[Show abstract][Hide abstract] ABSTRACT: To determine the effect of two variables not previously studied in the readmissions literature (frailty-related diagnoses and high-risk medications in the elderly (HRME)) and one understudied variable (volume of primary care visits in the prior year).
Retrospective cohort study using data from a study designed to examine outcomes associated with inappropriate prescribing in elderly adults.
All Veterans Affairs (VA) facilities with acute inpatient beds in fiscal year 2006 (FY06).
All veterans aged 65 and older by October 1, 2005, who received VA care at least once per year between October 1, 2004, and September 30, 2006, and were hospitalized at least once during FY06 on a medical or surgical unit.
A generalized linear interactive risk prediction model included demographic and clinical characteristics (mental health and chronic medical conditions, frailty-related diagnoses, number of medications) in FY05; incident HRME in FY06 before index hospitalization or readmission; chronic HRME in FY05; and FY05 emergency department (ED), hospital, geriatric, palliative, or primary care use. Facility-level variables were complexity, rural versus urban, and FY06 admission rate.
The mean adjusted readmission rate was 18.3%. The new frailty-related diagnoses variable is a risk factor for readmission in addition to Charlson comorbidity score. Incident HRME use was associated with lower rates of readmission, as were higher numbers of primary care visits in the prior year.
Frailty-related diagnoses may help to target individuals at higher risk of readmission to receive more-intensive care transition services. HRME use does not help in this targeting. A higher number of face-to-face primary care visits in the prior year, unlike ED and hospital use, correlates with fewer readmissions and may be another avenue for targeting prevention strategies.
Journal of the American Geriatrics Society 02/2014; 62(2):291-8. · 4.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine whether the protective effect of metformin against death is modified by frailty status in older adults with type 2 diabetes.
We conducted a cohort study during October 1, 1999-September 30, 2006 among veterans aged 65-89 years old with type 2 diabetes but without history of liver, renal diseases, or cancers, who had sulfonylureas or metformin as the sole antidiabetic drug for ≥180 days. The Cox proportional hazard model was used to compare hazard rates of all-cause mortality between the metformin and sulfonylurea users adjusting for the propensity score of metformin use and covariates: age, race/ethnicity, diabetes duration, Charlson comorbidity score, statin use, smoking status, BMI, LDL, and HbA1c.
In this cohort of 2,415 veterans, 307 (12.7%) were metformin users, 2,108 (87.3%) were sulfonylurea users, the mean age was 73.7±5.2 years, the mean study period was 5.6±2.3 years, the mean HbA1c at baseline was 6.7±1.0%, 23% had diabetes for ≥10 years, and 43.6% (N=1,048) died during the study period. For patients with and without frailty, the adjusted hazard ratio (HR) of death for metformin vs. sulfonylurea use were 0.92 (95% CI=0.90-1.31, p-value=0.19) and 0.69 (95% CI = 0.60-0.79, p-value<0.001), respectively. Logistic regression analyses showed that metformin (vs. sulfonylurea) was significantly associated with a decreased odds of frailty (OR: 0.66, 95% CI: 0.61-0.71, p-value <.0001).
Our study suggests that metformin could potentially promote longevity via preventing frailty in older adults with type 2 diabetes.
Journal of endocrinology, diabetes & obesity. 01/2014; 2(2).
[Show abstract][Hide abstract] ABSTRACT: Knowing health literacy levels of older patients and their caregivers is important because caregivers assist patients in the administration of medications, manage daily health care tasks, and help make health services utilization decisions. The authors examined the association of health literacy levels between older Hispanic patients and their caregivers among 174 patient-caregiver dyads enrolled from 3 community clinics and 28 senior centers in San Antonio, Texas. Health literacy was measured using English and Spanish versions of the Short-Test of Functional Health Literacy Assessment and categorized as "low" or "adequate." The largest dyad category (41%) consisted of a caregiver with adequate health literacy and patient with low health literacy. Among the dyads with the same health literacy levels, 28% had adequate health literacy and 24% had low health literacy. It is notable that 7% of dyads consisted of a caregiver with low health literacy and a patient with adequate health literacy. Low health literacy is a concern not only for older Hispanic patients but also for their caregivers. To provide optimal care, clinicians must ensure that information is given to both patients and their caregivers in clear effective ways as it may significantly affect patient health outcomes.
