Faculty Bibliography

OBJECTIVES: To determine whether receiving more recommended diabetes mellitus (DM) care processes (tests and screenings) would translate into better 9-year survival for middle-aged and older adults. DESIGN: Longitudinal mortality analysis using the Health and Retirement Study Diabetes Mailout Survey. SETTING: Health and Retirement Study (HRS). PARTICIPANTS: Individuals aged 51 and older (n = 1,879; mean age 68.8 +/- 8.7, 26.5% aged >/=75) with self-reported DM who completed the Diabetes Mailout Survey and the core 2002 HRS survey. MEASUREMENTS: A composite measure of five self-reported diabetes mellitus care process measures were dichotomized as greater (3-5 processes) versus fewer (0-2 processes) care processes provided. Cox proportional hazards models were used to test relationships between reported measures and mortality, controlling for sociodemographic characteristics, function, comorbidities, geriatric conditions, and insulin use. RESULTS: Prevalence of self-reported care processes was 80.1% for glycosylated hemoglobin test, 75.9% for urine test, 67.5% for eye examination, 67.7% for aspirin counseling, and 48.2% for diabetes education. In 9 years, 32.1% respondents died. Greater care correlated with 24% lower risk of dying (adjusted hazard ratio = 0.76, 95% confidence interval = 0.64-0.91) at 9-year follow up. When respondents were age-stratified (>/=75 vs <75) longer survival was statistically significant only in the older age group. CONCLUSION: Although it is not possible to account for differences in adherence to care that may also affect survival, this study demonstrates that monitoring of and counseling about types of DM care processes are associated with long-term survival benefit even in individuals aged 75 and older with DM.

Nearly 12 % of adults 65 years and over in Europe and 9 % in the USA are current cigarette smokers. Numerous studies have demonstrated tangible benefits of smoking cessation, regardless of advanced age. However, it is unclear which pharmacotherapy strategies are most effective in the elderly population. To that end, the literature on smoking cessation in older adults was reviewed with the aim of identifying the safest and most effective cessation pharmacotherapies. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for all articles pertaining to elderly smoking cessation strategies. Randomized controlled trials and cohort studies were included. Studies were included without regard to population or intervention, as long as results were analyzed with a group of smokers aged 60 years and above and at least one arm of the study involved a pharmacotherapy. Only 12 studies were identified that met our inclusion criteria. The limited existing literature does not allow for a definitive answer to the most effective pharmacotherapy for smoking cessation in older adult smokers. Nicotine replacement therapy (NRT) is the pharmacotherapy most studied in older adults, and the limited evidence that exists suggests that NRT is effective for smoking cessation among this population. Higher-quality studies that directly compare cessation strategies, including bupropion and varenicline, are needed in the older population in order to guide treatment decision making.

Background: Despite evidence of CV benefit of modest BP control in older patients, it is unclear when overly-aggressive treatment results in risk of fall injury that exceeds the CV benefits. Methods: Design: Longitudinal observation Sample: 5518 participants in the biennial Health and Retirement Study, age >65, with self-reported hypertension and taking BP medications, and who had BP measured by an enhanced HRS exam in 2008 or 2010 (randomly-assigned, mutually-exclusive cohorts). Measures: 2-year self-reported fall injury requiring medical care or acute CV event (stroke, infarction, heart failure), as a multinomial outcome: CV or fall injury, CV only, fall only, neither event. Increasing SBP control was tested in categories: (1) untreated or (2) inadequately- treated SBP >160 mmHg; (3) adequate treatment 121-159 mmHg, (3) overly-aggressive treatment to <120 mmHg. Analysis: Multinomial logistic regression to calculate net changes in risk across categories of BP control, controlling for age and sex. Results: Fall injury (12%) increased with age and was more prevalent than CV event (5%). Net harm of overly-controlling BP to <120 mmHg (compared to adequate control) was significant after age 73 (fig). Conclusions: Aggressiveness of BP care should be individualized by patient to steer clear of net harm, especially for older adults at advanced ages. (Figure Presented)

