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Quiñones AR, McAvay G, Vander Wyk B, Han L, Nagel C, Allore HG. A Joint Model for Disability, Self-Rated Health, and Mortality Among Medicare Beneficiaries-Differences by Chronic Disease and Race/Ethnicity. J Aging Health 2023:8982643231210027. [PMID: 37879084 DOI: 10.1177/08982643231210027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
OBJECTIVES Quantifying interdependence in multiple patient-centered outcomes is important for understanding health declines among older adults. METHODS Medicare-linked National Health and Aging Trends Study data (2011-2015) were used to estimate a joint longitudinal logistic regression model of disability in activities of daily living (ADL), fair/poor self-rated health (SRH), and mortality. We calculated personalized concurrent risk (PCR) and typical concurrent risk (TCR) using regression coefficients. RESULTS For fair/poor SRH, highest odds were associated with COPD. For mortality, highest odds were associated with dementia, hip fracture, and kidney disease. Dementia and hip fracture were associated with highest odds of ADL disability. Hispanic respondents had highest odds of ADL disability. Hispanic and NH Black respondents had higher odds of fair/poor SRH, ADL disability, and mortality. PCRs/TCRs demonstrated wide variability for respondents with similar sociodemographic-multimorbidity profiles. DISCUSSION These findings highlight the variability of personalized risk in examining interdependent outcomes among older adults.
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Affiliation(s)
- Ana R Quiñones
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
- OHSU-PSU School of Public Health, Portland, OR, USA
| | - Gail McAvay
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Brent Vander Wyk
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Ling Han
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Corey Nagel
- College of Nursing, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Heather G Allore
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Biostatistics, Yale University, New Haven, CT, USA
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Monin JK, McAvay G, Newkirk K, Samper-Ternent R. Longitudinal associations between cognitive functioning and depressive symptoms among couples in the Mexican Health and Aging Study. Int Psychogeriatr 2023; 35:576-586. [PMID: 36599661 PMCID: PMC10319915 DOI: 10.1017/s1041610222000898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To examine the bidirectional associations between older adult spouses' cognitive functioning and depressive symptoms over time and replicate previous findings from the United States (US) in Mexico. DESIGN Longitudinal, dyadic path analysis with the actor-partner interdependence model. SETTING Data were from the three most recent interview waves (2012, 2015, and 2018) of the Mexican Health and Aging Study (MHAS), a longitudinal national study of adults aged 50+ years in Mexico. PARTICIPANTS Husbands and wives from 905 community-dwelling married couples (N = 1,810). MEASUREMENTS The MHAS cognitive battery measured cognitive function. Depressive symptoms were assessed using a modified nine-item Center for Epidemiologic Studies Depression Scale. Baseline covariates included age, education, number of children, limitation with any activity of daily living, limitation with any instrumental activity of daily living, and pain. RESULTS As hypothesized, there were significant within-individual associations in which one person's own cognitive functioning and own depressive symptoms predicted their own follow-up cognitive functioning and depressive symptoms, respectively. In addition, a person's own cognitive functioning predicted their own depressive symptoms, and a person's own depressive symptoms predicted their own cognitive functioning over time. As hypothesized, there was a significant partner association such that one person's depressive symptoms predicted more depressive symptoms in the partner. CONCLUSION Findings from this study of older Mexican couples replicates findings from studies of older couples in the US, showing that depressive symptoms in one partner predict depressive symptoms in the other partner over time; however, there was no evidence for cognition-depression partner associations over time.
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Affiliation(s)
- Joan K. Monin
- Social and Behavioral Sciences Department, Yale School of Public Health, New Haven, CT, USA
| | - Gail McAvay
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Katie Newkirk
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Rafael Samper-Ternent
- School of Public Health, The University of Texas Health Science Center, Houston, TX, USA
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Monin JK, McAvay G, Zang E, Vander Wyk B, Carrión CI, Allore H. Associations between dementia staging, neuropsychiatric behavioral symptoms, and divorce or separation in late life: A case control study. PLoS One 2023; 18:e0289311. [PMID: 37585365 PMCID: PMC10431668 DOI: 10.1371/journal.pone.0289311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 07/14/2023] [Indexed: 08/18/2023] Open
Abstract
Dementia can be difficult for married couples for many reasons, including the introduction of caregiving burden, loss of intimacy, and financial strain. In this study, we investigated the impact of dementia staging and neuropsychiatric behavioral symptoms on the likelihood of divorce or separation for older adult married couples. For this case-control study, we used data from the National Alzheimer's Coordinating Center (NACC) Uniform dataset (UDS) versions 2 and 3. This dataset was from 2007 to 2021 and contains standardized clinical information submitted by NIA/NIH Alzheimer's Disease Research Centers (ADRCs) across the United States (US). This data was from 37 ADRCs. We selected participants who were married or living as married/domestic partners at their initial visit. Cases were defined by a first divorce/separation occurring during the follow-up period, resulting in 291 participants. We selected 5 controls for each married/living as married case and matched on age. Conditional logistic regression estimated the association between overall Neuro Psychiatric Inventory (NPI) score and severity of individual symptoms of the NPI with case/control status, adjusted for education, the CDR® Dementia Staging Instrument score, living situation, symptom informant, sex, and race. Separate analyses were conducted for each symptom. Multiple comparisons were accounted for with the Hochberg method. Later stage of dementia was negatively associated with divorce/separation with an adjusted odds ratio (AOR) = 0.68 (95%CI = 0.50 to 0.93). A higher overall NPI score was positively associated with divorce/separation AOR = 1.08 (95% CI = 1.03 to 1.12,). More severe ratings of agitation/aggression, depression/dysphoria, disinhibition, and elation/euphoria were associated with greater odds of divorce/separation. Among older adults in the US, a later stage of dementia is associated with a lower likelihood of divorce or separation, while having more severe neuropsychiatric behavioral symptoms of agitation/aggression, depression/dysphoria, disinhibition, and elation/euphoria are associated with a higher likelihood of divorce or separation.
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Affiliation(s)
- Joan K. Monin
- Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, United States of America
| | - Gail McAvay
- Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Emma Zang
- Sociology, Yale University, New Haven, CT, United States of America
| | - Brent Vander Wyk
- Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Carmen I. Carrión
- Neurology, Yale School of Medicine, New Haven, CT, United States of America
| | - Heather Allore
- Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America
- Biostatistics, Yale School of Public Health, New Haven, CT, United States of America
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Monin JK, McAvay G, Ali T, Feeney BC, Marottoli R, Gaugler JE, Birditt K. Activities of Daily Living Needs and Support in Adult Child-Parent Dyads. GeroPsych (Bern) 2023; 36:97-107. [PMID: 38213784 PMCID: PMC10783371 DOI: 10.1024/1662-9647/a000307] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
This study examined whether changes in middle-aged children's perceptions of their parents' activities of daily living needs (ADL needs) were associated with changes in the mutuality of support in their relationship. A group of 366 middle-aged children in Waves 1 (2008) and 2 (2013) of the Family Exchanges Study self-reported providing and receiving tangible, emotional, and informational support to and from their n = 468 parents. Increased perceived parental ADL needs were associated with increased provision of tangible and informational support to parents but not with changes in support received. Increases in perceived parental ADL needs were associated with higher incongruence for all three support types (the child providing more support than they receive).
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Affiliation(s)
- Joan K. Monin
- Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Gail McAvay
- Internal Medicine, Geriatric Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Talha Ali
- Internal Medicine, Geriatric Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Brooke C. Feeney
- Department of Psychology, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Richard Marottoli
- Internal Medicine, Geriatric Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Joseph E. Gaugler
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Kira Birditt
- Survey Research Center, University of Michigan, Ann Arbor, MI, USA
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5
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Ali T, McAvay G, Monin JK. Mealtime Behavior and Depressive Symptoms in Late-Life Marriage. GeroPsych (Bern) 2022; 35:211-225. [PMID: 36777454 PMCID: PMC9912988 DOI: 10.1024/1662-9647/a000285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
This study examined whether one spouse's mealtime behaviors were associated with their own and their partner's depressive symptoms among older, married couples. We examined gender differences in these associations and tested marital satisfaction as a mediator of these associations. 101 couples self-reported mealtime behavior (number of meals, snacks, fast-food meals, and meals eaten alone), depressive symptoms, and marital satisfaction. Results of the Actor Partner Interdependence Model revealed a statistically significant actor effect of number of fast-food meals on depressive symptoms and a significant partner effect of number of fast-food meals and number of meals eaten alone on depressive symptoms. There were gender differences. Husbands' marital satisfaction mediated the effect of meals eaten alone on depressive symptoms. Wife's marital satisfaction mediated the effect of the husband's meals eaten alone, and wife's number of fast-food meals on the wife's depressive symptoms. Findings have implications for dyadic interventions to improve depressive symptoms.
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Affiliation(s)
- Talha Ali
- Department of Internal Medicine, Yale School of Medicine
| | - Gail McAvay
- Department of Internal Medicine, Yale School of Medicine
| | - Joan K. Monin
- Social and Behavioral Sciences, Yale School of Public Health
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Ali T, McAvay G, Monin J, Gill T. Caregiving Patterns and Their Association with Caregiving Burden and Gains. Innov Aging 2021. [PMCID: PMC8682255 DOI: 10.1093/geroni/igab046.3572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Family and friend caregivers play a critical role in helping older adults live long and healthy lives. Using the construct of "care types" we examine whether caregivers providing more intense care experience higher burden and lower gain compared to caregivers providing less intense care. Data are from the 2015 and 2017 rounds of the National Study of Caregiving (N=2,146), a study of the caregivers of older adults enrolled in the National Health and Aging Trends Study. In a previous analysis, we derived five care types at baseline (2015), that varied in the number and type of care activities, care duration, and regularity of care provided. Caregivers reported whether caregiving was financially, emotionally, and physically difficult for them. Participants were also asked whether caregiving made them more confident, taught them to deal with difficult situations, brought them closer to the recipient, and gave them satisfaction that the recipient was well cared for. We estimated the association between care types derived at baseline and caregiver burden and gains at follow-up using logistic regression. Compared to caregivers in the least intense care type, those in the more intense care types were significantly more likely to report financial and physical burden, as well as increased ability to deal with difficult situations and increased satisfaction that their loved one was well cared for. These associations remained significant after adjusting for confounders. Care types can be used to predict burdens and gains experienced by caregivers and to effectively target caregiver support services and interventions.
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Affiliation(s)
- Talha Ali
- Yale School of Medicine, New Haven, Connecticut, United States
| | - Gail McAvay
- Yale School of Medicine, New Haven, Connecticut, United States
| | - Joan Monin
- Yale School of Public Health, New Haven, Connecticut, United States
| | - Thomas Gill
- Yale School of Medicine, New Haven, Connecticut, United States
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Wang KH, McAvay G, Warren A, Miller ML, Pho A, Blosnich JR, Brandt CA, Goulet JL. Examining Health Care Mobility of Transgender Veterans Across the Veterans Health Administration. LGBT Health 2021; 8:143-151. [PMID: 33512276 DOI: 10.1089/lgbt.2020.0152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: Transgender veterans are overrepresented in the Veterans Health Administration (VHA) compared with in the general population. Utilization of multiple different health care systems, or health care mobility, can affect care coordination and potentially affect outcomes, either positively or negatively. This study examines whether transgender veterans are more or less health care mobile than nontransgender veterans and compares the patterns of geographic mobility in these groups. Methods: Using an established cohort (n = 5,414,109), we identified 2890 transgender veterans from VHA electronic health records from 2000 to 2012. We compared transgender and nontransgender veterans on sociodemographic, clinical, and health care system-level measures and conducted conditional logistic regression models of mobility. Results: Transgender veterans were more likely to be younger, White, homeless, have depressive disorders, post-traumatic stress disorder (PTSD), and hepatitis C. Transgender veterans were more likely to have been health care mobile (9.9%) than nontransgender veterans (5.2%) (unadjusted odds ratio = 2.02, 95% confidence interval = 1.73-2.36). In a multivariable model, transgender status, being separated/divorced, receiving care in less-complex facilities, and diagnoses of depression, PTSD, or hepatitis C were associated with more mobility, whereas older age was associated with less mobility. For the top three health care systems utilized, a larger proportion of transgender veterans visited a second health care system in a different state (56.2%) than nontransgender veterans (37.5%). Conclusions: Transgender veterans were more likely to be health care mobile and more likely to travel out of state for health care services. They were also more likely to have complex chronic health conditions that require multidisciplinary care.
