PCORI-Funded Research Tackles the Healthcare Questions of Older Adults
Older adults make up an increasingly large proportion of the population in the United States. This is due in part to advances in care leading to longer life spans and also to the aging of the large baby boomer generation. The US Census Bureau projects that by 2040, older adults will account for over 20 percent of the national population, including 14.6 million adults over the age of 85.
Older adults have special health needs. They are frequent users of healthcare services and require clinicians with expertise in treating the particular range of conditions and concerns that affect them. Older adults are at high risk of chronic illnesses and injuries that can limit their ability to perform daily activities, undermine their independence, and prevent them from remaining in their own homes as long as they’d like.
As we wrap up Healthy Aging Awareness Month, we are highlighting PCORI-funded projects focused on improving care for older adults and helping people to age with dignity. Our authorizing law directs us to pay particular attention to health problems that disproportionately affect certain populations, including older adults. We also are charged with focusing on conditions that affect many people and place a significant burden on society, areas rich in opportunities for improving care of older adults. Requiring that older adults be partners in all of the aging-focused projects we fund is part of our commitment to patient-centered outcomes research that can help patients and those who care for them make better-informed healthcare decisions.
Dementia and Alzheimer's Disease
Dementia, characterized by serious problems with memory, thinking, and social abilities, is a major cause of dependence and disability among older adults. Its prevalence increases with age—an estimated 25 to 30 percent of people 85 or older show declines in mental ability that interfere with their daily life. Among people with dementia, 60 to 80 percent have Alzheimer's disease—about 5 million people in the United States alone. That number is expected to increase three-fold by 2050. Although currently there is no cure, treatments aim to improve the quality of life of people with the disease and their caretakers. We are funding several studies that consider approaches to treating Alzheimer's disease and other dementias.
A California study, for instance, will evaluate a process known as goal attainment scaling to identify and rank the goals of Alzheimer's disease patients and their families. The list of goals will be fluid and responsive to changes in the patient’s clinical or social conditions. Patients and their care teams can weigh trade-offs, such as whether they prefer better symptom management over a potentially shorter life span.
A study conducted in Minnesota examines a program already in use for patients who have been diagnosed with mild cognitive impairment, which can be a precursor to developing Alzheimer's disease or another dementia. Currently, the behavioral intervention program includes an hour each of physical exercise, computer-based cognitive exercise, patient and family education, support group participation, and memory training. The PCORI-funded study will follow patients for six months to determine what mix of the components is most effective in preventing or delaying the onset of dementia.
In August 2015, we announced funding for a Patient-Powered Research Network (PPRN) to connect patients, caregivers, and researchers focused on patient-centered research addressing Alzheimer's disease and other dementias, especially in African Americans and Latinos. Both these groups have higher-than-average rates of dementia and are underrepresented in clinical research. The network will be part of Phase II of PCORnet, our National Patient-Centered Clinical Research Network. This PPRN will link multiple registries to consolidate clinical trial opportunities into one platform for easier patient access.
Barriers to Remaining Independent at an Advanced Age
One of the biggest fears among older adults is a loss of independence, which often comes when they have problems getting around on their own. We’re funding several projects on staying independent and maintaining mobility—and treating the conditions that typically thwart self-sufficiency.
Planning ahead may enable older adults to remain safely in their homes longer. A study in Illinois is testing an advance planning tool to help older adults project their health needs and plan ways to remain in their own homes when these crises occur. The research team will measure patient-centered outcomes that include understanding of health trajectories, knowledge of home services and how to access them, and communication with their families and health providers. (You can see a feature on this project here.)
A study in Pennsylvania is testing the outcomes of a challenging group exercise program called On the Move. The study will compare outcomes, including ability to walk and carry out basic daily functions, of people who participate in this program with those of participants in typical senior-housing exercise classes. The typical classes often encourage less-intense, seated movements.
Less than five percent of older adults get as much exercises as is recommended to stay strong and to avoid fractures. After a fracture, that number drops even lower. Another study in Pennsylvania will use community locations and volunteers provided with professional training and oversight to run a well- tested exercise program that includes individual coaching for 2,000 older adults who have had a fall-related fracture. The study will compare muscle and bone strength, loneliness, depression, use of emergency medical care, and rates of future fractures of those receiving the coaching and of people who did not participate in the exercise program after a fall-related fracture.
Can the choice of anesthesia during surgery affect how mobile patients will be after recovery? We recently announced an award under our new initiative of large-scale pragmatic clinical studies for a Pennsylvania project that will compare the outcomes of 1,600 adults age 50 and older undergoing hip fracture surgery. The study will compare patients who receive spinal anesthesia and those receiving general anesthesia, assessing complications, ability to walk and return home, and satisfaction with care.
With nearly a million knee and hip replacement surgeries performed in the United States each year, often among older adults, these are the most common operations paid for by Medicare. But despite their prevalence, questions remain. We recently announced an award for a pragmatic clinical study that plans to enroll 25,000 older adults undergoing elective knee or hip replacement. The study will be large enough to compare differences—across the board and in different subgroups—in rates of life-threatening blood clots among the blood thinners most commonly used for these operations.
Engaging Older Adults as Research Partners
PCORI is supporting several projects focused on helping individuals and communities to identify and address issues faced by older adults. Two such projects were recently funded under the Eugene Washington PCORI Engagement Awards program, which supports more active integration of patient, other stakeholder, and research communities in the research process.
One Alabama project focuses on issues faced by ethnically diverse older adults as they try to live in their homes and communities as long as possible, or “age in place.” The project team seeks to recruit and train community partners to provide advice on selecting research questions, developing culturally appropriate interventions and measures, and offering learning opportunities in their communities. The other project, based in Georgia, aims to prepare older adults from groups underrepresented in research to serve as advocates on research advisory boards. It will use a two-part educational intervention to build trust and rapport between older adults and researchers and increase opportunities for older adults to influence, participate, and collaborate in all phases of the research process.
We have also funded projects related to older adults in our Pipeline to Proposal Award program, which is helping build a national community of patients, researchers, and other stakeholders ready to participate in patient-centered CER. The program encourages partnerships that lead to high-quality research proposals.
Among the projects recently awarded a second round of Pipeline funding is a California project that is increasing awareness of a Shared Medical Appointments (SMA) program helping older adults maintain their health and independence. In addition to receiving screening and care for chronic conditions, participants come together for sessions that address the aging brain, risk of falls, and challenges of growing older. Another project, in Utah, is identifying means for clinicians to collaborate with those who care for older adults to optimize patient care and increase support for caregivers.
Finally, a New York project that recently received its first round of funding is focusing on complex problems of the growing population of people over 50 living with HIV in a semirural setting. And an award announced this week went to a study aimed at improving outcomes for adults 65 and older living with dementia, depression, and/or delirium. It will compare health outcomes of participants receiving currently available care management and of those assigned to home-based clinical care teams guided by nurse practitioners.
We will keep you informed as these and other projects that we fund begin to provide valuable evidence to support informed decision making among the ever-increasing pool of older adults and their caregivers. Please let us know your ideas for other projects in this area.