Time-limited trials for acute dialysis decision-making for critically ill older patients: rationale, communication strategies, and future research.

The incidence and distribution of acute and chronic dialysis among patients with heart failure (HF), stratified by diabetes, remain uncertain. We hypothesized that with improved survival and rising comorbidities, the demand for dialysis would increase over time. Patients with incident HF, aged 18 to 100 years, between 2002 and 2016, were identified using Danish nationwide registers. Primary outcomes included acute and chronic dialysis initiation, HF-related hospitalization, and all-cause mortality. These outcomes were assessed in 2002 to 2006, 2007 to 2011, and 2012 to 2016, stratified by diabetes. We calculated incidence rates (IRs) per 1000 person-years and hazard ratios (HR) using multivariable Cox regression. Of 115 533 patients with HF, 2734 patients received acute dialysis and 1193 patients received chronic dialysis. The IR was 8.0 per 1000 and 3.5 per 1000 person-years for acute and chronic dialysis, respectively. Acute dialysis rates increased significantly among patients with diabetes over time, while no significant changes occurred in those without diabetes, chronic dialysis, HF-related hospitalization, or overall mortality. Diabetes was associated with significantly higher HRs of acute and chronic dialysis, respectively, compared with patients without diabetes (HR, 2.07 [95% CI, 1.80-2.39] and 2.93 [95% CI, 2.40-3.58] in 2002 to 2006; HR, 2.45 [95% CI, 2.14-2.80] and 2.86 [95% CI, 2.32-3.52] in 2007 to 2011; and 2.69 [95% CI, 2.33-3.10] and 3.30 [95% CI, 2.69-4.06] in 2012 to 2016). The IR of acute and chronic dialysis remained low compared with HF-related hospitalizations and mortality. Acute dialysis rates increased significantly over time, contrasting no significant trends in other outcomes. Diabetes exhibited over 2-fold increased rates of the outcomes. These findings emphasize the importance of continued monitoring and renal care in patients with HF, especially with diabetes, to optimize outcomes and prevent adverse events.

Decision-Making in Patients With Cancer and Kidney Disease

Time-Limited Trials for Patients With Critical Illness: A Review of the Literature

Acute kidney injury is a serious complication of elective major surgery. Acute dialysis is used to support life in the most severe cases. We examined whether rates and outcomes of acute dialysis after elective major surgery have changed over time. We used data from Ontario's universal health care databases to study all consecutive patients who had elective major surgery at 118 hospitals between 1995 and 2009. Our primary outcomes were acute dialysis within 14 days of surgery, death within 90 days of surgery and chronic dialysis for patients who did not recover kidney function. A total of 552,672 patients underwent elective major surgery during the study period, 2231 of whom received acute dialysis. The incidence of acute dialysis increased steadily from 0.2% in 1995 (95% confidence interval [CI] 0.15-0.2) to 0.6% in 2009 (95% CI 0.6-0.7). This increase was primarily in cardiac and vascular surgeries. Among patients who received acute dialysis, 937 died within 90 days of surgery (42.0%, 95% CI 40.0-44.1), with no change in 90-day survival over time. Among the 1294 patients who received acute dialysis and survived beyond 90 days, 352 required chronic dialysis (27.2%, 95% CI 24.8-29.7), with no change over time. The use of acute dialysis after cardiac and vascular surgery has increased substantially since 1995. Studies focusing on interventions to better prevent and treat perioperative acute kidney injury are needed.

Renal Support for Acute Kidney Injury in the Developing World

Social support can take many forms, such as practical help, time spent socially with others, or the satisfaction with personal relationships. Social support is known to affect quality of life (QoL) in both non-autistic older and autistic young adults. QoL reflects how satisfied an individual is with their life either overall or in a certain area. We know little about middle-aged and older autistic adults' experiences of social support or QoL. In this study, 388 adults aged 40-83 years old, completed online questionnaires asking about background such as age and sex, depression and anxiety symptoms, QoL (physical, psychological, social, environmental, and autism-specific), and different types of social support. Even after taking into account background, depression, and anxiety, social support was important for individuals' QoL. To our knowledge this is the first paper to examine the relationship between social support and QoL in middle-aged and older autistic adults. Improving social support may have a significant impact on the QoL of older autistic adults. Future studies should examine whether age-related changes in social support (size, content, and arrangement of social networks) that are common in non-autistic aging, also occur among older autistic adults.

