Factors Associated with Incarceration in Older Adults Experiencing Homelessness: Results from the HOPE HOME Study

BackgroundIn the US, the median age of adults experiencing homelessness and incarceration is increasing. Little is known about risk factors for incarceration among older adults experiencing homelessness. To develop targeted interventions, there is a need to understand their risk factors for incarceration.ObjectiveTo examine the prevalence and risk factors associated with incarceration in a cohort of older adults experiencing homelessness.DesignProspective, longitudinal cohort study with interviews every 6 months for a median of 5.8 years.ParticipantsWe recruited adults ≥50 years old and homeless at baseline (n=433) via population-based sampling.Main MeasuresOur dependent variable was incident incarceration, defined as one night in jail or prison per 6-month follow-up period after study enrollment. Independent variables included socioeconomic status, social, health, housing, and prior criminal justice involvement.Key ResultsParticipants had a median age of 58 years and were predominantly men (75%) and Black (80%). Seventy percent had at least one chronic medical condition, 12% reported heavy drinking, and 38% endorsed moderate-severe use of cocaine, 8% of amphetamines, and 7% of opioids. At baseline, 84% reported a lifetime history of jail stays; 37% reported prior prison stays. During follow-up, 23% spent time in jail or prison. In multivariable models, factors associated with a higher risk of incarceration included the following: having 6 or more confidants (HR=2.13, 95% CI=1.2–3.7, p=0.007), remaining homeless (HR=1.72, 95% CI=1.1–2.8, p=0.02), heavy drinking (HR=2.05, 95% CI=1.4–3.0, p<0.001), moderate-severe amphetamine use (HR=1.89, 95% CI=1.2–3.0, p=0.006), and being on probation (HR=3.61, 95% CI=2.4–5.4, p<0.001) or parole (HR=3.02, 95% CI=1.5–5.9, p=0.001).ConclusionsOlder adults experiencing homelessness have a high risk of incarceration. There is a need for targeted interventions addressing substance use, homelessness, and reforming parole and probation in order to abate the high ongoing risk of incarceration among older adults experiencing homelessness.KEY WORDS: incarceration, homelessness, vulnerable populations     

Racial and Ethnic Differences in the Mental Health Needs and Access to Care of Older Adults in California

Little is known about the unmet mental health needs of minority older adults. Racial and ethnic differences in the prevalence rates of psychological distress and reported need and use of mental health services were examined in a population‐based sample of older adults using the 2005 California Health Interview Survey. The sample comprised 16,974 people aged 55 and older, with 13,974 non‐Hispanic whites, 719 African Americans, 1,215 Asians, and 1,066 Latinos. Respondents were compared in terms of prevalence of symptoms of mental distress and serious mental illness, reported need for help, and access to mental health services. African Americans, Asians, and Latinos were more likely to have mental distress than whites (21.2–24.2% vs 14.4%, P<.001) and a higher prevalence of serious mental illness (4.1–7.7% vs 2.5%, P<.001). After adjustment for age, sex, birthplace, marital status, education, limited English proficiency, chronic health conditions, and insurance status, older African‐American (adjusted odds ratio (aOR)=1.37, 95% confidence interval (CI)=1.04–1.81) and Asian (aOR=1.50, CI=1.13–2.00) adults still had greater odds of mental distress than whites. Furthermore, all three groups had worse access to mental health services than whites (African American aOR=0.64, 95% CI=0.43–0.96; Asian aOR=0.32, CI=0.16–0.63; Latino aOR=0.35, CI=0.17–0.70). Clinicians caring for older individuals should be aware of their high risk for mental health needs. Given that minorities' access to mental health services is worse than whites', even after adjusting for health insurance status, providing insurance alone will not eliminate this disparity. Innovative clinical and systemic strategies are needed to better identify individuals at risk and to provide needed services.     

