Pneumonia and Influenza Hospitalizations in People Age 65 and Older with Cognitive Impairment M. Pandita1, P. Minihan1, D. Castronovo2, J. MacDonald1, S.M. Parisi1, E.N. Naumova1 1 Tufts University School of Medicine 2 Mapping Sustainability, LLC

Background: The Aging Population In 2000: 36 million of 65+years (12.5%) 30% of elderly Americans (~11 million) lived in 77 densely-populated urban metropolitan counties with a total population of over 200,000 people and an average of over 1,000 people per square mile the other 70% (~25 million) of elderly resided in 2,715 rural counties with an average of 76 people per square mile In 2030: estimated 71.5 mil of 65+years (20%). [1] References: Federal Interagency Forum on Aging-Related Statistics. Older Americans 2004: Key Indicators of Well- Being. Washington, DC: U.S. Government Printing Office. (2004).

Aging Communities in the US

Background: Elderly, Pneumonia & Flu Pneumonia and influenza (P&I) are the 5th leading causes of death in the elderly.[2] Potential cognitive, systemic and geographic barriers to receiving prompt care. Barriers to accessing healthcare services  Length of time between symptom onset and treatment  P&I related morbidity and mortality References: 2. N.R. Sahyoun, H. Lentzner, D. Hoyert and K.N. Robinson, Trends in Causes of Death Among the Elderly. Aging Trends 1 (2002), pp. 1–10.

Background: Cognitive Impairment Cognitive Impairment (CI) - general term, referring to deficits in memory, language and communication, executive functioning and/or other neurological processes. Dementia –“moderate to severe” CI entailing cognitive deficits and impaired daily functioning.[3] Alzheimer’s Disease is the most common form.[4] Patients with dementia report fewer symptoms during outpatient visits, despite similar degrees of medical comorbidity.[5] While dementia affects only 3-11% of older Americans, 50-70% of these elderly reside in nursing homes .[4] -Cognitive Impairment generally measured via a questionnaire. Not an official diagnosis in an of itself. A sign of other diagnoses. -Make the point that our data capture those with Mod-severe CI, not mild. You need to have mod-severe to be classified as having dementia, or mental retardation, or alzheimers, etc… -So we are focusing on the nursing home patients in the CMS data set as a group of extra risky patients. References: 3. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000. Cullum CM, Rosenberg RN. Memory Loss: When is it Alzheimer Disease? JAMA (1998) ;279:1689-1690 McCormick WC et al. Symptom Patterns and Co-morbidity in the Early Stages of Alzheimer's Disease. J Am Geriatr Soc (1994); 42: 517-521.

Percentage of U.S. Elderly Living in Nursing Homes Census 2000 We already know from our previous research that… This represents over half of the cognitively impaired in the country.

Annual P&I Hospitalization Rates Among U.S. Elderly 1992-2002 A number of factors could contribute to the higher rural hospitalization rates in the elderly: some of these could be intrinsic to rural health care and others to the rural environment. For health care differences, one factor is the Medicare-based physician bonus to improve medical coverage in rural areas. Another is increased avoidable hospitalizations for acute diseases such as influenza-induced pneumonia due to less frequent use of primary care services in those remote areas. Only nine percent of the nation’s physicians and ten percent of specialists practice in rural areas. As a result, residents of rural areas have less contact and fewer visits with physicians and are more likely to be hospitalized due to the lack of immediate medical attention with the onset of disease [25].

Research Objectives: Overall: To examine P&I hospitalizations in the US elderly, in relationship with various co-morbidities and socio-economic factors associated with aging and immunity to influenza, using innovative analytical technologies. Preliminary Analysis: 1) Quantify and describe the distribution of P&I hospitalizations among cognitively impaired elderly. 2) Examine whether elderly with Alzheimer’s disease are at an elevated risk for influenza complications and potentially in need of special considerations during influenza outbreaks. Focus on Influenza: Under-diagnosed in the elderly More likely than pneumonia to lead to complications Excess risk of mortality Because the majority of those with CI are in nursing homes, and because P&I hospitalitzation rates and nursing home % are geographically related, we have targeted the cognitively impaired in nursing homes as an extra-risky group.

Research Hypothesis: We say snf=special care, and nursing home. Do we want to stick to one term?

