• Depressive Symptoms, Non-Adherence to Discharge Instructions, and 30-Day Unplanned Hospital Readmission among Community-Dwelling Elders

      Albrecht, Jennifer S.; Furuno, Jon P.; Gruber-Baldini, Ann L. (2012)
      Background: Hospital readmissions are costly to the healthcare system. Understanding patient factors associated with hospital readmission will facilitate targeting of interventions designed to reduce readmissions. Depressive symptoms are associated with poor patient outcomes and may impact hospital readmission. Objective: To investigate the association between depressive symptoms and 30-day unplanned hospital readmission. Non-adherence to discharge instructions was examined as a potential mediator of this association. Methods: We conducted a prospective cohort study of hospitalized patients ages 65 and older. Depressive symptoms were measured within 72 hours of admission to the University of Maryland Medical Center and defined as a score of greater than or equal to 6 on the Geriatric Depression Scale-15. Patients were then contacted three times post-hospital discharge to ascertain incident deaths, unplanned hospital readmissions, and adherence to discharge instructions. Results: 750 patients were enrolled in the study. Depressive symptoms were not associated with 30-day unplanned hospital readmission (RR 1.20; 95% CI 0.83, 1.72). Depressive symptoms were associated with non-adherence to the medication domain of the discharge instructions (OR 1.75; 95% CI 1.02, 2.99), but not with follow-up appointments (OR 1.25; 95% CI 0.62, 2.52), lifestyle recommendations (RR 0.94; 95% CI 0.75, 1.17), or overall non-adherence to the discharge instructions (COR 1.17; 95% CI 0.78, 1.75). Non-adherence to one or more domains of the discharge instructions at 5 days (OR 1.58; 95% CI 0.94, 2.65) or 15 days (OR 1.37; 95% CI 0.68, 2.74) post-hospital discharge was not significantly associated with 30-day unplanned hospital readmission. Because a significant association between depressive symptoms and 30-day unplanned hospital readmission was not observed, mediation was not assessed. Conclusions: In this sample of hospitalized adults aged 65 and older, neither depressive symptoms nor non-adherence to discharge instructions was significantly associated with 30-day unplanned hospital readmission. Hence, targeting interventions toward patients with depressive symptoms may not result in decreased hospital readmission. While depressive symptoms were associated with non-adherence to medication, other factors may play a greater role in predicting non-adherence to the discharge instructions. Further research is needed to identify predictors of non-adherence to the discharge instructions as well as to understand perceived barriers to non- adherence.
    • The Effect of Resources on Caregiving Experiences in the U.S. Population and among Korean American Caregivers

      Hong, Michin; Harrington, Donna (2011)
      Informal caregivers play a major role in providing long-term care (LTC) for older adults. Given the demands of caregiving, caregivers experience various negative caregiving outcomes and eventually worse health. Despite extensive research, prior research reveals limited knowledge about caregiver health because of a lack of attention toward the role of resources, inconsistent findings, and a dearth of ethnic specific detailed knowledge. Thus, this study aims to examine a health model with two different samples drawn from (1) the 2004 National Long-term Caregiver Survey (NLTCS) and (2) a Korean American (KA) caregiver survey. The health model is built upon the Conservation of Resource (COR) Theory and consists of various sets of variables. Structural equation modeling was used to test the health model in each sample. The measurement models and the initial structural models produced poor model fit; however, after modifications were made the final structural models fit well in each data set. In the NLTCS model, more difficult caregiving condition (i.e., caring for older adults with more health problems and longer caregiving time) was related to having fewer resources (i.e., less feeling of mastery, fewer financial resources, less social support, and less family harmony) and negative primary outcomes (i.e., more stress and burden). Moreover, more resources were related to better primary outcomes and better physical health of caregivers. On the other hand, caregiving condition was not associated with resources in the KA model. However, other paths from caregiving condition to primary outcomes, and from resources (i.e., higher self-efficacy, more financial resources, greater social network, greater family harmony, and higher English proficiency) to primary outcomes and to health were also found in the KA models. The findings indicate that resources are related to primary outcomes as well as the final health outcomes across ethnicities, and the importance of resources may be particularly high among the KA population. This study suggests that caregiver support policies and culturally competent programs be expanded. Further studies using longitudinal data and different indicators of the constructs of interest are needed. Finally, some modifications are suggested for better application of the COR theory to caregiving condition.
    • Evaluating the Relationship between Muscle and Bone Modeling Response in Older Adults