Differences in Self‐Reported Physical Activity and Body Mass Index Among Older Hispanic and Non‐Hispanic White Men and Women: Findings from the 2009 California Health Interview Survey

Older Hispanic Americans are a rapidly growing minority group who are disproportionately affected by diabetes mellitus and obesity. Given the importance of physical activity, particularly leisure‐time activity, in the management of diabetes mellitus and obesity, the current study examined ethnic and sex differences in walking for transportation, leisure‐time walking, moderate activity (not including walking), and vigorous activity between Hispanic and non‐Hispanic white (NHW) older adults (age 55 and older) using the 2009 California Health Interview Survey, a population‐based survey representative of California's noninstitutionalized population. The total sample consisted of 21,702 participants (20,148 NHW (7,968 men, 12,180 women) and 1,554 Hispanic (609 men, 945 women)). Multivariable logistic and linear regression analyses were adjusted for sociodemographic characteristics. The findings revealed that Hispanic men and women were significantly less likely to engage in self‐reported leisure‐time walking and vigorous activity than NHW men (adjusted odds ratio (aOR) = 0.71, 95% confidence interval (CI) = 0.51–0.99) and women (aOR = 0.60, 95% CI = 0.42–0.87). Regardless of ethnic group, men were more likely than women to engage in self‐reported walking for transportation (aOR = 0.71, 95% CI = 0.58–0.87), moderate activity (aOR = 0.68, 95% CI = 0.57–0.81), and vigorous activity (aOR = 0.58, 95% CI = 0.50–0.68). All types of self‐reported physical activity were associated with lower body mass index (BMI; P < .001), although significant interactions between sex and leisure time walking (P < .001), moderate activity (P < .001), and vigorous activity (P < .001) indicated that women who engaged in these activities reported the lowest BMIs. The findings highlight the importance of emphasizing walking in efforts to increase moderate and vigorous activity, particularly for older women.     

Disparities in advance care planning among older US immigrants

Background

Despite known racial disparities in advance care planning (ACP), little is known about ACP disparities experienced by US immigrants.

Methods

We used data from the 2016 wave of the Health and Retirement Study. We defined ACP engagement as self-reported end-of-life (EOL) discussions, designation of a power of attorney (DPOA), documented living will, or “any” of the three behaviors. Immigration status was determined by respondent-reported birth outside the United States. Time in the United States was calculated by subtracting the year of arrival in the United States from the survey year of 2016. We used multivariable logistic regression to estimate the association between ACP engagement and immigration status and the relationship of acculturation to ACP engagement, adjusting for sociodemographics, religiosity, and life expectancy.

Results

Of the total cohort (N = 9928), 10% were immigrants; 45% of immigrants identified as Hispanic. After adjustment, immigrants had significantly lower adjusted probability of any ACP engagement (immigrants: 74% vs. US-born: 83%, p < 0.001), EOL discussions (67% vs. 77%, p < 0.001), DPOA designation (50% vs. 59%, p = 0.001) and living will documentation (50% vs. 56%, p = 0.03). Among immigrants, each year in the United States was associated with a 4% increase in the odds of any ACP engagement (aOR 1.04, 95% CI 1.03–1.06), ranging from 36% engaged 10 years after immigration to 78% after 70 years.

Conclusion

ACP engagement was lower for US immigrants compared to US-born older adults, particularly for those that recently immigrated. Future studies should explore strategies to reduce disparities in ACP and the unique ACP needs among different immigrant populations.     

Factors associated with access to antiviral treatment in a multicentre cross‐sectional study of patients with chronic hepatitis B in Italy

Summary. A multicentre cross‐sectional survey was performed to provide an accurate picture of patients with chronic hepatitis B (CHB) cared for by Italian Infectious Diseases Centers (IDCs). This analysis describes factors associated with access to the treatment of CHB in a country where barriers to treatment are not expected to exist because of comprehensive coverage under the National Health System (NHS). The study was performed in 74 IDCs. The analysis focused on 3305 patients with CHB of 3760 HBsAg‐positive patients enrolled from March to September, 2008. To account for missing values, a Multiple Imputation method was used. Treatment was reported in 2091 (63.3%) patients. In the multivariate analysis, an increased chance of getting treatment was independently associated with 10 years increase of age at diagnosis (adjusted odds ratio [aOR] 1.2, 95% confidence interval [CI] 1.1–1.3, P < 0.001), HBeAg positivity (aOR 1.8, 95% CI 1.1–2.8, P < 0.001), cirrhosis (aOR 3.6, 95% CI 2–6.3, P = 0.012), HDV (aOR 1.6, 95% CI 1.02–2.5, P = 0.042) and HIV positivity (aOR 6.5, 95% CI 4–10.8, P < 0.001). Conversely, a decreased chance was associated with female gender (aOR 0.6, 95% CI 0.5–0.7, P < 0.001), immigration (aOR 0.6, 95% CI 0.5–0.9, P = 0.009), alcohol consumption (aOR 0.7, 95% CI 0.5–0.98, P = 0.04) and HCV positivity (aOR 0.5, 95% CI 0.3–0.8, P = 0.005). Our study shows that Italian IDCs treat a high percentage of patients with CHB. Nevertheless, disparities exist which are not related to the severity of disease limiting access to antiviral therapy of CHB, even in a country with a universal healthcare system.     

