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Journal of the American Geriatrics Society Research Summary

Cognitive decline is the medical term for a decline in your abilities to think, remember, and make decisions. Researchers know now that cognitive decline may begin in midlife and can develop over a period of 20 years or so. In a new study, published in the Journal of the American Geriatrics Society (JAGS), researchers identified factors associated with brain health in middle age in order to identify ways to preserve brain function when people are older.

Several studies have shown links between changes in the senses and the development of cognitive decline. In earlier studies, the research team responsible for the new JAGS report found that problems with hearing, vision, or the sense of smell were associated with poorer cognitive function in middle-aged adults. These changes also have been linked to developing cognitive impairments for older people.

To learn more in this new work, the researchers used information from the ongoing Beaver Dam Offspring Study (BOSS; conducted from 2005 to the present), a study of the adult children of participants in the Epidemiology of Hearing Loss Study, a population-based study of aging.

Hearing, vision, and the ability to smell were measured with highly sensitive tests. The participants also took tests to measure their attention, thinking, and decision-making abilities, as well as their memory and ability to communicate. The researchers then combined the results of all these tests to use as a measure of the participants’ brain function. Blood tests and other measurements were also taken to create a complete health picture for each participant.

There were 2,285 participants included in this study, and most were younger than 65 years of age. Although those participants with signs of brain aging had overall worse performance on the sensory and cognitive tests, their losses in function were mild on average.

The researchers reported that participants who smoked, had larger waists, or had health issues related to inflammation or cardiovascular disease were more likely to show signs of brain aging. Older participants and those with diabetes were also more likely to develop brain aging over the following five years. Participants who exercised regularly or had more years of education were less likely to show signs of brain aging.

The researchers said their findings add to evidence that issues like diabetes, as well as other related health concerns impacting circulation, inflammation, and metabolism (the medical term for the chemical reactions in our bodies that help sustain life, such as converting food into energy), are important contributors to brain aging.

The researchers also noted that even minor injuries to the brain can have long-term effects on brain function. Participants with a history of a head injury had a 77 percent increased risk of developing brain aging. Symptoms of depression were also associated with an increased risk of brain aging.

The researchers said their findings suggest that some brain aging may be delayed or prevented. Just as middle-aged people can take steps to prevent heart disease by maintaining a healthy diet and weight and keeping physically active, they can also take steps to prevent early changes in brain health.

“Healthy lifestyles are important for healthy aging, and making healthy choices earlier in life may improve health later in life,” said lead author Carla R. Schubert, MS. The researchers concluded that identifying and targeting risk factors associated with poor brain function when people are middle-aged could help prevent cognitive decline with age.

This summary is from “Brain Aging in Midlife: The Beaver Dam Offspring Study.” It appears online ahead of print in the Journal of the American Geriatrics Society. The study authors are Carla R. Schubert, MS; Mary E. Fischer, PhD; A. Alex Pinto, MS; Yanjun Chen, MD; Barbara E.K. Klein, MD; Ronald Klein, MD; Michael Y. Tsai, PhD; Ted S. Tweed, MA; and Karen J. Cruickshanks, PhD.

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Journal of the American Geriatrics Society Research Summary

By today’s estimates, one-third of adults aged 65 or older are obese. This growing obesity trend, along with the decrease in our level of physical activity as we age, seriously raises our risk of diseases and death.

We know that aging leads to a gradual decrease in lean body mass (LBM). Put simply, LBM is the entire weight of your body minus the weight associated with fat tissue. As we age, fat distribution in the body can shift, and often increases in the belly region. This is a health concern for older adults, because so-called “belly fat” (also known as “central obesity”) is associated with a greater risk for heart disease than general obesity.

Now, a team of researchers have designed a study to learn more about the effects of a 10-week, easy-to-perform, personalized, progressive vigorous-intensity interval training among 70-year-olds with “belly fat.” Their study was published in the Journal of the American Geriatrics Society.

The researchers recruited participants between January 2018 and February 2018 from the Healthy Aging Initiative (HAI), an ongoing study conducted in northern Sweden. In the HAI, all of the 70-year-olds in the area were invited to participate in a free health survey. To date, 68 percent of the eligible population agreed to participate.