      Reider, Lisa; Magaziner, Jay (2014)
      Background: Bone modeling, the process that continually adjusts bone strength in response to prevalent muscle-loading forces throughout an individual's lifespan, may play an important role in bone fragility with age. Femoral stress, an index of bone modeling response can be estimated using measurements of DXA derived bone geometry and loading information incorporated into an engineering model. Assuming that individuals have adapted to habitual muscle loading forces, greater stresses indicate a diminished response and a weaker bone Aims/Methods: The aims of this dissertation were to 1) evaluate the association of femoral stress with measures of lean mass and muscle strength among healthy older adults participating in the Health ABC study using linear regression; 2) determine whether femoral stress predicts incident fracture among the same cohort of older adults using cox proportional hazards models; and 3) evaluate the association of femoral stress with measures of lean mass and muscle strength in women after hip fracture participating in the 3rd and 4th cohort of the Baltimore Hip Studies using linear regression and to determine whether femoral stress changes the year following fracture using longitudinal data analysis. Results: Lean mass explained more of the variation in femoral stress than measures of muscle strength among healthy older men and women as well as in women with hip fracture. Remaining variability in femoral stress may reflect individual variation in modeling response. After adjusting for measures of lean mass and strength, women in the highest tertile of femoral stress had 77% higher hazard of fracture and men in the highest tertile of femoral stress had 84% higher hazard of fracture relative to women and men in the lowest tertile, respectively. This suggests that deficiencies in bone modeling response may be an important predictor of fracture. Femoral stress did not appear to change the year following fracture in older women. Conclusion: Future studies should focus on refining measures of bone modeling response by incorporating better measures of muscle force. While femoral stress does not have clinical applications per se, it allows us to investigate a potentially important mechanism underlying bone fragility and provides a framework for thinking about treatments that could improve the interaction between muscle and bone.
    • Exploration of Coping Strategies in Older, Community Dwelling, HIV Positive Individuals in Baltimore

      DeGrezia, Mary G.; Kauffman, Karen (2012)
      Background: The CDC reports that by 2015 50% of HIV-positive individuals in the U.S. will be at least 50 years old. Individuals with HIV develop more comorbid health conditions at an earlier age than those without HIV. Older adults with HIV are a sizeable, growing population. However, published qualitative data on how older adults cope with HIV, comorbid conditions, and related stressors are extremely limited. Objectives: The purpose of this exploratory study was to identify comorbid conditions and other related stressors experienced by HIV-positive community-dwelling older adults in Baltimore and to understand how they cope. Methods: Forty HIV-positive individuals aged 50 and older (range 50-69 years; male, N=17, mean age 55; female, N=23, mean age 56) affiliated with at least one of two Baltimore-based HIV support groups with older adult members were recruited via purposeful sampling and interviewed to the point of data saturation. Data were analyzed using an interpretive hermeneutic methodology and qualitative content analysis. Results: Participants experienced one or more comorbid condition (range 1-18; male mean = 7; female mean = 6). The most frequently reported comorbid conditions for both genders were hypertension 48%, depression 43%, hypercholesterolemia 38%, memory difficulties 35%, Hepatitis C 34%, and anxiety 33%. Related stressors included HIV-related fear, perceived and actual stigma, multiple medications to treat comorbid conditions, and financial concerns. Participants learned to cope with stressors by accessing support, helping selves and helping others, and tapping into one's own spirituality. Employing these strategies helped participants cope, develop hope, and work toward psychological well-being. Conclusions: Participants employed active and meaning-based coping strategies to engage in life despite HIV, comorbid conditions, and related stressors. Findings are significant because this study is among the first to give voice to older HIV-positive community dwelling individuals in Baltimore about how they cope with HIV, comorbidities, and related stressors. Nurses' increased understanding of the impact of HIV, comorbidities, and related stressors in HIV-positive older adults along with knowledge of their active and meaning-based coping strategies can lead to holistic patient care with interventions encouraging hope and psychological well-being.
    • Factors Associated with Length of Stay and Discharge Disposition in Older Trauma Patients

