Outcomes of Disability
As persons age, they are at high risk for losing the abilty to independently care for themselves. They need the help of caregivers to do basic tasks of daily living like bathing, getting dressed, managing their medicines, or handling their finances. Our research group is focusing on: determining which persons are at highest risk of becoming disabled; preventing and delaying disability as persons age; and helping disabled elders maintain an excellent quality of life.
Our group has discovered:
- Psychosocial factors such as depression may be as important as medical diseases as risk factors for disability
- Risk factors for disability in middle age persons, decades before they become disabled
- Many older persons become disabled after hospitalization. This happens even for seemingly minor hospitalizations, even after the problem leading to the hospitalization has been remedied.
- Acute Care for Elders (ACE) units--a new model of hospital care that prevents disabilty when older persons are hospitalized. This model of care is now used at hospitals across the United States.
- Family caregivers play a crucial role in helping disabled elders maintain excellent quality of life, and that caregiving also comes at great personal sacrifice. An important focus of our work is to examine how to best advocate and care for the family caregiver.
Care of Vulnerable Populations
A core research mission of the UCSF Division of Geriatrics is to optimize health care for vulnerable older adults and to prevent health disparities.
- We have specific expertise in social determinants of health. For example, we have studied the effects of frailty in older incarcerated individuals, health literacy and mortality, race/ethnicity and hospice utilization, and frailty trajectories at the end of life for those who are cognitively impaired.
- We have also developed and tested low health literate informed consent materials, easy-to-read advance directives to improve informed medical decision making , and geriatrics models of care for prison and jail settings.
By understanding the specific needs of vulnerable populations and by developing, testing, and implementing targeted interventions for these populations, the Division of Geriatrics strives to improve the health of all older adults while decreasing health disparities.
Individualized Decision-Making & Prognosis
Individualized decision-making involves weighing potential risks and benefits of medical interventions in the context of an individual’s health and preferences rather than a one-size-fits-all approach. Our research group is focusing on improving individualized decisions for cancer screening, medication prescribing, advance care planning, and diabetes care in older adults:
- We developed a framework to guide how to think through cancer screening decisions in older adults that incorporates an individual’s characteristics (e.g., health, prognosis) and preferences instead of basing decisions solely on age.
- We developed a step-wise approach to improve medication use in older adults which considers principles of pharmacology in concert with an individual’s living situation and preferences.
- We have created easy-to-read health education materials about Advance Directives and Advance Care Planning to help older adults make more informed medical decisions.
Understanding prognosis is a key component of individualized decision-making. Our research group has developed several easy-to-use indices for predicting life expectancy over varying time frames in older adults in different settings (e.g., community-dwelling, hospitalized, nursing-home-eligible). A compendium of validated prognostic indices in older adults can be found at ePrognosis.
Care of Hospitalized Older Adults
Hospitalized older adults, especially those in their 80s and 90s, have high rates of adverse outcomes and account for half of all acute hospital expenditures not related to childbirth. For example, more than half of medical patients older than 85 years develop new or worsening disability during their acute illness and hospitalization. Disability on leaving the hospital is serious: it worsens quality of life, increases caregiver burden, risk for nursing home admission, and health care costs, and shortens survival.
The goal of our research is to improve the health and well-being of hospitalized older adults. Research to achieve this goal includes the following examples.
- We invented, developed, and disseminated Acute Care for Elders (ACE) Units as a comprehensive system-based approach to improving care and health outcomes for acutely ill older adults. In randomized trials, we demonstrated that ACE Units can improve functional outcomes, reduce nursing home placement, improve the satisfaction of patients, families, doctors, and nurses, and reduce length of stay and hospital costs by 5-10%. We also found that achieving these beneficial effects consistently from hospital to hospital, from one team to another, year in and year out is a serious challenge to achieving our goal.
- Recent research has focused on improving prognostic measures for hospitalized older adults and determining the effects of comorbid conditions, such as depressive symptoms and cognitive impairment, on patient outcomes.
- We are also concerned with the linkage between evidence and implementation of health care innovation, with special attention to assuring rigorous evaluation of novel approaches to achieve innovation that is both effective and efficient.
Improving Quality of Care for Older Adults
Many older adults suffer from multiple chronic illnesses and physical or cognitive frailty. In this setting, traditional ways of measuring and improving quality of medical care often do not work well. This is because these traditional methods were developed for single diseases and younger adults, and do not account for the intersection of multiple illnesses, functional impairments, and limited life expectancy commonly found as people enter their later years. Our research group is pioneering new ways of measuring and improving care quality in this setting. A partial list of topics include:
- Identifying problems with medication prescribing in clinically complex older adults
- Comparing the benefits and burdens of aggressive disease management in frail older adults
- Evaluating gaps in care for vulnerable older populations such as people with limited literacy, and older prisoners
Dementia is a huge burden for patients, families and society, affecting 13% of Americans over 65, 43% of Americans over 85 and costing $183 billion dollars annually. Our work focuses on improving the lives of frail, vulnerable patients with cognitive impairment and their families.
- Understand the epidemiology and novel risk factors of cognitive impairment
- Understanding the disparities in cognitive impairment across disadvantaged populations
- Evaluating interventions such as mental or physical activity as a treatment for cognitive impairment
- Improving the targeting of dementia screening tests to ensure that cognitive screening is directed to those elders most likely to benefit from preventive interventions