The participants who were assigned to the exercise group participated in a 10-week-long progressive exercise program starting in February 2018. The program consisted of short, supervised training sessions, performed in a group setting, three times per week for 10 weeks.

The 36 participants were taught to perform body-weight-training exercises with minimal use of equipment, at first for 18 minutes, alternating exercise with rest periods in a ratio of 40/20 (for example, 40 seconds of work and then 20 seconds of rest). The participants worked up to a 36-minute training period as their training volume gradually increased.

Thirty-six other participants maintained their daily living and routines throughout the study and served as a control group.

The participants were about 70 years of age, and about an equal number of men and women participated.

Participants in the exercise group decreased their fat mass by nearly two pounds and gained about one pound of lean body weight compared to the control group.

The researchers concluded that 10 weeks of vigorous intensity interval training improved body composition in older adults with belly fat. Those in the exercise group saw a nearly tripled decrease in their total fat mass compared with participants in the control group. The exercise group also saw positive effects on total lean body mass. The “do-ability” of the exercise program was reflected in the high attendance rates (89 percent) for the training sessions.

Interestingly, however, the exercise significantly decreased belly fat in the men but not the women who participated. It’s likely that more research is needed to explain this finding in greater detail.

Overall, the researchers suggested that the easy-to-perform exercises, designed to fit a home-environment without the need for expensive gym equipment, may be generalized to other settings and groups of people.

This summary is from “Effects of Interval Training on Visceral Adipose Tissue in Centrally Obese 70-Old-Individuals: A Randomized Controlled Trial.” It appears online ahead of print in the Journal of the American Geriatrics Society. The study authors are Marcel Ballin MSc; Emmy Lundberg BSc; Niklas Sörlén MSc; Peter Nordström MD, PhD; Andreas Hult PhD; and Anna Nordström MD, PhD.

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Journal of the American Geriatrics Society Research Summary

Poor sleep quality and peptic ulcer disease (PUD, a condition when sores known as ulcers develop on the lining of your stomach or in the first part of your small intestine) are both major public health problems that affect the physical and psychological wellbeing of older adults.

Poor sleep quality can be caused by age-related increases in chronic health conditions, medication use, sleep behavior changes, and other issues. It affects around one-third of all older adults. Peptic ulcers are common among older adults, too. They often result from the presence of a specific bacteria, Helicobacter pylori (H. pylori), in our gut. Thanks to the development of treatments for H. pylori infections, however, the rate of recurrent peptic ulcers (ulcers that consistently come back after treatment) has dropped dramatically. Few people who experience a recurrence of ulcers, for example, are infected with H. pylori.

However, that still doesn’t explain why some people experience recurrence.

Recently, a team of researchers designed a study to test their hypothesis that other factors besides the bacteria could cause peptic ulcer recurrence—and that poor sleep may be among them. They published their results in the Journal of the American Geriatrics Society.

The researchers enrolled 1,689 patients with H. pylori-infected peptic ulcer disease in their study. The participants received a 10-day course of anti-H. pylori treatment, followed by a four-week anti-ulcer therapy. Four weeks after treatment was completed, patients were tested and examined to see whether their ulcers had healed.

The researchers reported that 1,538 patients had achieved H. pylori eradication and had their peptic ulcers healed. These participants were then enrolled in a sleep study. They wore monitors that provided information about the length and quality of their sleep.

The 1,420 participants who completed the follow-up study were mostly around 69 years old and had a normal body weight. The participants who experienced a recurrence of their peptic ulcer had higher rates of heart disease, diabetes, and excessive alcohol consumption than those who had no recurrence. They also took longer to fall asleep, slept poorly, woke more during the night, and rated their sleep as poor compared to the participants who didn’t have a recurrence of ulcers.

The researchers concluded that poor sleep quality does indeed appear to contribute to the recurrence of peptic ulcers. They suggested that their findings highlight the importance of properly treating and preventing sleep problems in older adults with previous H. pylori-infected peptic ulcers.