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Affiliation(s)
- Karen H Wang
- Department of Internal Medicine, Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Gail McAvay
- Department of Internal Medicine, Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA.,Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Allison Warren
- Department of Internal Medicine, Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA.,Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Mary L Miller
- Department of Internal Medicine, Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Anthony Pho
- Columbia University School of Nursing, New York, New York, USA
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California, USA.,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Cynthia A Brandt
- Department of Internal Medicine, Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA.,Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Joseph L Goulet
- Department of Internal Medicine, Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA.,Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
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8
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Ali T, McAvay G, Monin J. Dietary Behavior and Depressive Symptoms in Late-Life Marriage. Innov Aging 2020. [PMCID: PMC7741739 DOI: 10.1093/geroni/igaa057.1190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Epidemiologic studies have linked dietary patterns to psychological health including depression, anxiety, and stress. However, no research has examined dyadic associations between dietary behavior and depressive symptoms in older married couples. In this study, one hundred and one couples 51 to 90 years of age who were married or in a marriage-like relationship and living together for at least 6 months were recruited. Participants completed questionnaires and self-reported their dietary behavior (i.e., the total number of meals, number of snacks, and number of fast-food meals eaten in a typical day and the number of meals they eat alone and eat sitting down). They also completed the 20-item Center for Epidemiologic Studies Depression Scale. Results of the Actor Partner Interdependence Models controlling for income, education, chronic conditions, and marital satisfaction, showed that for wives only, more meals eaten in a day were associated with lower depressive symptoms (actor effect). Additionally, more snacks eaten by the wife and more meals eaten alone by the wife were associated with higher depressive symptoms for the husband (partner effects). Findings suggest that wives’ dietary behavior is particularly important, not only for their own but also their husbands’ mental health in late-life marriage.
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Affiliation(s)
- Talha Ali
- Yale University, New Haven, Connecticut, United States
| | - Gail McAvay
- Yale School of Medicine, New Haven, Connecticut, United States
| | - Joan Monin
- Yale University, New Haven, Connecticut, United States
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Ouellet GM, McAvay G, Murphy TE, Tinetti ME. Treatment of Hypertension in Complex Older Adults: How Many Medications Are Needed? Gerontol Geriatr Med 2019; 5:2333721419856436. [PMID: 31245434 PMCID: PMC6580710 DOI: 10.1177/2333721419856436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/17/2019] [Accepted: 05/21/2019] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Gregory M Ouellet
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Gail McAvay
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Terrence E Murphy
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Mary E Tinetti
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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10
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McAvay G, Allore HG, Cohen AB, Gnjidic D, Murphy TE, Tinetti ME. Guideline-Recommended Medications and Physical Function in Older Adults with Multiple Chronic Conditions. J Am Geriatr Soc 2017; 65:2619-2626. [PMID: 28905359 DOI: 10.1111/jgs.15065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND/OBJECTIVES The benefit or harm of a single medication recommended for one specific condition can be difficult to determine in individuals with multiple chronic conditions and polypharmacy. There is limited information on the associations between guideline-recommended medications and physical function in older adults with multiple chronic conditions. The objective of this study was to estimate the beneficial or harmful associations between guideline-recommended medications and decline in physical function in older adults with multiple chronic conditions. DESIGN Prospective observational cohort. SETTING National. PARTICIPANTS Community-dwelling adults aged 65 and older from the Medicare Current Beneficiary Survey study (N = 3,273). Participants with atrial fibrillation, coronary artery disease, depression, diabetes mellitus, or heart failure were included. MEASUREMENTS Self-reported decline in physical function; guideline-recommended medications; polypharmacy (taking <7 vs ≥7 concomitant medications); chronic conditions; and sociodemographic, behavioral, and health risk factors. RESULTS The risk of decline in function in the overall sample was highest in participants with heart failure (35.4%, 95% confidence interval (CI) = 26.3-44.5) and lowest for those with atrial fibrillation (20.6%, 95% CI = 14.9-26.2). In the overall sample, none of the six guideline-recommended medications was associated with decline in physical function across the five study conditions, although in the group with low polypharmacy exposure, there was lower risk of decline in those with heart failure taking renin angiotensin system blockers (hazard ratio (HR) = 0.40, 95% CI = 0.16-0.99) and greater risk of decline in physical function for participants with diabetes mellitus taking statins (HR = 2.27, 95% CI = 1.39-3.69). CONCLUSIONS In older adults with multiple chronic conditions, guideline-recommended medications for atrial fibrillation, coronary artery disease, depression, diabetes mellitus, and heart failure were largely not associated with self-reported decline in physical function, although there were associations for some medications in those with less polypharmacy.
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Affiliation(s)
- Gail McAvay
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Heather G Allore
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut.,Department of Biostatistics, School of Public Health, Yale University, New Haven, Connecticut
| | - Andrew B Cohen
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Danijela Gnjidic
- Faculty of Pharmacy and Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Terrence E Murphy
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut.,Department of Biostatistics, School of Public Health, Yale University, New Haven, Connecticut
| | - Mary E Tinetti
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
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11
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Vaz Fragoso CA, McAvay G, Van Ness PH, Casaburi R, Jensen RL, MacIntyre N, Yaggi HK, Gill TM, Concato J. Phenotype of Spirometric Impairment in an Aging Population. Am J Respir Crit Care Med 2016; 193:727-35. [PMID: 26540012 DOI: 10.1164/rccm.201508-1603oc] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The Global Lung Initiative (GLI) provides age-appropriate criteria for establishing spirometric impairment, including mild, moderate, and severe chronic obstructive pulmonary disease (COPD) and restrictive pattern, but its association with respiratory-related phenotypes has not been evaluated. OBJECTIVES To evaluate respiratory-related phenotypes in GLI-defined spirometric impairment. METHODS In COPDGene (N = 10,131 patients; age range, 45-81 yr; average smoking history, 44.3 pack-years), we evaluated spirometry, dyspnea (modified Medical Research Council grade, ≥2), poor respiratory health-related quality of life (St. George's Respiratory Questionnaire total score, ≥25), poor exercise performance (6-minute-walk distance, <391 m), bronchodilator reversibility (FEV1 change, >12% and ≥200 ml), and computed tomography-diagnosed emphysema and gas trapping (>5% and >15% of lung, respectively). MEASUREMENTS AND MAIN RESULTS GLI established normal spirometry in 5,100 patients (50.3%), mild COPD in 669 (6.6%), moderate COPD in 865 (8.5%), severe COPD in 2,522 (24.9%), and restrictive pattern in 975 (9.6%). Relative to normal spirometry, graded associations with respiratory-related phenotypes were found for mild, moderate, and severe COPD, with respective adjusted odds ratios (95% confidence intervals) as follows: dyspnea-1.31 (1.10-1.56), 2.20 (1.81-2.68), and 10.73 (8.04-14.33); poor respiratory health-related quality of life-1.49 (1.28-1.75), 2.69 (2.08-3.47), and 14.61 (10.09-21.17); poor exercise performance-1.11 (0.94-1.31), 1.58 (1.33-1.88), and 4.58 (3.42-6.12); bronchodilator reversibility-2.76 (2.24-3.40), 5.18 (4.29-6.27), and 6.21 (5.06-7.62); emphysema-4.86 (3.16-7.47), 6.41 (4.09-10.05), and 17.79 (10.79-29.32); and gas trapping-3.92 (3.12-4.93), 5.20 (3.82-7.07), and 16.28 (9.71-27.30). Restrictive pattern was also associated with multiple respiratory-related phenotypes at a level similar to moderate COPD, but it was otherwise not associated with emphysema (0.89 [0.60-1.32]) or gas trapping (1.15 [0.92-1.42]). CONCLUSIONS GLI-defined spirometric impairment establishes clinically meaningful respiratory disease, as validated by graded associations with respiratory-related phenotypes.
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Affiliation(s)
- Carlos A Vaz Fragoso
- 1 Veterans Affairs Clinical Epidemiology Research Center, West Haven, Connecticut.,2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Gail McAvay
- 2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Peter H Van Ness
- 2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Richard Casaburi
- 3 Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Los Angeles, California
| | - Robert L Jensen
- 4 LDS Hospital and University of Utah, Salt Lake City, Utah; and
| | - Neil MacIntyre
- 5 Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
| | - H Klar Yaggi
- 1 Veterans Affairs Clinical Epidemiology Research Center, West Haven, Connecticut.,2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Thomas M Gill
- 2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - John Concato
- 1 Veterans Affairs Clinical Epidemiology Research Center, West Haven, Connecticut.,2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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Sankey CB, McAvay G, Siner JM, Barsky CL, Chaudhry SI. "Deterioration to Door Time": An Exploratory Analysis of Delays in Escalation of Care for Hospitalized Patients. J Gen Intern Med 2016; 31:895-900. [PMID: 26969311 PMCID: PMC4945556 DOI: 10.1007/s11606-016-3654-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 09/23/2015] [Accepted: 02/19/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Timely escalation of care for patients experiencing clinical deterioration in the inpatient setting is challenging. Deterioration on a general floor has been associated with an increased risk of death, and the early period of deterioration may represent a time during which admission to the intensive care unit (ICU) improves survival. Previous studies examining the association between delay from onset of clinical deterioration to ICU transfer and mortality are few in number and were conducted more than 10 years ago. OBJECTIVE We aimed to evaluate the impact of delays in the escalation of care among clinically deteriorating patients in the current era of inpatient medicine. DESIGN AND PARTICIPANTS This was a retrospective cohort study that analyzed data from 793 patients transferred from non-intensive care unit (ICU) inpatient floors to the medical intensive care unit (MICU), from 2011 to 2013 at an urban, tertiary, academic medical center. MAIN MEASURES "Deterioration to door time (DTDT)" was defined as the time between onset of clinical deterioration (as evidenced by the presence of one or more vital sign indicators including respiratory rate, systolic blood pressure, and heart rate) and arrival in the MICU. KEY RESULTS In our sample, 64.6 % had delays in care escalation, defined as greater than 4 h based on previous studies. Mortality was significantly increased beginning at a DTDT of 12.1 h after adjusting for age, gender, and severity of illness. CONCLUSIONS Delays in the escalation of care for clinically deteriorating hospitalized patients remain frequent in the current era of inpatient medicine, and are associated with increased in-hospital mortality. Development of performance measures for the care of clinically deteriorating inpatients remains essential, and timeliness of care escalation deserves further consideration.
