Phenotypes of Symptom, Function, and Medication Burden in Older Adults with Nondialysis Advanced Kidney Disease.
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ABSTRACT:
SUBMITTER: Ma JE
PROVIDER: S-EPMC10615372 | biostudies-literature | 2023 Oct
REPOSITORIES: biostudies-literature
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Phenotypes of Symptom, Function, and Medication Burden in Older Adults with Nondialysis Advanced Kidney Disease.
Ma Jessica E JE Berkowitz Theodore S Z TSZ Olsen Maren K MK Smith Battista B Lorenz Karl A KA Bowling C Barrett CB
Kidney360 20230908 10
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Project description:ImportanceUnderstanding how wealth influences the end-of-life experience is crucial for improving patient care and policy, particularly with regard to symptom burden.ObjectiveTo examine the prevalence of 12 end-of-life symptoms by wealth categories; the association between wealth and a composite measure of high symptom burden; and whether this association is mediated by multimorbidity, functional impairment, or dementia.Design, setting, and participantsThis cohort study used data from the Health and Retirement Study (HRS), a nationally representative survey of older adults in the US, on decedents who died between January 1, 2000, and February 28, 2021, from proxy-reported exit interviews through February 28, 2021. Decedents were HRS participants aged 65 years or older who had completed a core interview within 24 months before death and had a proxy-reported exit interview. The data analysis was performed from October 6, 2023, through November 26, 2024.ExposuresWealth (assets opposed to income) was categorized into low (bottom quartile, <$6000), medium (middle 2 quartiles, $6000-$120 000), and high (top quartile, >$120 000).Main outcomes and measuresThe presence of 12 individual end-of-life symptoms and a composite measure of high symptom burden (≥7 symptoms) were analyzed using modified Poisson regression. Mediators included multimorbidity, functional impairment, and dementia. Models were adjusted for age, sex, marital status, race and ethnicity, education, childhood socioeconomic status, HRS proxy respondent relationship, location of death, survey timing, year of death, and private insurance.ResultsOf 8976 decedents (mean [SD] age, 81.3 [8.6] years; 4927 women [55.1%] women) in the cohort, 2197 (22.5%) were included in the low wealth category, 4534 (50.5%) in the medium wealth category, and 2245 (27.1%) in the high wealth category. Decedents with lower wealth had a higher prevalence of end-of-life symptoms. High symptom burden was most common in the low wealth group (800 decedents [37.0%]) vs the medium (1301 decedents [28.0%]) and high wealth (512 decedents [23.2%]) groups. Low wealth was associated with a significantly increased risk of high symptom burden vs medium wealth (adjusted risk ratio, 0.79; 95% CI, 0.73-0.87) and high wealth (adjusted risk ratio, 0.71; 95% CI, 0.63-0.79). Multimorbidity, functional impairment, and dementia were more common in the low wealth group and mediated this association, with functional impairment being the strongest mediator.Conclusions and relevanceThis cohort study found that lower wealth was associated with a higher symptom burden at the end of life, mediated in part by higher rates of multimorbidity, functional impairment, and dementia. These findings highlight the need for policies and programs to support patients with lower financial resources to improve end-of-life experiences and mitigate wealth disparities.
