Hebrew SeniorLife Institute for Aging Research

Boston, MA, United States

Hebrew SeniorLife Institute for Aging Research

Boston, MA, United States

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Teno J.M.,Brown University | Gozalo P.L.,Brown University | Mitchell S.L.,Hebrew SeniorLife Institute for Aging Research | Kuo S.,Brown University | And 3 more authors.
Journal of the American Geriatrics Society | Year: 2012

Objectives To examine survival with and without a percutaneous endoscopic gastrostomy (PEG) feeding tube using rigorous methods to account for selection bias and to examine whether the timing of feeding tube insertion affected survival. Design Prospective cohort study. Setting All U.S. nursing homes (NHs). Participants Thirty-six thousand four hundred ninety-two NH residents with advanced cognitive impairment from dementia and new problems eating studied between 1999 and 2007. Measurements Survival after development of the need for eating assistance and feeding tube insertion. Results Of the 36,492 NH residents (88.4% white, mean age 84.9, 87.4% with one feeding tube risk factor), 1,957 (5.4%) had a feeding tube inserted within 1 year of developing eating problems. After multivariate analysis correcting for selection bias with propensity score weights, no difference was found in survival between the two groups (adjusted hazard ratio (AHR) = 1.03, 95% confidence interval (CI) = 0.94-1.13). In residents who were tube-fed, the timing of PEG tube insertion relative to the onset of eating problems was not associated with survival after feeding tube insertion (AHR = 1.01, 95% CI = 0.86-1.20, persons with a PEG tube inserted within 1 month of developing an eating problem versus later (4 months) insertion). Conclusion Neither insertion of PEG tubes nor timing of insertion affect survival. © 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.


News Article | September 23, 2016
Site: www.chromatographytechniques.com

Quitting smoking doesn’t mean the cigarettes quit your genome. The epigenetic changes wrought by methylation within smokers’ DNA can last decades, according to a new study by researchers at a Harvard-affiliated institute. “Our study has found compelling evidence that smoking has a long-lasting impact on our molecular machinery, an impact that can last more than 30 years,” said Roby Joehanes, first author, of the Hebrew SeniorLife Institute for Aging Research. The meta-analysis of entire genomes of nearly 16,000 people, including 2,400 current smokers, 6,500 former smokers and nearly 7,000 never smokers turned up an epigenetic array of changes at 185 sites which were “enriched for associations” with cancers, inflammatory disorders and heart disease, they write in the journal Circulation: Cardiovascular Genetics. Among the former smokers, some of those changes lasted an unexpectedly long time, they add. “These results are important because methylation, as one of the mechanisms of the regulation of gene expression, affects what genes are turned on, which has implication for the development of smoking-related diseases,” said Stephanie J. London, one of the authors, of the National Institute of Environmental Health Sciences. “Equally important is our finding that even after someone stops smoking, we still see the effects of smoking on their DNA.” Identification of the methylation sites could lead to treatments for smoking-related illnesses – and a better understanding of the accumulated changes in an unhealthy smoker’s genetic palette, they said. Smoking remains the biggest cause of preventable death around the world, for its many health factors. However, statistics indicate that smoking has seen a precipitous decline in recent years. The United States currently has more former smokers than active smokers, they add. “The encouraging news is that once you stop smoking, the majority of DNA methylation signals return to never-smoker levels after five years, which means your body is trying to heal itself of the harmful impacts of tobacco smoking,” added Joehanes. But not everyone feels the impact of long-term smoking – and there could be a genetic explanation for that, as well. Another Harvard-affiliated study in the journal Epigenetics last year analyzed the changes wrought in the genome of smokers. Those alterations in the genetic fabric were so diverse and widespread across the genome, that it explained why some tobacco users are never struck by serious disease.


Givens J.L.,Hebrew SeniorLife Institute for Aging Research | Givens J.L.,Beth Israel Deaconess Medical Center | Lopez R.P.,MGH Institute of Health Professions | Mazor K.M.,University of Massachusetts Medical School | And 2 more authors.
Alzheimer Disease and Associated Disorders | Year: 2012

The sources of stress for families of nursing home (NH) residents with advanced dementia have not been well described. Semistructured interviews were conducted with 16 family members previously enrolled in the Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life study, a prospective cohort of 323 NH residents with advanced dementia and their family members. Questions were asked pertaining to the experience of having a family member in the NH, communication with health-care professionals, surrogate decision making, emotional distress, and recommendations for improvement in care. Transcripts were analyzed using the constant comparative method. The majority of the participants were women (63%), children of the resident (94%), and white (94%). The average age was 62 years. Four themes emerged: (1) inadequate resident personal care, resulting in family member vigilance and participation in care; (2) stress at the time of NH admission; (3) lack of communication with NH physicians; and (4) challenges of surrogate decision making, including the need for education to support advance care planning and end-of-life decisions. Our results support the provision of emotional support to families upon resident admission, education regarding prognosis to guide decision making, improved resident care, and greater communication with health care professionals. Copyright © 2012 by Lippincott Williams & Wilkins.


