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Puhan M.A.,University of Zürich | Yu T.,University of Zürich | Stegeman I.,University Utrecht | Varadhan R.,Johns Hopkins University | Boyd C.M.,Center on Aging and Health
BMC Medicine | Year: 2015

Background: Clinical practice guidelines provide separate recommendations for different diseases that may be prevented or treated by the same intervention. Also, they commonly provide recommendations for entire populations but not for individuals. To address these two limitations, our aim was to conduct benefit-harm analyses for a wide range of individuals using the example of low dose aspirin for primary prevention of cardiovascular disease and cancer and to develop Benefit-Harm Charts that show the overall benefit-harm balance for individuals. Methods: We used quantitative benefit-harm modeling that included 16 outcomes to estimate the probability that low dose aspirin provides more benefits than harms for a wide range of men and women between 45 and 84years of age and without a previous myocardial infarction, severe ischemic stroke, or cancer. We repeated the quantitative benefit-harm modeling for different combinations of age, sex, and outcome risks for severe ischemic and hemorrhagic stroke, myocardial infarction, cancers, and severe gastrointestinal bleeds. The analyses considered weights for the outcomes, statistical uncertainty of the effects of aspirin, and death as a competing risk. We constructed Benefit-Harm Charts that show the benefit-harm balance for different combinations of outcome risks. Results: The Benefit-Harm Charts (http://www.benefit-harm-balance.com ) we have created show that the benefit-harm balance differs largely across a primary prevention population. Low dose aspirin is likely to provide more benefits than harms in men, elderly people, and in those at low risk for severe gastrointestinal bleeds. Individual preferences have a major impact on the benefit-harm balance. If, for example, it is a high priority for individuals to prevent stroke and severe cancers while severe gastrointestinal bleeds are deemed to be of little importance, the benefit-harm balance is likely to favor low dose aspirin for most individuals. Instead, if severe gastrointestinal bleeds are judged to be similarly important compared to the benefit outcomes, low dose aspirin is unlikely to provide more benefits than harms. Conclusions: Benefit-Harm Charts support individualized benefit-harm assessments and decision making. Similarly, individualized benefit-harm assessments may allow guideline developers to issue more finely granulated recommendations that reduce the risk of over- and underuse of interventions. The example of low dose aspirin for primary prevention of cardiovascular disease and cancer shows that it may be time for guideline developers to provide combined recommendations for different diseases that may be prevented or treated by the same intervention. © 2015 Puhan et al.


Puhan M.A.,University of Zürich | Yu T.,University of Zürich | Boyd C.M.,Center on Aging and Health | ter Riet G.,University of Amsterdam
BMC Medicine | Year: 2015

Background: When faced with uncertainties about the effects of medical interventions regulatory agencies, guideline developers, clinicians, and researchers commonly ask for more research, and in particular for more randomized trials. The conduct of additional randomized trials is, however, sometimes not the most efficient way to reduce uncertainty. Instead, approaches such as value of information analysis or other approaches should be used to prioritize research that will most likely reduce uncertainty and inform decisions. Discussion: In situations where additional research for specific interventions needs to be prioritized, we propose the use of quantitative benefit-harm assessments that illustrate how the benefit-harm balance may change as a consequence of additional research. The example of roflumilast for patients with chronic obstructive pulmonary disease shows that additional research on patient preferences (e.g., how important are exacerbations relative to psychiatric harms?) or outcome risks (e.g., what is the incidence of psychiatric outcomes in patients with chronic obstructive pulmonary disease without treatment?) is sometimes more valuable than additional randomized trials. Summary: We propose that quantitative benefit-harm assessments have the potential to explore the impact of additional research and to identify research priorities Our approach may be seen as another type of value of information analysis and as a useful approach to stimulate specific new research that has the potential to change current estimates of the benefit-harm balance and decision making. © 2015 Puhan et al.