Since the initial scientific statement on Secondary Prevention of Coronary Heart Disease (CHD) in the Elderly was published in 2002,1 several trends have continued that make an update highly appropriate. First, the graying of the US population and those of other industrialized countries has progressed unabated because more adults are surviving into their senior years. The number of Americans aged ≥75 years was estimated at 18.6 million in 2010, representing ≈6% of the population,2 and it is expected to double by 2050. The population aged ≥85 years is growing the most rapidly, with numbers expected to reach 19.5 million by 2040. In 2008, 67% of the 811 940 cardiovascular deaths in the United States occurred in people aged ≥75 years.3 In parallel to this increase in the older adult demographic, the number of Americans with CHD has increased to an estimated 16.3 million, more than half of whom are >65 years of age.3 Similarly, 7 million have had a stroke, the incidence of which approximately doubles with successive age decades after 45 to 54 years.3 Peripheral artery disease (PAD) affects 8 to 10 million Americans, the majority of whom are >65 years of age. Between 2015 and 2030, annual US costs related to atherosclerotic cardiovascular disease (ASCVD) are projected to increase from $84.8 billion to $202 billion.3 Moreover, given that ASCVD often undermines functional capacity and independence and increases reliance on long-term care, indirect expenses related to ASCVD are also expected to increase. Thus, the need for effective secondary prevention measures in the older adult population with known ASCVD has never been greater. Notably, the 2011 American Heart Association (AHA)/American College of Cardiology Foundation (ACCF) updated guidelines for secondary prevention of CHD broadened …

Emotional approach coping involves active attempts at emotional expression and processing in response to stressful circumstances. This study tested whether dispositional emotional approach coping processes predict changes in physical and mental health in community-dwelling older adults, particularly within the context of higher perceived stress. To test this, older adults (N = 150) completed assessments of emotional expression and emotional processing at study entry. They also completed measures of perceived stress, depressive symptoms, and ill-health (a composite of subjective and objective physical health indicators, which included blood draw for collection of biomarkers), every 6 months over 4.5 years. Emotional processing and emotional expression were not related significantly to ill-health at study entry. However, emotional processing (but not emotional expression) significantly predicted changes in ill-health. At higher levels of emotional processing, ill-health remained low and stable; at lower levels of emotional processing, ill-health increased over time. However, when perceived stress was high, higher emotional processing and emotional expression were related to lower depressive symptoms at study entry, but higher emotional processing was associated with increasing depressive symptoms over time. Emotional approach coping processes evidence prospective relations with health outcomes, which are partially conditioned by stress perceptions. Emotional processing appears to have a protective impact against declining physical health. Predictive relationships for depressive symptoms are more complex. Older adults with chronically high perceived stress might benefit from interventions that target emotion-regulating coping processes. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Older adults account for a disproportionate share of the morbidity and mortality after traumatic brain injury (TBI). Predicting functional and cognitive outcomes for individual older adults after TBI is challenging in the acute phase of injury. Given that neurologic recovery is possible and uncertain, life-sustaining therapy may be pursued initially, even if for some, there is a risk of survival to an undesired level of disability or dependence. Experts recommend early conversations about goals of care after TBI, but evidence-based guidelines for these discussions or for the optimal method for communicating prognosis are limited. The time-limited trial (TLT) model may be an effective strategy for managing prognostic uncertainty after TBI. TLTs can provide a framework for early management: specific treatments or procedures are used for a defined period of time while monitoring for an agreed-upon outcome. Outcome measures, including signs of worsening and improvement, are defined at the outset of the trial. In this Viewpoint article, we discuss the use of TLTs for older adults with TBI, their potential benefits, and current challenges to their application. Three main barriers limit the implementation of TLTs in these scenarios: inadequate models for prognostication; cognitive biases faced by clinicians and surrogate decision-makers, which may contribute to prognostic discordance; and ambiguity regarding appropriate endpoints for the TLT. Further study is needed to understand clinician behaviors and surrogate preferences for prognostic communication and how to optimally integrate TLTs into the care of older adults with TBI.

