Publications

BACKGROUND

Instructional forms of advance care planning depend on the ability of patients to predict their future treatment preferences. However, preferences may change with changes in patients' health states.

METHODS

We conducted in-home interviews of 226 older community-dwelling persons with advanced cancer, congestive heart failure, or chronic obstructive pulmonary disease at least every 4 months for up to 2 years. Patients were asked to rate whether treatment for their illness would be acceptable if it resulted in 1 of 4 health states.

RESULTS

The likelihood of rating as acceptable a treatment resulting in mild (odds ratio [OR], 1.11; 95% confidence interval [CI], 1.06-1.16) or severe (OR, 1.06; 95% CI, 1.03-1.09) functional disability increased with each month of participation. Patients who experienced a decline in their ability to perform instrumental activities of daily living were more likely to rate as acceptable treatment resulting in mild (OR, 1.23; 95% CI, 1.08-1.40) or severe (OR, 1.23; 95% CI, 1.11-1.37) disability. Although the overall likelihood of rating treatment resulting in a state of pain as acceptable did not change over time (OR, 0.98; 95% CI, 0.96-1.01), patients who had moderate to severe pain were more likely to rate this treatment as acceptable (OR, 2.55; 95% CI, 1.56-4.19) than were those who did not have moderate to severe pain.

CONCLUSIONS

For some patients, the acceptability of treatment resulting in certain diminished states of health increases with time, and increased acceptability is more likely among patients experiencing a decline in that same domain. These changes pose a challenge to advance care planning, which asks patients to predict their future treatment preferences.

Persons with chronic disease experience multiple symptoms. Understanding the association between these symptoms and health outcomes would facilitate a targeted approach to symptom assessment and treatment. Our objectives were to determine the association of a range of symptoms with quality of life, self-rated health, and functional status among chronically ill adults, and to assess methods for evaluating the independent associations of symptoms that may be interrelated. We consecutively enrolled 226 cognitively intact, community-dwelling adults, aged 60 years or older with chronic obstructive pulmonary disease, heart failure, or cancer. Seven symptoms (physical discomfort, pain, fatigue, problems with appetite, feelings of depression, anxiety, and shortness of breath) assessed using the Edmonton Symptom Assessment Scale were examined for their association with self-rated quality of life, self-rated health, and functional status. Principal component analysis and logistic regression revealed similar results. The latter demonstrated that physical discomfort was associated with lower self-rated health (adjusted odds ratio [OR] 1.9; 95% confidence interval 1.2-2.9) and functional disability (adjusted OR 1.8; 95% confidence interval 1.2-2.7). Feelings of depression were associated with poorer quality of life (adjusted OR 1.7; 95% confidence interval 1.1-2.6), and shortness of breath was associated with lower self-rated health (adjusted OR 1.5; 95% confidence interval 1.1-2.0). The association between a range of symptoms and quality of life, self-rated health, and functional status differed across outcomes, but only three symptoms-physical discomfort, feelings of depression, and shortness of breath-maintained their associations when multiple symptoms were examined concurrently. These findings suggest that interventions targeting these symptoms could improve several health-related outcomes.

BACKGROUND

There are conflicting assumptions regarding how patients' preferences for life-sustaining treatment change over the course of serious illness.

OBJECTIVE

To examine changes in treatment preferences over time.

DESIGN

Longitudinal cohort study with 2-year follow-up.

PARTICIPANTS

Two hundred twenty-six community-dwelling persons age > or =60 years with advanced cancer, congestive heart failure, or chronic obstructive pulmonary disease.

MEASUREMENTS

Participants were asked, if faced with an illness exacerbation that would be fatal if untreated, whether they would: a) undergo high-burden treatment at a given likelihood of death and b) undergo low-burden treatment at a given likelihood of severe disability, versus a return to current health.

