Journal of the American Medical Directors Association最新文献

Objectives: Older adults with physical or cognitive disabilities may need to move to residential care facilities (RCFs). Some older adults smoke tobacco and become dependent on their care professionals to continue smoking. Care professionals need to balance an individual resident's quality of life and well-being with the health and safety of all residents and staff. Shared decision-making (SDM) could support care professionals in these dilemmas. This study assesses multiple factors that could affect care professionals' behavior and degree of SDM regarding residents' tobacco use.

Design: We conducted quantitative cross-sectional research.

Setting and participants: We included care professionals working in psychogeriatric and somatic units in Dutch RCFs.

Methods: Data were collected with an online or hard copy survey and analyzed with t-tests and regression analyses using SPSS.

Results: Care professionals' positive attitudes toward residents' tobacco use are significantly associated with a lower degree of SDM concerning this use and enabling residents to smoke more often. The degree of SDM regarding residents' tobacco use is significantly positively associated with limiting residents' tobacco use and the degree of person-centered care (PCC). Care professionals working in somatic units report a significantly higher degree of SDM regarding residents' tobacco use compared with those working in psychogeriatric units.

Conclusions and implications: Residents' wish to smoke tobacco is a complex matter within RCFs. Care professionals' attitudes cause inconsistencies in their behavior and the degree of SDM. Moreover, care professionals tend to use SDM more often when they need to limit residents' use and cannot fulfill residents' unhealthy habits, such as smoking tobacco. SDM could support care professionals to deal with dilemmas regarding residents' tobacco use by including residents in decisions, regardless of the outcome. However, multiple factors affect care professionals' behavior and the degree of SDM. Especially, their attitudes need to be addressed. SDM is further complicated by national acts and organizational policies.

Objective: To examine racial and ethnic differences in telemedicine mental health (tele-MH) use among nursing home (NH) long-stay residents with Alzheimer's disease and related dementias (ADRD) during the pandemic.

Design: Observational study.

Setting and participants: The 2020-2021 Minimum Data Set 3.0, Medicare datasets, and Nursing Home Compare data were linked. A total of 259,467 NH long-stay residents with ADRD and 14,159 NHs were included.

Methods: The outcome variable was the percentage of NH ADRD long-stayers who used tele-MH in 2021. The main independent variables were NH racial and ethnic compositions (ie, percentages of Black and Hispanic residents) and individual race and ethnicity. We conducted a set of logistic regression models with NH random effect. We first included only individual characteristics and then added NH characteristics.

Results: Approximately 7% and 35% of the study cohort had tele-MH use and MH use in 2021, respectively. In our study cohort, 13.7% were Black, 6.6% were Hispanic, and 79.7% were white residents. The mean age was 83.4. After adjusting for NH characteristics, we found residents in NHs with a high proportion of Hispanic residents were more likely to use tele-MH both compared with those in NHs with a low proportion [odds ratio (OR), 1.867; 95% CI, 1.566-2.226], whereas residents in NHs with a high proportion of Black residents were less likely to use tele-MH both compared with those in NHs with a low proportion (OR, 0.843; 95% CI, 0.928-0.997).

Conclusions and implications: Telemedicine may offer an opportunity for NHs with a higher proportion of Hispanic residents to better address their needs for MH services. However, NHs with a higher proportion of Black residents may face challenges in telemedicine adoption. Future studies are needed to better understand factors that could impact tele-MH use in NHs and reasons that lead to racial and ethnic differences.

Objectives: To assess recent trends in antipsychotic use among older adults with Alzheimer's disease and related dementias (ADRDs) according to their residential status and determine the factors associated with the use of antipsychotics.

Design: Population-based, cross-sectional study using Texas Medicare Fee-for-Service data.

Setting and participants: Individuals ≥ 65 years of age with ADRDs who had at least 3 months of Medicare Part A and B, and Part D for prescription drug coverage, in any year between 2015 and 2020.