| S-EPMC11886723 | biostudies-literature
Project description:OBJECTIVES:To determine the prevalence and impact of common co-occurring symptoms among community-dwelling older adults in the United States. DESIGN:The National Health and Aging Trends Study is a nationally representative, prospective study with annual data collection between 2011 and 2017. SETTING:Community-based, in-person interviews (survey response rates, 71%-96%). PARTICIPANTS:A total of 7,609 community-dwelling Medicare beneficiaries, 65 years or older. MEASUREMENTS:Symptoms assessed at baseline include pain, fatigue, breathing difficulty, sleeping difficulty, depressed mood, and anxiety. Total symptom count ranged from zero to six. Several outcomes were examined, including grip strength, gait speed, and overall lower-extremity function as well as incidence of recurrent falls (two or more per year), hospitalization, disability, nursing home admission, and mortality. RESULTS:Prevalence of zero, one, two, three, and four or more symptoms was 25.0%, 26.6%, 20.7%, 14.0%, and 13.6%, respectively. Symptom count increased with advancing age and was higher in women than in men. Pain and fatigue were the most common co-occurring symptoms. Higher symptom count was associated with decreased physical capacity. For example, participants with one, two, three, and four or more symptoms had gait speeds that were 0.04, 0.06, 0.09, and 0.13 m/s slower, respectively, than those with no symptoms, adjusting for specific diseases, total number of diseases, and other potential confounders (P < .001). The risk of several adverse outcomes also increased with greater symptom count. For example, compared with those with no symptoms, the adjusted risk ratios for recurrent falls were 1.48 (95% confidence interval [CI] = 1.30-1.70), 1.54 (95% CI = 1.32-1.80), 1.90 (95% CI = 1.55-2.32), and 2.38 (95% CI = 2.00-2.83) for older adults with one, two, three, and four or more symptoms, respectively. CONCLUSIONS:Symptoms frequently co-occur among community-dwelling older adults and are strongly associated with increased risk of a range of adverse outcomes. Symptoms represent a potential treatment target for improving outcomes and should be systematically captured in health records. J Am Geriatr Soc 67:223-231, 2019.
| S-EPMC6367017 | biostudies-literature
Project description:BackgroundChronic kidney disease (CKD) afflicts many older adults and increases the risk for medication-related adverse events.ObjectiveThe aim of this study was to assess the prevalence and associated morbidity and mortality of polypharmacy (use of several medications concurrently), and potentially inappropriate medication (PIM) use in older adults, looking for differences by CKD status.MethodsWe quantified medication and PIM use (from Beers criteria, the Screening Tool of Older People's Prescriptions, and Micromedex®) by level of estimated glomerular filtration rate (eGFR) for participants aged 65 years or older attending a baseline study visit in the Atherosclerosis Risk in Communities study (n =6392). We used zero-inflated negative binomial and Cox proportional hazards regressions to assess the relationship between baseline polypharmacy, PIM use, and subsequent hospitalization and death.ResultsMean age at baseline was 76 (± 5) years, 59% were female, and 29% had CKD (eGFR < 60 ml/min/1.73 m2). Overall, participants reported 6.1 (± 3.5) medications and 2.3 (± 2.2) vitamins/supplements; 16% reported ≥ 10 medications; 31% reported a PIM based on their age. On average, participants with CKD reported more medications. A PIM based on kidney function was used by 36% of those with eGFR < 30 ml/min/1.73 m2. Over a median of 2.6 years, more concurrent medications were associated with higher risk of hospitalization and death, but PIM use was not. While those with CKD had higher absolute risks, there was no difference in the relative risks associated with greater numbers of medications by CKD status.ConclusionPolypharmacy and PIM use were common, with greater numbers of medications associated with higher risk of hospitalization and death; relative risks were similar for those with and without CKD.