This summary is from “Effect of subjective and objective sleep quality on peptic ulcer recurrence in older adults.” It appears online ahead of print in the Journal of the American Geriatrics Society. The study authors are Boye Fang, PhD; Huiying Liu, PhD Candidate; Shuyan Yang, PhD; Ruirui Xu, Master; and Gengzhen Chen, MD.

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Journal of the American Geriatrics Society Research Summary

Although the majority of patients who have blood cancers are older adults, they make up only a small percentage of participants in the clinical trials that lead to new therapies. That’s because the standard research methods used in oncology (cancer medicine) are not ideal for identifying certain vulnerabilities linked to aging, such as having multiple chronic diseases and being frail.

To help remedy that situation, the American Society of Clinical Oncology (ASCO) issued a guideline recommending that older adults who have cancer receive a geriatric assessment to see if they are at increased risk for experiencing side effects from medication and other complications from cancer and its treatment. Recently, a team of researchers examined older adults who have cancer to see whether their ability to manage daily activities as measured by these assessments was linked to staying alive longer. The team published their study in the Journal of the American Geriatrics Society.

A key part of the geriatric assessment is to determine how well an older adult performs the basic activities of daily living (ADLs). These include bathing, dressing, getting themselves from a chair to the bed (and vice versa), eating, grooming, and using the toilet.  The geriatric assessment also takes into account an older adult’s ability to perform instrumental activities of daily living (IADLS), or activities necessary for them to live on their own in the community. These activities include shopping, preparing meals, housework, taking medication, and handling their finances.

The researchers studied how performing daily activities was linked to survival and also to the use of medical care for adults living with cancer and aged 75 years and older. The researchers suspected that being unable to perform their daily activities would mean higher rates of death and unexpected visits to the Emergency Department (ED) and admissions to the hospital.

Participants included 464 people who on average were nearly 80 years old; 65 percent were male. All the participants were treated for blood cancers, including leukemia, multiple myeloma, and lymphoma, at the Dana-Farber Cancer Institute in Boston. About 38 percent of the participants had an aggressive form of blood cancer.

Of the participants, 11 percent reported they had trouble with at least one ADL and almost 27 percent had trouble performing at least one IADL.

The researchers also looked at a group of 318 participants who had visited the ED or had unplanned hospitalizations. Of them, 17 percent had at least one ED visit and 19 percent had at least one unplanned hospitalization. The five most common causes of hospitalization were pneumonia, fever, sepsis (the medical term for a blood infection), pain, and congestive heart failure.

For their main findings, the researchers reported that participants who had trouble performing at least one IADL had a higher risk for death, ED visits, and unplanned hospitalizations. This risk was not affected by how old they were, whether they had other chronic illnesses, how aggressive their cancers were, or the intensity of their cancer treatment.

What’s more, the researchers found that many of the patients who were dependent in performing their IADLS (meaning they relied on help from others) also had higher rates of age-related conditions, such as memory issues, problems with mobility, and feelings of loneliness or depression. The researchers concluded from their study that it is not only important to ask about function for older adults with blood cancer but to also screen for age-related conditions that could limit functioning.  Treating these other conditions to improve function might help older adults better tolerate the stress of blood cancers and their treatment, the researchers suggested.

This summary is from Function, Survival, and Care Utilization Among Older Adults with Hematologic Malignancies.” It appears online ahead of print in Journal of the American Geriatrics Society. The study authors are Clark DuMontier, MD; Michael A. Liu, MPH; Anays Murillo, MPH; Tammy Hshieh, MD, MPH; Houman Javedan, MD; Robert Soiffer, MD; Richard M. Stone, MD; Jane A. Driver, MD, MPH; and Gregory A. Abel MD, MPH.

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Journal of the American Geriatrics Society Research Summary

Acetaminophen (otherwise known by brand names such as Tylenol) is one of the most widely used pain relievers. Almost 60 years of widespread use have made acetaminophen a household product. It’s distributed over the counter (OTC) in most countries and judged safe by the scientific community. However, acetaminophen is also one of the most common medications involved in overdoses (the medical term for taking more of a medicine than you should) and is the most common cause of drug-induced liver failure.

