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Mitchell S.L.,Institute for Aging Research | Black B.S.,Johns Hopkins University | Ersek M.,University of Pennsylvania | Hanson L.C.,University of North Carolina at Chapel Hill | And 4 more authors.
Annals of Internal Medicine | Year: 2012

Dementia is a leading cause of death in the United States. This article outlines the current understanding of advanced dementia and identifies research priorities for the next decade. Research over the past 25 years has largely focused on describing the experience of patients with advanced dementia. This work has delineated abundant opportunities for improvement, including greater recognition of advanced dementia as a terminal illness, better treatment of distressing symptoms, increased access to hospice and palliative care services, and less use of costly and aggressive treatments that may be of limited clinical benefit. Addressing those opportunities must be the overarching objective for the field in the coming decade. Priority areas include designing and testing interventions that promote high-quality, goal-directed care; health policy research to identify strategies that incentivize cost-effective and evidencebased care; implementation studies of promising interventions and policies; and further development of disease-specific outcome measures. There is great need and opportunity to improve outcomes, contain expenditures, reduce disparities, and better coordinate care for the millions of persons in the United States who have advanced dementia. © 2012 American College of Physicians.

Gozalo P.,Brown University | Teno J.M.,Brown University | Mitchell S.L.,Institute for Aging Research | Skinner J.,Dartmouth Institute for Health Policy and Clinical Practice | And 3 more authors.
New England Journal of Medicine | Year: 2011

BACKGROUND: Health care transitions in the last months of life can be burdensome and potentially of limited clinical benefit for patients with advanced cognitive and functional impairment. METHODS: To examine health care transitions among Medicare decedents with advanced cognitive and functional impairment who were nursing home residents 120 days before death, we linked nationwide data from the Medicare Minimum Data Set and claims files from 2000 through 2007. We defined patterns of transition as burdensome if they occurred in the last 3 days of life, if there was a lack of continuity in nursing homes after hospitalization in the last 90 days of life, or if there were multiple hospitalizations in the last 90 days of life. We also considered various factors explaining variation in these rates of burdensome transition. We examined whether there was an association between regional rates of burdensome transition and the likelihood of feeding-tube insertion, hospitalization in an intensive care unit (ICU) in the last month of life, the presence of a stage IV decubitus ulcer, and hospice enrollment in the last 3 days of life. RESULTS: Among 474,829 nursing home decedents, 19.0% had at least one burdensome transition (range, 2.1% in Alaska to 37.5% in Louisiana). In adjusted analyses, blacks, Hispanics, and those without an advance directive were at increased risk. Nursing home residents in regions in the highest quintile of burdensome transitions (as compared with those in the lowest quintile) were significantly more likely to have a feeding tube (adjusted risk ratio, 3.38), have spent time in an ICU in the last month of life (adjusted risk ratio, 2.10), have a stage IV decubitus ulcer (adjusted risk ratio, 2.28), or have had a late enrollment in hospice (adjusted risk ratio, 1.17). CONCLUSIONS: Burdensome transitions are common, vary according to state, and are associated with markers of poor quality in end-of-life care. (Funded by the National Institute on Aging.). Copyright © 2011 Massachusetts Medical Society. All rights reserved.

Leslie D.L.,00 Centerview Drive | Leslie D.L.,Pennsylvania State University | Inouye S.K.,Beth Israel Deaconess Medical Center | Inouye S.K.,Institute for Aging Research
Journal of the American Geriatrics Society | Year: 2011

Although a number of studies have documented the negative clinical and economic consequences of delirium, interventions to prevent and treat delirium are infrequently implemented. The importance of delirium may continue to be underestimated until its societal and economic effects are documented. The current article outlines the existing literature related to long-term sequelae and costs associated with delirium and stresses the importance of such research in prompting recognition, prevention, and treatment efforts that could reduce the effect of delirium and improve quality of life for older adults and their caregivers. © 2011, Copyright the Authors.

Lipsitz L.A.,Institute for Aging Research | Lipsitz L.A.,Beth Israel Deaconess Medical Center | Lipsitz L.A.,Harvard University
JAMA - Journal of the American Medical Association | Year: 2013

IMPORTANCE: Hypertension is common among people older than 65 years, affecting nearly two-thirds of men and three-fourths of women by age 75 years. Treatment goals and medication selection for this population may differ from those for younger patients. OBJECTIVE: To discuss the presentation, pathophysiology, and optimal treatment of hypertension among elderly persons. EVIDENCE REVIEW MEDLINE: was searched from 1990 to 2013. A hand search of bibliographies from guidelines and review articles from 2000 to 2013 was also used to identify studies of hypertension treatment in patients older than 65 years. FINDINGS: Hypertension in elderly people differs from that in younger people in that (1) hypertension is predominantly systolic because of vascular stiffness; (2) it is associated with reduced baroreflex sensitivity, which increases blood pressure variability and vulnerability to hypotension during common daily activities; (3) it is associated with cognitive and functional decline as well as adverse cardiovascular outcomes; and (4) hypertension may be beneficial in frail people older than 85 years. Treatment of healthy patients up to age 85 years with most antihypertensive medications reduces cardiovascular morbidity and mortality and possibly cognitive and functional decline. CONCLUSION AND RELEVANCE: Although patients in their 90s have not been studied, any ambulatory and independent patient older than 80 years should have multiple blood pressure measurements taken during their usual daily activities, and if these show persistent hypertension, these patients should be treated judiciously.

Inouye S.K.,Beth Israel Deaconess Medical Center | Inouye S.K.,Institute for Aging Research | Westendorp R.G.J.,Leiden University | Westendorp R.G.J.,Vitality | Saczynski J.S.,University of Massachusetts Medical School
The Lancet | Year: 2014

Delirium is an acute disorder of attention and cognition in elderly people (ie, those aged 65 years or older) that is common, serious, costly, under-recognised, and often fatal. A formal cognitive assessment and history of acute onset of symptoms are necessary for diagnosis. In view of the complex multifactorial causes of delirium, multicomponent non-pharmacological risk factor approaches are the most effective strategy for prevention. No convincing evidence shows that pharmacological prevention or treatment is effective. Drug reduction for sedation and analgesia and non pharmacological approaches are recommended. Delirium offers opportunities to elucidate brain pathophysiology - it serves both as a marker of brain vulnerability with decreased reserve and as a potential mechanism for permanent cognitive damage. As a potent indicator of patients safety, delirium provides a target for system-wide process improvements. Public health priorities include improvements in coding, reimbursement from insurers, and research funding, and widespread education for clinicians and the public about the importance of delirium.

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