Medical Multimorbidity,Mental Illness,and Substance Use Disorder among Middle-Aged and Older Justice-Involved Adults in the USA, 2015–2018

BackgroundAdults age ≥ 50 are among the fastest growing populations in correctional supervision and are medically underserved while experiencing unique health disparities. Community-living older adults, referred to as “justice-involved,” are people who have been recently arrested, or are on probation or parole. Although medical complexity is common among incarcerated older adults, the occurrence of medical morbidity, substance use disorder (SUD), and mental illness among justice-involved older adults living in US communities is poorly understood.ObjectiveTo estimate the prevalence of medical multimorbidity (≥ 2 chronic medical diseases), SUDs, and mental illness among justice-involved adults age ≥ 50, and the co-occurrence of these conditions.DesignCross-sectional analysis.ParticipantsA total of 34,898 adults age ≥ 50 from the 2015 to 2018 administrations of the US National Survey on Drug Use and Health.Main MeasuresDemographic characteristics of justice-involved adults age ≥ 50 were compared with those not justice-involved. We estimated prevalence of mental illness, chronic medical diseases, and SUD among adults age ≥ 50 reporting past-year criminal justice system involvement. Logistic regression was used to estimate the odds of these conditions and co-occurrence of conditions, comparing justice-involved to non-justice-involved adults.Key ResultsAn estimated 1.2% (95% confidence interval [CI] = 1.1–1.3) of adults age > 50 experienced criminal justice involvement in the past year. Compared with non-justice-involved adults, justice-involved adults were at increased odds for mental illness (adjusted odds ratio [aOR] = 3.04, 95% CI = 2.09–4.41) and SUD (aOR = 8.10, 95% CI = 6.12–10.73), but not medical multimorbidity (aOR = 1.15, 95% CI = 0.85–1.56). Justice-involved adults were also at increased odds for all combinations of the three outcomes, including having all three simultaneously (aOR = 8.56, 95% CI = 4.10–17.86).ConclusionsCommunity-based middle-aged and older adults involved in the criminal justice system are at high risk for experiencing co-occurring medical multimorbidity, mental illness, and SUD. Interventions that address all three social and medical risk factors are needed for this population.Electronic supplementary materialThe online version of this article (10.1007/s11606-020-06297-w) contains supplementary material, which is available to authorized users.KEY WORDS: justice-involved, older adults, multimorbidity, substance use     

Is the consumption of fast foods associated with asthma or other allergic diseases?

The associations between the consumption of fast foods and asthma or allergic diseases have not been clarified. The aim of this study was to determine whether fast foods consumption is associated with asthma or allergic diseases. Databases were searched up to February 2018. Studies investigating the associations between fast foods consumption and asthma or allergic diseases were considered eligible. Included studies were assessed for quality using standardized critical appraisal checklists. The quality scores were 5.33 ± 1.16 in case–control studies and 5.69 ± 1.55 in cross‐sectional studies. Adjusted odds ratios (aOR) with 95% confidence interval (CI) were pooled. Sixteen studies (13 cross‐sectional and 3 case–control studies) were included. The consumption of fast foods was significantly related to current asthma (aOR: 1.58; 95% CI: 1.17–2.13 for case–control study and aOR: 1.58; 95% CI: 1.10–2.26 for cross‐sectional studies), severe asthma (aOR: 1.34; 95% CI: 1.23–1.46), asthma ever (aOR: 1.36; 95% CI: 1.06–1.75), current wheeze (aOR: 1.21; 95% CI: 1.16–1.27), wheeze ever (aOR: 1.65; 95% CI: 1.07–2.52), physician‐diagnosed allergic rhinitis (odds ratio: 1.43; 95% CI: 1.05–1.95), severe eczema (aOR: 1.51; 95% CI: 1.16–1.96) and severe rhino‐conjunctivitis (aOR: 1.54; 95% CI: 1.18–2.00). The consumption of hamburgers was associated with current asthma (aOR: 1.59; 95% CI: 1.13–2.25), severe asthma (aOR: 1.34; 95% CI: 1.23–1.46), asthma ever (aOR: 1.47; 95% CI: 1.13–1.92), severe eczema (aOR: 1.51; 95% CI: 1.16–1.96), severe rhino‐conjunctivitis (aOR: 1.54; 95% CI: 1.18–2.00) and rhino‐conjunctivitis (aOR: 1.21; 95% CI: 1.15–1.27). The consumption of fast foods, especially hamburgers, ≥3 times/week, was more likely to be associated with severe asthma and current wheeze compared with the consumption of 1–2 times/week (both P < 0.001). In conclusion, the consumption of fast foods, particularly hamburgers, correlates to asthma in a dose–response pattern, which needs to be further validated in longitudinal and interventional studies.     