Surprisingly, we are only now coming to understand how acetaminophen works—and recent research shows that we may need to develop a better understanding of the need for caution when using acetaminophen, especially when it comes to avoiding some of the risks associated with its use. Past research suggests these can range from increased asthma to interactions with other medications or the risk for developing other health concerns (such as kidney toxicity, bone fractures, or blood cancers).

Another important reason to look more carefully at all medications is that our bodies may react to these treatments differently as we age. Older adults experience physical changes as they age including, for example, reduced muscle mass, more fat tissue, changes in body composition, and less fluid in the body systems. Older people may also have multiple chronic conditions and take several different medications. These issues affect many different body functions, and that can raise your risk of having an unwanted reaction to a medication.

For all these reasons, a team of researchers decided to study the safety of acetaminophen in a nursing home setting. Their study was published in the Journal of the American Geriatrics Society.

The researchers’ aim was to explore any connection between acetaminophen use, death, and major heart events such as strokes and heart attacks in a large group of older adults living in nursing homes in southwestern France.

The researchers used information from the IQUARE study, which relied on two different questionnaires completed online by nursing home staffers. The researchers looked at deaths, heart attacks, and strokes that took place during the 18 months of the study period.

Of the 5,429 participants in the study, 3,190 were not taking acetaminophen and 2,239 were taking acetaminophen. Participants were around 86 years old and 74 percent were women.

The researchers reported that acetaminophen did not affect the number of heart attacks the participants experienced. There also was no increase in overall deaths.

The researchers found that the number of strokes was about the same in both groups—about 5 percent of the people who took acetaminophen had strokes, while about 4 percent of those who did not take acetaminophen had strokes. However, in participants who had diabetes, there was a slightly higher risk for stroke among people who took acetaminophen.

The researchers concluded that acetaminophen is a safe first choice in pain management for most older adults but should be considered with a bit more caution for older adults with diabetes.

As the population gets older and frailer, studies need to focus on the safety of the drugs these frail older adults commonly use to better our practice, said the researchers.

“My personal message to the people in my everyday practice is that any drug they take may have some form of harmful side effect unknown to them, even those they can buy over the counter. It is always best to check with your health care provider before you take any new medication, and make sure you’re taking the dose that’s right for you,” said study author Philippe Gerard, MD.

This summary is from “Acetaminophen safety: Risk of mortality and cardiovascular events in nursing home residents, a prospective study.” It appears online ahead of print in the February 2019 issue of the Journal of the American Geriatrics Society. The study authors are Philippe Girard, MD; Sandrine Sourdet, MD; Cantet Christelle MSc; Philipe de Souto Barreto, PhD; and Yves Rolland, PhD.

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Journal of the American Geriatrics Society Research Summary

The number of informal caregivers who look after older adults with cancer is on the rise. Caregivers could be relatives, partners, or even friends who provide assistance to people in order to help them function.

Most older people with cancer live at home and are dependent on informal caregivers for support with their cancer treatment, symptom management, and daily activities. Caregiving itself can also take a toll on a caregiver’s own physical and emotional well-being, which makes it important to ensure the proper supports are in place.

Until now, no large study has evaluated whether or not caring for older adults with advanced cancer is linked to caregivers’ emotional health or to their quality of life. Recently, researchers studied a group of adults aged 70 or older who had advanced cancer (as well as other challenges). This study used information from older patients with advanced cancer and their caregivers from local oncology practices enrolled in the “Improving Communication in Older Cancer Patients and Their Caregivers” study conducted through the University of Rochester National Cancer Institute Community Oncology Research Program Research Base between October 2014 and April 2017. Results from the study were published in the Journal of the American Geriatrics Society.

The researchers learned that the health problems of older patients with cancer were linked to a poorer quality of life for their caregivers, including poorer emotional health. This fact is confirmed by many other studies, which show that caregivers may even experience more emotional health challenges (such as anxiety, depression, and distress) than the people they care for, the researchers added.

What’s more, poorer patient health (measured by a geriatric assessment) was also associated with higher levels of caregiver distress.