RESULTS

There was little change in the overall proportions of participants who would undergo therapy at a given likelihood of death or disability from first to final interview. Diversity within the population regarding the highest likelihood of death or disability at which the individual would undergo therapy remained substantial over time. Despite a small magnitude of change, the odds of participants' willingness to undergo high-burden therapy at a given likelihood of death and to undergo low-burden therapy at a given likelihood of severe cognitive disability decreased significantly over time. Greater functional disability, poorer quality of life, and lower self-rated life expectancy were associated with decreased willingness to undergo therapy.

CONCLUSIONS

Diversity among older persons with advanced illness regarding treatment preferences persists over time. Although the magnitude of change is small, there is a decreased willingness to undergo highly burdensome therapy or to risk severe disability in order to avoid death over time and with declining health status.

OBJECTIVES

To determine whether an educational intervention would improve depression assessment and appropriate referral. Secondary analyses tested whether referral led to depression improvement.

DESIGN

Training in the Assessment of Depression (TRIAD) was a three-group, nurse-randomized trial. Researchers interviewed randomly selected patients at baseline and 8 weeks.

SETTING

Three certified home healthcare agencies in Westchester County, New York.

PARTICIPANTS

Fifty-three medical/surgical nurses were randomized within agency to three intervention groups: full, minimal, or control. Research contact with nurses' patients (aged >65; N=477) yielded 256 (53.7%) enrolled subjects, 84 (17.6%) ineligibles, and 120 (25.2%) refusals; 233 of the 256 (87.1%) enrolled patients completed follow-up interviews.

INTERVENTION

Nurse training in clinically meaningful use of depression sections of Medicare's mandatory Outcome and Assessment Information Set (OASIS).

MEASUREMENTS

Nurse-assessed mood or anhedonia (OASIS) versus research assessments using the Structured Clinical Interview for Axis I Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Disorders (SCID); referrals for mental health evaluation (agency records), and depression severity (24-item Hamilton Depression Rating Scale; HDRS).

RESULTS

Referral rates for patients with (SCID) depressed mood or anhedonia (n=75) varied according to nurse group: 50.0% full intervention, 18.5% minimal, 21.4% control (P=.047). Rates for nondepressed patients (n=180) did not differ (4.9%, 2.0%, 5.8%, respectively; P=.60). In patients with major or minor depression (n=37), referral was associated with symptom improvement. Change in HDRS was 5 points greater in referred patients than others (P=.04). Concordance between OASIS and SCID did not differ between intervention groups.

CONCLUSION

TRIAD showed that training nurses to assess for depression using an approach developed in partnership with home healthcare agencies led to appropriate referral and care for depressed patients.

BACKGROUND

Symptoms are a central component of health status; however, little is known about the full range and trajectory of symptoms experienced by persons with chronic diseases other than cancer.

METHODS

Observational cohort study with interviews performed at least every 4 months for up to 2 years among community-dwelling persons 60 years or older with chronic obstructive pulmonary disease (COPD) or heart failure (HF). Seven symptoms rated as absent, mild, moderate, or severe were assessed at each interview.

RESULTS

Among the 79 participants with COPD, at least 50% reported shortness of breath, physical discomfort, fatigue, and problems with appetite and anxiety. Among the 59 participants with HF, at least 50% reported physical discomfort, fatigue, and problems with appetite at both their initial and final interviews. Both disease-specific and non-disease-specific symptoms increased in severity over time. The prevalence of individual symptoms did not differ according to whether the participants lived or died.

CONCLUSIONS

As a potentially modifiable contributor to poor health status, the high symptom burden among older persons with COPD and HF represents a large unmet need for improved symptom assessment and treatment. This need may not be met by current disease management guidelines, which focus on a small number of symptoms except for patients at the end of life.