      Brotemarkle, Rebecca Ann; Resnick, Barbara (2013)
      Factors Associated with Length of Stay and Discharge Disposition in Older Trauma Patients Abstract Background: Trauma patients over the age of 65 are living longer and staying active at older ages. Older trauma patients tend to have longer lengths of stay (LOS) and to be discharged more often to rehabilitation and skilled nursing facilities. Understanding the factors that influence LOS and discharge disposition is needed to guide interventions focused on decreasing LOS and assuring that patients are discharged to the least restrictive setting. Purpose: The purpose of this study was to explore the impact of patient and system related factors on LOS and discharge disposition for older adults hospitalized for traumatic injury. Methods: This was a secondary data analysis using descriptive data from rehabilitation notes during inpatient encounters. Data analysis was done using structural equation modeling and logistic regression. Results: 132 patients were randomly selected from 1387 patients admitted to a level 1 trauma center. The majority were Caucasian (83.9%, n = 111), 46.9% (n = 62) were males with an average age of 78.3 (S.D. = 9.7) years. On average participants had 2.29 (S.D. = 1.96) comorbidities and approximately two thirds (65.9%, n = 87) were rated as having severe injuries. The average length of stay was 4.3 (S.D. = 4.0) days with 57.6% (n = 76) of patients discharged to a facility. The model had a fair fit to the data and demonstrated that younger patients who had more comorbidities, were likely to have more pain. Older patients with more comorbidities, higher injury severity, more days from admission to evaluation, and lower pain were more likely to have a longer LOS which explained 37% of the variance in LOS. Based on logistic regression analysis, having longer LOS (O.R. = .049, 95% CI .008 - .301, p=.001) and more pain (O.R. = .531, 95% CI .310 - .908, p=.021) were associated with decreased likelihood of returning home versus being discharged to a facility. Conclusion: Increased focus on pain and pain management, consideration of comorbidities, and decreasing time from admission to initial evaluation by rehabilitation therapists among older trauma patients may help to decrease LOS and facilitate discharge to the least restrictive setting.
    • Management of Traumatic Brain Injury with Statins among Older Medicare Beneficiaries