Objective:Epilepsy is the third most common neurological disorder among older adults, and as adults are living longer, the incidence of epilepsy is increasing (Kun Lee, 2019). The purpose of this study is to examine 1. differences in quality of life (QOL) between older and younger adults with medically intractable epilepsy and 2. the impact of seizure frequency, seizure duration, depression, sex, and marital status on QOL. Given differences in the prevalence rates of depression between men and women and importance of depression in QOL, we predicted that sex and marital status would moderate the effect of depression on total QOL (TQOL).Hypothesis I: Compared to younger adults, older adults with epilepsy will report lower TQOL scores and lower scores on subscales measuring energy/fatigue, cognition, and medication effects. Hypothesis II: Seizure variables and depression will significantly account for TQOL scores in both groups (younger and older) above demographic variables (sex, marital status, and education). Hypothesis III: Sex will moderate the effect of depression in both groups and marital status will moderate the effect of depression only in the older adults.Participants and Methods:Participants were 607 adults (> 18 years old) who were prospective candidates for epilepsy surgery and underwent a comprehensive neuropsychological evaluation including QOL assessment using the Quality of Life in Epilepsy Scale-31 (QOLIE-31). Individuals were grouped by older (> 50 years old; N = 122) and younger adults (< 50 years old; N = 485). Hierarchical regression was used to examine the proposed associations.Results:Hypothesis I: In contrast to our hypothesis, a one-way ANOVA did not reveal significant differences between the older and younger groups on the QOL subscales, TQOL, or depression.Hypothesis II: For older adults, longer seizure duration was associated with better TQOL; bivariate correlations showed no evidence of statistical suppression. Higher depression scores were associated with worse TQOL. Overall, the model accounted for 39.6% of variance among older adults. For younger adults, only depression was a significant predictor of TQOL wherein higher depression scores were associated with worse TQOL. Overall, the model accounted for 36.1% of the variance among younger adults. Hypothesis III: There was no moderation between depression and marital status in older or younger adults (b = -.009, p > .05). There was multicollinearity evidenced by VIF (variance inflation factor) greater than 10, so the associations between depression and sex could not be examined.Conclusions:Overall, there were no significant differences between QOL in younger versus older adults. Greater depression symptoms were associated with lower TQOL in both groups. Longer seizure duration was a significant predictor of better TQOL in older adults only, perhaps indicating better adjustment to having a seizure disorder with longer duration of epilepsy. Lastly, marital status did not moderate the effects of depression on TQOL and the moderating effects of sex on TQOL could not be assessed due to multicollinearity. Study limitations include dichotomizing the sample into these particular age groups and the heterogeneity of seizure types.