A neglected topic in aging depression research is the potential role of the parent-adult child relationship. In this study we examined whether adult children's reports of having relied upon parents for instrumental and expressive support are associated with parents' depressive symptoms. The sample included 304 parents (aged 50-72 years), matched to a randomly selected adult offspring, from the University of Southern California Longitudinal Study of Generations. We measured parents' depressive symptoms by using the Center for Epidemiologic Studies Depression Scale at baseline and 3 and 6 years later. The final longitudinal analysis showed that, when we adjusted for relevant variables including age, gender, income, self-rated health, and child's depressive symptoms, the adult child's reliance on instrumental support was associated with fewer parental depressive symptoms (p =.036). Expressive support did not show the same pattern. Thus, adult children's reliance on instrumental support might contribute to their parents' mental health.

Because falls are highly prevalent, harmful events for older adults, identification of patients at risk is a high priority for home health care agencies. Using routine administrative data, we demonstrated that patients with depressive symptoms on the Outcome and Assessment Information Set are at risk for falls. A prospective case-control study that matched 54 patients who experienced an adverse fall with 854 controls showed that patients who fell had twice the odds of being depressed (odds ratio = 1.90, 95% confidence interval = 1.01 to 3.59). Bowel incontinence, high medical comorbidity, stair use, injury and poisoning, memory deficit, and antipsychotic medication use were also predictors, but no association was found for antidepressant medications. These data suggest the potential benefit of including depression screening for multifactorial fall prevention interventions.

Older workers' share of involuntary job losses in the United States has grown fairly consistently in recent decades, prompting greater interest in the health consequences of involuntary unemployment among individuals nearing retirement. In this study, the authors applied the multifactorial model of geriatric health to investigate whether late-career involuntary job loss was associated with subsequent physical disability and whether the effect of involuntary job loss on physical disability varied by predisposition. Using data from the first four waves (1992 to 1998) of the Health and Retirement Survey, the authors measured predisposition with individual risk factors for functional disability and indices of aggregate risk. The results of gender-specific models fit with generalized estimating equations revealed that unmarried women and those with low predisplacement incomes had heightened risk for subsequent functional disability. No differential effects of job loss were found for men.

We present a case study using a multilevel modeling approach to determine whether depressive symptoms are affected by genetic factors. Existing studies examining this question have focused on twins. The present study built on the literature by conducting a preliminary study of the heritability of depressive symptoms within extended families. At the same time, this study assessed the need for adjustment of a heritability measure in a family study using a multigenerational sample. The sample consisted of 230 community-dwelling extended families that included 431 adult offspring, comprising full siblings, half siblings and cousins that participated in the University of Southern California Longitudinal Study of Generations. All participants filled out the Center for Epidemiologic Studies Depression (CES-D) scale. The multilevel analysis allowed us to model the natural hierarchy of the extended family. Results indicate that the proportion of the phenotypic variance for CES-D that occurs due to genetic differences is not significantly larger than zero among these participants [h(2) = 8.6%, 95% confidence interval (CI) = 0-57%, p = 0.71]. Our findings suggest that future studies examining depressive symptoms in this sample can focus on non-genetic explanatory factors without the necessity to control for genetic variation. However, our study may be limited by measurement of prevalent depressive symptoms, which may not generalize to lifetime depressive symptoms.

OBJECTIVE

This study evaluated the association between depression and hospitalization among geriatric home care patients.

METHODS

A sample of 477 patients newly admitted to home care over two years was assessed for depression. Bivariate and logistic regression analyses examined the likelihood of hospitalization during a 60-day home care episode.

RESULTS

The hospitalization rate was similar for the 77 depressed patients and 400 nondepressed patients (about 7%). However, mean time to hospitalization was 8.4 versus 19.5 days after start of care, respectively. Hospitalization risk was significantly higher for depressed patients during the first few weeks. A main effect for depression and a depression-by-time interaction was found when analyses controlled for medical comorbidity, cognitive status, age, gender, race, activities of daily living and instrumental activities of daily living, and referral to home care after hospitalization.

CONCLUSIONS

Depression appears to increase short-term risk of hospitalization for geriatric home care patients immediately after starting home care.