Talking to older adults about health prognosis may be helpful

Prognosis is the term for the most likely outcome of a medical condition. When it comes to health care, talking about your prognosis can be difficult for you, your family/friends, and even your healthcare providers. However, many of us prefer to talk to our healthcare providers about the expected course of an illness and about our life expectancy when living with a chronic or terminal illness. This is according to new research on advanced care planning (the technical term for having early conversations with our healthcare providers about our care needs, preferences, and expectations).

16 sept 2017--In a new study published in the Journal of the American Geriatrics Society, researchers examined how older adults with disabilities later in life might react to learning their prognosis, and how they evaluated their own prognosis compared to "official" estimates.
The study participants were 35 adults 70-years-old and older from four geriatrics clinics in the San Francisco Bay area. All the participants required help with daily activities, and they all participated in a 45-minute interview as part of the study.
The researchers asked older adults questions about how they would want to receive information about their life expectancy. For example, did they prefer hearing or reading news about their prognosis? Would they prefer receiving information about their prognosis while at home by themselves?
Additionally, participants circled the shortest, longest, and most likely number of years they thought they might live on a scale from zero to 30 years. Researchers then offered to give the participants an estimate of life expectancy with a visual presentation using an estimate system created for people older than age 50. Next, participants were given the option to see their prognosis. If they chose to see it, they discussed their reactions with the researchers. Afterward, researchers asked the participants 10 questions about their feelings based on hearing about estimated life expectancy. The researchers called the participants two to four weeks later to check on their reactions as a follow-up.
Over the course of the study, the researchers learned that:

• 16 participants (46 percent) had life expectancy estimates that were within two years of the "most likely" estimate from a healthcare professional.
• 15 participants (43 percent) over-estimated their own life expectancy by more than two years compared to the "most likely" estimate.
• 4 participants (11 percent) under-estimated their own life expectancy by more than two years compared to the "most likely" estimate.
• Overall, 30 participants (86 percent) estimated their life expectancy in a way that at least overlapped with the "official" estimated calculation.

The researchers concluded that most older adults wanted a health care practitioner to be present when discussing life expectancy. People in the study did not react with sadness or anxiety when they learned about life expectancies, though several disputed the calculated results.
"Health care practitioners may offer to discuss life expectancy with their older, disabled patients and expect the patients to tie the information into their own life narratives," said the researchers.
According to other research, key reasons for a healthcare professional's reluctance to have these discussions with their older adults may include:

• Fear of taking away hope
• Concern for a negative reaction
• Time restraints
• Poor training
• Worry about giving someone a mistaken prognosis, leading to incorrect information about a person's future

Addressing these and other important concerns remains key to advance care planning, which has been shown to improve the quality of care we receive as we age.

More information: Theresa W. Wong et al, Prognosis Communication in Late-Life Disability: A Mixed Methods Study, Journal of the American Geriatrics Society (2017). DOI: 10.1111/jgs.15025


Provided by American Geriatrics Society

Little progress made in reducing health disparities for people with disabilities

Psychological distress in people with disabilities is associated with increased prevalence of other chronic conditions and reduced access to health care and preventive care services, finds a new study in the Journal of Health Care for the Poor and Underserved.

30 jun 2014--The U.S. Department of Health and Human Services' Healthy People series established goals to reduce disparities among people with disabilities, but there has been very little progress toward reaching these goals, says lead author Catherine Okoro, Ph.D., of the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia.

"It's important to find out why there has been so little progress, since the prevention, detection, and treatment of secondary illnesses is critical for health maintenance, halting progression of disability, and helping people with disabilities to participate in life activities," she says.

The study analyzed data from the Behavioral Risk Factor Surveillance System, a telephone survey conducted in 2007 by most state health departments in conjunction with the CDC. Approximately 30 percent of adults with disabilities reported having moderate to serious psychological distress, with over 12 percent reporting serious psychological distress.

Adults who reported having a disability and serious psychological distress had a higher prevalence of seven chronic diseases and conditions—arthritis, asthma,coronary heart disease, diabetes, hypertension, high cholesterol, and stroke—when compared to adults with no psychological distress. Disabled adults with moderate psychological distress also had higher rates of these conditions, with the exception of diabetes.

"We found a strong association between increasing numbers of physical chronic conditions and prevalence of serious psychological distress," Okoro says. "For example, the prevalence of serious psychological distress was about two times as high among those with five to seven chronic conditions compared to those with no conditions."

