Primary Care Prognostic (PCP) Index of 11-Year Mortality Risk: Development and Validation of a Brief Prognostic Tool

BackgroundHealthcare providers use a life expectancy of at least 5 to 10 years in shared clinical decision-making with older adults about cancer screening, major surgeries, and disease prevention interventions. At present, few prognostic indexes predict long-term mortality beyond 10 years or are suited for use in primary care settings.ObjectiveWe developed and validated an 8-item multidimensional index predicting 11-year mortality for use in primary care.Design, Setting, and ParticipantsUsing data from the Singapore Longitudinal Ageing Studies (SLAS), we developed a Primary Care Prognostic (PCP) Index for predicting 11-year mortality risk in a development cohort (n = 1550) and validated it in a geographically different cohort (n = 928).Main MeasuresThe PCP Index was derived from eight indicators (body mass loss, weakness, slow gait, comorbidity, polypharmacy, IADL/BADL dependency, low albumin, low total cholesterol, out of 25 candidate indicators) using stepwise Cox proportional hazard models.Key ResultsIn the developmental cohort, the mortality hazard ratio increased by 53% per PCP point score increase, independent of age and sex. Across risk categories, absolute risks of mortality increased from 5% (score 0) to 67.9% (scores 7–9), with area under curve (AUC = 0.77 (95% CI 0.73–0.80)). The PCP Index also predicted mortality in the validation cohort, with AUC = 0.70 (95% CI 0.64–0.75).ConclusionsThe PCP Index using simple clinical assessments and point scoring is a potentially useful prognostic tool for predicting long-term mortality and is well suited for risk stratification and shared clinical decision-making with older adults in primary care.Electronic supplementary materialThe online version of this article (10.1007/s11606-020-06132-2) contains supplementary material, which is available to authorized users.KEY WORDS: older adults, prognosis, mortality, frailty, malnutrition     

Recovery of Activities of Daily Living in Older Adults After Hospitalization for Acute Medical Illness

OBJECTIVES: To compare functional outcomes in the year after discharge for older adults discharged from the hospital after an acute medical illness with a new or additional disability in their basic self‐care activities of daily living (ADL) (compared with preadmission baseline 2 weeks before admission) with those of older adults discharged with baseline ADL function and identify predictors of failure to recover to baseline function 1 year after discharge. DESIGN: Observational. SETTING: Tertiary care hospital, community teaching hospital. PARTICIPANTS: Older (aged ≥70) patients nonelectively admitted to general medical services (1993–1998). MEASUREMENTS: Number of ADL disabilities at preadmission baseline and 1, 3, 6, and 12 months after discharge. Outcomes were death, sustained decline in ADL function, and recovery to baseline ADL function at each time point. RESULTS: By 12 months after discharge, of those discharged with new or additional ADL disability, 41.3% died, 28.6% were alive but had not recovered to baseline function, and 30.1% were at baseline function. Of those discharged at baseline function, 17.8% died, 15.2% were alive but with worse than baseline function, and 67% were at their baseline function (P<.001). Of those discharged with new or additional ADL disability, the presence or absence of recovery by 1 month was associated with long‐term outcomes. Age, cardiovascular disease, dementia, cancer, low albumin, and greater number of dependencies in instrumental ADLs independently predicted failure to recover. CONCLUSION: For older adults discharged with new or additional disability in ADL after hospitalization for medical illness, prognosis for functional recovery is poor. Rehabilitation interventions of longer duration and timing than current reimbursement allows, caregiver support, and palliative care should be evaluated.     

Index to Predict 5-Year Mortality of Community-Dwelling Adults Aged 65 and Older Using Data from the National Health Interview Survey

BACKGROUND  

Prognostic information is becoming increasingly important for clinical decision-making.     

Environmental Risk Factors for Community-Acquired Pneumonia Hospitalization in Older Adults

OBJECTIVES: To investigate the risk of hospitalization for pneumonia in older adults in relation to biophysical environmental factors.
DESIGN: Population-based case control study with collection of personal interview data.
SETTING: Hamilton, Ontario, and Edmonton, Alberta, Canada.
PARTICIPANTS: Seven hundred seventeen people aged 65 and older hospitalized for community-acquired pneumonia (CAP) from September 2002 to April 2005 and 867 controls aged 65 and older randomly selected from the same communities as the cases.
MEASUREMENTS: Odds ratios (ORs) for risk of pneumonia in relation to environmental and other variables.
RESULTS: Exposure to secondhand smoke in the previous month (OR=1.73, 95% confidence interval (CI)=1.04–2.90); poor nutritional score (OR=1.83, 95% CI=1.19–2.80); alcohol use per month (per gram; OR=1.69, 95% CI=1.08–2.61); history of regular exposure to gases, fumes, or chemicals at work (OR=3.69, 95% CI=2.37–5.75); history of regular exposure to fumes from solvents, paints, or gasoline at home (OR=3.31, 95% CI=1.59–6.87); and non-English language spoken at home (OR=5.31, 95% CI=2.60–10.87) were associated with a greater risk of pneumonia hospitalization in multivariable analysis. Age, congestive heart failure, chronic obstructive lung disease, dysphagia, renal disease, functional status, use of immunosuppressive disease medications, and lifetime history of smoking of more than 100 cigarettes were other variables associated with hospitalization for pneumonia.
CONCLUSION: In elderly people, present and past exposures in the physical environmental are associated with hospitalization for CAP.     