The average caregiver in the study was 66 years old, though 49 percent of the caregivers were aged 70 or older. The majority of caregivers were female and white (non-Hispanic), and 67 percent were the patient’s spouse or partner who lived with them.

Close to 40 percent of the caregivers had serious chronic illnesses of their own. Nearly half (43.5 percent) said they experienced moderate to high distress, 19 percent reported having symptoms of depression, and 24 percent were anxious.

Interestingly, older caregiver experienced less anxiety and depression and better mental health, said the researchers. However, they were in poorer physical health. Being female was associated with experiencing less distress. An income of more than $50,000 a year also was linked to having better physical and mental health.

The researchers concluded that caregivers for older patients with advanced cancer are a vulnerable group. Thankfully, there are strategies caregivers can incorporate into their routines to help keep their own health and well-being top-of-mind. Talk with a healthcare provider about your own stress related to caregiving. If you prefer, you can ask to talk privately, without the person you care for present. Your healthcare provider may suggest ways to address the burdens you may experience with caregiving. There are strategies that have been found to help with specific tasks and challenges, decrease caregiver stress, and improve quality of life. You can learn more—and take a free and private assessment of caregiver health—at HealthinAging.org.

This summary is from “Quality of Life of Caregivers of Older Patients with Advanced Cancer.” It appears online ahead of print in the Journal of the American Geriatrics Society. The study authors are Lee A. Kehoe, MS, LMHC; Huiwen Xu, MHA; Paul Duberstein, PhD; Kah Poh Loh, MBBCh, BA; Eva Culakova, PhD; Beverly Canin; Arti Hurria, MD4; William Dale, MD, PhD; Megan Wells, MPH; Nikesha Gilmore, PhD; Amber S. Kleckner, PhD; Jennifer Lund, PhD; Charles Kamen, PhD; Marie Flannery, PhD; Mike Hoerger, PhD, MSCR; Judith O. Hopkins, MD; Jane Jijun Liu, MD; Jodi Geer; Ron Epstein, MD; and Supriya G. Mohile, MD, MS.

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Journal of the American Geriatrics Society Research Summary

Mild cognitive impairment (MCI) refers to having problems with your memory and decision-making abilities. Usually, people with MCI experience few if any problems with performing their daily activities. Experts say that MCI could be a stage between normal aging and Alzheimer’s disease.

A growing number of studies suggest that obstructive sleep apnea (OSA), or “sleep-disordered breathing,” is associated with a higher risk for memory problems and for problems with thinking and making decisions. OSA is a common condition in older adults who have MCI. Symptoms include disturbed sleep due to reduced or momentarily stopped breathing at night.

If your healthcare practitioner diagnoses you with OSA, she may recommend treatment with continuous positive airway pressure (CPAP), a pressurized mask worn during sleep. CPAP treatment eliminates obstructive sleep apnea. However, to be effective, people must use the CPAP machine regularly for at least four hours per night. Only 30 to 60 percent of people who are prescribed CPAP therapy use the machine regularly as prescribed. Additionally, few studies have confirmed whether or not CPAP treatment delays cognitive decline. Now researchers in a new study examined whether using CPAP treatment had an effect on slowing cognitive decline. Their study was published in the Journal of the American Geriatrics Society.

Researchers enrolled 68 participants with MCI, aged 55 to 89, who were patients at sleep and geriatric clinics from September 2012 through December 2014. Some of the participants used CPAP machines while others did not.

Researchers reported that participants who had MCI and who used the CPAP machine experienced cognitive improvement. The participants also experienced significantly less daytime sleepiness and improved attention levels.

What’s more, said the researchers, the group who had MCI but didn’t use the CPAP machine experienced significant cognitive decline.

The researchers said that their study, “Memories,” is the first clinical trial to show that using a CPAP machine can significantly improve cognitive function for people with MCI.