| S-EPMC6093216 | biostudies-literature
Project description:To determine whether cumulative symptom burden predicts hospitalization or emergency department (ED) visits in a cohort of older adults.Prospective, observational study with a baseline in-home assessment of symptom burden.Central Alabama.Nine hundred eighty community-dwelling adults aged 65 and older (mean 75.3 ± 6.7) recruited from a random sample of Medicare beneficiaries stratified according to sex, race, and urban/rural residence.Symptom burden score (range 0-10). One point was given for each symptom reported: shortness of breath, tiredness or fatigue, problems with balance or dizziness, leg weakness, poor appetite, pain, stiffness, constipation, anxiety, and loss of interest in activities. Dependent variables were hospitalizations and ED visits, assessed every 6 months during the 8.5-year follow-up period. Using Cox proportional hazards models, time from the baseline in-home assessment to the first hospitalization and first hospitalization or ED visit was determined.During the 8.5-year follow-up period, 545 (55.6%) participants were hospitalized or had an ED visit. Participants with greater symptom burden had higher risk of hospitalization (hazard ratio (HR) = 1.09, 95% confidence interval (CI) = 1.05-1.14) and hospitalization or ED visit (HR = 1.10, 95% CI = 1.06-1.14) than those with lower scores. Participants living in rural areas had significantly lower risk of hospitalization (HR = 0.83, 95% CI = 0.69-0.99) and hospitalization or ED visit (HR = 0.80, 95% CI = 0.70-0.95) than individuals in urban areas, independent of symptom burden and comorbidity.Greater symptom burden was associated with higher risk of hospitalization and ED visits in community-dwelling older adults. Healthcare providers treating older adults should consider symptom burden to be an additional risk factor for subsequent hospital utilization.
| S-EPMC3458585 | biostudies-literature
Project description:ObjectivesTo evaluate the independent association between symptom burden and physical function impairment in older adults with cancer.DesignCross-sectional.SettingTwo university-based geriatric oncology clinics.ParticipantsPatients with cancer aged 65 years or older who underwent evaluation with geriatric assessment (GA).MeasurementsSymptom burden was measured as a summary score of severity ratings (range = 0-10) of 10 commonly reported symptoms using a Clinical Symptom Inventory (CSI). Functional impairment was defined as the presence of one or more impairments of instrumental activities of daily living (IADLs), any significant physical activity limitation on the Medical Outcomes Survey (MOS), one or more recent falls in the previous 6 months, or a Short Physical Performance Battery (SPPB) score of 9 or less. Multivariate analysis evaluated the association between symptom burden and physical function impairment, adjusting for other clinical and sociodemographic variables.ResultsFrom 2011 to 2015, 359 patients with cancer and a median age of 81 years (range = 65-95 y) consented. The mean CSI score was 23.2 ± 20.5 with an observed range of 0 to 90. Patients in the highest quartile of symptom burden (N = 91; CSI score 52 ± 13) had a higher prevalence of IADL impairment (91% vs 51%), physical activity limitation (93% vs 65%), falls (55% vs 21%), and SPPB score of 9 or less (92% vs 69%) (all P values <.01) when compared with those in the bottom quartile (N = 81; CSI score: 2 ± 2). With each unit increase in CSI score, the odds of having IADL impairment, physical activity limitations, falls, and SPPB scores of 9 or less increased by 4.8%, 4.4%, 2.9%, and 2.5%, respectively (P < .05 for all results).ConclusionsIn older patients with cancer, higher symptom burden is associated with functional impairment. Future studies are warranted to evaluate if improved symptom management can improve function in older cancer patients. J Am Geriatr Soc 67:998-1004, 2019.
| S-EPMC7851835 | biostudies-literature
Project description:BackgroundElderly patients with chronic kidney disease (CKD) frequently present comorbidities that put them at risk of polypharmacy and medication-related problems. This study aims to describe the overall medication profile of patients aged ≥75 years with advanced CKD from a multicenter French study and specifically the renally (RIMs) and potentially inappropriate-for-the-elderly medications (PIMs) that they take.MethodsThis is a cross-sectional analysis of medication profiles of individuals aged ≥75 years with eGFR < 20 ml/min/1.73 m2 followed by a nephrologist, who collected their active prescriptions at the study inclusion visit. Medication profiles were first analyzed according to route of administration, therapeutic classification. Second, patients were classified according to their risk of potential medication-related problems, based on whether the prescription was a RIM or a PIM. RIMs and PIMs have been defined according to renal appropriateness guidelines and to Beer's criteria in the elderly. RIMs were subclassified by 4 types of category: (a) contraindication; (b) dose modification is recommended based on creatinine clearance (CrCl); (c) dose modification based on CrCl is not recommended but a maximum daily dose is mentioned, (d) no specific recommendations based on CrCl: "use with caution", "avoid in severe impairment", "careful monitoring of dose is required" "reduce the dose".ResultsWe collected 5196 individual medication prescriptions for 556 patients, for a median of 9 daily medications [7-11]. Antihypertensive agents, antithrombotics, and antianemics were the classes most frequently prescribed. Moreover, 77.0% of patients had at least 1 medication classified as a RIM. They accounted 31.3% of the drugs prescribed and 9.25% was contraindicated drugs. At least 1 PIM was taken by 57.6 and 45.5% of patients had at least one medication classified as RIM and PIM. The prescriptions most frequently requiring reassessment due to potential adverse effects were for proton pump inhibitors and allopurinol. The PIMs for which deprescription is especially important in this population are rilmenidine, long-term benzodiazepines, and anticholinergic drugs such as hydroxyzine.ConclusionWe showed potential drug-related problems in elderly patients with advanced CKD. Healthcare providers must reassess each medication prescribed for this population, particularly the specific medications identified here.Trial registrationNCT02910908.