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Affiliation(s)
- Christopher B Sankey
- Section of General Medicine, Department of Internal Medicine, Yale University School of Medicine, Harkness Hall A, Room 306, 367 Cedar St., New Haven, CT, 06510, USA. .,Yale-New Haven Hospital, New Haven, CT, USA.
| | - Gail McAvay
- Section of Geriatric Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jonathan M Siner
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Carol L Barsky
- Patient Safety and Quality, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Sarwat I Chaudhry
- Section of General Medicine, Department of Internal Medicine, Yale University School of Medicine, Harkness Hall A, Room 306, 367 Cedar St., New Haven, CT, 06510, USA.,Yale-New Haven Hospital, New Haven, CT, USA
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Allore H, McAvay G, Vaz Fragoso CA, Murphy TE. Individualized Absolute Risk Calculations for Persons with Multiple Chronic Conditions: Embracing Heterogeneity, Causality, and Competing Events. ACTA ACUST UNITED AC 2016; 5:48-55. [PMID: 27076862 PMCID: PMC4827855 DOI: 10.6000/1929-6029.2016.05.01.5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Approximately 75% of adults over the age of 65 years are affected by two or more chronic medical conditions. We provide a conceptual justification for individualized absolute risk calculators for competing patient-centered outcomes (PCO) (i.e. outcomes deemed important by patients) and patient reported outcomes (PRO) (i.e. outcomes patients report instead of physiologic test results). The absolute risk of an outcome is the probability that a person receiving a given treatment will experience that outcome within a pre-defined interval of time, during which they are simultaneously at risk for other competing outcomes. This allows for determination of the likelihood of a given outcome with and without a treatment. We posit that there are heterogeneity of treatment effects among patients with multiple chronic conditions (MCC) largely depends on those coexisting conditions. We outline the development of an individualized absolute risk calculator for competing outcomes using propensity score methods that strengthen causal inference for specific treatments. Innovations include the key concept that any given outcome may or may not concur with any other outcome and that these competing outcomes do not necessarily preclude other outcomes. Patient characteristics and MCC will be the primary explanatory factors used in estimating the heterogeneity of treatment effects on PCO and PRO. This innovative method may have wide-spread application for determining individualized absolute risk calculations for competing outcomes. Knowing the probabilities of outcomes in absolute terms may help the burgeoning population of patients with MCC who face complex treatment decisions.
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Affiliation(s)
- Heather Allore
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Gail McAvay
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Carlos A Vaz Fragoso
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Veterans Affairs Clinical Epidemiology Research Center, West Haven, CT, USA
| | - Terrence E Murphy
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Vaz Fragoso CA, McAvay G, Van Ness PH, Casaburi R, Jensen RL, MacIntyre N, Gill TM, Yaggi HK, Concato J. Phenotype of normal spirometry in an aging population. Am J Respir Crit Care Med 2016; 192:817-25. [PMID: 26114439 DOI: 10.1164/rccm.201503-0463oc] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE In aging populations, the commonly used Global Initiative for Chronic Obstructive Lung Disease (GOLD) may misclassify normal spirometry as respiratory impairment (airflow obstruction and restrictive pattern), including the presumption of respiratory disease (chronic obstructive pulmonary disease [COPD]). OBJECTIVES To evaluate the phenotype of normal spirometry as defined by a new approach from the Global Lung Initiative (GLI), overall and across GOLD spirometric categories. METHODS Using data from COPDGene (n = 10,131; ages 45-81; smoking history, ≥10 pack-years), we evaluated spirometry and multiple phenotypes, including dyspnea severity (Modified Medical Research Council grade 0-4), health-related quality of life (St. George's Respiratory Questionnaire total score), 6-minute-walk distance, bronchodilator reversibility (FEV1 % change), computed tomography-measured percentage of lung with emphysema (% emphysema) and gas trapping (% gas trapping), and small airway dimensions (square root of the wall area for a standardized airway with an internal perimeter of 10 mm). MEASUREMENTS AND MAIN RESULTS Among 5,100 participants with GLI-defined normal spirometry, GOLD identified respiratory impairment in 1,146 (22.5%), including a restrictive pattern in 464 (9.1%), mild COPD in 380 (7.5%), moderate COPD in 302 (5.9%), and severe COPD in none. Overall, the phenotype of GLI-defined normal spirometry included normal adjusted mean values for dyspnea grade (0.8), St. George's Respiratory Questionnaire (15.9), 6-minute-walk distance (1,424 ft [434 m]), bronchodilator reversibility (2.7%), % emphysema (0.9%), % gas trapping (10.7%), and square root of the wall area for a standardized airway with an internal perimeter of 10 mm (3.65 mm); corresponding 95% confidence intervals were similarly normal. These phenotypes remained normal for GLI-defined normal spirometry across GOLD spirometric categories. CONCLUSIONS GLI-defined normal spirometry, even when classified as respiratory impairment by GOLD, included adjusted mean values in the normal range for multiple phenotypes. These results suggest that among adults with GLI-defined normal spirometry, GOLD may misclassify normal phenotypes as having respiratory impairment.
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Affiliation(s)
- Carlos A Vaz Fragoso
- 1 Veterans Affairs Clinical Epidemiology Research Center, West Haven, Connecticut.,2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Gail McAvay
- 2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Peter H Van Ness
- 2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Richard Casaburi
- 3 Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Los Angeles, California
| | - Robert L Jensen
- 4 LDS Hospital and University of Utah, Salt Lake City, Utah; and
| | - Neil MacIntyre
- 5 Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Thomas M Gill
- 2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - H Klar Yaggi
- 1 Veterans Affairs Clinical Epidemiology Research Center, West Haven, Connecticut.,2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - John Concato
- 1 Veterans Affairs Clinical Epidemiology Research Center, West Haven, Connecticut.,2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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Allore HG, Zhan Y, Cohen AB, Tinetti ME, Trentalange M, McAvay G. Methodology to Estimate the Longitudinal Average Attributable Fraction of Guideline-recommended Medications for Death in Older Adults With Multiple Chronic Conditions. J Gerontol A Biol Sci Med Sci 2016; 71:1113-6. [PMID: 26748093 DOI: 10.1093/gerona/glv223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 11/30/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND 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. METHODS 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 and >80 years) were analyzed to determine heterogeneity of both cardiovascular conditions and medications. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Heather G Allore
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut. Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut.
| | - Yilei Zhan
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut. Department of Statistics and Biostatistics, Rutgers University, New Brunswick, New Jersey
| | - Andrew B Cohen
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Mary E Tinetti
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Mark Trentalange
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Gail McAvay
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
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Vaz Fragoso CA, Gill TM, McAvay G, Yaggi HK, Van Ness PH, Concato J. Respiratory Impairment and Mortality in Older Persons. J Investig Med 2015; 59:1089-95. [DOI: 10.2310/jim.0b013e31822bb213] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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17
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Vaz Fragoso CA, McAvay G, Van Ness PH, Metter EJ, Ferrucci L, Yaggi HK, Concato J, Gill TM. Aging-Related Considerations When Evaluating the Forced Expiratory Volume in 1 Second (FEV1) Over Time. J Gerontol A Biol Sci Med Sci 2015; 71:929-34. [PMID: 26525091 DOI: 10.1093/gerona/glv201] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 10/08/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Forced expiratory volume in 1 second (FEV1) over time is commonly expressed in liters and percent predicted (%Pred), or alternatively in L/m(3) and Z-scores-which approach is more clinically meaningful has not been evaluated. Because it uniquely accounts for the effect of aging on FEV1 and spirometric performance, we hypothesized that the Z-score approach is more clinically meaningful, based on associations between cardiopulmonary predictors and FEV1 over time. METHODS Using linear mixed-effects models and data from the Baltimore Longitudinal Study on Aging, including 501 white participants aged 40-95 who had completed at least three longitudinal spirometric assessments, we evaluated the associations between cardiopulmonary predictors (obesity, smoking status, hypertension, chronic bronchitis, diabetes mellitus, and myocardial infarction) and FEV1 over time, in liters, %Pred, L/m(3), and Z-scores. RESULTS Mean baseline values for FEV1 were 3.240L, 96.4%Pred, 0.621L/m(3), and -0.239 as a Z-score (40.6th percentile). The annual decline in FEV1 was 0.040L, 0.234 %Pred, 0.007L/m(3), and 0.008 Z-score units. Baseline age was associated with FEV1 over time in liters and L/m(3) (p < .001), and included a time interaction for %Pred (p < .001), but was not associated with Z-scores (p = .933). The associations of cardiopulmonary predictors with FEV1 over time were all significant when using Z-scores (p < .05), but varied for other methods of expressing FEV1. CONCLUSION A Z-score approach is more clinically meaningful when evaluating FEV1 over time, as it accounted for the effect of aging and was more frequently associated with multiple cardiopulmonary predictors.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Veterans Affairs Clinical Epidemiology Research Center, West Haven, Connecticut. Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
| | - Gail McAvay
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Peter H Van Ness
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - E Jeffrey Metter
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Luigi Ferrucci
- Harbor Hospital, National Institute on Aging, Baltimore, Maryland
| | - H Klar Yaggi
- Veterans Affairs Clinical Epidemiology Research Center, West Haven, Connecticut. Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - John Concato
- Veterans Affairs Clinical Epidemiology Research Center, West Haven, Connecticut. Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Thomas M Gill
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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Tinetti ME, McAvay G, Trentalange M, Cohen AB, Allore HG. Association between guideline recommended drugs and death in older adults with multiple chronic conditions: population based cohort study. BMJ 2015; 351:h4984. [PMID: 26432468 PMCID: PMC4591503 DOI: 10.1136/bmj.h4984] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To estimate the association between guideline recommended drugs and death in older adults with multiple chronic conditions. DESIGN Population based cohort study. SETTING Medicare Current Beneficiary Survey cohort, a nationally representative sample of Americans aged 65 years or more. PARTICIPANTS 8578 older adults with two or more study chronic conditions (atrial fibrillation, coronary artery disease, chronic kidney disease, depression, diabetes, heart failure, hyperlipidemia, hypertension, and thromboembolic disease), followed through 2011. EXPOSURES Drugs included β blockers, calcium channel blockers, clopidogrel, metformin, renin-angiotensin system (RAS) blockers; selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs); statins; thiazides; and warfarin. MAIN OUTCOME MEASURE Adjusted hazard ratios for death among participants with a condition and taking a guideline recommended drug relative to participants with the condition not taking the drug and among participants with the most common combinations of four conditions. RESULTS Over 50% of participants with each condition received the recommended drugs regardless of coexisting conditions; 1287/8578 (15%) participants died during the three years of follow-up. Among cardiovascular drugs, β blockers, calcium channel blockers, RAS blockers, and statins were associated with reduced mortality for indicated conditions. For example, the adjusted hazard ratio for β blockers was 0.59 (95% confidence interval 0.48 to 0.72) for people with atrial fibrillation and 0.68 (0.57 to 0.81) for those with heart failure. The adjusted hazard ratios for cardiovascular drugs were similar to those with common combinations of four coexisting conditions, with trends toward variable effects for β blockers. None of clopidogrel, metformin, or SSRIs/SNRIs was associated with reduced mortality. Warfarin was associated with a reduced risk of death among those with atrial fibrillation (adjusted hazard ratio 0.69, 95% confidence interval 0.56 to 0.85) and thromboembolic disease (0.44, 0.30 to 0.62). Attenuation in the association with reduced risk of death was found with warfarin in participants with some combinations of coexisting conditions. CONCLUSIONS Average effects on survival, particularly for cardiovascular study drugs, were comparable to those reported in randomized controlled trials but varied for some drugs according to coexisting conditions. Determining treatment effects in combinations of conditions may guide prescribing in people with multiple chronic conditions.