This summary is from “CPAP Adherence May Slow 1-Year Cognitive Decline in Older Adults with Mild Cognitive Impairment and Apnea.” It appears online ahead of print in the Journal of the American Geriatrics Society. The study authors are Kathy C. Richards, PhD; Nalaka Gooneratne, MD; Barry Dicicco, MD; Alexandra Hanlon, PhD; Stephen Moelter, PhD; Fannie Onen, MD; Yanyan Wang, PhD; Amy Sawyer, PhD; Terri Weaver, PhD; Alicia Lozano; Patricia Carter, PhD; and Jerry Johnson, MD.

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Journal of the American Geriatrics Society Research Summary

Gum disease (gingivitis) that goes untreated can become periodontitis. When this happens, the infection that affected your gums causes loss in the bone that supports your teeth. Periodontitis is the main cause of tooth loss in adults.Interestingly, periodontitis is also a risk factor for developing dementia, one of the leading causes for disability in older adults. A United Nations forecast estimates that 1 in 85 individuals will be diagnosed with Alzheimer’s disease, a form of dementia, by the year 2050. Reducing the risk factors that lead to dementia and Alzheimer’s disease could potentially lower older adults’ chances of developing those conditions.

Recently, researchers in South Korea studied the connection between chronic periodontitis and dementia. They published their findings in the Journal of the American Geriatrics Society.

The research team examined information from the National Health Insurance Service-Health Screening Cohort (NHIS-HEALS). In South Korea, the NHIS provides mandatory health insurance covering nearly all forms of health care for all Korean citizens. The agency also provides health screening examinations twice a year for all enrollees aged 40 years or older and maintains detailed health records for all enrollees.

The researchers looked at health information from 262,349 people aged 50 or older. All of the participants were grouped either as being healthy (meaning they had no chronic periodontitis) or as having been diagnosed with chronic periodontitis. The researchers followed the participants from January 1, 2005 until they were diagnosed with dementia, died, or until the end of December 2015, whichever came first.

The researchers learned that people with chronic periodontitis had a 6 percent higher risk for dementia than did people without periodontitis. This connection was true despite behaviors such as smoking, consuming alcohol, and remaining physically active. The researchers said that to their knowledge, this is the first study to demonstrate that chronic periodontitis could be linked to a higher risk for dementia even after taking lifestyle behaviors into account.

The researchers suggested that future studies be conducted to investigate whether preventing and treating chronic periodontitis could lead to a reduced risk of dementia.

This summary is from “Association of Chronic Periodontitis on Alzheimer’s Disease or Vascular Dementia.” It appears online ahead of print in the February 2019 issue of the Journal of the American Geriatrics Society. The study authors are Seulggie Choi, MD; Kyuwoong Kim, BSc; Jooyoung Chang, MD; Sung Min Kim, BSc; Seon Jip Kim, RDH; Hyun-Jae Cho, DDS, PhD; and Sang Min Park, MD, PhD, MPH.

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Journal of the American Geriatrics Society Research Summary

Caring for older adults with multiple chronic conditions can create challenging situations. For example, some treatments may be harmful to older adults who live with and manage several chronic conditions. In some cases, several treatments might be available but healthcare providers may not know which are best for a particular individual. In other cases, older adults and caregivers could even receive different treatment recommendations depending on the healthcare providers who offer guidance. Most important of all, managing care for multiple chronic conditions can make it difficult to focus on what matters most to us as individual—a key priority when we think about the high-quality, person-centered care we all want and need as we age.

In 2010, the American Geriatrics Society (AGS) convened a panel of medical experts to address how to provide the best care for older adults living with multiple chronic conditions. The panel reviewed a host of clinical studies and developed the AGS Guiding Principles for the Care of Older Adults with Multimorbidity as a result.