Adults ages 18 to 64 with disabilities and moderate-to-serious psychological distress were also found to have several barriers to accessing health care. They were more likely to be uninsured and unable to afford care than those with no distress. Researchers found that the use of mental health services increased with the severity of psychological distress, but a larger proportion of older adults with serious psychological distress reported not receiving mental health care when compared to their younger counterparts. "It's possible this may be due to competing health conditions, stigma, or avoidance," Okoro comments.

The study illustrates that a relatively small but highly vulnerable population bears the majority of burden of poor physical and psychological health, says Benjamin Druss, M.D., a psychiatrist at Emory University. "These problems tend to be tangled up with one another so a person who has physical problems tends to be more stressed about their problems—particularly if they can't get health care," he comments. "It's not easy to untangle all these issues, but these individuals should be treated in a holistic way, looking at their mental problems, their physical health, and their psychosocial issues," he adds.

More information: Okoro A, Dhingra SS, and Li C. "A triple play: psychological distress, physical comorbidities, and access and use of health services among US adults with disabilities." J of Health Care for the Poor and Underserved. 2014;(25):814-836.

Provided by Health Behavior News Service

A walking revolution helps older adults get and stay active

Uneven sidewalks are hazardous for older or disabled pedestrians. These are one of the obstacles to outdoor walking for exercise explored in a recent study.

8 jun 2013—It sounds simple: get outside and take a walk. Walking on its own is known to offer numerous health benefits, everything from lower blood pressure to less aches and pains. For some people, though, getting outside and taking that walk can be a challenge. This is especially true for the elderly or those with disabilities. How will I get to my destination? Is it a safe place to walk? Are there street lights? Will sidewalk cracks make it harder for my walker to roll?

These questions are pondered by millions of Americans who live with physical mobility challenges. After all, more than 40 percent of adults age 45 or older have difficulty with physical movement, and 58 percent of adults age 65 or older have a disability, according to a recent paper appearing in The Gerontologist.

The report covers study findings from the University of Washington schools of nursing and public health. The work was led by Basia Belza, professor of biobehavioral nursing and health systems, and Dori Rosenberg, a postdoctoral fellow in rehabilitation medicine and an affiliate assistant professor of health services, based at Group Health Research Institute.

Their research team sought to better understand the needs of adults with mobility disabilities related to neighborhood walkability. The investigators interviewed older adults with mobility disabilities about their experiences and impressions of trying to get about in built environments – the settings in which human activities take place. The researchers learned that poorly lit neighborhoods, lack of public transportation, sidewalks in disrepair, and unmarked or poorly marked intersections prevent people with disabilities from taking advantage of the benefits of walking.

Belza said that older adults, who are the fastest growing demographic, are also the most physically inactive group and the age group most likely to face chronic disease due to inactivity.

"People who are inactive in general have a higher incidence of chronic disease such as stroke, heart disease, arthritis," Belza said. "Regular engagement in physical activities leads to better health outcomes, including improved mobility, weight loss and fewer falls. This is especially important in older adults who may already be dealing with health challenges."

Belza noted that one study participant who lives in the Phinney Ridge neighborhood of Seattle has already approached the Seattle City Council to ask for neighborhood improvements.

In another related project, Belza partnered with an Easter Seals project, called Accessible Community Transportation in Our Nation, and the Centers for Disease Control and Prevention Healthy Aging Research Network to create a Neighborhood Wayfinding Pocket Guide. This guide was designed to show people ways to check out their neighborhoods and assess the state of sidewalks, transportation, street lights and other factors that could encourage or discourage neighborhood walking.

"The guide is a great way for people to get out in their neighborhoods and learn to be more active in general while also helping others," Belza said.

The guide encourages people to consult with their city and town governments to share ideas for improvement, with the hope that this will encourage cities to invest more in communities. Belza continues to look for ways to improve access to the built environment and increase physical activity in older adults. She and her colleagues in the Centers for Disease Control and Prevention Healthy Aging Network are doing a systematic review to better understand how older adults use technology to find their way.

Belza believes that with improved information and resources, older adults who have mobility disabilities will reap the benefits of walking, which has long been reported by adults as the most preferred way to be physically active and applauded by health experts as one of the best ways to improve overall health.

"Walking is a great way to decrease your risk for many chronic conditions, including heart disease, obesity and other health challenges," she said. "We hope that our guide will help people improve their health by finding new and safe places to walk."

More information: Download a wayfinding guide and supplement.

Provided by University of Washington

More Disabilities Today In 60-Year-Olds Than In Prior Generations

14 nov 2009--In a development that could have significant ramifications for the nation's health care system, Baby Boomers may well be entering their 60s suffering far more disabilities than their counterparts did in previous generations, according to a new UCLA study. The findings, researchers say, may be due in part to changing American demographics.