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Affiliation(s)
- Mary E Tinetti
- Department of Internal Medicine (Geriatrics), Yale School of Medicine, New Haven, CT 06520, USA
| | - Gail McAvay
- Section of Geriatrics, Yale School of Medicine, New Haven, CT, USA
| | - Mark Trentalange
- Section of Geriatrics, Yale School of Medicine, New Haven, CT, USA
| | - Andrew B Cohen
- Section of Geriatrics, Yale School of Medicine, New Haven, CT, USA
| | - Heather G Allore
- Section of Geriatrics, Yale School of Medicine, New Haven, CT, USA
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Allore HG, Zhan Y, Tinetti M, Trentalange M, McAvay G. Longitudinal average attributable fraction as a method for studying time-varying conditions and treatments on recurrent self-rated health: the case of medications in older adults with multiple chronic conditions. Ann Epidemiol 2015; 25:681-686.e4. [PMID: 26033374 DOI: 10.1016/j.annepidem.2015.03.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 02/06/2015] [Accepted: 03/04/2015] [Indexed: 12/21/2022]
Abstract
PURPOSE The objective is to modify the longitudinal extension of the average attributable fraction (LE-AAF) for recurrent outcomes with time-varying exposures and control for covariates. METHODS We included Medicare Current Beneficiary Survey participants with two or more chronic conditions enrolled from 2005 to 2009 with follow-up through 2011. Nine time-varying medications indicated for nine time-varying common chronic conditions and 14 of 18 forward-selected participant characteristics were used as control variables in the generalized estimating equations step of the LE-AAF to estimate associations with the recurrent universal health outcome self-rated health (SRH). Modifications of the LE-AAF were made to accommodate these indicated medication-condition interactions and covariates. Variability was empirically estimated by bias-corrected and accelerated bootstrapping. RESULTS In the adjusted LE-AAF, thiazide, warfarin, and clopidogrel had significant contributions of 1.2%, 0.4%, 0.2%, respectively, to low (poor or fair) SRH; whereas there were no significant contributions of the other medications to SRH. Hyperlipidemia significantly contributed 4.6% to high SRH. All the other conditions except atrial fibrillation contributed significantly to low SRH. CONCLUSIONS Our modifications to the LE-AAF method apply to a recurrent binary outcome with time-varying factors accounting for covariates.
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Affiliation(s)
- Heather G Allore
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT; Department of Biostatistics, Yale School of Public Health, Yale University, New Haven, CT.
| | - Yilei Zhan
- Department of Biostatistics, Yale School of Public Health, Yale University, New Haven, CT
| | - Mary Tinetti
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT; Department of Chronic Disease, Yale School of Public Health, Yale University, New Haven, CT
| | - Mark Trentalange
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT
| | - Gail McAvay
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT
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Allore HG, McAvay G, Tinetti M. Health Outcome Effects of Common Medications in Elders With Multiple Conditions. J Patient Cent Res Rev 2015. [DOI: 10.17294/2330-0698.1118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Hartaigh BÓ, Allore HG, Trentalange M, McAvay G, Pilz S, Dodson JA, Gill TM. Elevations in time-varying resting heart rate predict subsequent all-cause mortality in older adults. Eur J Prev Cardiol 2015; 22:527-34. [PMID: 24445263 PMCID: PMC4156557 DOI: 10.1177/2047487313519932] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND An increased resting heart rate (RHR) has long been associated with unhealthy life. Nevertheless, it remains uncertain whether time-varying measurements of RHR are predictive of mortality in older persons. DESIGN The purpose of this study was to assess the relationship between repeated measurements of RHR and risk of death from all causes among older adults. METHODS We evaluated repeat measurements of resting heart rate among 5691 men and women (aged 65 years or older) enrolled in the Cardiovascular Health Study. RHR was measured annually for six consecutive years by validated electrocardiogram. All-cause mortality was confirmed by a study-wide Mortality Review Committee using reviews of obituaries, death certificates and hospital records, interviews with attending physicians, and next-of-kin. RESULTS Of the study cohort, 974 (17.1%) participants died. Each 10 beat/min increment in RHR increased the risk of death by 33% (adjusted hazard ratio, 95% confidence interval (CI) = 1.33, 1.26-1.40). Similar results were observed (adjusted hazard ratio, 95% CI = 2.21, 1.88-2.59) when comparing the upper-most quartile of RHR (mean = 81 beats/min) with the lowest (mean = 53 beats/min). Compared with participants whose RHR was consistently ≤65 beats/min during the study period, the risk of death increased monotonically for each 10 beat/min (consistent) increment in RHR, with adjusted hazard ratios (95% CI) ranging from 1.30 (1.23-1.37) for 75 beats/min to 4.78 (3.49-6.52) for 125 beats/min. CONCLUSIONS Elevations in the RHR over the course of six years are associated with an increased risk of all-cause mortality among older adults.
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Affiliation(s)
- Bríain ó Hartaigh
- Department of Internal Medicine/Geriatrics, Yale School of Medicine, USA
| | - Heather G Allore
- Department of Internal Medicine/Geriatrics, Yale School of Medicine, USA
| | - Mark Trentalange
- Department of Internal Medicine/Geriatrics, Yale School of Medicine, USA
| | - Gail McAvay
- Department of Internal Medicine/Geriatrics, Yale School of Medicine, USA
| | - Stefan Pilz
- Department of Internal Medicine, Medical University of Graz, Austria
| | - John A Dodson
- Department of Internal Medicine, Brigham and Women's Hospital, USA
| | - Thomas M Gill
- Department of Internal Medicine/Geriatrics, Yale School of Medicine, USA
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Marcus BS, McAvay G, Gill TM, Vaz Fragoso CA. Respiratory symptoms, spirometric respiratory impairment, and respiratory disease in middle-aged and older persons. J Am Geriatr Soc 2015; 63:251-7. [PMID: 25643966 PMCID: PMC4333080 DOI: 10.1111/jgs.13242] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To evaluate whether a novel definition of spirometric respiratory impairment from the Global Lung Initiative (GLI) is strongly associated with respiratory symptoms and, in turn, frequently establishes symptomatic respiratory disease. DESIGN Cross-sectional. SETTING Third National Health and Nutrition Examination Survey. PARTICIPANTS Community-dwelling individuals aged 40 to 80 (N = 7,115). MEASUREMENTS GLI-defined spirometric respiratory impairment (airflow obstruction and restrictive pattern), dyspnea on exertion (DOE), chronic bronchitis (CB), and wheezing. RESULTS Prevalence rates were 12.7% for airflow obstruction, 6.2% for restrictive pattern, 28.6% for DOE, 12.6% for CB, and 12.9% for wheezing. Airflow obstruction was associated with DOE (adjusted odds ratio (aOR) = 1.69, 95% confidence interval (CI) = 1.42-2.02), CB (aOR = 1.92, 95% CI = 1.62-2.29), and wheezing (aOR = 2.50, 95% CI = 2.08-3.00), and restrictive pattern was associated with DOE (aOR = 1.75, 95% CI = 1.36-2.25), CB (aOR = 1.39, 95% CI = 1.08-1.78), and wheezing (aOR = 1.53, 95% CI = 1.15-2.04). Nonetheless, among participants who had airflow obstruction and restrictive pattern, only a minority had DOE (38.6% and 45.5%), CB (23.3% and 15.9%), and wheezing (24.4% and 19.1%), yielding a positive predictive value (PPV) of only 53% for any respiratory symptom in the setting of any spirometric respiratory impairment. In addition, most participants who had DOE (73.0%), CB (67.8%), and wheezing (66.8%) did not have airflow obstruction or restrictive pattern, yielding a PPV of only 26% for any spirometric respiratory impairment in the setting of any respiratory symptom. The results differed only modestly when stratified according to age (40-64 vs 65-80). CONCLUSION GLI-defined spirometric respiratory impairment increased the likelihood of respiratory symptoms but was nonetheless a poor predictor of respiratory symptoms. Similarly, respiratory symptoms were poor predictors of GLI-defined spirometric respiratory impairment. Hence, a comprehensive assessment is needed when evaluating respiratory symptoms, even in the presence of spirometric respiratory impairment.
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Affiliation(s)
| | | | | | - Carlos A. Vaz Fragoso
- Yale School of Medicine, New Haven, CT, USA
- Veterans Affairs Clinical Epidemiology Research Center, West Haven, CT, USA
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Lorgunpai SJ, Grammas M, Lee DSH, McAvay G, Charpentier P, Tinetti ME. Potential therapeutic competition in community-living older adults in the U.S.: use of medications that may adversely affect a coexisting condition. PLoS One 2014; 9:e89447. [PMID: 24586786 PMCID: PMC3934884 DOI: 10.1371/journal.pone.0089447] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 01/20/2014] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE The 75% of older adults with multiple chronic conditions are at risk of therapeutic competition (i.e. treatment for one condition may adversely affect a coexisting condition). The objective was to determine the prevalence of potential therapeutic competition in community-living older adults. METHODS Cross-sectional descriptive study of a representative sample of 5,815 community-living adults 65 and older in the U.S, enrolled 2007-2009. The 14 most common chronic conditions treated with at least one medication were ascertained from Medicare claims. Medication classes recommended in national disease guidelines for these conditions and used by ≥ 2% of participants were identified from in-person interviews conducted 2008-2010. Criteria for potential therapeutic competition included: 1), well-acknowledged adverse medication effect; 2) mention in disease guidelines; or 3) report in a systematic review or two studies published since 2000. Outcomes included prevalence of situations of potential therapeutic competition and frequency of use of the medication in individuals with and without the competing condition. RESULTS Of 27 medication classes, 15 (55.5%) recommended for one study condition may adversely affect other study conditions. Among 91 possible pairs of study chronic conditions, 25 (27.5%) have at least one potential therapeutic competition. Among participants, 1,313 (22.6%) received at least one medication that may worsen a coexisting condition; 753 (13%) had multiple pairs of such competing conditions. For example, among 846 participants with hypertension and COPD, 16.2% used a nonselective beta-blocker. In only 6 of 37 cases (16.2%) of potential therapeutic competition were those with the competing condition less likely to receive the medication than those without the competing condition. CONCLUSIONS One fifth of older Americans receive medications that may adversely affect coexisting conditions. Determining clinical outcomes in these situations is a research and clinical priority. Effects on coexisting conditions should be considered when prescribing medications.
