Abstract Session A2: Aging/Geriatrics/End of Life Moderator: Daniel - - PDF document

Abstract Session A2: Aging/Geriatrics/End of Life Moderator: Daniel Matlock, MD, MPH Discussant: Catherine Sarkisian, MD, MSPH, SGIM 2014 Distinguished Professor in Geriatrics LOOKING BEYOND THE PROSTATE: DETERMINANTS AND IMPACT OF NOCTURIA IN MIDDLE-AGED AND OLDER WOMEN Amy Hsu1; Sanae Nakagawa2; Louise Walter1; Stephen K. Van Den Eeden3; Jeanette S. Brown2; David Thom2; Sei Lee1; Alison J. Huang2. 1San Francisco VA Medical Center, San Francisco, CA; 2University of California San Francisco, San, CA; 3Kaiser Permanente Division of Research, San, CA. (Tracking ID #1926776) BACKGROUND: Nocturia is a common complaint in middle-aged and older adults presenting to primary care, and is linked to poor sleep quality, decreased mental and somatic health, falls and fractures. Among older men, nocturia is widely considered to be a consequence of prostate-related outflow obstruction. In contrast, the determinants of nocturia in older women are poorly understood and little is known about why some women suffer from nocturia but not others. METHODS: We conducted a cross-sectional study of 2016 community-dwelling women, aged 41 to 83 years, from four racial/ethnic groups (White, Black, Asian and Latina), and enrolled in a group health delivery plan in Northern California. During home-based study visits, interviewers asked women about nocturnal voiding frequency, as well as bother and interference associated with this symptom. Other participant characteristics were examined by questionnaire, medical record abstraction, or physical examination and performance testing. Multivariable models were developed to assess for factors associated with nocturia, defined as waking two or more times to void at night. Potential predictors included demographics, gynecologic history, chronic medical conditions, medication use, and physical and mental functional status. RESULTS: Of the 2016 participants, mean (SD) age was 56 (9) years, and over half were racial or ethnic minorities (22% Black, 20% Asian, 23% Latina). Thirty-four percent reported waking to urinate at least two times per night, and 15% reported waking to urinate at least four times per night. Of those with nocturia, 39% reported being at least "moderately" bothered by this symptom, and 15% reported that nocturia affected their day-to-day activities. Factors associated with nocturia in multivariable analysis included older age (OR 1.18, CI: 1.10-1.27 per 5 year increase), Black race (OR 1.86, CI: 1.39-2.50), Latina ethnicity (OR 1.36, CI: 1.02- 1.83), hysterectomy (OR 1.85, CI: 1.13-3.05), vaginal estrogen use (OR 1.48, CI: 1.02-2.14), decreased mobility (OR 1.29, CI: 1.05-1.58 per 5-second increase in the Timed Up and Go test), and depression (OR 1.09, CI: 1.05-1.13 per 1-point increase on the Hospital Anxiety and Depression Scale score). The strongest predictor

• f being bothered by nocturia was greater frequency of nocturia (OR 2.63, CI: 2.08-3.31 per each additional

nocturnal voiding episode), although 26% of women who voided 4 or more times per night were only "slightly"

• r not at all bothered by this symptom.

CONCLUSIONS: Over a third of middle-aged and older community-dwelling women experience nocturia, and nearly 40% of those with nocturia are significantly distressed by it. A variety of demographic, gynecologic, and geriatric factors are associated with nocturia in women, which suggests that a comprehensive evaluation of the patient is necessary to evaluate the risk for nocturia and tailor management to the individual.

ANTIBIOTIC SUSCEPTIBILITIES OF URINARY ISOLATES IN OLDER ADULTS Theresa A. Rowe; Lee Lindquist; Abel Kho. Northwestern University Feinberg School of Medicine, Chicago,

• IL. (Tracking ID #1927517)

BACKGROUND: Background: Older adults are at an increased risk for development of multi-drug resistant

• rganisms because of compounded exposure to antibiotics. Clinicians empirically treat suspected urinary tract