Impact of Malnutrition on Hospitalization Outcomes for Older Adults Admitted for Sepsis

BackgroundMalnutrition is a major determinant of health outcomes among the older adult population. Our goal was to evaluate the impact of malnutrition on hospitalization outcomes for older adults who were admitted with a diagnosis of sepsis.MethodsThe National Inpatient Sample was queried for all patients who were admitted with a primary diagnosis of sepsis from January to December 2016. These patients were identified using the International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code A419. Patients who were diagnosed with malnutrition were identified using ICD-10 codes E43, E440, E441, E45, and E46. Outcomes of hospitalization were modeled using logistic regression for binary outcomes and generalized linear models for continuous outcomes.ResultsOverall, a total of 808,030 patients were admitted for sepsis. Those diagnosed with malnutrition were 15.6% (126,335) of the total. The mean age (standard error of the mean) was 78 years (0.03). On multivariate analysis, malnutrition correlated with increased odds for mortality: adjusted OR (aOR) 1.20; 95% confidence interval [CI], 1.15-1.26; P < .001; septic shock: aOR 1.50; 95% CI, 1.44-1.57; P < .001; and intubation: aOR 1.45; 95% CI, 1.38-1.52; P < .001. It was also associated with higher odds for acute kidney injury and stroke. Malnutrition correlated with a 53% increase in the length of stay, with mean ratio 1.53; 95% CI, 1.51-1.56; P < .01; and a 54% increase in cost, with mean cost ratio 1.54; 95% CI, 1.51-1.58; P < .001.ConclusionAmong the geriatric population diagnosed with sepsis, malnutrition is an independent predictor for poor hospitalization outcomes.     

Systolic BP and Mortality in Older Adults with CKD

Background and objectives

Optimal BP targets for older adults with CKD are unclear. This study sought to determine whether a nonlinear relationship between BP and mortality—as described for the broader CKD population and for older adults in the general population—is present for older adults with CKD.

Design, setting, participants, & measurements

A cohort of 21,015 adults age 65–105 years with a moderate or severe reduction in eGFR (<60 ml/min per 1.73 m²) were identified within the Kaiser Permanente Northwest Health Maintenance Organization population. The relationship between baseline systolic BP (SBP; ≤120, 121–130, 131–140, 141–150, >150 mmHg; referent, 131–140 mmHg) and all-cause mortality across age groups (65–70, 71–80, and >80 years) was examined; patients were followed for up to 11 years after cohort entry.

Results

The median times at risk were 3.15 years, 3.53 years, and 2.76 years for adults age 65–70, 71–80, and >80 years, respectively. Mortality during follow-up was 19.6% for those age 65–70 years, 33.4% for those age 71–80 years, and 55.7% for those age >80 years. The relationship between SBP and mortality varied as a function of age. The risk of death was highest for patients with the lowest SBP in all age groups. Only among adults age 65–70 years was an SBP>140 mmHg associated with a higher risk of death compared with the referent category. Patterns of age modification of the relationship between SBP and mortality were consistent in all sensitivity analyses.

Conclusions

In a cohort of older adults, the relationship between SBP and mortality varied systematically with age. A relationship between higher SBP and mortality was present only for younger members of this cohort and not for those older than 70. These results raise the question of whether the relative benefits and harms of lowering BP to recommended targets for older adults with CKD may vary as a function of age.     

Pain and Mortality in Older Adults: The Influence of Pain Phenotype

Objective

Moderate to severe chronic pain affects 1 in 5 adults. Pain may increase the risk of mortality, but the relationship is unclear. This study investigated whether mortality risk was influenced by pain phenotype, characterized by pain extent or pain impact on daily life.

Methods

The study population was drawn from 2 large population cohorts of adults ages ≥50 years, the English Longitudinal Study of Ageing (n = 6,324) and the North Staffordshire Osteoarthritis Project (n = 10,985). Survival analyses (Cox's proportional hazard models) estimated the risk of mortality in participants reporting any pain and then separately according to the extent of pain (total number of pain sites, widespread pain according to the American College of Rheumatology [ACR] criteria, and widespread pain according to Manchester criteria) and pain impact on daily life (pain interference and often troubled with pain). Models were cumulatively adjusted for age, sex, education, and wealth/adequacy of income.

