Prevalence and Impact of Comorbid Cancer and Dementia on Health Outcomes in Older Adults: A Longitudinal Study

Dementia and cancer are two common chronic conditions in older adults. However, there are few studies examining the prevalence of comorbid cancer and dementia and the longitudinal impact of these comorbid conditions on health outcomes. This study investigated the prevalence and longitudinal impact on health outcomes in older adults with comorbid cancer and dementia. This is a secondary analysis, using data from the 2010 and 2016 waves of the Health and Retirement Study (HRS). The health outcomes of the study included nursing home stay, hospital stay, home care use, activities of daily living (ADL) limitations, instrumental activities of daily living (IADL), self-rated health status, mortality, and the out-of-pocket medical expenditure in older adults with cancer and dementia. Data were analyzed using descriptive statistics, logistic regression, and linear regression analyses. The results revealed that the prevalence of comorbid cancer and dementia ranged from 2.6% to 2.8% over the 6-year period. Older adults with comorbid cancer and dementia demonstrated higher likelihood of nursing home stay, ADL and IADL limitations, and mortality; but a decreased likelihood of homecare use and hospital stay compared to older adults with cancer only or dementia only (some outcomes were not significant for dementia only group). Findings point out the risk of increased functional decline and mortality in older adults with comorbid cancer and dementia. Future research is needed to explore the contributing factors of the risk and identify interventions to promote physical function and reduce mortality for this population.

Formal and Informal Care Use Over the Course of Cognitive Deterioration Among Adults With a Disability

The dynamics between formal and informal care among persons with a disability may substantially differ over the course of their cognitive decline. Based on a nationally representative study of older adults, the analysis sample included 3,685 individuals who had at least one activity of daily living (ADL) limitation. We estimated probabilities of using formal care and informal care in the years before and over the course of dementia after controlling for sociodemographic factors, survey mode, and proxy interview status. The adjusted probability of receiving care from an informal helper increased before the onset of dementia: 36% in 4 years prior to the onset (T=-4); 46% at T=-2. In contrast, the increase in the probability of using formal care was pronounced primarily at the onset of dementia; for example, the probability of overnight nursing home stay was 12% at T=-2 vs. 31% at T=0, which continued to increase over the subsequent years (39% at T=6). The probability of using nursing home care at the onset was significantly greater for women vs. men (Adjusted risk ratio (ARR)=1.21; p=0.010); non-Hispanic white vs. Hispanic (ARR=1.62; p=0.004); those with low vs. high wealth (ARR=1.60; p < 0.001); those without a spouse vs. with a spouse prior to the onset (ARR=1.39; p < 0.001); and those with all adult children living far vs. at least one coresident adult child prior to the onset (ARR=1.51; p= < 0.001). Public policies and interventions aimed at providing for the needs of people with dementia should consider disparities in care use across racial/ethnic and socioeconomic groups.

Intrinsic capacity predicts negative health outcomes in older adults

BACKGROUND Monitoring trajectories of intrinsic capacity (IC) in older adults has been suggested by the WHO as a means to inform prevention to avoid or delay negative health outcomes. Due to a lack of longitudinal studies, it is currently unclear how IC changes over time and whether repeatedly measured IC predicts negative health outcomes. METHODS Based on 4,751 repeated observations of IC (range=0-100) during 21 years of follow-up among 754 older adults 70+ years, we assessed longitudinal trajectories of IC, and whether time-varying IC predicted the risk of chronic ADL disability, long-term nursing home stay, and mortality using joint models. RESULTS Average IC declined progressively from 77 to 11 points during follow-up, with substantial heterogeneity between older adults. Adjusted for socio-demographics and chronic diseases, a one-point lower IC value was associated with a 7% increase in the risk of ADL disability, a 6% increase in the risk of a nursing home stay, and a 5% increase in mortality. Accuracy for 5- and 10-year predictions based on up to three repeated measurements of IC ranged between moderate and good (AUC = 0.76-0.82). DISCUSSION Our study indicates that IC declines progressively and that it predicts negative health outcomes among older adults. Therefore, regular monitoring of IC could work as an early warning system informing preventive efforts.