Goldfeld K.S.,Columbia University | Hamel M.B.,Beth Israel Deaconess Medical Center | Mitchell S.L.,Beth Israel Deaconess Medical Center | Mitchell S.L.,Hebrew SeniorLife Institute for Aging Research
Medical Care | Year: 2012

Background: Nursing home residents with advanced dementia commonly experience burdensome and costly interventions (eg, hospitalization) of questionable clinical benefit. To facilitate cost-effectiveness analyses of these interventions, utility-based measures are needed in order to estimate quality-adjusted outcomes. Methods: Nursing home residents with advanced dementia in 22 facilities were followed for 18 months (N=319). Validated health status measures ascertained from nurses at baseline, quarterly, and death (N=1702 assessments) were mapped to the Health Utilities Index Mark 2 [range, 1 (perfect health) to 0 (death); scores below 0 indicate states worse than death]. To assess validity, utility scores were compared between residents who did and did not receive burdensome interventions (parenteral therapy, percutaneous endoscopic gastrostomy tubes, and hospital transfers), residents with and without pneumonia, and residents who did and did not die at the last assessment. Results: Mean (±SD) Health Utilities Index Mark 2 utility score for the cohort was 0.165±0.060 (range,-0.005 to 0.215). Residents spent an average of 15.5% of their days with utilities <0.10. Lower utility scores were found among residents who received burdensome interventions (0.152±0.067 vs. 0.171±0.056; P=0.0003); had pneumonia (0.147±0.066 vs. 0.170±0.057; P=0.003); and were dying (0.163±0.057 vs. 0.180±0.055; P=0.006). Conclusions: It is feasible to map health status measures to utility-based measures for advanced dementia. This work will facilitate future cost-effectiveness analyses aimed at quantifying the cost of interventions relative to quality-based outcomes for patients with this condition. © 2012 Lippincott Williams & Wilkins.


Kiely D.K.,Hebrew SeniorLife Institute for Aging Research | Givens J.L.,Hebrew SeniorLife Institute for Aging Research | Givens J.L.,Beth Israel Deaconess Medical Center | Shaffer M.L.,Pennsylvania State University | And 3 more authors.
Journal of the American Geriatrics Society | Year: 2010

Objectives: To identify characteristics of nursing home (NH) residents with advanced dementia and their healthcare proxies (HCPs) associated with hospice referral and to examine the association between hospice use and the treatment of pain and dyspnea and unmet needs during the last 7 days of life. Design: Prospective cohort study. Setting: Twenty-two Boston-area NHs. Participants: Three hundred twenty-three NH residents with advanced dementia and their HCPs. Measurements: Data were collected at baseline and quarterly for up to 18 months. Hospice referral, frequency of pain and dyspnea, and treatment of these symptoms was ascertained. HCPs reported unmet needs during the last 7 days of the residents' lives for communication, information, emotional support, and help with personal care. Results: Twenty-two percent of residents were referred to hospice. After multivariable adjustment, factors associated with hospice referral were nonwhite race, eating problems, HCP's perception that the resident's had less than 6 months to live, and better HCP mental health. Residents in hospice were more likely to receive scheduled opioids for pain (adjusted odds ratio (AOR)=3.16; 95% confidence interval (95% CI)=1.57-6.36) and oxygen, morphine, scopolamine, or hyoscyamine for dyspnea (AOR=3.28, 95% CI=1.37-7.86). HCPs of residents in hospice reported fewer unmet needs in all domains during the last 7 days of the residents' life. Conclusion: A minority of NH residents with advanced dementia received hospice care. Hospice recipients were more likely to received scheduled opioids for pain and symptomatic treatment for dyspnea and had fewer unmet needs at the end of life. © 2010, The American Geriatrics Society.