Factors Associated with Readmission Among General Internal Medicine Patients Experiencing Homelessness

BackgroundPeople who are homeless have a higher burden of illness and higher rates of hospital admission and readmission compared to the general population. Identifying the factors associated with hospital readmission could help healthcare providers and policymakers improve post-discharge care for homeless patients.ObjectiveTo identify factors associated with hospital readmission within 90 days of discharge from a general internal medicine unit among patients experiencing homelessness.DesignThis prospective observational study was conducted at an urban academic teaching hospital in Toronto, Canada. Interviewer-administered questionnaires and chart reviews were completed to assess medical, social, processes of care, and hospitalization data. Multivariable logistic regression with backward selection was used to identify factors associated with a subsequent readmission and estimate odds ratios and 95% confidence intervals.ParticipantsAdults (N = 129) who were admitted to the general internal medicine service between November 2017 and November 2018 and who were homeless at the time of admission.Main MeasuresUnplanned all-cause readmission to the study hospital within 90 days of discharge.Key ResultsThirty-five of 129 participants (27.1%) were readmitted within 90 days of discharge. Factors associated with lower odds of readmission included having an active case manager (adjusted odds ratios [aOR]: 0.31, 95% CI, 0.13–0.76), having informal support such as friends and family (aOR: 0.25, 95% CI, 0.08–0.78), and sending a copy of the patient’s discharge plan to a primary care physician who had cared for the patient within the last year (aOR: 0.44, 95% CI, 0.17–1.16). A higher number of medications prescribed at discharge was associated with higher odds of readmission (aOR: 1.12, 95% CI, 1.02–1.23).ConclusionInterventions to reduce hospital readmission for people who are homeless should evaluate tailored discharge planning and dedicated resources to support implementation of these plans in the community.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06483-w.KEY WORDS: homeless persons, patient readmission, hospitalization, health services, poverty     

Factors influencing attitudes toward advance directives in Korean older adults

AimWe aimed to determine the factors influencing attitudes toward advance directives in Korean older adults with consideration of an Asian cultural background.MethodsWe recruited community-dwelling older adults aged 60 years or older at a regional senior welfare center in Korea. Demographic factors and mental and physical health status were examined using questionnaires and a physical examination. The questionnaire also assessed perceived necessity of advance directives and related experiences.ResultsMost participants (79.32%) agreed that advance directives were necessary. Older adults with high education levels (odds ratio [OR] 2.31, 95% confidence interval [CI] 0.84–6.34), low economic status (OR 2.09, 95% C.I. 0.60–7.27), and poor cognitive function (adjusted odds ratio [aOR] 2.10, 95% CI 0.89–4.97) had a greater odds of agreeing that advance directives are necessary. All participants with self-care problems (9/9) and most participants with at risk status of physical functioning (13/14) reported agreement. Death-related experiences were also associated. Notably, individuals who had discussions on end-of-life care with family members showed a greater odds of agreeing that advance directives are necessary (aOR 2.12, 95% CI 0.88–5.11).ConclusionsThe factors associated with increased agreement that advance directives are necessary were high education level, low economic status, poor cognitive function, problems in self-care, poor physical functioning, death-related experiences. Especially, discussions of end-of-life care with family members increased the agreement. Thus, discussion on end-of-life care should be encouraged and the factors influencing older adults’ attitudes toward advance directives should be considered in developing policies for such discussion.     