Journal of Health Communication 12/2013; 18(sup1):256-272. · 1.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Frailty is a geriatric syndrome associated with physical decline with aging. Using a proteomics-based screening method to screen plasma for potential biomarkers, we previously found inflammatory glycoproteins to be increased with frailty. The purpose of this study was to confirm if plasma levels of these glycoproteins, as well as of interleukin-6, are increased with frailty in a larger sample (n = 65) of community-dwelling older adults. Plasma levels of transferrin, fibrinogen, haptoglobin, and interleukin-6 were determined with enzyme-linked immunosorbent assay. Differences in protein concentrations by frailty status were determined using analysis of variance. Higher levels of transferrin (p < .001), fibrinogen (p < .0001), and interleukin-6 (p = .0035) were associated with frailty status (nonfrail, prefrail, or frail) and frailty score (0-5) in this sample even after adjustment for age and sex. Haptoglobin did not differ by frailty status (p = .05). Our findings largely confirmed the findings of our nontargeted approach that inflammatory glycoproteins are increased with frailty. Future studies should include larger examinations of these associations and consider the potential usefulness of these glycoproteins as biomarkers for frailty.
The Journals of Gerontology Series A Biological Sciences and Medical Sciences 11/2013; · 4.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To examine predictors of mortality in aging Mexican Americans (MAs) and European Americans (EAs).
Longitudinal, observational cohort study.
Socioeconomically diverse neighborhoods in San Antonio, Texas.
Community-dwelling adults aged 65 and older (394 MA; 355 EA) who completed the baseline examination (1992-96) of the San Antonio Longitudinal Study of Aging (SALSA) and for whom vital status was ascertained over an average 8.2 years of follow-up.
Ethnic group was classified using a validated algorithm. Hazard ratios (HRs) for mortality were estimated using Cox proportional hazards models with age, sex, ethnic group, education, income, frailty, diabetes mellitus with and without complications, comorbidity, cognition, depressive symptoms, and body mass index included as predictors in sequential models.
At baseline, MAs had a higher prevalence of diabetes mellitus and frailty and lower socioeconomic status (SES) than EAs. The age- and sex-adjusted ethnic HR (MA vs EA) for mortality was 1.54 (95% confidence interval (CI) = 1.17-2.03). After adjusting for SES, the ethnic HR was no longer significant (HR = 1.16, 95% CI = 0.83-1.61). In the final model, comorbidity, diabetes mellitus with complications, depressive symptoms, and cognitive impairment were significant independent risk factors for mortality.
Contrary to the Hispanic paradox, MAs were at greater risk of mortality than EAs. SES differences largely explained this ethnic disparity. Significant independent predictors of mortality, regardless of ethnic group, were diabetes mellitus with complications, comorbidity, depressive symptoms, and cognitive impairment. Mortality reduction in older MAs requires attention to socioeconomic disparities and disease factors.
Journal of the American Geriatrics Society 09/2013; · 4.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To examine frailty transitions in Mexican American (MA) and European American (EA) older adults.
Longitudinal, observational cohort study.
Socioeconomically diverse neighborhoods in San Antonio, Texas.
Three hundred twelve MA and 285 EA community-dwelling older adults (≥ 65) with frailty information at baseline (1992-1996) and transition information at follow-up (2000/01) in the San Antonio Longitudinal Study of Aging.
Five frailty characteristics (weight loss, exhaustion, weakness, slowness, and low physical activity), frailty score (0-5), and overall frailty state (nonfrail = 0 characteristics, prefrail = 1 or 2, frail = ≥ 3) were assessed at baseline. Transitions (progressed, regressed, or no change) were assessed for frailty score and state. Odds ratios (ORs) of progression and regression in individual characteristics were estimated using generalized estimating equations adjusted for age, sex, ethnic group, socioeconomic status, comorbidity, diabetes, and follow-up interval.
Diabetes mellitus with macrovascular complications (OR = 1.84, 95% confidence interval (CI) = 1.02-3.33), fewer years of education (OR = 0.96, 95% CI = 0.93-1.0) and follow-up interval (OR = 1.3, 95% CI = 1.17-1.46) were significant predictors of progression in any frailty characteristic. Mortality increased with greater frailty state, and prefrail individuals were more likely than frail individuals to regress.
Diabetes mellitus with macrovascular complications and fewer years of education are important predictors of progression in any frailty characteristic. Because of greater risk of death than for the nonfrail state and greater likelihood of regression than for the frail state, the prefrail state may be an optimal target for intervention.