Brown R.T.,Beth Israel Deaconess Medical Center | Brown R.T.,Hebrew SeniorLife Institute for Aging Research | Kiely D.K.,Hebrew SeniorLife Institute for Aging Research | Bharel M.,Boston Healthcare | And 4 more authors.
Journal of General Internal Medicine | Year: 2012

BACKGROUND: The average age of the US homeless population is increasing. Little is known about the prevalence of geriatric syndromes in older homeless adults. OBJECTIVE: To determine the prevalence of common geriatric syndromes in a sample of older homeless adults, and to compare these prevalences to those reported in the general older population. DESIGN: Cross-sectional. PARTICIPANTS: Two hundred and forty-seven homeless adults aged 50-69 recruited from eight homeless shelters in Boston, MA. MAIN MEASURES: Interviews and examinations for geriatric syndromes, including functional impairment, cognitive impairment, frailty, depression, hearing impairment, visual impairment, and urinary incontinence. The prevalences of these syndromes in the homeless cohort were compared to those reported in three population-based cohorts. KEY RESULTS: The mean age of the homeless cohort was 56.0 years, and 19.8% were women. Thirty percent of subjects reported difficulty performing at least one activity of daily living, and 53.2% fell in the prior year. Cognitive impairment, defined as a Mini-Mental State Examination score <24, was present in 24.3% of participants; impaired executive function, defined as a Trail Making Test Part B duration >1.5 standard deviations above population-based norms, was present in 28.3% of participants. Sixteen percent of subjects met criteria for frailty, and 39.8% had major depression, defined as a score ≥10 on the Patient Health Questionnaire 9. Self-reported hearing and visual impairment was present among 29.7% and 30.0% of subjects, respectively. Urinary incontinence was reported by 49.8% of subjects. After multivariate adjustment for demographic characteristics, homeless adults were more likely to have functional impairment, frailty, depression, visual impairment and urinary incontinence compared to three population-based cohorts of older persons. CONCLUSIONS: Geriatric syndromes that are potentially amenable to treatment are common in older homeless adults, and are experienced at higher rates than in the general older population. © 2011 Society of General Internal Medicine.


Goldfeld K.S.,New York University | Hamel M.B.,Beth Israel Deaconess Medical Center | Mitchell S.L.,Beth Israel Deaconess Medical Center | Mitchell S.L.,Hebrew SeniorLife Institute for Aging Research
Journal of Pain and Symptom Management | Year: 2013

Context: Nursing home (NH) residents with advanced dementia commonly experience burdensome and costly hospitalizations that may not extend survival or improve quality of life. Cost-effectiveness analyses of decisions to hospitalize these residents have not been reported. Objectives: To estimate the cost-effectiveness of 1) not having a do-not-hospitalize (DNH) order and 2) hospitalization for suspected pneumonia in NH residents with advanced dementia. Methods: NH residents from 22 NHs in the Boston area were followed in the Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life study conducted between February 2003 and February 2009. We conducted cost-effectiveness analyses of aggressive treatment strategies for advanced dementia residents living in NHs when they suffer from acute illness. Primary outcome measures included quality-adjusted life days (QALD) and quality-adjusted life years, Medicare expenditures, and incremental net benefits (INBs) over 15 months. Results: Compared with a less aggressive strategy of avoiding hospital transfer (i.e., having DNH orders), the strategy of hospitalization was associated with an incremental increase in Medicare expenditures of $5972 and an incremental gain in quality-adjusted survival of 3.7 QALD. Hospitalization for pneumonia was associated with an incremental increase in Medicare expenditures of $3697 and an incremental reduction in quality-adjusted survival of 9.7 QALD. At a willingness-to-pay level of $100,000/quality-adjusted life years, the INBs of the more aggressive treatment strategies were negative and, therefore, not cost effective (INB for not having a DNH order, -$4958 and INB for hospital transfer for pneumonia, -$6355). Conclusion: Treatment strategies favoring hospitalization for NH residents with advanced dementia are not cost effective. © 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.


Givens J.L.,Beth Israel Deaconess Medical Center | Givens J.L.,Hebrew SeniorLife Institute for Aging Research | Selby K.,Beth Israel Deaconess Medical Center | Goldfeld K.S.,Columbia University | And 2 more authors.
Journal of the American Geriatrics Society | Year: 2012