Despite well-documented declines in most cognitive domains, some emotional processes appear to be preserved or even enhanced in late adulthood. A good example of this is the information processing bias older adults show towards positive relative to negative emotional stimuli, often referred to as the age-related positivity effect. The present thesis presents a series of experiments that were designed to better understand the mechanisms that contribute to age-related changes in emotional processing, focusing in particular on the role of cognitive mechanisms and neural networks. In Study 1 aimed to identify the underlying cognitive mechanisms of the positivity effect. The primary focus of this study was to explore the role of distractors during the early attention allocation stage, and to also measure how selective attentional processes during encoding influence later memory outcomes for emotional items. The results showed that consistent with prior literature, a memory positivity effect was found among older relative to younger adults. However, of particular interest was the finding that, participants’ memory for negative targets was not influenced by the presence of positive distractors. This finding suggests that positive distractors did not automatically capture older adults’ attention during encoding for negative items. Importantly, we found that participants’ pupillary responses to negative items mediated the relationship between age and the memory positivity effect, indicating that older adults use their cognitive control resources when encoding negative information, perhaps to down regulate the impact of negative emotions on their memory. Collectively, these two findings provide converging support for the cognitive control account of the positivity effect. Study 2 used a similar paradigm to Study 1 to examine the underlying neural networks involved in processing emotional items during working memory encoding among older and younger adults. Results indicated that a cognitive control network that included fronto-parietal regions, was functionally connected to the left ventrolateral prefrontal cortex during the encoding of negative items among older adults. This network contributed to performance, both accuracy and response times, in older adults’ group. A less distributed network was found for encoding of positive items among older and both items among younger adults. Although older adults recruited a same network that was functionally connected to the amygdala for encoding positive and negative items, younger adults recruited this particular network specifically for encoding negative items. This network facilitated older adults’ higher accuracy and faster response times during retrieval. Taken together, the results from these functional connectivity analyses suggest that there is differential engagement of brain networks connected to these two regions, which are modulated by the emotional valence. While two separate brain networks underlying the encoding of emotionally valence targets are connected to the vlPFC region, one distinct network is functionally connected to the amygdala and subserves the processing of both positive and negative targets. In Study 3 age-related differences in neural substrates involved when processing happy and angry expressions presented with direct versus averted gaze were investigated. This research was motivated by studies that show older adults not only have difficulties processing emotional cues such as facial expression and eye gaze cues, but also have problems integrating these cues. Study 3 provides the first empirical examination of the underlying neural correlates of age-related difficulties in integrating communicative cues. The results showed that for angry facial expressions, younger adults recruited distinct networks while processing direct versus averted eye-gaze cues, however, older adults showed a lack of neural sensitivity to these cues, recruiting a single network for both types of stimuli. In contrast, for happy facial expressions, only older adults showed neural sensitivity to eye gaze cues. Participants’ performance on the scanner task was then correlated with a measure of theory of mind (TOM). Younger (but not older) adults’ performance on a measure of TOM and recognition of angry expressions was differentially correlated with activation in two sets of brain regions as a function of eye gaze. Unlike younger adults, older adults’ performance on TOM was also differentially correlated with the key node of mentalizing brain network during happy expressions as a function of eye gaze. The findings from Study 3 suggest that the age-related difficulties in integrating facial cues could be associated with the recruitment of the mentalizing network when the task imposes high demand on social-cognitive processing. Taken together, the three Studies reported in this thesis provide novel insights into our understanding of age-related differences in the processing of emotionally valenced items, particularly with respect to initial encoding of this information, and how this relates to later memory outcomes. Moreover, for the first time the neural correlates of integrating two important types of facial cue has been identified, and potentially linked to broader social cognitive difficulties. Overall, the findings of this thesis have broad implications for understanding the underlying cognitive mechanisms and neural networks that contribute to age-related differences in the processing of emotional stimuli.