Journal of the American Geriatrics Society 02/2012; 60(4):652-60. · 4.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The application of proteomics methodology for analyzing human blood samples is of increasing importance as a noninvasive method for understanding, detecting, and monitoring disease. In particular, glycoproteomic analysis may be useful in the study of age-related diseases and syndromes, such as frailty. This study demonstrates the use of methodology for isolating plasma glycoproteins using lectins, comparing the glycoproteome by frailty status using two-dimensional polyacrylamide gel electrophoresis and identifying glycoproteins using mass spectrometry. In a pilot study, we found seven glycoproteins to differ by at least twofold in prefrail compared with nonfrail older adults, including haptoglobin, transferrin, and fibrinogen, consistent with known inflammatory and hematologic changes associated with frailty. Enzyme-linked immunosorbent assay analysis found that plasma transferrin concentration was increased in frail and prefrail older adults compared with nonfrail, confirming our proteomic findings. This work provides evidence for using a reproducible methodology for conducting clinical proteomic comparative studies of age-related diseases.
The Journals of Gerontology Series A Biological Sciences and Medical Sciences 01/2012; 67(8):853-64. · 4.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Only a minority of patients who die in the medical intensive care unit (MICU) receive palliative care services. At the South Texas Veterans Health Care System Audie L. Murphy Hospital, only 5% of patients who died in the MICU from May to August 2010 received a palliative care consultation.
We measured the percentage of MICU patients for which there was a palliative care consultation during the intervention period.
Starting October 1, 2010 and ending April 30, 2011, the palliative care and MICU teams participated in daily "pre-rounds" to identify patients at risk for poor outcomes, who may benefit from a palliative care consultation.
Palliative care consultation increased significantly from 5% to 59% for patients who died in the MICU during the intervention period. Additionally, palliative care consultation increased from 5% to 21% for all patients admitted to the MICU during the intervention period. CONCLUSIONS/LESSONS LEARNED: Daily pre-rounds between the palliative care and MICU teams increased palliative care services for MICU patients at risk for poor outcomes, who may benefit from a palliative care consultation.
Journal of pain and symptom management 11/2011; 42(5):676-9. · 2.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To directly compare frailty incidence of older Mexican American (MA) and European American (EA) adults.
Longitudinal, observational cohort study.
Socioeconomically diverse neighborhoods in San Antonio, Texas.
Three hundred one older MA and 305 older EA adults in the San Antonio Longitudinal Study of Aging (SALSA) who were nonfrail at baseline.
Frailty was assessed at baseline, and three follow-ups conducted over an average of 9.9 years using well-established criteria from the Cardiovascular Health Study. Covariates were baseline age, sex, socioeconomic status (SES), prefrailty status, diabetes mellitus, and comorbidity. The adjusted ethnic odds (MA vs EA) of incident frailty were estimated using generalized estimating equations.
There was no ethnic difference in the unadjusted incidence of frailty over the three follow-up examinations (odds ratio (OR) = 0.97, 95% confidence interval (CI) = 0.62-1.52), even though baseline SES was significantly lower in MAs than EAs. After covariate adjustment, the odds of incident frailty were significantly lower for MAs than EAs (OR = 0.40, 95% CI = 0.23-0.72). Other significant predictors of frailty in the adjusted model were pre-frailty (present vs absent OR = 3.19, 95% CI = 1.86-5.47), education (1-year increment OR = 0.89, 95% CI = 0.83-0.96), and income (1-year increment OR = 0.88, 95% CI = 0.79-2.04).
These findings lend support to the Hispanic Paradox and suggest that MAs who live to older ages are less likely than similarly aged EAs to become frail. Further research is needed to identify the underlying biological and social mechanisms that explain this finding to enhance the development of interventions for the prevention and treatment of this clinical geriatric syndrome.