In the study, which will be published in the January 2010 issue of the American Journal of Public Health, researchers from the division of geriatrics at the David Geffen School of Medicine at UCLA found that the cohort of individuals between the ages of 60 and 69 exhibited increases in several types of disabilities over time. By contrast, those between the ages of 70 and 79 and those aged 80 and over saw no significant increases - and in some cases exhibited fewer disabilities than their previous cohorts.

While the study focused on groups born prior to the post-World War II Baby Boom, the findings hold "significant and sobering implications" for health care because they suggest that people now entering their 60s could have even more disabilities, putting an added burden on an already fragile system and boosting health costs for society as a whole, researchers say.

If this is true, it's something we need to address," said Teresa Seeman, UCLA professor of medicine and epidemiology and the study's principal investigator. "If this trend continues unchecked, it will put increasing pressure on our society to take care of these disabled individuals. This would just put more of a burden on the health care system to address the higher levels of these problems."

The researchers used two sets of data - the National Health and Nutrition Examination Surveys (NHANES) for 1988 and 1999 - to examine how disabilities for the three groups of adults aged 60, 70, and 80 and older had changed over time. They assessed disability trends in four areas: basic activities associated with daily living, such as walking from room to room and getting into and out of bed; instrumental activities, such as performing household chores or preparing meals; mobility, including walking one-quarter mile or climbing 10 steps without stopping for rest; and functional limitations, which include stooping, crouching or kneeling.

The study focused primarily on trends for the more recent 60 age group - those born between 1930 and 1944, just before the start of the Baby Boom, whose data was included in the 1999 NHANES. In particular, researchers felt this group could offer insights into the health of the Boomers following them, who are now entering their 60s.

The researchers found that between the periods 1988 and 1999, disability among those in their 60s increased between 40 and 70 percent in each area studied except functional limitations, independent of sociodemographic characteristics, health status and behaviors, and relative weight. The increases were considerably higher among non-white and overweight subgroups.

By contrast, the researchers found no significant changes among the group aged 70 to 79, while the 80-plus group actually saw a drop in functional limitations.

One reason for this uptick, researchers say, is that disabilities may be linked with the changing racial and ethnic makeup of the group that recently reached or will soon be reaching its 60s, with the most rapid growth projected to be among African Americans and Hispanics - groups with significantly higher rates of obesity and lower socioeconomic status, both of which are associated with higher risk for functional limitations and disabilities.

The researchers note that their controls for differences in sociodemographics, health status (such as chronic conditions and biological risk factors) and health behavior do not completely explain the increase in disability trends among the 60- to 69-year olds. Still, the trends within that group "are disturbing," Seeman said.

"Increases in disability in that group are concerning because it's a big group," she said. "These may be people who have longer histories of being overweight, and we may be seeing the consequences of that. We're not sure why these disabilities are going up. But if this trend continues, it could have a major impact on us, due to the resources that will have to be devoted to those people."

Study co-authors included Arun Karlamangla and Sharon Merkin, of UCLA's geriatrics division, and Eileen Crimmins, of the Andrus Gerontology Center at the University of Southern California.

The National Institute on Aging funded this study.

Source: Enrique Rivero
University of California - Los Angeles

Moderate Alcohol Consumption May Protect Against Disabilities

By Carolyn Colwell
23 jan 2009-- Healthy people 50 and older who drink alcohol moderately are less likely to suffer physical disabilities that cause so many seniors to lose their independence, a new study says.

The study authors said their research showed that healthy older adults who were light-to-moderate drinkers had 25 percent lower odds of being unable to carry out daily activities such as walking, dressing, eating, running errands or doing chores.

Conversely, heavy drinkers and abstainers had higher risks of disabilities that would limit such activities.

"What it's really telling light-to-moderate drinkers is don't worry, you're probably in good company, and you're probably going to get good benefits from this," said lead researcher Dr. Arun S. Karlamangla, an associate professor of medicine at the David Geffen School of Medicine at the University of California, Los Angeles.

But, the study should also serve as a warning to older adults who aren't in good health, Karlamangla added. For the participants who reported that their overall health was fair or worse, alcohol offered no benefit at all.

"If you're health is not good, you probably should not be drinking," he said.

Study co-author Dr. Alison A. Moore, an associate professor of medicine in the geriatrics division at the David Geffen School of Medicine, said there were two possible reasons why the unhealthy didn't benefit. Alcohol may have negatively interacted with their medications, or their health may have been so poor it wasn't reversible, she said.

The researchers defined light-to-moderate drinking as less than 15 drinks a week with a daily maximum of five for men and four for women. Moore said the study included the number of drinks a day to eliminate people who binge drink. The daily consumption may be part of the protective mechanism, she explained.