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Affiliation(s)
| | - Marianthe Grammas
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - David S. H. Lee
- Oregon State University/Oregon Health and Science University, College of Pharmacy, Portland, Oregon, United States of America
| | - Gail McAvay
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Peter Charpentier
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Mary E. Tinetti
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
- School of Epidemiology and Public Health, New Haven, Connecticut, United States of America
- * E-mail:
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Abstract
OBJECTIVE Spirometric Z scores by lambda-mu-sigma (LMS) rigorously account for age-related changes in lung function. Recently, the Global Lung Function Initiative (GLI) expanded LMS spirometric Z scores to multiple ethnicities. Hence, in aging populations, the GLI provides an opportunity to rigorously evaluate ethnic differences in respiratory impairment, including airflow limitation and restrictive pattern. METHODS Using data from the Third National Health and Nutrition Examination Survey, including participants aged 40-80, we evaluated ethnic differences in GLI-defined respiratory impairment, including prevalence and associations with mortality and respiratory symptoms. RESULTS Among 3506 white Americans, 1860 African Americans and 1749 Mexican Americans, the prevalence of airflow limitation was 15.1% (13.9% to 16.4%), 12.4% (10.7% to 14.0%) and 8.2% (6.7% to 9.8%), and restrictive pattern was 5.6% (4.6% to 6.5%), 8.0% (6.9% to 9.0%) and 5.7% (4.5% to 6.9%), respectively. Airflow limitation was associated with mortality in white Americans, African Americans and Mexican Americans-adjusted HR (aHR) 1.66 (1.23 to 2.25), 1.60 (1.09 to 2.36) and 1.80 (1.17 to 2.76), respectively, but associated with respiratory symptoms only in white Americans-adjusted OR (aOR) 2.15 (1.70 to 2.73). Restrictive pattern was associated with mortality but only in white Americans and African Americans-aHR 2.56 (1.84 to 3.55) and 3.23 (2.06 to 5.05), and associated with respiratory symptoms but only in white Americans and Mexican Americans-aOR 2.16 (1.51 to 3.07) and 2.12 (1.45 to 3.08), respectively. CONCLUSIONS In an aging population, we found ethnic differences in GLI-defined respiratory impairment. In particular, African Americans had high rates of respiratory impairment that were associated with mortality but not respiratory symptoms.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Veterans Affairs Clinical Epidemiology Research Center, VA Connecticut Healthcare System, , West Haven, Connecticut, USA
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Ning Y, McAvay G, Chaudhry SI, Arnold AM, Allore HG. Results differ by applying distinctive multiple imputation approaches on the longitudinal cardiovascular health study data. Exp Aging Res 2013; 39:27-43. [PMID: 23316735 DOI: 10.1080/0361073x.2013.741968] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
UNLABELLED BACKGROUND/STUDY CONTEXT: The objective of this study was to examine sequential and simultaneous approaches to multiple imputation of missing data in a longitudinal data set where losses due to death were common. METHODS Comparison of results from analyses and simulations of time to incident difficulty of activities of daily living (ADL) in the Cardiovascular Health Study when missing data were imputed simultaneously or sequentially. RESULTS Results differed with imputation methods. The largest proportional differences in 12 risk factor parameter estimates were heart failure by 106%, social support by 33%, and arthritis by 27%. CONCLUSION Decedents' final characteristics were influential on future imputations of those with missing values.
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Affiliation(s)
- Yuming Ning
- Section of Geriatrics, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06511, USA
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Chaudhry SI, McAvay G, Chen S, Whitson H, Newman AB, Krumholz HM, Gill TM. Risk factors for hospital admission among older persons with newly diagnosed heart failure: findings from the Cardiovascular Health Study. J Am Coll Cardiol 2013; 61:635-42. [PMID: 23391194 DOI: 10.1016/j.jacc.2012.11.027] [Citation(s) in RCA: 142] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 10/12/2012] [Accepted: 11/12/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES This study sought to identify risk factors for the occurrence of all-cause hospital admissions among older persons after heart failure diagnosis, and to determine whether geriatric conditions would emerge as independent risk factors for admission when evaluated in the context of other relevant clinical data. BACKGROUND Efforts to reduce costs in heart failure have focused on hospital utilization, yet few studies have examined how geriatric conditions affect the long-term risk for hospital admission after heart failure diagnosis. With the aging of the population with heart failure, geriatric conditions such as slow gait and muscle weakness are becoming increasingly common. METHODS The study population included participants with a new diagnosis of heart failure in the Cardiovascular Health Study, a longitudinal study of community-living older persons. Data were collected through annual examinations and medical-record reviews. Geriatric conditions assessed were slow gait, muscle weakness (defined as weak grip), cognitive impairment, and depressive symptoms. Anderson-Gill regression modeling was used to determine the predictors of hospital admission after heart failure diagnosis. RESULTS Of the 758 participants with a new diagnosis of heart failure, the mean rate of hospital admission was 7.9 per 10 person-years (95% CI: 7.4 to 8.4). Independent risk factors for hospital admission included diabetes mellitus (HR: 1.36; 95% CI: 1.13 to 1.64), New York Heart Association functional class III or IV (HR: 1.32; 95% CI: 1.11 to 1.57), chronic kidney disease (HR: 1.32; 95% CI: 1.14 to 1.53), slow gait (HR: 1.28; 95% CI: 1.06 to 1.55), depressed ejection fraction (HR: 1.25; 95% CI: 1.04 to 1.51), depression (HR: 1.23; 95% CI: 1.05 to 1.45), and muscle weakness (HR: 1.19; 95% CI: 1.00 to 1.42). CONCLUSIONS Geriatric conditions are important, and potentially modifiable, risk factors for hospital admission in heart failure that should be routinely assessed at the time of heart failure diagnosis.
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Affiliation(s)
- Sarwat I Chaudhry
- Section of General Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.
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Vaz Fragoso CA, Gill TM, McAvay G, Quanjer PH, Van Ness PH, Concato J. Respiratory impairment in older persons: when less means more. Am J Med 2013; 126:49-57. [PMID: 23177541 PMCID: PMC3529831 DOI: 10.1016/j.amjmed.2012.07.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Revised: 07/11/2012] [Accepted: 07/11/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Among older persons, within the clinical context of respiratory symptoms and mobility, evidence suggests that improvements are warranted regarding the current approach for identifying respiratory impairment (ie, a reduction in pulmonary function). METHODS Among 3583 white participants aged 65 to 80 years (Cardiovascular Health Study), we calculated the prevalence of respiratory impairment using the current spirometric standard from the Global Initiative for Obstructive Lung Disease (GOLD) and an alternative spirometric approach termed "lambda-mu-sigma" (LMS). Results for GOLD- and LMS-defined respiratory impairment were evaluated for their (cross-sectional) association with respiratory symptoms and gait speed, and for the 5-year cumulative incidence probability of mobility disability. RESULTS The prevalence of respiratory impairment was 49.7% (1780/3583) when using the GOLD and 23.2% (831/3583) when using LMS. Differences in prevalence were most evident among participants who had no respiratory symptoms, with respiratory impairment classified more often by the GOLD (38.1% [326/855]) than LMS (12.3% [105/855]), as well as among participants who had normal gait speed, with respiratory impairment classified more often by the GOLD (46.4% [1003/2164]) than LMS (19.3% [417/2164]). Conversely, the 5-year cumulative incidence probability of mobility disability for respiratory impairment was higher for LMS than GOLD (0.313 and 0.249 for never-smokers, and 0.352 and 0.289 for ever-smokers, respectively), but was similar for normal spirometry by LMS or GOLD (0.193 and 0.185 for never-smokers, and 0.219 and 0.216 for ever-smokers, respectively). CONCLUSIONS Among older persons, the LMS approach (vs the GOLD approach) classifies respiratory impairment less frequently in those who are asymptomatic and is more strongly associated with mobility disability.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Veterans Affairs Clinical Epidemiology Research Center, West Haven, CT 06250-8025, USA.
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Murphy TE, McAvay G, Carriero NJ, Gross CP, Tinetti ME, Allore HG, Lin H. Deaths observed in Medicare beneficiaries: average attributable fraction and its longitudinal extension for many diseases. Stat Med 2012; 31:3313-9. [PMID: 22415597 PMCID: PMC3719164 DOI: 10.1002/sim.5337] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 01/11/2012] [Indexed: 11/11/2022]
Abstract
Calculating the longitudinal extension of the average attributable fraction (LE-AAF) for many risk factors (RFs) requires a two-stage computational process using only those combinations of RFs observed in the dataset. We first screen candidates RFs in a Cox Model, and assuming piecewise constant hazards, use pooled logistic regression to model the probability of death as a function of combinations of selected RFs. We average the iterative differencing of the attributable fractions calculated for all overlapping subsets of co-occurring RFs to obtain a LE-AAF for each RF that is additive and symmetrical. We illustrate by partitioning the additive proportions of death from 10 different groupings of acute and chronic diseases, on a national sample of older persons from the US (Medicare Beneficiary Survey) over a 4-year period and compare with results reported by the National Center for Healthcare Statistics. We conclude that careful screening of RFs with analysis restricted to extant combinations greatly reduces computational burden. LE-AAF accounted for a cumulative total of 66% of the deaths in our sample, compared with the 83% accounted for by the National Center for Healthcare Statistics.
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Affiliation(s)
- T E Murphy
- Department of Internal Medicine and the Program on Aging, Yale University School of Medicine, New Haven, CT, USA.
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Abstract
The aim of the present study was to evaluate, among older persons, the association between respiratory impairment and hospitalisation for chronic obstructive pulmonary disease (COPD), based on spirometric Z-scores, i.e. the LMS (lambda, mu, sigma) method, and a competing risk approach. Using data on 3,563 white participants aged 65-80 yrs (from the Cardiovascular Health Study) we evaluated the association of LMS-defined respiratory impairment with the incident of COPD hospitalisation and the competing outcome of death without COPD hospitalisation, over a 5-yr period. Respiratory impairment included airflow limitation (mild, moderate or severe) and restrictive pattern. Over a 5-yr period, 276 (7.7%) participants had a COPD hospitalisation incident, whereas 296 (8.3%) died without COPD hospitalisation. The risk of COPD hospitalisation was elevated more than two-fold in LMS-defined mild and moderate airflow limitation and restrictive pattern (adjusted HR (95% CI): 2.25 (1.25-4.05), 2.54 (1.53- 4.22) and 2.65 (1.82-3.86), respectively), and more than eight-fold in LMS-defined severe airflow limitation (adjusted HR (95% CI) 8.33 (6.24-11.12)). Conversely, only LMS-defined restrictive-pattern was associated with the competing outcome of death without COPD hospitalisation (adjusted HR (95% CI) 1.68 (1.22-2.32)). In older white persons, LMS-defined respiratory impairment is strongly associated with an increased risk of COPD hospitalisation. These results support the LMS method as a basis for defining respiratory impairment in older persons.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, 950 Campbell Ave, Mailcode 151B, West Haven, CT, USA.
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Chaudhry SI, McAvay G, Ning Y, Allore HG, Newman AB, Gill TM. Risk factors for onset of disability among older persons newly diagnosed with heart failure: the Cardiovascular Health Study. J Card Fail 2012; 17:764-70. [PMID: 21872147 DOI: 10.1016/j.cardfail.2011.04.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Revised: 04/15/2011] [Accepted: 04/28/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND As the heart failure population continues to age, disability is becoming an increasingly important issue. Our objective was to identify risk factors for the onset of disability in activities of daily living among older persons with heart failure. METHODS The study population included participants with newly diagnosed heart failure from the Cardiovascular Health Study, a longitudinal study of community-living, older persons. Data were collected through annual examinations. Cox regression modeling was used to examine associations between time-dependent predictors and onset of disability. RESULTS Of 461 participants newly diagnosed with heart failure (mean age 78.7 [SD 5.89]), 23% subsequently developed disability. The first year after heart failure diagnosis was the period of greatest risk for onset of disability (chi-square P value <.001). Factors that were independently associated with disability included: impaired gait speed (HR 2.29, 95% CI 1.34-3.90); impaired cognition (HR 1.87, 95% CI 1.14-3.05); and depressive symptoms (HR 1.72, 95% CI 1.04-2.83). CONCLUSIONS Onset of disability is a common occurrence among older persons newly diagnosed with heart failure. Risk factors for onset of disability in this population are potentially modifiable, and should be routinely assessed in an effort to reduce disability in this growing population.
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Affiliation(s)
- Sarwat I Chaudhry
- Section of General Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut 06520-8093, USA.