Methods: Temporal trends for antipsychotic use were reported by calendar year, and the associations between antipsychotic use and potential predictors were assessed overall and by residential status.

Results: Among an annual average of 161,848 older adults with ADRDs (median age, 82 years; 64.8% female), overall antipsychotic use decreased by 25.8%, from 14.5% in 2015 to 10.8% in 2020. The decline was primarily observed among those with any nursing facility (NF) residence, where use dropped from 22.1% to 12.4%, whereas community-dwelling individuals maintained a steady rate of approximately 10%. Factors associated with increased antipsychotic use included male sex, Black and Hispanic individuals, dual eligibility, Alzheimer's disease, emergency department visits, hospitalization, depression, and anxiety disorders. However, these associations varied across residential statuses. Older age was more strongly associated with decreased antipsychotic use among those with NF residence than those in the community. Compared with White individuals, Black individuals were more likely to receive antipsychotics in the community, whereas Hispanic and Asian individuals were more likely to receive antipsychotics among those with NF residence.

Conclusions and implications: Although antipsychotic use substantially decreased among those with NF residence, it remained steady among community-dwelling individuals. Given that two-thirds of individuals with dementia reside in the community, more attention is needed to understand antipsychotic use in this population.

Objectives: To examine transitions to a nursing home among residents of assisted living relative to community-dwelling home care recipients.

Design: Population-based retrospective cohort study emulating a target trial.

Setting and participants: Linked, individual-level health system data were obtained from older adults (aged ≥65 years) who made an incident application for a bed in a nursing home in Ontario, Canada, between April 1, 2014, and March 31, 2019, and were followed until December 31, 2019.

Methods: Residency in assisted living was compared with only community-dwelling home care. Any long-stay (≥90 days) and short-stay (<90 days) transitions to a nursing home were examined. Inverse probability weighted pooled logistic regression models were used to generate marginal cumulative incidence curves under each exposure status that were standardized by the covariates.

Results: This study included 10,012 residents of assisted living [mean (SD) aged 88.7 (6.26) years, 75% female] and 131,679 home care recipients [mean (SD) aged 84.8 (7.43) years, 63% female] who applied for a bed in a nursing home (N = 141,691; 95,744.6 person-years). There were 6049 transitions among applicants from assisted living and 85,190 transitions among applicants who were home care recipients to a nursing home. The 5-year absolute risk reduction was 110 transitions to a nursing home per 1000 older adult applicants if all applicants resided in assisted living (95% CI, 71-148). Residency in assisted living resulted in a 12.7% relative decrease in the 5-year risk of any transition to a nursing home had all applicants resided in assisted living (95% CI, 8.3%-17.1%).

Conclusions and implications: Residents of assisted living were less likely to transition to a nursing home, despite equivalent clinical complexity and health care needs. The integration of assisted living into the continuum of care from the community to institutionalized nursing homes would better inform health system capacity and planning.

Objectives: We aimed to examine changes in the incidence of injurious falls before, during, and after stroke, and to identify risk factors of injurious falls before and after stroke diagnosis.

Design: Prospective cohort study.

Setting and participants: Within the Swedish Twin Registry, 4431 participants (aged 66.5 ± 10.3 years) with incident stroke and 4431 stroke-free controls (aged 66.5 ± 10.3 years) were identified and matched with cases according to birth year and sex. Cases and controls were retrospectively and prospectively followed for a total of 21 years.

Methods: Information on the onset of stroke and injurious falls was ascertained from medical records in the National Patient Registry. Data were analyzed using conditional Poisson regression and generalized estimating equation models.