Journal of the American Geriatrics Society 11/2010; 58(11):2142-8. · 4.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Because conventional frailty screening criteria have been standardized in predominantly European-American (EA) cohorts, applying them to ethnically diverse populations may result in inaccurate estimation of frailty prevalence in ethnic minorities. The objective of this study was to determine whether use of ethnic-specific criteria (EC) to characterize frailty in a bi-ethnic cohort results in significant differences in frailty prevalence when compared with the prevalence obtained using conventional criteria (CC). Data were from a random sample of community-dwelling Mexican Americans (MAs) (n=394) and EAs (n=355) aged 65 to 80 who participated in the baseline examination of the San Antonio Longitudinal Study of Aging. Frailty was defined as three or more of five characteristics: slow walking speed, weak grip strength, low energy expenditure, self-reported exhaustion, and weight loss. For CC, walking speed was standardized to height and sex, grip strength was standardized to body mass index and sex, and energy expenditure was standardized to sex using the pooled sample. For EC, these criteria were applied within each ethnic group. Frailty prevalence in MAs and EAs was compared using chi-square statistic. Using CC, a higher proportion of MAs than EAs were frail (11.3% vs 7.0%, P=.045). Using EC, there was no difference in frailty prevalence between MAs and EAs (9.9% in both ethnic groups). The application of conventional frailty screening criteria in a bi-ethnic cohort results in a higher prevalence of frailty in MAs than in EAs. In determining whether there are ethnic disparities in frailty, future studies should carefully consider whether CC or EC should be applied.
Journal of the American Geriatrics Society 08/2008; 56(9):1744-9. · 4.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The development of animal models that approximate human frailty is necessary to facilitate etiologic and treatment-focused frailty research. The genetically altered IL-10(tm/tm) mouse does not express the antiinflammatory cytokine interleukin 10 (IL-10) and is, like frail humans, more susceptible to inflammatory pathway activation. We hypothesized that with increasing age, IL-10(tm/tm) mice would develop physical and biological characteristics similar to those of human frailty as compared to C57BL/6J control mice.
Strength, activity, serum IL-6, and skeletal muscle gene expression were compared between age-matched and gender-matched IL-10(tm/tm) mice on C57BL/6J background and C57BL/6J control mice using a longitudinal design for physical characteristics and cross-sectional design for biological characteristics.
Strength levels declined significantly faster in IL-10(tm/tm) compared to control mice with increasing age. Serum IL-6 levels were significantly higher in older compared to younger IL-10(tm/tm) mice and were significantly higher in older IL-10(tm/tm) compared to age- and gender-matched C57BL/6J control mice. One hundred twenty-five genes, many related to mitochondrial biology and apoptosis, were differentially expressed in skeletal muscle between 50-week-old IL-10(tm/tm) and 50-week-old C57BL/6J mice. No expression differences between IL-10(tm/tm) age groups were identified by quantitative polymerase chain reaction.
These physical and biological findings suggest that the IL-10(tm/tm) mouse develops inflammation and strength decline consistent with human frailty at an earlier age compared to C57BL/6J control type mice. This finding provides rationale for the further development and utilization of the IL-10(tm/tm) mouse to study the biological basis of frailty.
The Journals of Gerontology Series A Biological Sciences and Medical Sciences 05/2008; 63(4):391-8. · 4.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: It is hypothesized that free radical damage contributes to aging. Age-related decline in activity of the antioxidant enzyme glutathione peroxidase (GPx) may contribute to increased free radicals. We hypothesized that GPx activity decreases with age in a population of older women with disability.
Whole blood GPx activity was measured in baseline stored samples from participants in the Women's Health and Aging Study I, a cohort of disabled community-dwelling older women. Linear regression was used to determine cross-sectional associations between GPx activity and age, adjusting for hemoglobin, coronary disease, diabetes, selenium, and body mass index.
Six hundred one participants had complete demographic, disease, and laboratory information. An inverse association was observed between GPx and age (regression coefficient = -2.9, p <.001), indicating that for each 1-year increase in age, GPx activity decreased by 2.9 micromol/min/L. This finding remained significant after adjustment for hemoglobin, coronary disease, diabetes, and selenium, but not after adjustment for body mass index and weight loss.
This is the first study to examine the association between age and GPx activity in an older adult cohort with disability and chronic disease. These findings suggest that, after age 65, GPx activity declines with age in older women with disability. This decline does not appear to be related to diseases that have been previously reported to alter GPx activity. Longitudinal examination of GPx activity and other antioxidant enzymes in diverse populations of older adults will provide additional insight into age- and disease-related changes in these systems.
The Journals of Gerontology Series A Biological Sciences and Medical Sciences 05/2008; 63(5):505-9. · 4.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Frailty is a state of vulnerability that carries an increased risk of poor outcomes in older adults. Common signs and symptoms are fatigue, weight loss, muscle weakness, and progressive decline in function. Frail older adults are among the most challenging for medical management. However, awareness of this syndrome and its risks can help us care for these patients more confidently and decrease their risk for adverse outcomes.
Cleveland Clinic Journal of Medicine 01/2006; 72(12):1105-12. · 3.40 Impact Factor