BACKGROUND: Treating systolic blood pressure (BP) of 150 mmHg with multiple medications prevents cardiovascular events and death. However, modest antihypertensive medication use is associated with an increase in fall injury risk. It is unclear whether the harms outweigh the benefits, and whether the net effects vary by degree of BP control. We aimed to quantify the net effect of increasingly aggressive hypertension control (AHC) on cardiovascular benefit versus fall-related harm in a nationally-representative sample. METHODS: Longitudinal study of 5518 participants of the Health and Retirement Study (HRS) aged 65 or older with self-reported hypertension and taking BP medications, and who had BP measured at baseline by an enhanced HRS exam in 2008 or 2010 (two randomly-assigned, mutually exclusive cohorts). The sample was categorized by increasing AHC: (1) untreated SBP >160 mmHg, (2) poorly controlled and treated SBP >160 mmHg, (3) adequate control, defined as treated SBP 121-159 mmHg or untreated SBP 140-159 mmHg, and (4) overly aggressive SBP treated to <120 mmHg. The 120 and 160mmHg cutoffs ensured that the over-and under-control groups were truly different from 140 mmHg. We determined the effect of AHC over a 2-year follow-up (2008-10 or 2010-12) on incidence of self-reported fall injury requiring medical care, acute stroke, myocardial infarction, and acute heart failure. We used multinomial logistic regression to consider fall injury only, any cardiovascular (CV) outcome, and both fall and CV outcome (compared to neither outcome), controlling for age at baseline and sex, to calculate net absolute changes in risk across increasing levels of AHC. We considered AHC classes first as a numeric predictor (where greater=more aggressive) and second as a categorical predictor. We calculated net effect of increasing AHC from one category to the next higher category, in units of absolute percentage points, with bootstrapped confidence intervals (95 %) around the net effect to determine statistical difference from zero. RESULTS: Two-year incidence of fall injury (11 % overall) increased with age and was more prevalent than any CV event (5% overall). Most of the sample (n=3676, 66 %) was classified in group 3 (BP 120-160 mmHg). Group 4, the over controlled group with BP< 120 mmHg, included n=1037 (19 %). The poorly controlled groups 1 and 2 were small (n=223 [4 %] and n=582 [11 %], respectively). When we considered AHC as a continuous predictor (greater=more aggressive), per level of AHC increased risk of fall injury (RR 1.15 [95 % CI 1.0-1.3]), but not cardiovascular events (RR=1.08 [.81- 1.44]) or both (RR=1.33 [.94-.1.9). When net harm was considered across advancing age, net harm was associated with group 4 (<120 mmHg) compared to group 3 (BP 120-160mmHg). The net harm associated with overly-treated BP ranged from2 absolute %-points at age 65, increasing to 10 absolute %-points at age 85, with net harm statistically different from zero above the age of 73 (Figure), mostly due to fall injury. There were no differences in net benefit or harm between group 3 (120-160 mmHg) compared to the poorly-controlled groups (1 and 2). CONCLUSIONS: Aggressiveness of BP control should be individualized by patient to steer clear of net harm, especially for older adults at advanced ages. Those with overly-controlled BP and at risk of net harm should be considered for de-escalation. (Figure Presented)

The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 American Geriatrics Society (AGS) Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at the website of the AGS. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium in older adults; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium in older adults. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate-to-high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines, Delirium: Diagnosis, Prevention and Management. Clinical Guideline 103; London (UK): 2010 July 29). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety and improve outcomes.

BACKGROUND: The population of adults accessing opioid treatment is growing older, but exact estimates vary widely, and little is known about the characteristics of the aging treatment population. Further, there has been little research regarding the epidemiology, healt h status, and functional impairments in this population. OBJECTIVES: To determine the utilization of opioid treatment services by older adults in New York City. METHODS: This study used administrative data from New York State licensed drug treatment programs to examine overall age trends and characteristics of older adults in opioid treatment programs in New York City from 1996 to 2012. RESULTS: We found significant increases in utilization of opioid treatment programs by older adults in New York City. By 2012, those aged 50-59 made up the largest age group in opioid treatment programs. Among older adults there were notable shifts in demographic background including gender and ethnicity, and an increase in self-reported impairments. Conclusions/Importance: More research is needed to fully understand the specific characteristics and needs of older adults with opioid dependence.