Harrison Bush A.L.,University of South Florida | Lister J.J.,University of South Florida | Lin F.R.,Center on Aging and Health | Betz J.,Johns Hopkins Medical Institutions | Edwards J.D.,University of South Florida
Ear and Hearing | Year: 2015

Research has increasingly suggested a consistent relationship between peripheral hearing and selected measures of cognition in older adults. However, other studies yield conflicting findings. The primary purpose of the present study was to further elucidate the relationship between peripheral hearing and three domains of cognition and one measure of global cognitive status. It was hypothesized that peripheral hearing loss would be significantly associated with poorer performance across measures of cognition, even after adjusting for documented risk factors. No study to date has examined the relationship between peripheral hearing and such an extensive array of cognitive measures. Design: Eight hundred ninety-four older adult participants from the Staying Keen in Later Life study cohort were eligible, agreed to participate, and completed the baseline evaluation. Inclusion criteria were minimal to include a sample of older adults with a wide range of sensory and cognitive abilities. Multiple linear regression analyses were conducted to evaluate the extent to which peripheral hearing predicted performance on a global measure of cognitive status, as well as multiple cognitive measures in the domains of speed of processing (Digit Symbol Substitution and Copy, Trail Making Test Part A, Letter and Pattern Comparison, and Useful Field of View), executive function (Trail Making Test Part B and Stroop Color-Word Interference Task), and memory (Digit Span, Spatial Span, and Hopkins Verbal Learning Test). Results: Peripheral hearing, measured as the three-frequency pure-tone average (PTA) in the better ear, accounted for a significant, but minimal, amount of the variance in measures of speed of processing, executive function, and memory, as well as global cognitive status. Alternative measures of hearing (i.e., three-frequency PTAs in the right and left ears and a bilateral, six-frequency PTA [three frequencies per ear]) yielded similar findings across measures of cognition and did not alter the study outcomes in any meaningful way. Conclusions: Consistent with literature suggesting a significant relationship between peripheral hearing and cognition, and in agreement with our hypothesis, peripheral hearing was significantly related to 10 of 11 measures of cognition that assessed processing speed, executive function, or memory, as well as global cognitive status. Although evidence, including the present results, suggests a relationship between peripheral hearing and cognition, little is known about the underlying mechanisms. Examination of these mechanisms is a critical need to direct appropriate treatment. © 2015 Wolters Kluwer Health, Inc.


Xia J.,Johns Hopkins Medical Institutions | Xia J.,Johns Hopkins University | Xue Q.-L.,Johns Hopkins Medical Institutions | Xue Q.-L.,Johns Hopkins University | And 4 more authors.
Journal of the International Neuropsychological Society | Year: 2012

This study examined whether participation in a variety of lifestyle activities was comparable to frequent participation in cognitively challenging activities in mitigating impairments in cognitive abilities susceptible to aging in healthy, community-dwelling older women. Frequencies of participation in various lifestyle activities on the Lifestyle Activities Questionnaire (LAQ) were divided according to high (e.g., reading), moderate (e.g., discussing politics), and low (e.g., watching television) cognitive demand. We also considered the utility of participation in a variety of lifestyle activities regardless of cognitive challenge. Immediate and delayed verbal recall, psychomotor speed, and executive function were each measured at baseline and at five successive exams, spanning a 9.5-year interval. Greater variety of participation in activities, regardless of cognitive challenge, was associated with an 8 to 11% reduction in the risk of impairment in verbal memory and global cognitive outcomes. Participation in a variety of lifestyle activities was more predictive than frequency or level of cognitive challenge for significant reductions in risk of incident impairment on measures sensitive to cognitive aging and risk for dementia. Our findings offer new perspectives in promoting a diverse repertoire of activities to mitigate age-related cognitive declines. Copyright © The International Neuropsychological Society 2011.


Chen D.S.,Johns Hopkins University | Clarrett D.M.,University of Cincinnati | Li L.,Center on Aging and Health | Bowditch S.P.,Johns Hopkins University | And 3 more authors.
Otology and Neurotology | Year: 2013

Objectives: To analyze the postoperative complications associated with cochlear implant (CI) surgery in a large consecutive case series of older adults (≥60 yr). Study Design: Retrospective case review. Setting: Tertiary referral center. Patients: Approximately 445 individuals aged 60 years and older who received a first CI between1999 and 2011. Interventions: Cochlear implantation. Main Outcome Measure(S): Postoperative complications classified as major (meningitis, immediate postoperative facial weakness, device failure, flap dehiscence, and surgical removal) and minor (surgical site infection, balance problems, delayed postoperative facial weakness, and facial nerve stimulation). Results: The mean age at implantation was 72.7 years (60-94.9 yr), and the median duration of follow-up was 4.8 years (0.1-12.5 yr). There were 42 minor complications in 41 patients (9.2%) and 36 major complications in 21 patients (4.7%). Seventeen patients (3.8%) required surgical device removal, 15 of whom underwent reimplantation. A Kaplan-Meier analysis of rates of device explantation demonstrated that at 5 and 10 years after CI, respectively, 95.4% and 93.1% of patients retained their original CI. When comparing complications between patients aged 60 to 74 years and those aged 75 years and older, there was a higher prevalence of balance problems lasting more than 1 month in the older group (9.5% versus 4.9%, p = 0.05). Conclusion: Our results indicate that the safety profile of cochlear implantation in an older population is comparable to that of younger adults and children. We suggest that concerns for increased postoperative complications in patients of advanced age do not need to be a primary consideration when determining CI candidacy. © 2013, Otology & Neurotology, Inc.