infections (UTI) in older adults, selecting antibiotics based on guidelines intended for younger patients. No prior studies have examined whether there are age-related differences in UTI antibiotic susceptibility. We sought to identify antibiotic susceptibility patterns of urinary isolates in outpatient older adults and compare them to younger patients over a 3-year period. METHODS: Retrospective analysis of all adult outpatients with a positive urine culture who received antibiotic treatment for UTI within 3 days. The most common organisms Escherichia Coli (E. Coli) and Klebsiella spp. were tested for resistance to commonly prescribed antibiotics. We compared resistance patterns of adults over the age of 65 to younger adults under the age of 65 using descriptive statistics and chi square analysis. RESULTS: Urine cultures from 8,659 patients were reviewed. For E.Coli the percentage of resistance for adults ≥ 65, compared to adults < 65 were: Ciprofloxacin (31.97% in 65 years and older patients vs. 16.85% in under 65 year old patients; p <0.01), Trimethoprim/Sulfamethoxazole (30.12% vs 25.19%; p <0.01), Ampicillin/Sulbactam (19.47% vs 19.36%), Cefuroxime (5.27% vs 4.23%; p<0.05), Nitrofurantoin (1.80% vs 1.47%). For the second most common organism, Klebsiella species: Ciprofloxacin (5.28% vs 4.99%), Trimethroprim/Sulfamethoxazole (12.61% vs 13.59%), Ampicillin/Sulbactam (6.88% vs 12.85%; p<0.01), Cefuroxime (6.39% vs 7.91%), Nitrofurantoin (26.28% vs 24.36%) CONCLUSIONS: Older adults with UTIs have different resistance patterns to microorganisms when compared to younger patients. Current clinical guidelines for treatment may not reflect these differences. Clinicians need to be aware of the resistance patterns unique to older adults so that they can be appropriately treated

IS STRENGTH TRAINING ASSOCIATED WITH MORTALITY BENEFITS? A 15 YEAR COHORT STUDY OF US OLDER ADULTS. Christopher Sciamanna; Jennifer Kraschnewski; Liza S. Rovniak; Erik B. Lehman. Penn State Hershey, Hershey, PA. (Tracking ID #1936358) BACKGROUND: Guideline-concordant aerobic activity has consistent and powerful relationships with future

• mortality. Specific recommendations regarding strength training have come only more recently; in 2007 the

American Heart Association (AHA) and American College of Sports Medicine (ACSM) recommended all adults participate in such activities at least twice each week. Although several smaller clinical studies have

• bserved that greater amounts of muscle strength are associated with lower risks of death, few have studied the

relationship between strength training behavior and mortality in a large national sample over an extended time

• period. We undertook this investigation to understand the association between meeting strength training

guidelines and future mortality. METHODS: Data from the 1997-2001 National Health Interview Survey (NHIS), linked to death certificate data found in the National Death Index, were analyzed. The main independent variable, guideline-concordant strength training, was assessed using the following question: "How often do you do leisure-time physical activities specifically designed to strengthen your muscles, such as lifting weight or doing calisthenics?" Responses were categorized to signify whether the individual performed these activities at least twice each week, consistent with guidelines. Covariates included demographics variables, past medical history (i.e. diabetes, hypertension, coronary artery disease, and non-skin cancer), and other health behaviors (i.e. body mass index, physical activity, alcohol use and smoking status), consistent with variables shown to be associated with strength training in other studies. Analysis was limited to adults of 65 years or older. Mutlitivariate analysis was conducted using multiple logistic regression analysis, with the dependent variable being all-cause mortality. RESULTS: Overall, 9.6% of NHIS adults age 65 and older (N=30,162) reported doing strength training consistent with guidelines and 31.6% died during the follow-up period. After adjusting for demographic covariates, those who reported guideline-concordant strength training had 46% lower odds of all-cause mortality than those who did not (adjusted odds ratio: 0.64; 95% CI: 0.57, 0.70; p<0.001). This association remained when adjusting for past medical history and health behaviors. CONCLUSIONS: Guideline-concordant strength training is significantly associated with decreased overall mortality in older US adults. Unfortunately, only a minority of adults currently meet recommendations of strength training at least twice each week. This suggests we are far from engaging patients in the "Exercise is Medicine" campaign launched by the AHA/ACSM, where doctors are encouraged to recommend physical activity to patients as they would any other effective treatment. Identifying interventions to successfully engage

• lder adults in guideline-concordant strength training has the potential to significantly reduce all-cause

mortality in this population.

POLYPHARMACY AND PHYSIOLOGIC FRAILTY IN HIV-INFECTED VETERANS Minhee Sung1; Kirsha S. Gordon2; E. Jennifer Edelman3,2; Amy C. Justice2. 1Yale University School of Medicine, New Haven, CT; 2VA Connecticut Healthcare System, West Haven, CT; 3Yale University School of Medicine, New Haven, CT. (Tracking ID #1936987) BACKGROUND: HIV-infected (HIV+) patients are exposed to polypharmacy, the use of multiple medications concurrently, more frequently and at younger ages than their uninfected counterparts. While antiretroviral therapy (ART) sustains life for HIV+, non ART medication benefits are less clear and may contribute to frailty. Clinical research outside of HIV has found associations between polypharmacy and outcomes of frailty like fragility fractures, falls, and cognitive decline. Yet little research demonstrates the associations between polypharmacy and frailty in HIV+. We hypothesized that polypharmacy would be associated with increased risk

• f frailty among HIV+ veterans.