Driving Patterns of Older Adults: Results from the Second Injury Control and Risk Survey

OBJECTIVES: To describe older adults' driving patterns, including self‐imposed driving restrictions and motor vehicle crashes (MVCs). DESIGN: The Second Injury Control and Risk Survey (ICARIS‐2) was a national, random‐digit‐dial telephone survey conducted by the Centers for Disease Control and Prevention in 2001 to 2003. ICARIS‐2 sampled 113,476 English‐ and Spanish‐speaking households, using weighting variables to generate national estimates. RESULTS: The response rate was 48% (N=9,684). Six percent (n=728) of respondents were aged 75 and older. Of these, 85.6% (n=613) were aged 75 to 84, and 14.4% (n=115) were aged 85 and older; 59.2% were female. Three‐fourths (74.9%, 95% confidence interval (CI)=70.4–79.4%) of adults aged 75 to 84 and 69.9% (95% CI=48.2–71.6%) aged 85 and older were current drivers. Most (81.9%; 95% CI=77.6–86.2%) older drivers limited their driving, usually in bad weather (59.0%), at night (57.0%), on long trips (49.6%), in traffic (49.0%), or at high speeds (33.6%); only 15.4% limited driving for medical reasons. Women were more likely to self‐limit driving (odds ratio (OR)=1.83, 95% CI=0.99–3.39). Few (4.2%, 95% CI=2.4–6.1%) older adults reported MVC involvement in the past year as a driver or passenger. In multivariate analysis, drivers living alone (OR=3.93, 95% CI=1.55–9.95) and men (OR=2.59, 95% CI=1.18–5.67) were more likely to report a recent crash; drivers who self‐limited were less likely (OR=0.55, 95% CI=0.18–1.60). CONCLUSION: Large majorities of older adults, including those aged 85 and older, are current drivers. Although many limit driving in hazardous conditions, fewer do for medical reasons. Men and older adults who live alone are more likely to report a recent MVC; those who self‐limit their driving are less likely to report crash involvement.     

Chronic Kidney Disease and Cognitive Function in Older Adults: Findings from the Chronic Renal Insufficiency Cohort Cognitive Study

OBJECTIVES: To investigate cognitive impairment in older, ethnically diverse individuals with a broad range of kidney function, to evaluate a spectrum of cognitive domains, and to determine whether the relationship between chronic kidney disease (CKD) and cognitive function is independent of demographic and clinical factors. DESIGN: Cross‐sectional. SETTING: Chronic Renal Insufficiency Cohort Study. PARTICIPANTS: Eight hundred twenty‐five adults aged 55 and older with CKD. MEASUREMENTS: Estimated glomerular filtration rate (eGFR, mL/min per 1.73 m²) was estimated using the four‐variable Modification of Diet in Renal Disease equation. Cognitive scores on six cognitive tests were compared across eGFR strata using linear regression; multivariable logistic regression was used to examine level of CKD and clinically significant cognitive impairment (score ≤1 standard deviations from the mean). RESULTS: Mean age of the participants was 64.9, 50.4% were male, and 44.5% were black. After multivariable adjustment, participants with lower eGFR had lower cognitive scores on most cognitive domains (P<.05). In addition, participants with advanced CKD (eGFR<30) were more likely to have clinically significant cognitive impairment on global cognition (adjusted odds ratio (AOR) 2.0, 95% CI=1.1–3.9), naming (AOR=1.9, 95% CI=1.0–3.3), attention (AOR=2.4, 95% CI=1.3–4.5), executive function (AOR=2.5, 95% CI=1.9–4.4), and delayed memory (AOR=1.5, 95% CI=0.9–2.6) but not on category fluency (AOR=1.1, 95% CI=0.6–2.0) than those with mild to moderate CKD (eGFR 45–59). CONCLUSION: In older adults with CKD, lower level of kidney function was associated with lower cognitive function on most domains. These results suggest that older patients with advanced CKD should be screened for cognitive impairment.     