Methodology: Source of Data Dataset: Centers for Medicare & Medicaid Services (CMS) Databases Part A Hospitalization Claims Time Period: 5 Years of Data (1998 – 2002) Coverage: U.S. Elderly (≥65yo) 2000 34,795,453 (12.4% of U.S. Population)[7] Medicare beneficiaries ~ 95% of all elderly Total Number of CMS records 62,301,882 Avg. Number of CMS records/year 12,460,376 the most detailed and complete dataset of hospitalization records for Americans aged 65+. References: 7. We the People: Aging in the United States. Census 2000 Special Reports. US Census Bureau (Dec. 2004)

Methodology: Data Abstraction 62,301,882 records 6,277,684 records 1,865,996 records 26,779 records 3,853 records Total Number of CMS Hospitalization Records Abstracted records with Pneumonia and/or Influenza (ICD-9CM codes: 480-487) 30% of records had an indication of a potential cognitive impairment (loosely defined as ICD-9CM codes 290-359). Potential cognitive impairment records with a diagnosis of influenza. Selected records with influenza and Alzheimer’s Disease, specific for this analysis. Alzheimer's Disease, the most common form of dementia, affects nearly 4 million people and is the fourth leading cause of death for the elderly.[4]

Objective #1: Quantify and describe the distribution of P&I hospitalizations among cognitively impaired elderly.

Distribution of P&I Hospitalization Codes 1998-2002, National Average ICD Code Condition Total Cases Percent of Total 486 Pneumonia, organism NOS 5,049,565 79.2 % 482 Other bacterial pneumonia 834,773 13.1 % 481 Pneumococcal pneumonia 172,176 2.7 % 485 Bronchopneumonia, organism, NOS 146,768 2.3 % 487 Influenza 101,642 1.6 % 480 Viral pneumonia 37,101 0.6 % 483 Pneumonia, other specified organism 18,177 0.3 % 484 Pneumonia in infectious disease 11,676 0.2 % All Cases of Pneumonia & Influenza 6,371,878 Influenza has an increased chance of complications.

P&I Hospitalization by Age Average Annual National P&I Cases and Rates (1998-2002)

Objective #2: Examine whether elderly with Alzheimer’s are at an elevated risk for influenza complications, as measured by length of stay and death in the hospital.

Distribution of P&I Hospitalization Codes 1998-2002, by Selected Cognitive Impairments ICD Code Condition P&I cases Influenza cases % of P&I cases with influenza 294 Persistent mental disorders due to conditions classified elsewhere 484,796 5,857 1.2 % 331 Alzheimer’s disease 290,258 3,872 1.3 % 311 Depressive disorder, NES 244,125 793 0.3 % 290 Senile dementia, uncomplicated 208,707 2,768 332 Parkinson’s disease 165,929 2,432 1.5 % 295 Schizophrenic disorders 43,930 450 1.0 % 310 Mental disorder due to brain damage 43,412 626 1.4 % 319 Mental retardation, NOS 10,719 130 318 Moderate-Profound Mental Retardation 2,846 44 1.6 % NATIONAL AVERAGE 6,371,878 101,642

Discharge Destinations of Influenza Patients With Alzheimer's 170 (5%) (N = 3,124) 1,064 (34%) Influenza Patients 2,815 (3%) National Average 1,886 (61%) (N = 81,414) 26,216 (32%) 52,297 (65%) home other* expired *Other = Skilled nursing facility or other hospitals

Results: Only 1.3% of Alzheimer’s patients hospitalized with P&I were diagnosed with influenza, compared to the national average of 1.6%. Length of stay in the hospital due to influenza was longer among Alzheimer’s patients than nationwide estimates. Alzheimer’s patients: median=5 days, mean [SD] =5.9 [4.7] days Nationwide estimates: median=4 days, mean [SD]=5.6 [5.1] days 5.5% of Alzheimer’s patients with influenza expired in the hospital (males: 6.4% and females: 4.9%) compared to a national average of 3.5% for influenza deaths. SHORT STAY!!!!

Questions: Preliminary results support our hypothesis that elderly with CI are at an elevated risk for influenza complications and may be in need of special attention during influenza outbreaks. The cognitively impaired elderly appear to be hospitalized for influenza less frequently than the national average. Less testing for flu? Different clinical manifestation of flu? Better vaccine coverage for CI patients? Alzheimer’s patients hospitalized with influenza do appear to be at increased risk of complications including: Higher susceptibility? Rapid immunosenecence? Delayed or insufficient health care?

Next Steps: Continue to examine the impact of barriers to healthcare on pneumonia and influenza (P&I) outcomes in elderly with cognitive impairment. Expand analysis to include additional cognitive impairment ICD codes, in addition to Alzheimer’s. Explore severity of outcomes in pneumonia patients as well as influenza patients. Investigate how proximity to health care facilities affects severity of P&I outcomes using innovative Geographic Information Systems (GIS) software technology.

Distance from Nursing Homes to Hospitals: Mapping Accessibility in Massachusetts County Level Accessibility Estimation for Massachusetts

Acknowledgements The following funding agencies are thanked for their continuous support: The National Institute of Allergy and Infectious Diseases (U19AI062627, HHSN266200500024C) & Environmental Health Sciences (R01ES013171)

Total U.S. Elderly Population By County Is this actually supposed to be 85 and over? Or 65 and over? Seems like we’d want 65 and over, not sure if it’s a labeling issue or if it’s the wrong map.

Number of Hospital Beds per 100 Elderly Residents By County