Results: During the 4- to 10-year pre-stroke period, the standardized incidence rates of injurious falls were 4.29-7.53 per 1000 person-years in stroke and 3.97-7.47 per 1000 person-years in control groups. The incidence of injurious falls among participants with stroke was significantly higher compared with non-stroke controls beginning 3 years before stroke (incidence rate ratio [IRR], 1.27; 95% confidence interval [CI], 1.02-1.59), peaked during the year of stroke diagnosis (IRR, 2.55; 95% CI, 2.17-3.01), and declined 4 years after stroke (IRR, 1.42; 95% CI, 1.14-1.77) until reaching a similar level as the controls (IRRs around 1.11-1.56). Former/current smoking, heavy drinking, and overweight were associated with increased falls during the pre-stroke period, and being single and heart disease with falls during the post-stroke period.

Conclusions and implications: Among people with stroke, incidence of injurious falls is significantly elevated already 3 years before stroke diagnosis and lasting until 4 years post-stroke. Risk factors for falls differ pre-stroke and post-stroke. Taking preventive measures may be beneficial in managing both stroke and fall-related risks.

Objectives: The 3 most frequently utilized frailty assessment measures are the Fried criteria, FRAIL scale, and Frailty Index (FI). This study aimed to compare predictive capabilities of these 3 measures regarding all-cause mortality in the United States and to identify the key predictive variables.

Design: Cross-sectional study.

Setting and participants: From the National Health and Nutrition Examination Survey (NHANES) 2005-2018 cycles, a total of 39,631 participants aged 20 and older were included.

Methods: Fried status, FRAIL status, and FI status were determined for each individual based on the cutoff values from the continuous scores of their respective scales. Univariate and multivariate models, incorporating 11 covariates-sex, age, body mass index, ethnicity, education, marital status, smoking status, alcohol intake, employment status, poverty-to-income ratio, and total energy intake-were fitted using Cox proportional hazards and 2 machine learning models. Model performance was assessed through Integrated Brier Score (IBS), concordance index (C-index), and area under the curve (AUC) values from 10-fold cross-validation. Key variable analysis was performed using permutation importance and C-index increment. Subgroup analysis was developed according to age.

Results: In univariate analyses, FI consistently outperformed Fried and FRAIL, showing significantly lower IBS, and higher C-index and AUC values. In multivariate analyses, few significant differences were found. Permutation importance analysis identified age as the most important variable, followed by Fried status and FI status. Similarly, in C-index increment analysis, age was the top one variable. Subgroup analyses showed that FI status consistently performed best in all metrics across univariate analyses at least in 40-59 and 60-79 age groups. FI status consistently emerged as the most important variable in permutation analysis across all age groups.

Conclusions and implications: FI demonstrated the best performance as a single predictor in predicting all-cause mortality, with age being crucial for enhancing predictive performance. Future research should explore the applicability of FI in different populations and its relationship with cause-specific mortality.

Objectives: Reaching the moderate-to-vigorous physical activity (MVPA) recommendations of 150 min/wk is difficult for older adults, particularly among those living with frailty and its associated risk of dementia. We examined the dose-response relationship between MVPA and dementia risk among at-risk persons living with and without frailty enrolled in the UK Biobank study.

Design: Survival analysis within a prospective cohort study.

Settings and participants: Participants at risk for all-cause dementia who wore an Axivity AX3 triaxial wrist-worn accelerometer between February 2013 and December 2015.

Methods: MVPA was estimated from wrist-worn accelerometry in a subpopulation of the UK Biobank study. A modified version of the physical frailty phenotype was used to define frailty. Associations between MVPA dose (including interactions with frailty) and first-time incident dementia were analyzed using Cox regression models. MVPA was treated continuously and categorically across 5 levels to estimate the dose-response curve. Models were adjusted for demographics, frailty status, and comorbidities.

Results: This study included 89,667 adults (median age, 63 years; 56% women), with 735 participants developing dementia over an average of 4.4 years. Average weekly MVPA was 126 minutes. Each 30 minutes higher MVPA was associated with a 4% reduction in the risk of all-cause dementia (hazard ratio, 0.96; 95% CI, 0.93-0.99). The hazard ratios for engaging in 0-34.9, 35-69.9, 70-139.9, and ≥140 MVPA minutes per week were 0.59, 0.40, 0.37, and 0.31, respectively (P < .05 for all) compared with 0 MVPA minutes per week. All associations were similar across frailty status (interaction P for all models > .21).