Objectives To describe diagnoses and factors associated with hospital transfer in nursing home (NH) residents with advanced dementia. Design Prospective cohort study. Setting Twenty-two Boston, Massachusetts-area NHs. Participants Three hundred twenty-three NH residents with advanced dementia. Measurements Data were collected quarterly for up to 18 months. Data regarding transfers were collected with regard to hospitalization or emergency department (ED) visit, diagnosis, and duration of inpatient admission. Information on the occurrence of any acute medical event (pneumonia, febrile episode, or other acute illness) in the prior 90 days was obtained quarterly. Logistic regression conducted at the level of the acute medical event identified characteristics associated with hospital transfer. Results The entire cohort experienced 74 hospitalizations and 60 ED visits. Suspected infections were the most common reason for hospitalization (44, 59%), most frequently attributable to a respiratory source (30, 41%). Feeding tube-related complications accounted for 47% of ED visits. In adjusted analysis conducted on acute medical events, younger resident age, event type (pneumonia or other event vs febrile episode), chronic obstructive pulmonary disease, and the lack of a do-not-hospitalize (DNH) order (adjusted odds ratio = 5.22, 95% confidence interval = 2.31-11.79) were associated with hospital transfer. Conclusion The majority of hospitalizations of NH residents with advanced dementia were due to infections and thus were potentially avoidable, because infections are often treatable in the NH. Feeding tube-related complications accounted for almost half of all ED visits, representing a common but underrecognized burden of this intervention. Advance care planning in the form of a DNH order was the only identified modifiable factor associated with avoiding hospitalization. © 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.


Kiely D.K.,Hebrew SeniorLife Institute for Aging Research | Shaffer M.L.,Beth Israel Deaconess Medical Center | Mitchell S.L.,Hebrew SeniorLife Institute for Aging Research | Mitchell S.L.,Penn State College of Medicine
Alzheimer Disease and Associated Disorders | Year: 2012

The paucity of valid and reliable instruments designed to measure end-of-life experiences limits advanced dementia and palliative care research. Two end-of-life in dementia (EOLD) scales that evaluate the experiences of severely cognitively impaired persons and their health care proxies (HCP) have been developed: (1) symptom management (SM) and (2) satisfaction with care (SWC). The aim of this study was to examine the sensitivity of the EOLD scales in detecting significant differences in clinically relevant outcomes in nursing home residents with advanced dementia. The SM-EOLD scale was sensitive to detecting changes in comfort among residents with pneumonia, pain, dyspnea, and receiving burdensome interventions. The SWC-EOLD scale was sensitive to detecting changes in HCP satisfaction with the care of residents when addressing whether the health care provider spent >15 minutes discussing the resident's advanced care planning, whether the physician counseled about the resident's live expectancy, whether the resident resided in a special care unit, and whether the physician counseled possible resident health problems. This study extends the psychometric properties of the EOLD scales by showing the sensitivity to clinically meaningful change in these scales to specific outcomes related to end-of-life care and quality of life among residents with end-stage advanced dementia and their HCPs.© 2012 by Lippincott Williams & Wilkins.


Parsons C.,Queen's University of Belfast | Briesacher B.A.,University of Massachusetts Medical School | Givens J.L.,Hebrew SeniorLife Institute for Aging Research | Chen Y.,University of Massachusetts Medical School | Tjia J.,University of Massachusetts Medical School
Journal of the American Geriatrics Society | Year: 2011

OBJECTIVES: To quantify the use of cholinesterase inhibitors (ChEIs) and memantine in nursing home (NH) residents with dementia upon NH admission and 3 months later and to examine factors associated with reduction in therapy. DESIGN: Retrospective cohort study. SETTING: Nationwide sample of U.S. NHs. PARTICIPANTS: Three thousand five hundred six NH residents with dementia newly admitted in 2006. MEASUREMENTS: Data from pharmacy dispensing records were used to determine ChEI and memantine medication use upon NH admission and at 3-month follow-up. The Minimum Data Set was used to determine resident- and facility-level characteristics. Severity of dementia was defined using the Cognitive Performance Scale (CPS). RESULTS: Overall, 40.1% (n=1,407) of newly admitted NH residents with dementia received ChEIs and memantine on NH admission. Use of ChEIs and memantine on admission was significantly greater in residents with mild to moderately severe dementia (41.2%) than in those with advanced dementia (33.3%, P=.001). After 3 months, ChEI and memantine use decreased by about half in both groups (48.6% with mild to moderately severe dementia vs 57.0% with advanced dementia, P<.05). NH residents with advanced dementia were significantly more likely reduce their use of ChEIs and memantine than those with mild to moderately severe dementia (odds ratio=1.44, 95% confidence interval=1.03-2.01, P=.04). CONCLUSION: Many NH residents with advanced dementia receive ChEIs and memantine upon NH admission, and approximately half of these decrease their medication use over the ensuing months. Further study is required to optimize use of ChEIs and memantine in NH populations and to determine the effects of withdrawing therapy on resident outcomes. © 2011, The American Geriatrics Society.

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