Schrack J.A.,U.S. National Institute on Aging | Schrack J.A.,Center on Aging and Health | Simonsick E.M.,U.S. National Institute on Aging | Ferrucci L.,U.S. National Institute on Aging
PLoS ONE | Year: 2010

Background and Aims: Recent introduction of the Cosmed K4b2 portable metabolic analyzer allows measurement of oxygen consumption outside of a laboratory setting in more typical clinical or household environments and thus may be used to obtain information on the metabolic costs of specific daily life activities. The purpose of this study was to assess the accuracy of the Cosmed K4b2 portable metabolic analyzer against a traditional, stationary gas exchange system (the Medgraphics D-Series) during steady-state, submaximal walking exercise. Methods:Nineteen men and women (9 women, 10 men) with an average age of 39.8 years (±13.8) completed two 400 meter walk tests using the two systems at a constant, self-selected pace on a treadmill. Average oxygen consumption (VO2) and carbon dioxide production (VCO 2) from each walk were compared. Results: Intraclass Correlation Coefficient (ICC) and Pearson correlation coefficients between the two systems for weight indexed VO2 (ml/kg/min), total VO2 (ml/min), and VCO2 (ml/min) ranged from 0.93 to 0.97. Comparison of the average values obtained using the Cosmed K4b2 and Medgraphics systems using paired t-tests indicate no significant difference for VO2 (ml/kg/min) overall (p = 0.25), or when stratified by sex (p = 0.21 women, p = 0.69 men). The mean difference between analyzers was - 0.296 ml/kg/min (±0.26). Results were not significantly different for VO2 (ml/min) or VCO 2 (ml/min) within the study population (p = 0.16 and p = 0.08, respectively), or when stratified by sex (VO2: p = 0.51 women, p = 0.16 men; VCO2: p = .11 women, p = 0.53 men). Conclusion: The Cosmed K4b2 portable metabolic analyzer provides measures of VO2 and VCO2 during steady-state, submaximal exercise similar to a traditional, stationary gas exchange system.


Cohen A.A.,Université de Sherbrooke | Milot E.,Université de Sherbrooke | Yong J.,Université de Sherbrooke | Seplaki C.L.,University of Rochester | And 3 more authors.
Mechanisms of Ageing and Development | Year: 2013

Previous studies have identified many biomarkers that are associated with aging and related outcomes, but the relevance of these markers for underlying processes and their relationship to hypothesized systemic dysregulation is not clear. We address this gap by presenting a novel method for measuring dysregulation via the joint distribution of multiple biomarkers and assessing associations of dysregulation with age and mortality. Using longitudinal data from the Women's Health and Aging Study, we selected a 14-marker subset from 63 blood measures: those that diverged from the baseline population mean with age. For the 14 markers and all combinatorial sub-subsets we calculated a multivariate distance called the Mahalanobis distance (MHBD) for all observations, indicating how " strange" each individual's biomarker profile was relative to the baseline population mean. In most models, MHBD correlated positively with age, MHBD increased within individuals over time, and higher MHBD predicted higher risk of subsequent mortality. Predictive power increased as more variables were incorporated into the calculation of MHBD. Biomarkers from multiple systems were implicated. These results support hypotheses of simultaneous dysregulation in multiple systems and confirm the need for longitudinal, multivariate approaches to understanding biomarkers in aging. © 2013 Elsevier Ireland Ltd.


