and number of medications), statin users also showed similar 1-year changes as nonusers, although worsened depression scores were found in those with greater comorbidity (10.88 points; P 5.10). CONCLUSION: Older, community-dwelling male participants taking maintenance statin therapy had similar outcomes to those of nonusers in tests of muscle strength, cognition, and depression, but further examination of benefits and harms in different subgroups is warranted. J Am Geriatr Soc 55:420–425, 2007.

Older adults generally have multiple medical problems as well as subclinical changes in several physiologic systems. This special article presents a framework (based on the World Health Organization International Classification of Functioning, Disability, and Health) for organizing comorbid processes and diseases to facilitate research and assist clinicians caring for older adults. The nosology begins with physiologic systems (e.g., cardiovascular, endocrine) and assesses each system in several domains (e.g., coronary blood flow, systemic blood pressure, and cardiac function in the cardiovascular system). Functioning in each domain can range from high-functioning, even protective, zones (e.g., high levels of high-density-lipoprotein cholesterol) to severe dysfunction (as in end-stage disease). The approach has four advantages. First, it explicitly recognizes that decrements in health begin before onset of symptomatic disease. Second, it accommodates the full range of possible performance for each system instead of measuring only negative aspects. Third, it avoids arbitrary diagnostic thresholds. Fourth, it sets up an exhaustive and mutually exclusive classification system that can stimulate development of summary indices of total comorbidity burden for both research and clinical settings. As the knowledge base grows, the nosology can be updated to add new domains and refine extant ones.

Objectives To examine older persons’ understanding of healthcare decision-making involving trade-offs. Design Cross-sectional survey. Setting Primary care clinics. Participants Community-living persons aged 65 and older (N = 50). Measurements After being primed to think about trade-offs with a focus on chronic disease management, participants were asked to describe a decision they had made in the past involving a trade-off. If they could not, they were asked to describe a decision they might face in the future and were then given an example of a decision. They were also asked about communication with their primary care provider about their priorities when faced with a trade-off. Results Forty-four participants (88%) were able to describe a healthcare decision involving a trade-off; 25 provided a decision in the past, 17 provided a decision they might face in the future, and two provided a future decision after hearing an example. One participant described a nonmedical decision, and two participants described goals without providing a trade-off. Of the healthcare decisions, 26 involved surgery, seven were end-of life decisions, seven involved treatment of chronic disease, and four involved chemotherapy. When asked whether their providers should know their health outcome priorities, 44 (88%) replied yes, and 35 (70%) believed their providers knew their priorities, but only 18 (36%) said that they had had a specific conversation about priorities. Conclusion The majority of participants were able to recognize the trade-offs involved in healthcare decision-making and wanted their providers to know their priorities regarding the trade-offs. Despite being primed to think about the trade-offs involved in day-to-day treatment of chronic disease, participants most frequently described episodic, high-stakes decisions including surgery and end-of-life care.

Objective: Risk stratification models support clinical decision making in acute myocardial infarction (AMI) care. Existing models were developed using data from younger populations, potentially limiting accuracy and relevance in older adults. We describe physician-perceived risk factors, views of existing models, and preferences for future model development in older adults. Method: Qualitative study using semi-structured telephone interviews and the constant comparative method. Results: Twenty-two physicians from 14 institutions completed the interviews. Median age was 37, and median years of clinical experience was 11.5. Perceived predictors included cardiovascular, comorbid, functional, and social risk factors. Physicians viewed models as easy to use, yet neither inclusive of risk factors nor predictive of non-mortality outcomes germane to clinical decision making in older adults. Ideal models included multidimensional risk domains and operational requirements. Discussion: Physicians reported limitations of available risk models when applied to older adults with AMI. New models are needed to guide AMI treatment in this population.

Objectives To ascertain the effect of common chronic conditions on mortality in older persons with colorectal cancer. Design Retrospective cohort study. Setting Population-based cancer registry. Participants Patients in the Surveillance Epidemiology and End Results-Medicare linked database who were aged 67 and older and had a primary diagnosis of Stage 1 to 3 colorectal cancer during 1993 through 1999. Measurements Chronic conditions were identified using claims data, and vital status was determined from the Medicare enrollment files. After estimating the adjusted hazard ratios for mortality associated with each condition using a Cox model, the population attributable risk (PAR) was calculated for the full sample and by age subgroup. Results The study sample consisted of 29,733 patients, 88% of whom were white and 55% were female. Approximately 9% of deaths were attributable to congestive heart failure (CHF; PAR = 9.4%, 95% confidence interval (CI) = 8.4-10.5%), more than 5% were attributable to chronic obstructive pulmonary disease (COPD; PAR = 5.3%, 95% CI = 4.7-6.6%), and nearly 4% were attributable to diabetes mellitus (PAR = 3.9%, 95% CI = 3.1-4.8%). The PAR associated with CHF increased with age, from 6.3% (95% CI = 4.4-8.8%) in patients aged 67 to 70 to 14.5% (95% CI = 12.0-17.5%) in patients aged 81 to 85. Multiple conditions were common. More than half of the patients who had CHF also had diabetes mellitus or COPD. The PAR associated with CHF alone (4.29%, 95% CI = 3.68-4.94%) was similar to the PAR for CHF in combination with diabetes mellitus (3.08, 95% CI = 2.60-3.61%) or COPD (3.93, 95% CI = 3.41-4.54%). Conclusion A substantial proportion of deaths in older persons with colorectal cancer can be attributed to CHF, diabetes mellitus, and COPD. Multimorbidity is common and exerts a substantial effect on colorectal cancer survival.

Objective: It is critical to identify modifiable factors associated with functional recovery from hip fracture. The authors examined the association between pain intensity and two functional endpoints—instrumental activities of daily living and social activity participation—after hip fracture. Method: A total of 270 cognitively intact, community-dwelling persons older than 65 who underwent surgical hip fracture repair in New Haven, Connecticut, were followed for 12 months. Results: Pain intensity was strongly negatively associated with both instrumental and social functioning ( p values < .001). Increases in pain intensity between 6 and 12 months were also associated with concurrent decreases in function ( p values < .001). These relationships were partly explained by depressive symptoms and a marker of physical ability—gait speed. Discussion: Interventions to control pain may enhance functional status after hip fracture; however, pain relief must be maintained to sustain recovery. Attention to the complex relationships among pain, depressive symptoms, and physical impairments should inform intervention development.

Objectives: To identify clinical and laboratory criteria used by nursing home practitioners for diagnosis and treatment of urinary tract infections (UTIs) in nursing home residents. To determine practitioner knowledge of the most commonly used consensus criteria (i.e., McGeer criteria) for UTIs. Design: Self-administered survey. Setting: Three New Haven–area nursing homes. Participants: Physicians (n=25), physician assistants (PAs, n=3), directors/assistant directors of nursing (n=8), charge nurses (n=37), and infection control practitioners (n=3). Measurements: Open- and closed-ended questions. Results: Nineteen physicians, three PAs, and 41 nurses completed 63 of 76 (83%) surveys. The five most commonly reported triggers for suspecting UTI in noncatheterized residents were change in mental status (57/63, 90%), fever (48/63, 76%), change in voiding pattern (44/63, 70%), dysuria (41/63, 65%), and change in character of urine (37/63, 59%). Asked to identify their first diagnostic step in the evaluation of UTIs, 48% (30/63) said urinary dipstick analysis, and 40% (25/63) said urinalysis and urine culture. Fourteen of 22 (64%) physicians and PAs versus 40 of 40 (100%) nurses were aware of the McGeer criteria for noncatheterized patients (P