High rates of advance care planning in New York City's elderly population

BACKGROUND: Previous studies have demonstrated low rates of advance care planning (ACP), particularly among nonwhite populations, raising questions about the generalizability of this decision-making process. OBJECTIVE: To explore factors that may influence patients' willingness to engage in ACP. DESIGN: Survey. SETTING: Thirty-four randomly selected New York City senior centers. PARTICIPANTS: A total of 700 African American (n = 239), Hispanic (n = 237), and white (n = 224) adults 60 years and older. INTERVENTION: Participants were administered a 51-item survey that assessed attitudes, beliefs, and practices regarding ACP. MAIN OUTCOME MEASURES: Attitudes and beliefs about physicians' trustworthiness, fatalism, beliefs about surrogate decision making, and comfort discussing end-of-life medical care; factors associated with health care proxy completion; and health care proxy completion rates. RESULTS: More than one third of the participants had completed a health care proxy. There were no significant differences in completion rates across the 3 ethnic groups. Respondents who had a primary care physician (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.3-3.2), were more knowledgeable about advance directives (OR, 2.0; 95% CI, 1.4-2.9), or had seen a friend or family member use a mechanical ventilator (OR, 1.5; 95% CI, 1.02-2.1) were significantly more likely to have designated a health care proxy. Respondents who were only comfortable discussing ACP if the discussion was initiated by the physician (OR, 0.6; 95% CI, 0.0-0.8) were significantly less likely to have completed a health care proxy. CONCLUSIONS: African American, Hispanic, and white community-dwelling, older adults had similarly high rates of advance directive completion. The primary predictors of advance directive completion involved modifiable factors such as established primary care physicians, personal experience with mechanical ventilation, knowledge about the process of ACP, and physicians' willingness to effectively initiate such discussions. Some of the racial/ethnic differences in desire for collective family-based decision making that were observed in this study have implications for the evolution of ACP policy that respects and operationalizes these preferences.     

Serum Parathyroid Hormone Levels Predict Falls in Older Adults with Diabetes Mellitus

OBJECTIVES: To examine the association between serum parathyroid hormone (PTH) levels and incident falls in older adults with diabetes mellitus. DESIGN: Longitudinal analysis of incident falls over 1 year in a substudy of participants with diabetes mellitus in the Health, Aging and Body Composition Study. SETTING: Pittsburgh, Pennsylvania, and Memphis, Tennessee. PARTICIPANTS: Well‐functioning, community‐dwelling black and white adults aged 70 to 79 with diabetes mellitus (N=472). MEASUREMENTS: Measured baseline serum PTH. Self‐report of falls over the subsequent 12 months. Baseline physical performance and self‐reported demographic, behavioral, and health status measures including kidney function, chronic conditions, and medication use. RESULTS: One‐third (30.3%) of participants reported falling over 1 year of follow‐up. Mean baseline serum PTH was 53.5±30.0 pg/mL in nonfallers and 62.6±46.2 pg/mL in fallers (P=.01). For every 1 standard deviation (36 pg/mL) increment in baseline serum PTH, there was approximately a 30% greater likelihood of reporting a fall in the subsequent year, after adjusting for age, sex, race, field center, alcohol consumption, body mass index, physical activity, and winter or spring season (adjusted odds ratio (aOR)=1.30, 95% confidence interval (CI)=1.06–1.59). Further adjustment for kidney function, chronic conditions, medication and supplement use, and physical performance attenuated the association slightly (aOR=1.26, 95% CI=1.01–1.58). A trend remained after additional adjustment for reported falls in the previous year. CONCLUSION: Higher serum PTH was associated with incident falls in older, well‐functioning men and women with diabetes mellitus. Further investigation aimed at understanding the underlying mechanism for the association between serum PTH and falls is needed.     

Pneumococcal meningitis in the intensive care unit: prognostic factors of clinical outcome in a series of 80 cases

We have undertaken this retrospective study to determine factors associated with in-hospital mortality and morbidity in 80 adult patients with severe Streptococcus pneumoniae meningitis. Clinical characteristics at admission of patients infected with susceptible (n = 54) and nonsusceptible (n = 17) strains to penicillin G were similar: age: 51 +/- 19 versus 58 +/- 15 yr (p = 0.16); Simplified Acute Severity Score (SAPS II): 39 +/- 14 versus 41 +/- 11 (p = 0.68); and Glasgow Coma Score: 8 +/- 3 versus 9.5 +/- 3 (p = 0.21), respectively. In-hospital mortality was 25% (20/80), with one death among the 17 patients (6%) infected with a nonsusceptible strain (p = 0.03). High-dose dexamethasone was used in 22 cases. By multivariate analysis, three factors were independently associated with death: platelet count < 100 G/L (adjusted odds ratio [aOR] = 32.7; 95% CI = 3.2 to 332.5; p = 0.0032), arterial pH > 7.47 (aOR = 33.1; 95% CI = 3.4 to 319.7; p = 0.0025), and mechanical ventilation (aOR = 48.8; 95% CI = 2.6 to 901.5; p = 0.009). When adjusting for the identified prognostic factors, corticosteroids significantly reduced the risk of death (aOR = 0.069; 95% CI = 0.005 to 0.9; p = 0.048). Only SAPS II was predictive of adverse outcome (death or neurologic deficit). We conclude that in intubated patients with S. pneumoniae meningitis, hyperventilation should be used with caution. Nonsusceptibility to penicillin G is not associated with a worse outcome. High-dose corticosteroids may be beneficial in the most severely ill patients.     