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Lin H, Allore HG, McAvay G, Tinetti ME, Gill TM, Gross CP, Murphy TE. A method for partitioning the attributable fraction of multiple time-dependent coexisting risk factors for an adverse health outcome. Am J Public Health 2012; 103:177-82. [PMID: 22515873 DOI: 10.2105/ajph.2011.300458] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We decomposed the total effect of coexisting diseases on a timed occurrence of an adverse outcome into additive effects from individual diseases. METHODS In a cohort of older adults enrolled in the Precipitating Events Project in New Haven County, Connecticut, we assessed a longitudinal extension of the average attributable fraction method (LE-AAF) to estimate the additive and order-free contributions of multiple diseases to the timed occurrence of a health outcome, with right censoring, which may be useful when relationships among diseases are complex. We partitioned the contribution to death into additive LE-AAFs for multiple diseases. RESULTS The onset of heart failure and acute episodes of pneumonia during follow-up contributed the most to death, with the overall LE-AAFs equal to 13.0% and 12.1%, respectively. The contribution of preexisting diseases decreased over the years, with a trend of increasing contribution from new onset of diseases. CONCLUSIONS LE-AAF can be useful for determining the additive and order-free contribution of individual time-varying diseases to a time-to-event outcome.
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Affiliation(s)
- Haiqun Lin
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT, USA.
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Vaz Fragoso CA, Enright PL, McAvay G, Van Ness PH, Gill TM. Frailty and respiratory impairment in older persons. Am J Med 2012; 125:79-86. [PMID: 22195532 PMCID: PMC3246194 DOI: 10.1016/j.amjmed.2011.06.024] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Revised: 06/30/2011] [Accepted: 06/30/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND Among older persons, the association between frailty and spirometry-confirmed respiratory impairment has not been evaluated yet. METHODS By using data on white participants aged 65 to 80 years (Cardiovascular Health Study, N=3578), we evaluated cross-sectional and longitudinal associations between frailty and respiratory impairment, including their combined effect on mortality. Baseline assessments included frailty status (Fried phenotype: non-frail, pre-frail, and frail) and spirometry. Outcomes included development of frailty features (pre-frail or frail) at year 3 and respiratory impairment (airflow limitation or restrictive pattern) at year 4, and death (median follow-up, 13.2 years). RESULTS At baseline, 48.3% of participants were pre-frail, 5.8% of participants were frail, 13.8% of participants had airflow limitation, and 9.3% of participants had restrictive pattern; 46.1% of participants subsequently died. At baseline, pre-frail and frail were cross-sectionally associated with airflow limitation (adjusted odds ratio [OR], 1.62; 95% confidence interval [CI], 1.29-2.04 and adjusted OR 1.88; 95% CI, 1.15-3.09) and restrictive pattern (adjusted OR, 1.80; 95% CI, 1.37-2.36 and adjusted OR, 3.05; 95% CI, 1.91-4.88), respectively. Longitudinally, participants with baseline frailty features had an increased likelihood of developing respiratory impairment (adjusted OR, 1.42; 95% CI, 1.11-1.82). Conversely, participants with baseline respiratory impairment had an increased likelihood of developing frailty features (adjusted OR, 1.58; 95% CI, 1.17-2.13). Mortality was highest among participants who were frail and had respiratory impairment (adjusted hazard ratio, 3.91; 95% CI, 2.93-5.22), compared with those who were non-frail and had no respiratory impairment. CONCLUSION Frailty and respiratory impairment are strongly associated with one another and substantially increase the risk of death when both are present. Establishing these associations may inform interventions designed to reverse or prevent the progression of either condition and to reduce adverse outcomes.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT, USA.
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Fragoso CAV, Concato J, McAvay G, Yaggi HK, Van Ness PH, Gill TM. Staging the severity of chronic obstructive pulmonary disease in older persons based on spirometric Z-scores. J Am Geriatr Soc 2011; 59:1847-54. [PMID: 22091498 PMCID: PMC3227010 DOI: 10.1111/j.1532-5415.2011.03596.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Among older persons, the use of spirometric Z-scores as calculated by the Lambda-Mu-Sigma (LMS) method has a strong scientific rationale for establishing a diagnosis of chronic obstructive pulmonary disease (COPD), but its clinical validity in staging COPD severity is not yet known. The current study has therefore evaluated the association between LMS-staged COPD and health outcomes, in two separate cohorts of older persons. DESIGN Longitudinal cohort study. SETTING The Cardiovascular Health Study (CHS, N = 3,248) and the Third National Health and Nutrition Examination Survey (NHANES-III, N = 1,354). PARTICIPANTS Community-living white participants aged 65 to 80. MEASUREMENTS Using spirometric data, COPD was staged as mild, moderate, or severe based on LMS-derived Z-scores. Clinical validity was then evaluated according to all-cause mortality, respiratory symptoms (chronic bronchitis, dyspnea, or wheezing), and moderate to severe dyspnea (available in CHS only). RESULTS In CHS, the LMS staging of COPD as mild, moderate, and severe was associated with mortality (adjusted HR (aHR) = 1.50, 95% confidence interval (CI) = 1.15-1.94; aHR = 1.31, 95% CI = 1.03-1.67; and aHR = 2.00, 95% CI = 1.70-2.36, respectively) and with respiratory symptoms (adjusted OR (aOR) = 1.69, 95% CI = 1.12-2.56; aOR = 1.87, 95% CI = 1.28-2.73; and aOR = 3.99, 95% CI = 2.91-5.48, respectively). Also in CHS, moderate and severe, but not mild, LMS-staged COPD was associated with moderate to severe dyspnea (aOR = 2.16, 95% CI = 1.24-3.75; aOR = 3.98, 95% CI = 2.77-5.74; and aOR = 0.84, 95% CI = 0.35-2.01, respectively). Similar associations were found for mortality and respiratory symptoms in NHANES-III, except mild severity was not associated with mortality (aHR = 0.93, 95% CI = 0.62-1.40). CONCLUSION In white older persons, the spirometric staging of COPD severity based on LMS-derived Z-scores was associated with several clinically relevant health outcomes. These results support the use of the LMS method for staging the severity of COPD in older populations.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Veterans Affairs Clinical Epidemiology Research Center, West Haven, Connecticut 06516, USA.
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Vaz Fragoso CA, Gill TM, McAvay G, Yaggi HK, Van Ness PH, Concato J. Respiratory impairment and mortality in older persons: a novel spirometric approach. J Investig Med 2011. [PMID: 22011620 PMCID: PMC3198012 DOI: 10.231/jim.0b013e31822bb213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The Lambda-Mu-Sigma (LMS) method calculates the lower limit of normal for spirometric measures of pulmonary function as the fifth percentile of the distribution of z scores, suitably accounting for age-related changes in pulmonary function. Extending prior work, and to assess whether the LMS method is clinically valid when evaluating respiratory impairment in the elderly, our current objective was to evaluate the association of LMS-defined respiratory impairment (airflow limitation and restrictive pattern) with all-cause mortality and respiratory symptoms (chronic bronchitis, dyspnea, or wheezing) in older persons. METHODS Spirometric data and outcome data on white participants aged 65 to 80 years were obtained from the Third National Health and Nutrition Examination Survey (NHANES-III, n = 1497) and the Cardiovascular Health Study (CHS, n = 3583). Multivariable analyses determined the corresponding associations, adjusting for important covariates. RESULTS In the NHANES-III and CHS populations, respectively, LMS-defined airflow limitation had adjusted hazard ratios (95% confidence interval) of 1.64 (1.28-2.11) and 1.69 (1.48-1.92) for mortality; adjusted odds ratios for respiratory symptoms were 2.71 (1.92-3.83) and 2.63 (2.11-3.27). The LMS-defined restrictive pattern was also significantly associated with mortality (adjusted hazard ratios of 1.98 [1.54-2.53] and 1.68 [1.44-1.95]), as well as with respiratory symptoms (adjusted odds ratios of 1.55 [1.03-2.34] and 1.37 [1.07-1.75]) in NHANES-III and CHS, respectively. CONCLUSIONS The LMS-defined airflow limitation and restrictive pattern confers a significantly increased risk of death and likelihood of having respiratory symptoms. These results support the use of LMS-derived spirometric z scores as a basis for evaluating respiratory impairment in older persons.
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Affiliation(s)
- Carlos A. Vaz Fragoso
- Veterans Affairs (VA) Clinical Epidemiology Research Center, West Haven, CT,Yale University School of Medicine, Department of Internal Medicine, New Haven, CT
| | - Thomas M. Gill
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT
| | - Gail McAvay
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT
| | - H. Klar Yaggi
- Veterans Affairs (VA) Clinical Epidemiology Research Center, West Haven, CT,Yale University School of Medicine, Department of Internal Medicine, New Haven, CT
| | - Peter H. Van Ness
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT
| | - John Concato
- Veterans Affairs (VA) Clinical Epidemiology Research Center, West Haven, CT,Yale University School of Medicine, Department of Internal Medicine, New Haven, CT
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Tinetti ME, McAvay G, Chang SS, Ning Y, Newman AB, Fitzpatrick A, Fried TR, Harris TB, Nevitt MC, Satterfield S, Yaffe K, Peduzzi P. Effect of chronic disease-related symptoms and impairments on universal health outcomes in older adults. J Am Geriatr Soc 2011; 59:1618-27. [PMID: 21883120 DOI: 10.1111/j.1532-5415.2011.03576.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine the extent to which disease-related symptoms and impairments, which constitute measures of disease severity or targets of therapy, account for the associations between chronic diseases and universal health outcomes. DESIGN Cross-sectional. SETTING The Cardiovascular Health Study (CHS) and the Health, Aging and Body Composition Study (Health ABC). PARTICIPANTS Five thousand six hundred fifty-four CHS members and 2,706 Health ABC members. MEASUREMENTS Diseases included heart failure (HF), chronic obstructive pulmonary disease (COPD), osteoarthritis, and cognitive impairment. The universal health outcomes included self-rated health, basic and instrumental activities of daily living (ADLs and IADLs), and death. Disease-related symptoms and impairments included HF symptoms and ejection fraction (EF) for HF, Dyspnea Scale and forced expiratory volume in 1 second for COPD, joint pain for osteoarthritis, and executive function for cognitive impairment. RESULTS The diseases were associated with the universal health outcomes (P<.001) except osteoarthritis with death (both cohorts) and cognitive impairment with self-rated health (Health ABC). Symptoms and impairments accounted for 30% or more of each disease's effect on the universal health outcomes. In CHS, for example, HF was associated with one fewer (0.918) ADL and IADL performed without difficulty than no HF; HF symptoms accounted for 27% of this effect and EF for only 5%. The hazard ratio for death with HF was 6.5 (95% confidence interval=4.7-8.9) with EF accounting for 40% and HF symptoms for only 14%. CONCLUSION Disease-related symptoms and impairments accounted for much of the significant associations between the four chronic diseases and the universal health outcomes. Results support considering universal health outcomes as common metrics across diseases in clinical decision-making, perhaps by targeting the disease-related symptoms and impairments that contribute most strongly to the effect of the disease on the universal health outcomes.
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Affiliation(s)
- Mary E Tinetti
- Department of Medicine, School of Medicine, Yale University, New Haven, Connecticut 06520-8025, USA.