Parrinello C.M.,Welch Center for Prevention | Rastegar I.,Welch Center for Prevention | Rastegar I.,Baltimore Polytechnic Institute | Godino J.G.,Welch Center for Prevention | And 5 more authors.
Diabetes Care | Year: 2015

OBJECTIVE: Controversy surrounds appropriate risk factor targets in older adults with diabetes. We evaluated the proportion of older adults with diabetes meeting different targets, focusing on possible differences by race, and assessed whether demographic and clinical characteristics explained disparities. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional study of 5,018 participants aged 67-90 years (1,574 with and 3,444 without diagnosed diabetes) who attended visit 5 of the Atherosclerosis Risk in Communities (ARIC) study (2011-2013). Risk factor targets were defined using both stringent (and less stringent) goals: hemoglobin A1c (HbA1c) <7%, <53 mmol/mol (<8%, <64 mmol/mol); LDL cholesterol (LDL-c) <100 mg/dL (<130 mg/dL); and blood pressure (BP) <140/90 mmHg (<150/90 mmHg). We used Poisson regression to obtain prevalence ratios (PRs). RESULTS: Most older adults with diabetes met stringent (and less stringent) targets: 72% (90%) for HbA1c, 63% (86%) for LDL-c, and 73% (87%) for BP; but only 35% (68%) met all three. A higher proportion of whites than blacks met targets, however defined. Among people treated for risk factors, racial disparities in prevalence of meeting stringent targets persisted even after adjustment: PRs (whites vs. blacks) were 1.03 (95% CI 0.91, 1.17) for HbA1c, 1.21 (1.09, 1.35) for LDL-c, 1.10 (1.00, 1.21) for BP, and 1.28 (0.99, 1.66) for all three. Results were similar but slightly attenuated using less stringent goals. Black women were less likely than white women to meet targets for BP and all three risk factors; this disparity was not observed in men. CONCLUSIONS: Black-white disparities in risk factor control in older adults with diabetes were not fully explained by demographic or clinical characteristics and were greater in women than men. Further study of determinants of these disparities is important. © 2015 by the American Diabetes Association.


Palta P.,Center on Aging and Health | Page G.,Johns Hopkins University | Piferi R.L.,Johns Hopkins University | Gill J.M.,George Mason University | And 3 more authors.
Journal of Urban Health | Year: 2012

Hypertension affects a large proportion of urban African-American older adults. While there have been great strides in drug development, many older adults do not have access to such medicines or do not take them. Mindfulness-based stress reduction (MBSR) has been shown to decrease blood pressure in some populations. This has not been tested in low-income, urban African-American older adults. Therefore, the primary purpose of this pilot study was to test the feasibility and acceptability of a mindfulness-based program for low income, minority older adults provided in residence. The secondary purpose was to learn if the mindfulness-based program produced differences in blood pressure between the intervention and control groups. Participants were at least 62 years old and residents of a low-income senior residence. All participants were African-American, and one was male. Twenty participants were randomized to the mindfulness-based intervention or a social support control group of the same duration and dose. Blood pressure was measured with the Omron automatic blood pressure machine at baseline and at the end of the 8-week intervention. A multivariate regression analysis was performed on the difference in scores between baseline and post-intervention blood pressure measurements, controlling for age, education, smoking status, and anti-hypertensive medication use. Effect sizes were calculated to quantify the magnitude of the relationship between participation in the mindfulness-based intervention and the outcome variable, blood pressure. Attendance remained >80%in all 8 weeks of both the intervention and the control groups. The average systolic blood pressure decreased for both groups post-intervention. Individuals in the intervention group exhibited a 21.92-mmHg lower systolic blood pressure compared to the social support control group post-intervention and this value was statistically significant (p=0.020). The average diastolic blood pressure decreased in the intervention group postintervention, but increased in the social support group. Individuals in the intervention group exhibited a 16.70-mmHg lower diastolic blood pressure compared to the social support group post-intervention, and this value was statistically significant (p=0.003). Older adults are at a time in life when a reflective, stationary intervention, delivered in residence, could be an appealing mechanism to improve blood pressure. Given our preliminary results, larger trials in this hypertensive study population are warranted. © 2012 The New York Academy of Medicine.


Boyd C.M.,Center on Aging and Health | Lucas G.M.,Johns Hopkins University
Current Opinion in HIV and AIDS | Year: 2014

PURPOSE OF REVIEW: The purpose of this review is to consider a patient-centred approach to the care of people living with HIV (PLWH) who have multimorbidity, irrespective of the specific conditions. RECENT FINDINGS: Interdisciplinary care to achieve patient-centred care for people with multimorbidity is recognized as important, but the evaluation of models designed to achieve this goal are needed. Key elements of such approaches include patient preferences, interpretation of the evidence, prognosis as a tool to inform patient-centred care, clinical feasibility and optimization of treatment regimens. SUMMARY: Developing and evaluating the best models of patient-centred care for PLWH who also have multimorbidity is essential. This challenge represents an opportunity to leverage the lessons learned from the care of people with multimorbidity in general, and vice versa. © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.

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