The expert panel identified five “key principles” that healthcare providers should follow to support the best care for older adults with multiple chronic conditions:

  1. Include personal preferences in care decision-making. Older adults who have multiple chronic health conditions should be asked how they wish to make medical decisions affecting their care. Whenever appropriate, caregivers and family members should also be involved in these discussions.
  2. Understand the limits of evidence on treatment options. Clinicians must understand that specific, evidence-backed answers to questions about the best medical choices for individual older adults may not exist. That’s because every older adult and every health situation is unique.
  3. Weigh benefits versus harms. When addressing multiple chronic conditions for an older individual, clinicians must consider how a person might be burdened by one medical plan or treatment versus others. They also must weigh the benefits of treatment options, as well as information on the person’s functional status (their ability to perform daily activities such as bathing and eating), life expectancy (how long they are likely to live), and quality of life.
  4. Consider if treatment is manageable. When sharing recommendations, clinicians must account for the complexity of a treatment and whether it suits an older adult’s particular situation.
  5. Make the best informed choice possible. Ultimately, healthcare professionals also must try to choose therapies that have the most benefit, pose the least harm, and will work to enhance an older person’s quality of life.

Now, an expert group of geriatricians, cardiologists, and general physicians have identified a set of action steps based on those guiding principles to help healthcare providers work with older adults and caregivers to make the best treatment choices possible when addressing multiple chronic conditions.

These steps include:

1) Identify and communicate your health priorities.

• Health Priorities and Decision-Making. There are many reasons we might make a decision about different health tests or treatments, but the best care possible supports decisions based on our personal needs and preferences. The first step toward supporting that type of care is identifying those needs and preferences.

Sitting down for a frank conversation with your health professionals, family, and caregivers can help you identify and communicate what matters most to you in your health and health care. We all prioritize things differently when we are faced with tradeoffs, which are common when we have multiple chronic conditions. The more you and those who care for you understand what matters most, the better you can align your healthcare to help achieve what matters most. For some people, what matters most may mean living as long as possible (even if our quality of life isn’t the same as it once was). For others, it may mean living independently as long as we can (even if that means choosing less aggressive treatments because they might impact our ability to live on our own). Some people make health decisions for religious reasons. Others may be most concerned about staying in a particular location. And others may make decisions based on additional, personal factors. It’s important to remember that none of these decision-making strategies are “right” or “wrong,” but they can only be implemented when you take the time to identify and discuss them with partners like your caregivers and health professionals.

• Health Trajectory & Your “Health Future.” Work with your health professionals to assess and take into consideration your anticipated future health when it comes to deciding on treatments. As older adults, our “health trajectory” and “health future” anticipate how likely it is that we will live for a given number of years, and how likely it is for us to continue performing our daily activities during that same timeframe. Discussing how our health and function may change over time helps identify the most beneficial treatments.

2) Stop, Start, or Continue Care Based on Health Priorities, Potential Benefits/Harms, and Health Trajectory.

• Understanding “Harmful Treatments” and “Medical Uncertainty.” “Do no harm” is a guiding principle for all of our health care. It’s also a principle that’s especially important for people who may be managing multiple treatment plans and how they interact (especially if they may result in unintended consequences when managed together). Since having more than one chronic condition means one health concern (or even its treatment) can worsen another, older adults need to work closely with their health professionals to assess all treatment options (including any treatments you may buy “over the counter” from a pharmacy or supermarket). We should consider the risks of each individual treatment plan in light of all the other care we may be receiving. It’s also important that we understand what potential outcomes from treatment may be “uncertain.” While research and health expertise gives our health professionals a solid sense of how safe and effective various treatment options may be, care is always personal (and not all research involves older adults specifically). That means that what’s very effective for one individual may not work for another. Knowing about uncertainties in advance can help us make educated decisions about the potential benefits and harms of different treatment options.

• Understanding “Beneficial Treatments.” Many beneficial treatments exist for older adults with multiple chronic diseases. Some are preventive (meaning they help us avoid a potential disease, such as getting an annual flu vaccine to avoid the flu virus). Some are diagnostic (meaning they help determine if we are living with a condition, such as a chest x-ray to see if you have pneumonia). Others, such as diuretics (water pills), control the symptoms of a chronic disease. And others are palliative (meaning they are designed to help make us feel better), rehabilitative (meaning they work to restore our function or quality of life), or supportive (meaning they help us to live as best as we can with a care condition or concern).

Though many of us may only think about “cures” when we consider treatment, it’s important to think about all these beneficial options when it comes to our care—especially because some options (like rehabilitation) may be even more helpful in promoting what we most want and need from care.