      Khokhar, Bilal; Simoni-Wastila, Linda; 0000-0003-0143-1390 (2016)
      Background: Traumatic brain injury (TBI) is a major health concern for older adults aged 65 and older. Older TBI patients are at increased risk of primary injury (in-hospital and all-cause mortality) and secondary injury (stroke, depression, and Alzheimer's disease and related dementias (ADRD)). There is limited research regarding optimal pharmacotherapeutic options and management of TBI patients; however, several studies have highlighted statins, used to treat hyperlipidemia, as potential pharmacologic agents to reduce inflammation and improve impaired cerebral blood flow associated with primary and secondary injury. The objectives of the study are to: 1) quantify statin utilization, and 2) determine the associations between statin use and primary and secondary injury among TBI patients. Methods: Statin use (atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin), primary injury, and secondary injury were examined among Medicare beneficiaries hospitalized with a TBI between 2006 and 2010. Logistic regression was used to investigate the relationship between pre-TBI statin use and in-hospital mortality, while discrete time analysis was used to investigate the relationship between statin use following TBI and all-cause mortality and secondary injury. Results: Among the 75,698 beneficiaries who met study criteria, 37,874 (50.0%) beneficiaries used a statin at least once during the study period. The most common statin used was simvastatin, followed by atorvastatin. Fluvastatin was the least used statin. Pre-TBI use of atorvastatin (odds ratio (OR) 0.88; 95% confidence interval (CI) 0.82, 0.96), simvastatin (OR 0.84; 95% CI 0.79, 0.91), and rosuvastatin (OR 0.79; 95% CI 0.67, 0.94) were associated with significant decreases in the risk of in-hospital mortality. Any statin use was associated with reduced all-cause mortality following TBI-hospitalization discharge. Atorvastatin and simvastatin use also were associated with reductions in all secondary injury outcomes. Conclusion: Tens of thousands of older adults are hospitalized annually with TBI and experience disabling primary and secondary injury; findings from these analyses have salient implications for reducing the risk of TBI complications among older adults. The evidence generated suggests that preemptive use of statins may decrease the risk of in-hospital and all-cause mortality, as well as reduce the likelihood of stroke, depression, and ADRD.
    • Oral Anticoagulation Medication Usage in Older Adults with Atrial Fibrillation Residing in Long-term Care Facilities

      Gill, Christine; Baumgarten, Mona
      Statement of the problem: Oral anticoagulants (AC) reduce the risk of ischemic stroke (IS) in older adults with atrial fibrillation (AF) but increase the risk of major hemorrhage. Treatment with ACs requires prescribers and patients to weigh benefits against risks. Many older adults with AF residing in long-term care (LTC) facilities may not be using ACs, even in the absence of absolute contraindications. This study (1) examined the prevalence of AC use, (2) assessed which factors were associated with AC use, and (3) estimated the net effect of ACs weighing the benefit (IS prevention) against the risk (intracranial hemorrhage [ICH]) in older adults with AF residing in LTC facilities. Methods: An observational cohort study was performed using a 5% random sample of older adults with AF residing in LTC facilities for at least 101 days from 2007 to 2013 using a Medicare administrative claims database linked to the Minimum Dataset assessments. Results: Of the 21,877 Medicare beneficiaries meeting the study eligibility criteria, over half (54.6%) were 85 years or older, most were female (75.9%) and white (88.1%). The prevalence of AC use was 36.2% (95% confidence interval [CI]: 35.6%-36.8%). History of stroke or transient ischemic attack and history of thromboembolism were associated with an increased likelihood of AC use, while history of internal bleed was associated with a decreased likelihood of AC use. The net effect of AC use was 1.07 per 100 person-years, 95% CI: 0.31-3.01; this is the difference between, on the one hand, the difference in the estimated rate of IS while not using ACs and using ACs and, on the other hand, the difference between the estimated rate of ICH while using ACs and not using ACs . Conclusions: The majority of older adults with AF residing in LTC facilities are not being managed with ACs. While this study provides evidence suggestive of a net benefit of AC use in older adults with AF residing in LTC facilities, health status and the burden of medication monitoring are among the other factors that patients, their caregivers and providers should consider when making the decision about initiating ACs.
    • Outcomes of Older Adults Admitted to a Level I Trauma Center