Moore said that a common recommendation for older adults is consuming about one drink a day. This study and other new data may change that standard. "There are healthy 65- to 70-year-olds who can take more than a drink a day," she added.

The UCLA researchers said their study was the first to follow a large, nationally representative sample over a period of years to look at the relationship between alcohol and physical disabilities. The findings were published online Jan. 15 in the American Journal of Epidemiology.

Dr. Kenneth J. Mukamal, an associate professor of medicine at Harvard Medical School, said the new research "adds to quite a substantial body of evidence that suggests in people who can demonstrate they can drink safely, there is no inherent medical reason not to drink." Studies by Mukamal and others have suggested that moderate drinking is associated with a lower risk of heart attacks and strokes.

Alcohol isn't the only adult beverage that may offer health benefits. Drinking coffee daily in midlife may decrease the chance of Alzheimer's and dementia in later years, according to a new Finnish study.

Ths study, published in the January issue of the Journal of Alzheimer's Disease, found that people who drank three to five cups of coffee a day had the lowest risk. Their risk was decreased by 65 percent compared to those who drank no or little coffee, the study found.

More information

For more on the benefits and risks of moderate drinking, visit the University of North Carolina at Chapel Hill.

Runners Live Longer and Have Fewer Disabilities

By Todd Neale
PALO ALTO, 12 aug 2008-- Regular running in middle age and beyond may lengthen lifespans and retard the disabilities of aging, a longitudinal study showed. Runners ages 50 to 72 had a 40% reduced risk of being moderately disabled or of dying after a 21-year follow-up than healthy controls, Eliza Chakravarty, M.D., of Stanford, and colleagues reported in the Aug. 11 issue of the Archives of Internal Medicine. Disability and survival curves continued to diverge between groups after the 21-year follow-up as participants approached their ninth decade of life, they added.
"Our findings of decreased disability in addition to prolonged survival among middle-age and older adults participating in routine physical activities further support recommendations to encourage moderate to vigorous physical activity at all ages," the researchers said.
The study began in 1984, when 538 members of a nationwide running club for those 50 and older and 423 healthy controls -- Stanford faculty and staff members ages 26 to 70 -- were recruited to complete yearly questionnaires.
At baseline, runners were younger (mean age 58 versus 62), leaner, more likely to be male, and less likely to smoke than the controls (P<0.001 for all).
Both groups had little disability -- measured using the Health Assessment Questionnaire Disability Index (HAQ-DI), which asked the participants about their level of difficulty in completing eight tasks -- but runners had a significantly lower mean score compared with controls (P<0.001).
Two previous reports on this cohort showed that disability was decreased and survival was increased in runners at eight and 13 years of follow-up.
A total of 284 runners and 156 controls completed the study through 21 years of follow-up, and the results extended the previous findings.
Disability scores increased with time for both groups, but at a significantly greater rate for the controls (0.016 points/year versus 0.007, P<0.001). Runners had significantly lower mean disability levels at all time points.
Runners took longer to reach various levels of disability compared with controls -- for example, it took 2.6 years for controls to reach a mean HAQ-DI score of 0.075 and 8.7 years for runners, for a difference of 6.2 years (95% CI 3.9 to 8.9).
Among participants who had a baseline disability score of zero, runners had a significantly lower risk of being moderately disabled (HR 0.62, 95% CI 0.46 to 0.84).
Through follow-up, 15% of runners died compared with 34% of controls (P<0.001). In a multivariate analysis, runners were 39% less likely to die than controls (HR 0.61, 95% CI 0.45 to 0.82).
Rates of death were higher in controls than in runners for cardiovascular disease (P=0.001), cancer (P=0.004), neurological disease (P=0.007), infections (P<0.001), and other causes (P<0.001).
The study's findings were similar when the participants were divided into ever-runners -- those who ran regularly for more than one month at some point in their lives -- and never-runners.
The authors suggested several possible reasons for the disability and survival advantages found in runners, including "increased cardiovascular fitness and improved aerobic capacity and organ reserve, increases in skeletal mass and metabolic adaptations of muscle with decreased frailty, lower levels of circulating inflammatory markers, improved response to vaccinations, and improved higher-order cognitive functions."
They acknowledged some limitations, including the self-reported data, possible self-selection bias, and potential confounding by unmeasured lifestyle variables.
In addition, they said, the results of the study may not be generalizable beyond the mostly white and college-educated study population.
The study was supported by grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Institute on Aging.
The authors made no financial disclosures.
Primary source: Archives of Internal MedicineSource reference:Chakravarty E, et al "Reduced disability and mortality among aging runners: a 21-year longitudinal study" Arch Intern Med 2008; 168: 1638-1646.