| S-EPMC7057617 | biostudies-literature
Project description:BackgroundIn older adults, kidney function declines with age. People with advanced kidney diseases may have poor olfaction. However, it is unclear whether poor olfaction is a marker for declining renal function or future risk of chronic kidney disease (CKD). We therefore investigated olfaction in relation to kidney function and risk of CKD.MethodsThese secondary data analyses were limited to participants of the year 3 clinical visit of the Health Aging and Body Composition Study. The analytic sample size varied between 1427 to 2531, depending on participant eligibility and data availability for each analysis. Olfaction was tested using the Brief Smell Identification Test (B-SIT), defined as anosmia (score≤6), hyposmia (7-8), moderate (9-10), and good function (10-11) at baseline. We estimated glomerular filter rate (eGFR) at baseline and seven years later using the CKD-EPI creatinine-cystatin C equation, and defined incident CKD as eGFR<60 ml/min/1.73m2 and eGFR decline ≥1 ml/min/1.73m2/year. Further, we identified CKD hospitalization events from hospitalization and death records. We used inverse probability weighting and weighted multivariable regressions to account for censoring in the prospective analyses and used absolute risk regression to account for competing risk of death.ResultsAt baseline, compared to participants with good olfaction, the multivariable-adjusted mean eGFR was 3.00 ml/min/1.73m2 lower (95% confidence interval (CI): -5.25, -0.75) for those with anosmia and 1.87 lower (95% CI: -3.94, 0.21) for those with hyposmia with a P for linear trend < 0.001. Those with anosmia at baseline was had a significantly lower eGFR seven years later (-5.31, 95% CI: -8.58, -2.04, P for trend = 0.002), but the association was attenuated after further accounting for baseline eGFR (-2.37, 95%CI: -4.91, 0.16, P for linear trend = 0.147). Olfactory function was not associated with incident CKD or CKD hospitalization.ConclusionIn older adults > age 70 years, poor olfaction is associated with lower kidney function, but not future CKD risk. These associations should be further investigated in relatively younger population.
| S-EPMC8880852 | biostudies-literature
Project description:This study aimed to examine the association between medication-related factors and risk of hospital readmission in older patients with chronic kidney disease (CKD). A retrospective analysis was conducted targeting older CKD (n = 204) patients admitted to an Australian hospital. Medication appropriateness (Medication Appropriateness Index; MAI), medication regimen complexity (number of medications and Medication Regimen Complexity Index; MRCI) and use of selected medication classes were exposure variables. Outcomes were occurrence of readmission within 30 and 90 days, and time to readmission within 90 days. Logistic and Cox hazards regression were used to identify factors associated with readmission. Overall, 50 patients (24%) were readmitted within 30 days, while 81 (40%) were readmitted within 90 days. Mean time to readmission within 90 days was 66 (SD 34) days. Medication appropriateness and regimen complexity were not independently associated with 30- or 90-day hospital readmissions in older adults with CKD, whereas use of renin‒angiotensin blockers was associated with reduced occurrence of 30-day (adjusted OR 0.39; 95% CI 0.19⁻0.79) and 90-day readmissions (adjusted OR 0.45; 95% CI 0.24⁻0.84) and longer time to readmission within 90 days (adjusted HR 0.52; 95% CI 0.33⁻0.83). This finding highlights the importance of considering the potential benefits of individual medications during medication review in older CKD patients.