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Vaz Fragoso CA, Gill TM, McAvay G, Van Ness PH, Yaggi HK, Concato J. Use of lambda-mu-sigma-derived Z score for evaluating respiratory impairment in middle-aged persons. Respir Care 2011; 56:1771-7. [PMID: 21605489 DOI: 10.4187/respcare.01192] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The lambda-mu-sigma (LMS) method calculates the lower limit of normal for spirometric values as the 5th percentile of the distribution of Z scores. Conceptually, LMS-derived Z scores account for normal age-related changes in pulmonary function, including variability and skewness in reference data. Evidence is limited, however, on whether the LMS method is valid for evaluating respiratory impairment in middle-aged persons. OBJECTIVE To evaluate the association of LMS-defined respiratory impairment (airflow limitation and restrictive pattern) with mortality and respiratory symptoms. METHODS We analyzed spirometric data from white participants ages 45-64 years in the Third National Health and Nutrition Examination Survey (NHANES III, n = 1,569) and the Atherosclerosis Risk in Communities study (ARIC, n = 8,163). RESULTS LMS-defined airflow limitation was significantly associated with mortality (adjusted hazard ratios: NHANES III 1.90, 95% CI 1.32-2.72, ARIC 1.28, 95% CI 1.06-1.57), and respiratory symptoms (adjusted odds ratios: NHANES III 2.48, 95% CI 1.75-3.51, ARIC 2.27, 95% CI 1.98-2.62). LMS-defined restrictive-pattern was also significantly associated with mortality (adjusted hazard ratios: NHANES III 1.98, 95% CI 1.08-3.65, ARIC 1.38, 95% CI 1.03-1.85), and respiratory symptoms (adjusted odds ratios: NHANES III 2.34, 95% CI 1.44-3.80, ARIC 1.89, 95% CI 1.46-2.45). CONCLUSIONS In white middle-age persons, LMS-defined airflow limitation and restrictive-pattern were significantly associated with mortality and respiratory symptoms. Consequently, an approach that reports spirometric values based on LMS-derived Z scores might provide an age-appropriate and clinically valid strategy for evaluating respiratory impairment.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.
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Chaudhry SI, McAvay G, Ning Y, Allore HG, Newman AB, Gill TM. Geriatric impairments and disability: the cardiovascular health study. J Am Geriatr Soc 2010; 58:1686-92. [PMID: 20863328 DOI: 10.1111/j.1532-5415.2010.03022.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine the relative importance of geriatric impairments (in muscle strength, physical capacity, cognition, vision, hearing, and psychological status) and chronic diseases in predicting subsequent functional disability in longitudinal analyses. DESIGN Longitudinal data from the Cardiovascular Health Study were analyzed. Multivariable Cox hazards regression modeling was used to analyze associations between time-dependent predictors and onset of disability in activities of daily living (ADLs) and mobility. SETTING Four communities across the United States (Sacramento County, CA; Washington County, MD; Forsyth County, NC; and Allegheny County, PA). PARTICIPANTS Five thousand eight hundred eighty-eight elderly persons. MEASUREMENTS Data were collected annually through in-person examinations. RESULTS ADL disability developed in 15% of participants and mobility disability in 30%. A single multivariable model was developed that included demographics, marital status, body mass index, and number of impairments and diseases. The hazard ratios (HRs) of having one, two, and three or more geriatric impairments (vs none) for the outcome of ADL disability were 2.12 (95% confidence interval (CI)=1.63-2.75), 4.25 (95% CI=3.30-5.48), and 7.87 (95% CI=6.10-10.17), respectively, and for having one, two, and three or more chronic diseases were 1.75 (95% CI=1.41-2.19), 2.45 (95% CI=1.95-3.07), and 3.26 (95% CI=2.53-4.19), respectively. Similarly, the HRs of having one, two, and three or more impairments for the outcome of mobility disability were 1.48 (95% CI=1.27-1.73), 2.08 (95% CI=1.77-2.45), and 3.70 (95% CI=3.09-4.42), respectively, and for having one, two, and three or more diseases were 2.06 (95% CI=1.76-2.40), 2.80 (95% CI=2.36-3.31), and 4.20 (95% CI=3.44-5.14), respectively. CONCLUSION Number of geriatric impairments was more strongly associated than number of chronic diseases with subsequent ADL disability and nearly as strongly associated with the subsequent mobility disability.
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Affiliation(s)
- Sarwat I Chaudhry
- Section of General Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut, USA.
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Vaz Fragoso CA, Concato J, McAvay G, Van Ness PH, Rochester CL, Yaggi HK, Gill TM. Chronic obstructive pulmonary disease in older persons: A comparison of two spirometric definitions. Respir Med 2010; 104:1189-96. [PMID: 20199857 DOI: 10.1016/j.rmed.2009.10.030] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Revised: 10/10/2009] [Accepted: 10/20/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Among older persons, we previously endorsed a two-step spirometric definition of chronic obstructive pulmonary disease (COPD) that requires a ratio of forced expiratory volume in 1sec to forced vital capacity (FEV(1)/FVC) below .70, and an FEV(1) below the 5th or 10th standardized residual percentile ("SR-tile strategy"). OBJECTIVE To evaluate the clinical validity of an SR-tile strategy, compared to a current definition of COPD, as published by the Global Initiative for Obstructive Lung Disease (GOLD-COPD), in older persons. METHODS We assessed national data from 2480 persons aged 65-80 years. In separate analyses, we evaluated the association of an SR-tile strategy with mortality and respiratory symptoms, relative to GOLD-COPD. As per convention, GOLD-COPD was defined solely by an FEV(1)/FVC<.70, with severity staged according to FEV(1) cut-points at 80 and 50 percent predicted (%Pred). RESULTS Among 831 participants with GOLD-COPD, the risk of death was elevated only in 179 (21.5%) of those who also had an FEV(1)<5th SR-tile; and the odds of having respiratory symptoms were elevated only in 310 (37.4%) of those who also had an FEV(1)<10th SR-tile. In contrast, GOLD-COPD staged at an FEV(1) 50-79%Pred led to misclassification (overestimation) in terms of 209 (66.4%) and 77 (24.6%) participants, respectively, not having an increased risk of death or likelihood of respiratory symptoms. CONCLUSION Relative to an SR-tile strategy, the majority of older persons with GOLD-COPD had neither an increased risk of death nor an increased likelihood of respiratory symptoms. These results raise concerns about the clinical validity of GOLD guidelines in older persons.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT 06516, USA.
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Vaz Fragoso CA, Concato J, McAvay G, Van Ness PH, Rochester CL, Yaggi HK, Gill TM. The ratio of FEV1 to FVC as a basis for establishing chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2009; 181:446-51. [PMID: 20019341 DOI: 10.1164/rccm.200909-1366oc] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The lambda-mu-sigma (LMS) method is a novel approach that defines the lower limit of normal (LLN) for the ratio of FEV1/FVC as the fifth percentile of the distribution of Z scores. The clinical validity of this threshold as a basis for establishing chronic obstructive pulmonary disease is unknown. OBJECTIVE To evaluate the association between the LMS method of determining the LLN for the FEV1/FVC, set at successively higher thresholds, and clinically meaningful outcomes. METHODS Using data from a nationally representative sample of 3,502 white Americans aged 40-80 years, we stratified the FEV1/FVC according to the LMS-LLN, with thresholds set at the 5th, 10th, 15th, 20th, and 25th percentiles (i.e., LMS-LLN5, LMS-LLN10, etc.). We then evaluated whether these thresholds were associated with an increased risk of death or prevalence of respiratory symptoms. Spirometry was not specifically completed after a bronchodilator. MEASUREMENTS AND MAIN RESULTS Relative to an FEV1/FVC greater than or equal to LMS-LLN25 (reference group), the risk of death and the odds of having respiratory symptoms were elevated only in participants who had an FEV1/FVC less than LMS-LLN(5), with an adjusted hazard ratio of 1.68 (95% confidence interval, 1.34-2.12) and an adjusted odds ratio of 2.46 (95% confidence interval, 2.01-3.02), respectively, representing 13.8% of the cohort. Results were similar for persons aged 40-64 years and those aged 65-80 years. CONCLUSIONS In white persons aged 40-80 years, an FEV1/FVC less than LMS-LLN5 identifies persons with an increased risk of death and prevalence of respiratory symptoms. These results support the use of the LMS-LLN5 threshold for establishing chronic obstructive pulmonary disease.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Yale Claude D. Pepper Older Americans Independence Center, New Haven, Connecticut, USA.
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Abstract
BACKGROUND Syncopal episodes are common among older adults; etiologies range from benign to life threatening. We determined the frequency, yield, and costs of tests obtained to evaluate older persons with syncope. We also calculated the cost per test yield and determined whether the San Francisco syncope rule (SFSR) improved test yield. METHODS Review of 2106 consecutive patients 65 years or older admitted following a syncopal episode. RESULTS Electrocardiograms (in 99% of admissions), telemetry (in 95%), cardiac enzyme tests (in 95%), and head computed tomographic (CT) scans (in 63%) were the most frequently obtained tests. Results from cardiac enzymes tests, CT scans, echocardiography, carotid ultrasonography, and electroencephalography all affected diagnosis or management in less than 5% of cases and helped determine the etiology of syncope less than 2% of the time. Postural blood pressure (BP) recording, performed in only 38% of episodes, had the highest yield with respect to affecting diagnosis (18%-26%) or management (25%-30%) and determining etiology of the syncopal episode (15%-21%). The cost per test affecting diagnosis or management was highest for electroencephalography ($32 973), CT scans ($24 881), and cardiac enzymes test ($22 397) and lowest for postural BP recording ($17-$20). The yields and costs for cardiac tests were better among patients meeting, vs those not meeting, the SFSR. For example, the cost per cardiac enzymes test affecting diagnosis or management was $10 331 in those meeting, vs $111 518 in those not meeting, the SFSR. CONCLUSIONS Many unnecessary tests are obtained to evaluate syncope. Selecting tests based on history and examination and prioritizing less expensive and higher yield tests would ensure a more informed and cost-effective approach to evaluating older patients with syncope.
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Affiliation(s)
- Mallika L Mendu
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut 06520-8025, USA
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Vaz Fragoso CA, Concato J, McAvay G, Van Ness PH, Rochester CL, Yaggi HK, Gill TM. Defining chronic obstructive pulmonary disease in older persons. Respir Med 2009; 103:1468-76. [PMID: 19464159 DOI: 10.1016/j.rmed.2009.04.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2008] [Revised: 04/17/2009] [Accepted: 04/23/2009] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To develop a more age-appropriate spirometric definition of chronic obstructive pulmonary disease (COPD) among older persons. METHODS Using data from the Third National Health and Nutrition Examination Survey (NHANES III), we developed a two-part spirometric definition of COPD in older persons, aged 65-80 years, that 1) determines a cut-point for the ratio of forced expiratory volume in 1 s to forced vital capacity (FEV1/FVC) based on mortality risk; and 2) among persons below this critical FEV1/FVC threshold, determines cut-points for the FEV1, expressed as a standardized residual percentile (SR-tile) and based on the prevalence of respiratory symptoms and mortality risk. Measurements included spirometry, health questionnaires, and mortality (National Death Index). RESULTS There were 2480 older participants with a mean age of 71.7 years; 1372 (55.4%) had a smoking history, 1097 (44.2%) had respiratory symptoms and, over the course of 12-years, 868 (35.0%) had died. Among participants with an FEV1/FVC<.70 and FEV1<5th SR-tile, representing 7.7% of the cohort, the risk of death was doubled (adjusted hazard ratio, 2.01; 95% confidence interval [CI], 1.60-2.54). Among participants with an FEV1/FVC<.70 and FEV1<10th SR-tile, representing 13.4% of the cohort, the prevalence of respiratory symptoms was elevated (adjusted odds ratio, 2.44; CI, 1.79-3.33). CONCLUSION In a large, nationally representative sample of community-living older persons, defining COPD based on an FEV1/FVC<.70, with FEV1 cut-points at the 10th and 5th SR-tiles, identifies individuals with an increased prevalence of respiratory symptoms and an increased risk of death, respectively.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Claude D. Pepper Older Americans Independence Center, Yale University, New Haven, CT, USA.