Risk factors for perceived unmet medical needs in human immunodeficiency virus-infected adults in Seoul,Korea

To identify the factors associated with perceived unmet medical needs in human immunodeficiency virus (HIV)-infected adults, we analyzed the results from a series of city-wide cross-sectional surveys of HIV-infected adults living in Seoul, Korea. Multivariate logistic regression analysis was used to identify factors related to unmet medical needs. Among the 775 subjects included in the study, 15.4% had perceived unmet medical needs. Significant factors included age group (35–49 years; adjusted odds ratio [aOR], 1.80; 95% confidence interval [CI], 1.06–3.06), lower monthly income (aOR, 3.75 for the <$900/mo group and 2.44 for the $900–$1800/mo group; 95% CI, 1.68–8.35 and 1.18–5.04, respectively), beneficiaries of the National Medical Aid Program (aOR, 1.78; 95% CI, 1.01–3.17), recent CD4 cell counts <500/µL (aOR, 1.53; 95% CI, 1.01–2.33). Taken together, these data reveal strong associations of middle age and low socioeconomic status with perceived unmet medical needs among HIV-infected adults.     

Advance Care Planning in Cognitively Impaired Older Adults

Older adults with cognitive impairment face many healthcare challenges, chief among them participating in medical decision‐making about their own health care. Advance care planning (ACP) is the process whereby individuals communicate their wishes for future care with their clinicians and surrogate decision‐makers while they are still able to do so. ACP has been shown to improve important outcomes for individuals with cognitive impairment, but rates of ACP for these individuals are low because of individual‐, clinician‐, and system‐related factors. Addressing ACP early in the illness trajectory can maximize the chances that people can participate meaningfully. This article recommends best practices for approaching ACP for older adults with cognitive impairment. The importance of providing anticipatory guidance and eliciting values to guide future care to create a shared framework between clinicians, individuals, and surrogate decision‐makers is emphasized. It is recommended that ACP be approached as an iterative process to continue to honor and support people's wishes as cognitive impairment progresses and increasingly threatens independence and function. The article describes effective strategies for assessing decision‐making capacity, identifying surrogate decision‐makers, and using structured communication tools for ACP. It also provides guidelines for documentation and billing. Finally, special considerations for individuals with advanced dementia are described, including the use of artificial hydration and nutrition, decisions about site of care, and the role of hospice care.     

Willingness of Older Korean‐American Adults to Use Hospice

Responding to an urgent need for more research on end‐of‐life concerns of racial and ethnic minorities, the present study explored predictors of willingness of older Korean‐American adults (N=675) to use hospice. Guided by Andersen's behavioral health model, the study considered predisposing factors (age, sex, marital status, education), potential health needs (chronic conditions, functional disability), and enabling factors (health insurance, acculturation, prior awareness of hospice). Nearly three‐quarters of the sample answered yes to the following statement and question, “Hospice is a program that helps people who are dying by making them feel comfortable and free of pain when they can no longer be cured of their disease. If you needed hospice services, would you use them?” A greater willingness was observed in younger persons (odds ratio (OR)=0.96, 95% confidence interval (CI)=0.93–0.98) and those with higher levels of education (OR=1.67, 95% CI=1.12–2.48), more chronic conditions (OR=1.23, 95% CI=1.05–1.44), health insurance (OR=0.59, 95% CI=0.37–0.94), higher levels of acculturation (OR=1.07, 95% CI=1.03–1.10), and prior awareness of hospice (OR=4.43, 95% CI=2.85–6.90). The present study highlights the role of prior awareness in shaping individuals' attitudes toward services, calling attention to a need for community education and outreach programs for racial and ethnic minorities, with specific emphasis on dissemination of information and greater awareness of hospice services.     