| S-EPMC6462973 | biostudies-literature
Project description:BackgroundOlder adults with chronic kidney disease (CKD) are at heightened risk for polypharmacy. We examined potentially inappropriate prescribing in this population and whether introducing pharmacists into the ambulatory kidney care model was associated with improved prescribing practices.MethodsRetrospective cohort study using linked administrative databases. We included patients with an eGFR ≤30 mL/min/1.73 m2 ≥66 years of age followed in multidisciplinary kidney clinics in Ontario, Canada (n = 25,016 from 28 centres). The primary outcome was the absence of a statin prescription or the receipt of a potentially inappropriate prescription defined by the American Geriatric Society Beers Criteria® and a modified Delphi panel that identified key drugs of concern in CKD. We calculated the crude cumulative incidence and incidence rate for the primary outcome and used change-point regression to determine if a change occurred following pharmacist introduction.ResultsThere were 6,007 (24%) and 16,497 patients (66%) not prescribed a statin and with ≥1 potentially inappropriate prescription, respectively. The rate of potentially inappropriate prescribing was 125.6 per 100 person-years and was higher in more recent years. The change-point regression analysis included 2,275 patients from two centres. No immediate change was detected at pharmacist introduction, but potentially inappropriate prescribing was increasing pre-pharmacist introduction, and this rising trend was reversed post-pharmacist introduction. The incidence of potentially inappropriate prescribing still remained high post-pharmacist introduction.ConclusionsPotentially inappropriate prescribing practices were common. Incorporating pharmacists into the kidney care model may improve prescribing practices. The role of pharmacists in the ambulatory kidney care team warrants further investigation in a randomized controlled trial.
| S-EPMC7444541 | biostudies-literature
Project description:Although progressive decline in physical activity and function are common in individuals with worsening CKD, little is known about the effect of dialysis initiation on physical activity. We assessed for any association of progression to dialysis in people with advanced CKD with temporal rates of change in physical activity and function. Canadian Frailty Observation and Interventions Trial (CanFIT) participants with an eGFR of <30 ml/min per 1.73 m2 were included. Outcomes included change in physical activity level, measured using the Physical Activity Scale for the Elderly, and physical function, measured using the chair stand, 4-m gait speed, and grip strength tests. Generalized linear regression models were conducted to determine whether dialysis initiation was associated with greater decline in physical activity or function. Of 386 individuals, 162 progressed to dialysis. Both assessments were completed by 98% of individuals for the Physical Activity Scale for the Elderly, 86% for the chair stand test, 84% for the gait speed test, and 91% for the grip strength test. Median (interquartile range) interassessment follow-up was 427 (357-578) days for the "stable advanced CKD" group and 606 (428-1000) days for the "progressed to dialysis" group. Self-reported physical activity and gait speed significantly declined in both groups. Mean (SD) chair stand time increased from 20.8 (17.1) to 24.0 (21.0) seconds among patients with stable advanced CKD, and from 18.5 (15.4) to 27.4 (22.2) seconds among those who progressed to dialysis (adjusted difference in change, 5.2 seconds; 95% confidence interval, 0.8 to 9.7 seconds; P=0.02). Patients with advanced CKD experience progressive declines in physical activity and function. Transition to dialysis is associated with accelerated decline in physical function, as measured by the chair stand test. This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_12_01_CJN07050521.mp3.
| S-EPMC8729498 | biostudies-literature