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Fragoso C, McAvay G, Van Ness PH, Yaggi H, Rochester C, Concato J, Gill TM. DEFINING CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN OLDER PERSONS. Chest 2008. [DOI: 10.1378/chest.134.4_meetingabstracts.s27003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Agostini JV, Tinetti ME, Han L, McAvay G, Foody JM, Concato J. Effects of Statin Use on Muscle Strength, Cognition, and Depressive Symptoms in Older Adults. J Am Geriatr Soc 2007; 55:420-5. [PMID: 17341246 DOI: 10.1111/j.1532-5415.2007.01071.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
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 community-dwelling 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=315) took a mean 6.6 medications, versus 4.6 for nonusers (n=441), 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=.04), Trail Making Test Part B (-7.7 seconds; P=.08), and depression scores (-0.2 points; P=.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 (+0.88 points; P=.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.
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Affiliation(s)
- Joseph V Agostini
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut 06516, USA.
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Abstract
OBJECTIVE To examine the relationship between religious practice and depression in a sample of geriatric patients receiving homecare nursing services. METHODS Patients were sampled weekly for six months from all those aged 65 to 102, and newly enrolled in a visiting nurse agency (N = 130). Depression was assessed by home interviews using the SCID and HRSD. Patients reported their religious service participation prior to receiving homecare and currently. Health status, disability, pain, social support and history of depression were also assessed. RESULTS The current prevalence of DSM-IV Major Depressive Disorder (MDD) was significantly greater (p < .05), and depressive symptoms were more severe (p < .02), among those persons who had not attended religious services prior to receiving homecare. Logistic regression demonstrated that the effect of religious attendance remained significant when controlling for health status, disability, pain, social support and history of depression. A subsequent analysis compared three groups of patients. They were those who had: 1) Not attended religious services; 2) Stopped attending since homecare; 3) Continued attending. Data demonstrated significantly decreasing prevalence of MDD (p < .03) across the groups. CONCLUSIONS Prevalence of DSM-IV Major Depressive Disorder and the severity of depressive symptoms were significantly lower among homecare patients who attend religious services. Because a large proportion of persons stop attending religious services after initiating homecare, it is suggested that visitation by clergy may improve depressive symptoms for these patients.
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Affiliation(s)
- Glen Milstein
- Department of Psychology, City College of the City University of New York, NY 10031, USA.
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Abstract
OBJECTIVE Depression among older home care patients is prevalent but undertreated. The purpose of this study was to investigate the ability of home health nurses to correctly identify depression among older patients and to describe nurse and patient characteristics associated with more accurate assessment of depression. METHODS Forty-two nurses were surveyed about the presence of depressive symptoms among patients who had been evaluated independently for depressive disorders by research staff using the Structured Clinical Interview for Axis I DSM-IV Disorders. A sample of newly admitted home health care patients who were aged 65 years or older was randomly selected for this evaluation on a weekly basis from December 1997 to December 1999. RESULTS Of 403 patients who were evaluated, 97 (24 percent) were found to have either major depression (64 patients) or minor depression (33 patients). The nurses correctly identified depression among 44 of the 97 patients who were depressed (sensitivity of 45.4) and 230 of the 306 patients who were not depressed (specificity of 75.2). The kappa coefficient measuring overall agreement between the nurses' assessment and the diagnosis of depression was.19. Nurses who had more geriatric nursing experience were more likely to correctly identify depression. CONCLUSIONS Home health nurses have difficulty making accurate assessments of depression among older home care patients. Inaccuracy in assessment of depression by home health nurses is a significant barrier to treatment in this elderly homebound population.
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Affiliation(s)
- Ellen L Brown
- Department of Psychiatry, Weill Medical College, Cornell University, White Plains, New York 10605, USA.
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Abstract
OBJECTIVE The study assessed the contribution of depressive symptoms and cognitive impairment to the prediction of self-neglect in elderly persons living in the community. METHOD Data were drawn from the New Haven Established Populations for Epidemiologic Studies of the Elderly cohort, which included 2,812 community residents age 65 years and older in 1982. The principal outcome examined was the incidence of self-neglect, corroborated by the state's investigation, during 9 years of follow-up (1982-1991). RESULTS Among the 2,161 subjects included in the analysis, 92 corroborated cases of self-neglect occurred from 1982 to 1991. The prevalence of clinically significant depressive symptoms at baseline (score > or=16 on the Center for Epidemiologic Studies Depression Scale [CES-D]) was 15.4%, and the prevalence of clinically significant cognitive impairment (four or more errors on the Pfeiffer Short Portable Mental Status Questionnaire) was 7.5%. Subjects with clinically significant depressive symptoms and/or cognitive impairment were more likely than others to experience self-neglect. Clinically significant depressive symptoms and cognitive impairment remained significant predictors of self-neglect in a multivariate model that included age, gender, race, and income. A final model for self-neglect constructed with stepwise selection of risk factors included depressive symptoms and cognitive impairment, as well as male gender, older age, income less than $5,000 per year, living alone, history of hip fracture, and history of stroke. CONCLUSIONS Elderly individuals living in the community who experience clinically significant depressive symptoms and/or cognitive impairment may be at risk for the development of self-neglect and may become candidates for intervention.
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Affiliation(s)
- Robert C Abrams
- Weill Medical College of Cornell University, New York Presbyterian Hospital-Cornell University Medical Center, Box 140, 525 E. 68th Street, New York, NY 10021, USA.
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Nunes EV, Weissman MM, Goldstein R, McAvay G, Beckford C, Seracini A, Verdeli H, Wickramaratne P. Psychiatric disorders and impairment in the children of opiate addicts: prevalances and distribution by ethnicity. Am J Addict 2001; 9:232-41. [PMID: 11000919 DOI: 10.1080/10550490050148062] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
This study examined rates of psychiatric disorders and impairment in 283 children, aged 6 to 17, of 69 Caucasian, 45 African-American, and 47 Hispanic-American methadone maintenance patients. Children were evaluated by direct and/or parental interview with the K-SADS-E. Final DSM-III-R diagnoses and Global Assessment Scale (C-GAS) were assigned by best estimate. Substantial lifetime prevalences of mood (21%), anxiety (24%) and disruptive disorders (30%), school problems (37%), and global impairment (C-GAS < 61) (25%) were observed in the children of opiate-dependent patients. There were few differences between ethnic groups. Effects of proband gender and major depression and their interactions with ethnicity on risk for childhood psychopathology were also examined. The results suggest children of patients in treatment for opiate dependence from diverse ethnic groups are at risk for psychopathology. Programs for early detection and intervention should be devised and evaluated.
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Affiliation(s)
- E V Nunes
- Depression Evaluation Service, New York State Psychiatric Institute, NY 10032, USA.
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McAvay G, Nunes EV, Zaider TI, Goldstein RB, Weissman MM. Physical health problems in depressed and nondepressed children and adolescents of parents with opiate dependence. Depress Anxiety 2000; 9:61-9. [PMID: 10207660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
The increased risk of physical health problems in adult depressed patients has been shown in numerous studies. A recent study of the offspring of depressed parents found similar associations. The purpose of this study is to examine the strength and specificity of the association between depression and physical health problems in children and adolescents whose parents are dependent upon opiates. The sample consisted of offspring ages 6-17 (mean age 11 years) of opiate addicts who had a history of major depressive disorder (MDD; n = 28); other mood disorders (n = 31); no history of mood disorders but other psychiatric disorders (n = 92); or no history of psychiatric disorder (n = 127). Detailed psychiatric assessment and medical history of the offspring by direct interview with the offspring and an informant were obtained blind to parental diagnosis. After controlling for possible confounders, there was an increased risk of dermatological disorders, headache, other neurological/neuromuscular disorders, bronchitis, other respiratory disorders and hospitalizations for nonsurgical procedures in offspring with MDD, as compared to nonpsychiatrically ill controls. The offspring with other mood disorders had a slightly elevated risk. Major depression in children and adolescents whose parents are dependent on opiates is associated with increased risk of physical health problems. This finding is consistent with other reports and the timing of the physical health problems requires further study.
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Affiliation(s)
- G McAvay
- Columbia University, School of Public Health, New York, New York, USA
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Weissman MM, McAvay G, Goldstein RB, Nunes EV, Verdeli H, Wickramaratne PJ. Risk/protective factors among addicted mothers' offspring: a replication study. Am J Drug Alcohol Abuse 1999; 25:661-79. [PMID: 10548441 DOI: 10.1081/ada-100101885] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
There are few systematic studies of the school-aged offspring of drug-dependent patients, although this information is useful for planning evidence-based prevention programs. We have completed such a study, which we compare to a similar study independently conducted in 1998. In both studies, both the parent and offspring were assessed blindly and independently by direct diagnostic interviews, and parental assessment of offspring was also obtained. The similarity in design and methods between studies provided an opportunity for replication by reanalysis of data. The major findings are a replication in two independently conducted studies of school-aged offspring of opiate- and/or cocaine-addicted mothers of the high rates of any psychiatric disorder (60% in both studies), major depression (20%, 26%), oppositional defiant disorder (ODD) (18%, 23%), conduct disorder (17%, 9%), attention-deficit/hyperactivity disorder (ADHD) (13%, 8%), and substance abuse (5%, 10%) among offspring. Both studies also found high rates of comorbid alcohol abuse, depression, and multiple drugs of abuse in the mothers. We conclude that efforts to replicate findings by analyses of independently conducted studies are an inexpensive way to test the sturdiness of findings that can provide the empirical basis for preventive efforts. Clinically, the data in both studies suggest that both drug dependence and associated psychopathology should be assessed and treated in opiate addicts with young offspring, and the offspring should be monitored for the development of conduct and mood disorders and substance use.
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Affiliation(s)
- M M Weissman
- Department of Clinical and Genetic Epidemiology, New York State Psychiatric Institute, New York, New York 10032, USA. weissmanchild.cpmc.columbia.edu
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Unger JB, McAvay G, Bruce ML, Berkman L, Seeman T. Variation in the impact of social network characteristics on physical functioning in elderly persons: MacArthur Studies of Successful Aging. J Gerontol B Psychol Sci Soc Sci 1999; 54:S245-51. [PMID: 10542826 DOI: 10.1093/geronb/54b.5.s245] [Citation(s) in RCA: 187] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Social support and social networks have been shown to exert significant effects on health and functioning among elderly persons. Although theorists have speculated that the strength of these effects may differ as a function of sociodemographic characteristics and prior health status, few studies have directly tested the moderating effects of these variables. METHODS Longitudinal data from the MacArthur Study of Successful Aging were used to examine the effects of structural and functional social support on changes in physical functioning over a 7-year period, measured by the Nagi scale, in a sample of initially high-functioning men and women aged 70 to 79 years. Multiple regression analyses were used to test the main effects of social support and social network variables, as well as their interactions with gender, income, and baseline physical performance. RESULTS After controlling for potential confounding effects, respondents with more social ties showed less functional decline. The beneficial effects of social ties were stronger for respondents who were male or had lower levels of baseline physical performance. DISCUSSION The effects of social support and social networks may vary according to the individual's gender and baseline physical capabilities. Studies of functional decline among elderly persons should not ignore this population variation in the effects of social networks.
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Affiliation(s)
- J B Unger
- University of Southern California, USA
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