METHODS: We conducted a cross-sectional analysis of data from October 2009 to September 2010 from the Veterans Aging Cohort Study (VACS), which prospectively collects demographic, pharmacologic, and clinical data on HIV-infected patients receiving care through the Veterans Health Administration (VHA) system. The sample was restricted to HIV+ on ART for at least 12 months. Active long-term medication use (defined as > 90 days, allowing for 30 day gap between fill/refill) was determined using electronic pharmacy fill/refill data. Physiologic frailty was determined from self-reported survey items capturing physical shrinking, exhaustion, low physical activity, and slowness, and was categorized as pre-frail/frail vs. not frail. A logistic regression was used to assess the association between average long-term medication count and frailty after adjusting for demographics, VACS Index Score (a validated predictor of all-cause mortality), common medical comorbidities (including chronic obstructive pulmonary disease (COPD), diabetes mellitus, gastroesophageal reflux disease, hypertension, and osteoarthritis), substance use disorders (based on ICD-9 codes for alcohol and drug abuse and dependence), and mental illness. RESULTS: The sample of 2281 HIV+ was predominately male (98%), with a mean age of 55 years, and was racially/ethnically diverse (67% black, 24% white, 8% Hispanic). The number of patients who were pre-frail or frail was 723 and not frail was 1558. The mean non ART medication count was 4 and the median and interquartile range was 3 (2,6). Each additional long-term non ART medication conferred a greater odds of being frail/pre-frail (OR [95% CI] =1.15 [1.12, 1.18]) compared to not frail. This relationship persisted in the adjusted model (OR [95% CI] =1.11 [1.07, 1.15]). Non ART medication count was the strongest predictor of being pre-frail/frail and osteoarthritis was the second strongest predictor (OR 2.23 [1.50, 3.33]). In addition, COPD was associated with being pre-frail/frail vs. not frail (OR =2.54[1.46,4.42]). CONCLUSIONS: After adjusting for severity of illness among HIV+ on ART, for every additional long-term non ART medication the risk of being pre-frail or frail increases 11% after adjustment for severity of illness. Average long-term non ART medication count was the single best predictor of pre-frailty/frailty. Future studies must consider whether particular additional medications do more harm than good among HIV+ on ART.

DEFICITS IN THE TRANSFER OF ADVANCE CARE PLANNING INFORMATION FOR PATIENTS DISCHARGED FROM HOSPITALS TO NURSING HOMES Peggy Leung2,1; Clarke Low1; Anne M. Walling1,2; Neil Wenger1,2. 1University of California, Los Angeles, Los Angeles, CA; 2David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA. (Tracking ID #1939638) BACKGROUND: Prognostic discussions and decisions about aggressiveness of care made in the hospital are

• ften lost when patients transition to nursing facilities. For patients with serious illness and particularly for

those for whom decisions have been made not to use cardiopulmonary resuscitation (CPR) and other burdensome treatments, Physician Orders for Life-Sustaining Treatment (POLST) is a legal document that translates patient end-of-life treatment preferences into actionable medical orders that are preserved across venues of care. This tool is widely used in hospitals and nursing homes across California. We aimed to investigate how often patients with do not resuscitate (DNR) orders were discharged from the hospital to a nursing facility without adequate transmission of this information across facilities. METHODS: We identified all adult discharges from two hospitals to a skilled nursing facility over a three month period in 2013. We developed a medical record abstraction instrument that identified a patient's resuscitation status during hospitalization and at discharge and whether this was communicated to the nursing home in the discharge summary and whether a POLST was completed. In cases where there was discrepancy between the resuscitation status at discharge and the information communicated, we explored the reasons for the difference. RESULTS: Of 461 patient discharges (449 unique patients), 347 (75.3%) patients were "full code" at time of transfer, 89 (19.3%) patients had a DNR status at the time of transfer, and for 25 (5.4%) patients there was no "code status" documented on transfer. Of the 347 patients who were full code, 65 (18.7%) had a POLST indicating this at discharge. Of the 89 patients who had a DNR order at the time of transfer, 29 (32.7%) had a valid POLST on transfer that contained this information. An additional 23 patients had POLST forms on transfer that were inconsistent with resuscitation decisions at discharge: 13 patients with a "full code" status had a POLST that indicated DNR, 5 patients with a DNR status on transfer had a POLST that indicated CPR, and 5 patients had POLST forms with other content inconsistent with decisions made on discharge. CONCLUSIONS: At two hospitals in one health system, detailed evaluation of medical records for patients discharged to nursing homes demonstrated that even among patients for whom a DNR order was in place at time of transfer, less than one third had POLST documentation of this preference. In the studied hospitals, efforts are needed to improve the transition of resuscitation information from hospital to nursing home.