• Minimizing “Treatment Burden.” Older adults and caregivers managing multiple chronic conditions spend an average of two hours daily on healthcare-related activities. They also spend up to two hours at each healthcare visit—and there can be many visits to coordinate when you have multiple health concerns. This much care risks causing what health professionals refer to as “treatment burden” (the term for feeling overwhelmed or incapable when it comes to carrying out our treatment plans). When we consider all the options available for multiple chronic conditions, it’s important to consider which treatments may be most helpful in light of our abilities, and which—conversely—may be more difficult for us to follow or implement (especially when we may need assistance from a caregiver). Removing healthcare that is burdensome and not beneficial creates the opportunity to start care that is helpful and consistent with our own personal health priorities.

3) Align Decisions and Care for Us, Our Caregivers, and Our Clinicians Based on Our Health Priorities and Health Trajectory.

• Seeking Agreement on Health Priorities & Health Information. Two critical steps for anyone living with multiple chronic conditions are (1) identifying our own health priorities and (2) getting information on how treatment options can help us achieve our health priorities. To make the most of these actions, however, we need to make sure everyone involved in our care understands our care priorities and can help us make sense of health information based on our needs. Everyone involved in our care should be using the same information when it comes to decisions about treatment plans.

• Promoting Communication. Seeing a number of specialists for multiple chronic conditions can lead to fragmented healthcare (the term for care that feels uncoordinated or “choppy”). In some cases, fragmented care can lead to conflicting treatment recommendations from different providers, as well as burdensome treatments that may not be focused on what matters most to us individually. Decision-making and communication must fit into our care decisions and care plans. This means keeping an open, honest, and ongoing dialogue with our health providers, as well as any individuals (such as our caregivers) who we may want to play a role in our care. If you’re worried about coordinating care with different providers/offices, it may also be helpful to identify a primary point-of-contact (such as your geriatrician), who can gather information from all your providers and help you understand and assess different options.

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Journal of the American Geriatrics Society Research Summary

As we age, we become more likely to experience symptoms of depression. Research shows that depression’s symptoms can be linked to a higher risk for death. Yet often, older adults’ symptoms of depression may be missed by healthcare professionals.

What’s more, symptoms of depression have been linked to heart disease and stroke in middle-aged and older adults. Researchers suggest that the depression-heart disease link could play a role in the increased risk of death among older adults who have symptoms of depression. There’s also a known link between depression and deaths from cancer and falls in older adults. These connections might contribute to an increased risk of death for older adults, researchers suggest.

Since depression symptoms change over time, it’s possible that studying those symptoms during an older adult’s doctor visits could provide more information. To learn more, a research team designed a study to investigate the role depression symptoms play in an increased risk of death over time. The team also examined the role heart disease and stroke play in the link between depression symptoms and increased risk of death. Their study was published in the Journal of the American Geriatrics Society.

The researchers used information from the Three-City Study, a French study that investigated dementia, heart disease, and stroke in people aged 65 and older during five healthcare visits the participants made over 10 years.

At the start of the study, 16 percent of 9,294 participants had a history of heart disease. Most participants were around 73 years old; 37 percent were men.

About 23 percent of participants had symptoms of depression when the study began (28 percent of women and 13 percent of men). Almost 7 percent were taking medication for their depression. At three follow-up visits, the participants were tested again for symptoms of depression.

When the participants were monitored for depression symptoms at several visits over time, symptoms of depression were linked to an increased risk for death, including death from heart disease and stroke. However, those diseases explained only a small percentage of the deaths associated with depression symptoms over time.

The researchers said their study suggested that, for older adults living with depression, preventing heart disease may not be the only factor that will help prevent or delay death. Interestingly, antidepressants were not associated with an increased risk of death in this study.

This summary is from “Depression increases the risk of death independently from vascular events in elderly. The 3C Study.” It appears online ahead of print in the Journal of the American Geriatrics Society. The study authors are Renaud Péquignot, MD, PhD; Carole Dufouil, PhD; Karine Pérès, PhD; Sylvaine Artero,PhD; Christophe Tzourio, MD, PhD; and Jean-Philippe Empana, MD, PhD.

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