Association of Marijuana Use and Cardiovascular Disease: A Behavioral Risk Factor Surveillance System Data Analysis of 133,706 US Adults

BackgroundMarijuana is the most commonly used psychoactive drug, while its effects on cardiovascular health are not well known and remain a subject of interest.MethodsWe used the pooled 2016-2018 data from the Behavioral Risk Factor Surveillance System to perform a cross-sectional analysis evaluating the association of marijuana and cardiovascular disease among US adults who never smoked cigarettes.ResultsAmong US adults ages 18-74 years, when compared with nonusers, frequent marijuana use was associated with 88% higher odds of myocardial infarction or coronary artery disease (adjusted odds ratio [aOR] 1.88; 95% confidence interval [CI], 1.15-3.08), and 81% higher odds of stroke (aOR 1.81; 95% CI, 1.14-2.89). Among the premature cardiovascular disease group, frequent marijuana users had 2.3 times higher odds of myocardial infarction or coronary artery disease (aOR 2.27; 95% CI, 1.20-4.30), and 1.9 times higher odds of stroke (aOR 1.92; 95% CI, 1.07-3.43). In terms of the modality of marijuana use, frequent marijuana smoking had 2.1 times higher odds of myocardial infarction or coronary artery disease (aOR 2.07; 95% CI, 1.21-3.56), and 1.8 times higher odds of stroke (aOR 1.84; 95% CI, 1.09-3.10). A similar association was observed in the premature cardiovascular disease group who smoked marijuana (aOR [for myocardial infarction or coronary artery disease] 2.64; 95% CI, 1.37-5.09; aOR [for stroke] 2.00; 95% CI, 1.05-3.79). No association was observed between marijuana use in any form other than smoking and cardiovascular disease, across all age groups.ConclusionFrequent marijuana smoking is associated with significantly higher odds of stroke and myocardial infarction or coronary artery disease, with a possible role in premature cardiovascular disease.     

Opiniones: End‐of‐Life Care Preferences and Planning of Older Latinos

OBJECTIVES: To measure end‐of‐life (EOL) care preferences and advance care planning (ACP) in older Latinos and to examine the relationship between culture‐based attitudes and extent of ACP. DESIGN: Cross‐sectional interview. SETTING: Twenty‐two senior centers in greater Los Angeles. PARTICIPANTS: One hundred forty‐seven Latinos aged 60 and older. MEASUREMENTS: EOL care preferences, extent of ACP, attitudes regarding patient autonomy, family‐centered decision‐making, trust in healthcare providers, and health and sociodemographic characteristics. RESULTS: If seriously ill, 84% of participants would prefer medical care focused on comfort rather than care focused on extending life, yet 47% had never discussed such preferences with their family or doctor, and 77% had no advance directive. Most participants favored family‐centered decision making (64%) and limited patient autonomy (63%). Greater acculturation, education, and desire for autonomy were associated with having an advance directive (P‐values <.03). Controlling for sociodemographic characteristics, greater acculturation (adjusted odds ratio (AOR)=1.6, 95% confidence interval (CI)=1.1–2.4) and preferring greater autonomy (AOR=1.6, 95% CI=1.1–2.3) were independently associated with having an advance directive. CONCLUSIONS: The majority of older Latinos studied preferred less‐aggressive, comfort‐focused EOL care, yet few had documented or communicated this preference. This discrepancy places older Latinos at risk of receiving high‐intensity care inconsistent with their preferences.     

Obesity‐related eating behaviours in the adult population of Spain, 2008–2010

Knowledge of the socio‐demographic distribution of eating behaviours can aid our understanding of their contribution to the obesity epidemic and help to address healthy eating interventions to those who can benefit most. This cross‐sectional study assessed the frequency of self‐reported eating behaviours among 11,603 individuals representative of the non‐institutionalized Spanish population aged ≥18 years in the period 2008–2010. In the adult population of Spain, 24.3% had lunch and 18.2% had dinner away from home >3 times per month. About three‐fourths of adults did not plan the amount of food to be eaten, and did not choose light foods and/or skim dairy products. Also, 26% did not trim visible fat from meat, and 74.7% usually ate while watching television. Compared with individuals with primary or less education, those with university studies were more likely to remove fat from meat (age‐ and sex‐adjusted odds ratio [aOR] 1.25; 95% confidence interval [CI] 1.08–1.44), and to choose light food and/or skim dairy (aOR 1.50; 95% CI 1.30–1.77), and less likely to eat while watching television (aOR 0.54; 95% CI 0.47–0.63). In conclusion, the prevalence of several obesity‐related eating behaviours is high in Spain, which indicates a deficient implementation of dietary guidelines. Socioeconomic inequalities in eating behaviours should also be addressed.