Evaluation of Electronic Health Record and Long-Term Care Pharmacy Data for Tracking and Reporting Antibiotic Use in the United States

Background: Antibiotics are frequently prescribed in nursing homes, often inappropriately. Data sources are needed to facilitate measurement and reporting of antibiotic use to inform antibiotic stewardship efforts. Previous analyses have shown that the type of nursing-home stay, that is, short stay (<100 days), is a strong predictor of high antibiotic use compared to longer nursing-home stays. The study objective was to compare 2 different data sources, electronic health record (EHR) and long-term care (LTC) pharmacy data, for surveillance of antibiotic use and type of nursing-home stay. Methods: EHR and pharmacy data during 2017 were included from 1,933 and 1,348 US-based nursing homes, respectively. We compared data elements available in each data source for antibiotic use reporting. In each data set, we attempted to describe antibiotic use as the proportion of residents on an antibiotic, days-of-therapy (DOT) per 1,000 resident days (RD), and distribution of antibiotic course duration, overall and at the facility level. Facility proportion of short-stay and long-stay (>100 days) nursing-home residents were calculated using admission dates and census data in the EHR data set and a payor variable in the pharmacy data set (Figure 1). The 2 data sources also provided antibiotic characteristics, including antibiotic class, agent, and route of administration. The deidentified nature of facility data prevented direct comparison of antibiotic use measures between facilities. Results: The EHR and pharmacy data sets contained 381,382 and 326,713 residents, respectively (Table 1). Within the EHR, 51% of residents were prescribed an antibiotic in 2017, at a median rate of 77 DOT per 1,000 RD. In the LTC pharmacy, 46% of residents were prescribed an antibiotic at a median rate of 79 DOT per 1,000 RD (Table 1). Short-stay residents contributed a smaller proportion of total RDs in the EHR relative to the pharmacy cohort (21% vs 50%, respectively). Conclusions: Nursing-home antibiotic use data obtained from EHR and pharmacy vendors can be used for calculating antibiotic use measures, which is important for antibiotic use reporting and facility-level tracking to identify opportunities for improving prescribing practices and provide facility-level benchmarks. Further validation of both data sources in the same facilities is needed to compare antibiotic use rates and to determine the most appropriate proxy for type of nursing-home stay for facility-level risk adjustment of antibiotic use rates.Funding: NoDisclosures: None

Intrinsic capacity predicts negative health outcomes in older adults

BACKGROUND: Monitoring trajectories of intrinsic capacity (IC) in older adults has been suggested by the WHO as a means to inform prevention to avoid or delay negative health outcomes. Due to a lack of longitudinal studies, it is currently unclear how IC changes over time and whether repeatedly measured IC predicts negative health outcomes. METHODS: Based on 4,751 repeated observations of IC (range=0-100) during 21 years of follow-up among 754 older adults 70+ years, we assessed longitudinal trajectories of IC, and whether time-varying IC predicted the risk of chronic ADL disability, long-term nursing home stay, and mortality using joint models for longitudinal and time-to-event data. RESULTS: Average IC declined progressively from 77 to 11 points during follow-up, with substantial heterogeneity between older adults. Adjusted for socio-demographics and chronic diseases, a one-point lower IC value was associated with a 7% increase in the risk of ADL disability, a 6% increase in the risk of a nursing home stay, and a 5% increase in mortality. Accuracy for 5- and 10-year predictions based on up to three repeated measurements of IC ranged between moderate and good (AUC = 0.76-0.82). DISCUSSION: Our study indicates that IC declines progressively and that it predicts negative health outcomes among older adults. Therefore, regular monitoring of IC could work as an early warning system informing preventive efforts.

VA’s Life-Sustaining Treatment Decisions Initiative: First 20 Months of National Implementation

This retrospective observational study describes the first 20 months of implementing the Life-Sustaining Treatment Decisions Initiative. We examined patient and facility characteristics associated with life sustaining treatment (LST) orders template completion, including the association between template completion and the Care Assessment Need (CAN) score, which quantifies Veterans’ risk of hospitalization and mortality. As of February 29, 2020, over 274,200 Veterans received at least one goal of care conversation and LST preferences documented on a template. Eighty-two percent of deceased Veterans with the highest risk of hospitalization or mortality had an LST note and order documented prior to their death. Factors that predicted a greater likelihood of LST template completion included higher CAN score, older age, nursing home stay, and being white non-Hispanic. Findings suggest that clinicians are engaging older, sicker veterans in goals of care conversations. Research is needed to understand potential disparities in LST template completion.

A MIXED-METHODS STUDY OF NURSING HOME RESIDENTS’ EXPERIENCES OF RELATIONSHIPS AND DAY-TO-DAY SOCIAL INTERACTIONS

Nursing home residents with and without cognitive impairment (N=38) answered open-ended questions about their day-to-day social interactions and ongoing relationships with family and friends. One author (SW) completed a conventional content analysis of the transcripts and the other (AW), a phenomenological-hermeneutic analysis. Findings from these analyses were combined and examined further using data from measures of social cognition and staff ratings of social behavior. Participants’ social experiences appeared to be determined not only by long-established habits and preferences and length of nursing home stay but also by their cognitive status and social cognition competencies. A central theme was the importance of managing ongoing relationships and day-to-day interactions so as to reduce one’s own stress as well as the burden on others. This presentation details how findings from distinct analytic strategies were combined to characterize the researchers’ understanding of participants’ lives in their networks of care from their own perspective.