      Tang, Ying; Smith, Gordon S., M.B., Ch.B., M.P.H. (2013)
      Background: The outcomes of injury and the associated risk factors among older adults are poorly understood. Objective: To examine the associations of pre-existing medical conditions (PMCs) and mechanism of injury (MOI) with the outcomes and to estimate the impact of injury upon long-term mortality of older adults. Methods: Injured older adults admitted to the Shock Trauma Center, University of Maryland Medical Center, between July 1, 1995 and November 30, 2008 were followed until the end of 2008. Logistic regression and Cox proportional hazard models were fit to analyze the outcomes. Standardized mortality ratios (SMRs) and relative survival ratios (RSRs), comparing the observed to the expected proportion of Maryland older adult population were calculated. Results: Among 6,162 injured older adults, 27% developed in-hospital complications, 15% (N=918) died within 30 days of admission, and 43% (N=2,323) of those who were discharged died during the follow-up. Hypertension, prior myocardial infarction, congestive heart failure, and chronic obstructive pulmonary disease (COPD) were associated with increased odds of in-hospital complications, with adjusted ORs ranging from 1.2 (95% confidence interval (CI): 1.1-1.5) to 2.2 (95% CI: 1.6-3.0). Hypertension was associated with lower odds (OR=0.7, 95% CI: 0.6-0.8) while COPD with increased odds of 30-day mortality (OR=1.5, 95% CI: 1.1-2.1). All PMCs, except hypertension, were associated with increased hazard of death after discharge (adjusted hazard ratios range: 1.1-1.7). MVC injuries were associated with higher odds of complications than fall injuries (adjusted ORs range: 1.3-2.2). Older adults with MVC injuries had lower odds of 30-day mortality (OR=0.8, 95% CI: 0.6-0.9) and a lower hazard of death after discharge (HR=0.6, 95% CI: 0.6-0.7). SMR was 4.5 (95% CI: 4.1-4.8) at 6 months and 1.4 (95% CI: 1.2-1.5) between 5-10 years after discharge. The RSR was 91.0% (95% CI: 90.1%-91.9%) at 6 months and 72.6% (95% CI: 69.3%-75.8%) at 10 years after discharge. Conclusions: The associations between PMCs and outcomes are disease-specific. Older adults sustaining MVC injuries have a better survival compared to those sustaining fall injuries. The impact of injury on mortality is most evident during the first 6 months after discharge and can last as long as 10 years.
    • Sarcopenia and PRAISEDD-2 Intervention's Impact on Diet, Physical Activity, and Body Composition

      Hammersla, Margaret; Resnick, Barbara (2017)
      Background: Older adults with a low socioeconomic status and African Americans are more sedentary than the general population. This contributes to the development of sarcopenia and has a negative impact on the health and function of these individuals. PRAISEDD-2 was a 24-month quasi-experimetnal study of low income adults living in senior housing. A focused 3-month intervention included education about stroke prevention and heart health through adherence to heart healthy diets, regular exercise, and prescribed medication combined with exercise classes that included verbal encouragement, blood pressure feedback, and role modeling. Classes continued to be offered in months 4-24 but only included a monthly motivational intervention. The impact of the PRAISEDD-2 intervention on diet (fat, sodium, and protein intake), time spent in physical activity, and body composition are examined in the study reported here. Design: Diet and body composition measures were collected at baseline, 3, 6, 12, and 24 months. Sample included 29 residents of a low-income senior housing complex in Baltimore, MD. Complete data was obtain from 13 participants. Generalized estimating equations (GEE) were used to examine change over the time periods. An intention-to-treat (ITT) paradigm was followed. Results: At 3 months, participants experienced a decrease in sodium (p<0.01) and fat intake (p<0.01), as well as in a decrease in percent body fat (p<.001). However, at 24 months, fat intake (p<0.001) and percent body fat (p<0.001) increased, although protein intake increased (p<.001). No significant change was noted in physical activity (p=.056) or sodium intake (p=0.69) at 24 months. Conclusions: The findings from this study provided some support for the feasibility and preliminary efficacy of the PRAISEDD-2 intervention. The changes that occurred in the early 3 month period were likely due to the intensive nature of the education and exercise classes. Future research should focus on building a stronger self-efficacy based motivational component into the exercise classes to strengthen long term adherence to the recommended dietary change and physical activity, essential to promote decrease in body fat and increases in muscle mass. Interventions may need to be sustained longer to achieve more permanent changes in diet and exercise.