EVERY YEAR MORE THAN 1 MILLION HOSPITALIZATIONS in the United States are complicated by acute kidney injury, accounting for an estimated $10 billion in excess costs to the health care system. Acute kidney injury has been shown to be a potent predictor of excess length of stay, morbidity, and mortality in a number of clinical settings. The incidence of acute kidney injury has increased more than 4-fold since 1988 and is estimated to have a yearly population incidence of more than 500 per 100 000 population—higher than the yearly incidence of stroke. Survival from an episode of acute kidney injury may be increasing by virtue of advances in critical care medicine and dialysis technologies. In short, more hospitalized patients are being discharged alive after an episode of acute kidney injury. The report by Wald and colleagues in this issue of JAMA provides valuable insights into the complex complications faced by survivors of an episode of severe acute kidney injury. Using linked administrative health databases covering the entire province of Ontario, Canada, the authors addressed the long-term risks of death and dialysis dependence among individuals who developed acute kidney injury requiring acute temporary dialysis during hospitalization. During a 10-year period between 1996 and 2006, they identified 18 551 individuals with acute kidney injury requiring dialysis, which corresponds to an approximate yearly incidence of 19 per 100 000 population—lower than the estimate of 24.4 per 100 000 population reported in Northern California between 1996 and 2003. After excluding 3321 individuals who had previous acute kidney injury, dialysis, or kidney transplantation in the preceding 5 years, and 202 who had extreme lengths of hospital stay, the authors identified 15 028 patients with a first hospitalization for acute kidney injury requiring dialysis. More than 40% of these individuals died during hospitalization, in keeping with previous reports of the grave implications of severe acute kidney injury. Nearly half of these patients recovered kidney function for at least 30 days following hospitalization, attesting to the remarkable ability of the kidneys to repair and regenerate even after severe, dialysis-requiring injury. Another 23% of patients required further dialysis within 30 days of discharge, but it is not reported how many of those required chronic dialysis. The final study cohort included 4066 survivors, 3769 (92.7%) of whom were matched to control patients and observed for a median of 3 years after discharge. Even among this selected cohort of survivors, mortality rates exceeded 10% per year. One of every 12 survivors of acute kidney injury requiring acute dialysis required subsequent initiation of chronic dialysis despite being dialysis-free at 30 days after discharge. These findings are noteworthy even without considering the next step in the analysis, which was to compare this incidence rate against that of matched individuals without acute kidney injury. From the perspective of a clinician caring for an individual with severe acute kidney injury, the findings by Wald et al provide an important quantitative estimate that can be shared with affected patients and their families: even in the best of circumstances—meaning survival during hospitalization and recovery of kidney function sufficient to stop dialysis for a month—there is almost a 10% chance of requiring chronic dialysis in the next few years. The chronic dialysis incidence rate reported by Wald et al is 72 times higher than that reported for the general population in the United States in 2006 (366/1 million person-years). This finding has important implications for the postdischarge care of patients successfully treated with acute temporary dialysis: follow-up care with a nephrologist for secondary prevention is absolutely necessary. These findings also highlight the magnitude of the problem of acute kidney injury as a cause of end-stage renal disease (ESRD): extrapolating from the data of Wald et al, a rough estimate of the yearly incidence of ESRD due to acute kidney injury is 0.3 per 100 000 population, which is approximately onethird of the incidence of ESRD secondary to cystic kidney disease. The true magnitude is even higher because this estimate does not consider the 3481 individuals excluded from the final cohort because of the need for dialysis during the

This study aimed to (1) explore the quality of life (QoL) profiles of older adults in Hong Kong and (2) examine their association with predictors (age, sex, body mass index, and depressive symptoms) and distal outcome (cognitive impairment) using a person-centered approach. A total number of 328 community-dwelling older adults in Hong Kong were invited to participate in this study. Data from 259 older adults were identified as valid for the primary analysis. Latent profile analysis was used to explore QoL profiles. Multinomial logistic regression using the R3STEP function in Mplus was used to explore the predictive role of age, sex, body mass index, and depressive symptoms in profile membership. The Bolck-Croon-Hagenaars approach was used to examine how the distal outcome of cognitive impairment differs as a function of QoL profiles. Three QoL profiles emerged from the latent profile analysis (Low, Moderate and High QoL). It was found that depression, but not age, sex, or body mass index, significantly predicted QoL profile membership. The results of the Bolck-Croon-Hagenaars analysis revealed no significant differences in cognitive impairment across the three QoL profiles. This is the first study that examined the relationship between QoL, depressive symptoms and cognitive impairment of older adults using a person-centered approach. The findings provide additional information for the evidence obtained from variable-centered approach on the associations among variables abovementioned. Our additional focus on the antecedents of emergent QoL profiles also provide practical knowledge regarding timely treatment for or prevention of depressive symptoms, which we submit will be crucial for enhancing the QoL of older adults.

Social Isolation of Older Adults in Long Term Care as a Result of COVID-19 Mitigation Measures During the COVID-19 Pandemic

Exploring the influence of walking on quality of life among older adults: Case study in Hohhot, China