Results

After adjustments, the report of any pain (mortality rate ratio [MRR] 1.06 [95% confidence interval (95% CI) 0.95–1.19]) or having widespread pain (ACR 1.07 [95% CI 0.92–1.23] or Manchester 1.16 [95% CI 0.99–1.36]) was not associated with an increased risk of mortality. Participants who were often troubled with pain (MRR 1.29 [95% CI 1.12–1.49]) and those who reported quite a bit of pain interference (MRR 1.38 [95% CI 1.20–1.59]) and extreme pain interference (MRR 1.88 [1.54–2.29]) had an increased risk of all‐cause mortality.

Conclusion

Pain that interferes with daily life, rather than pain per se, was associated with an increased risk of mortality. Future studies should investigate the mechanisms through which pain increases mortality risk.

     

Perceived Burden of Thai Caregivers for Older Adults After Stroke

Perception of caregiver burden among stroke survivors varies based on socioeconomic and cultural backgrounds. The objectives of this study were to identify the burdens among Thai caregivers of older stroke survivors, characteristics of caregivers and severity of caregiver burden. Caregivers of older stroke survivors were randomly interviewed (March–June, 2012). Information on baseline characteristics and caregiver burden using Zarit Burden Inventory (ZBI) was collected. One hundred one participants were assessed. The mean ZBI was 21.6 ± 14.5 [95% CI, 18.7–24.8]. More than half of caregivers reported no burden (54.5%). High burdens were associated with low self-reported income, high numbers of basic activities of daily living needed and coexisting musculoskeletal conditions. The observed low degree of burden might be the result of the sociocultural view of the study participants.     

Diabetes and Coronary Heart Disease as Risk Factors for Mortality in Older Adults

Background

Type 2 diabetes has been described as a coronary heart disease (CHD) “risk equivalent.” We tested whether cardiovascular and all-cause mortality rates were similar between participants with prevalent CHD vs diabetes in an older adult population in whom both glucose disorders and preexisting atherosclerosis are common.

Methods

The Cardiovascular Health Study is a longitudinal study of men and women (n = 5784) aged ≥65 years at baseline who were followed from baseline (1989/1992-1993) through 2005 for mortality. Diabetes was defined by fasting plasma glucose ≥7.0 mmol/L or use of diabetes control medications. Prevalent CHD was determined by confirmed history of myocardial infarction, angina, or coronary revascularization.

Results

Following multivariable adjustment for other cardiovascular disease risk factors and subclinical atherosclerosis, CHD mortality risk was similar between participants with CHD alone vs diabetes alone (hazard ratio [HR] 1.04, 95% confidence interval [CI], 0.83-1.30). The proportion of mortality attributable to prevalent diabetes (population-attributable risk percent = 8.4%) and prevalent CHD (6.7%) was similar in women, but the proportion of mortality attributable to CHD (16.5%) as compared with diabetes (6.4%) was markedly higher in men. Patterns were similar for cardiovascular disease mortality. By contrast, the adjusted relative hazard of total mortality was lower among participants with CHD alone (HR 0.85, 95% CI, 0.75-0.96) as compared with those who had diabetes alone.

Conclusions

Among older adults, diabetes alone confers a risk for cardiovascular mortality similar to that from established clinical CHD. The public health burden of both diabetes and CHD is substantial, particularly among women.     

Muscle Mass Index As a Predictor of Longevity in Older Adults

Objective

Obesity (as defined by body mass index) has not been associated consistently with higher mortality in older adults. However, total body mass includes fat and muscle, which have different metabolic effects. This study was designed to test the hypothesis that greater muscle mass in older adults is associated with lower all-cause mortality.

Methods

All-cause mortality was analyzed by the year 2004 in 3659 participants from the National Health and Nutrition Examination Survey III who were aged 55 years or more (65 years if women) at the time of the survey (1988-1994). Individuals who were underweight or died in the first 2 years of follow-up were excluded to remove frail elders from the sample. Skeletal muscle mass was measured using bioelectrical impedance, and muscle mass index was defined as muscle mass divided by height squared. Modified Poisson regression and proportional hazards regression were used to examine the relationship of muscle mass index with all-cause mortality risk and rate, respectively, adjusted for central obesity (waist hip ratio) and other significant covariates.

Results

In adjusted analyses, total mortality was significantly lower in the fourth quartile of muscle mass index compared with the first quartile: adjusted risk ratio 0.81 (95% confidence interval, 0.71-0.91) and adjusted hazard ratio 0.80 (95% confidence interval, 0.66-0.97).

Conclusions

This study demonstrates the survival predication ability of relative muscle mass and highlights the need to look beyond total body mass in assessing the health of older adults.