Conclusions and implications: Our results suggest engaging in any additional amount of MVPA reduces dementia risk, with the highest benefit appearing among individuals with no MVPA. These associations are not substantially modified by frailty status.

Objectives: Gastrointestinal bleeding, an emergency and critical disease, is affected by multiple factors. This study aims to systematically summarize and appraise various factors associated with gastrointestinal bleeding.

Design: Umbrella review.

Setting and participants: Meta-analyses that evaluated environmental and clinical factors concerning gastrointestinal bleeding.

Methods: We conducted a systematic search to identify eligible meta-analyses. For each included study, the risk estimates, heterogeneity estimates, small-study effects, excess significance tests, and publication biases were recalculated and appraised. Furthermore, we considered the methodologic quality and classified the evidence.

Results: In this study, 51 beneficial and 44 harmful associations were found. This study found that preemptive transjugular intrahepatic portosystemic shunt was the most reliable treatment to reduce gastroesophageal variceal bleeding and mortality risk, followed by antibiotics. For gastroduodenal ulcer bleeding, Yunnan Baiyao and proton pump inhibitors (PPIs) were relatively dependable treatment drugs, and the comparatively reliable prophylactic drugs comprised PPIs and H₂-receptor antagonists. Patients with hemodynamic instability and larger ulcers had a higher risk of rebleeding. Both weekend admissions and the combination of selective serotonin reuptake inhibitors and nonsteroidal anti-inflammatory drugs were high-risk factors for upper gastrointestinal bleeding and mortality. We also found that tranexamic acid was a credible drug for overall gastrointestinal bleeding. Meanwhile, aspirin, warfarin, diabetes, and renal failure were all high-risk factors.

Conclusions and implications: Altogether, many factors can substantially influence gastrointestinal bleeding. Therefore, in daily life and clinical practice, we should not only remain cautious in prescribing and taking some drugs but also pay attention to the management of lifestyle and underlying diseases. If necessary, protective drugs should be properly supplemented.

Objectives: Little information exists on whether nationwide efforts to reduce antipsychotic use among nursing home (NH) residents with Alzheimer's disease and related dementias improved mortality and hospitalization outcomes for residents. Our objective was to examine the effect of NH decreases in antipsychotic use on outcomes for residents with Alzheimer's disease and related dementias.

Design: Observational nationwide study that emulated a series of cluster randomized trials.

Setting and participants: Long-stay NH residents with Alzheimer's disease and related dementias in US NHs.

Methods: The study used data from Medicare claims to emulate cluster randomized trials in which NHs were assigned to either decrease or maintain/increase antipsychotic use. Outcome ascertainment for the first trial began on April 1, 2012 (ie, following the announcement of the National Partnership to Improve Dementia Care in NHs). The last day of follow-up was December 31, 2017. Outcomes measured included 12-month all-cause mortality, all-cause hospitalization, and hospitalization for stroke, myocardial infarction, fracture, and psychiatric conditions. Use of other psychotropic medications was also evaluated. Inverse-probability-of-treatment-weighted pooled Poisson regression models estimated covariate-adjusted risk ratios (RRs).

Results: The adjusted risks of death (RR, 1.01; 95% CLs, 1.00, 1.01), all-cause hospitalization (RR, 1.00; 95% CLs, 1.00, 1.01), and hospitalization for specific causes were similar between resident-trials in NHs that decreased vs maintained/increased antipsychotic use. Use of antidepressants, anxiolytic/sedative-hypnotics, anticonvulsant/mood stabilizers, and antidementia medications was slightly higher among resident-trials in NHs that decreased antipsychotic use.

Conclusions and implications: Decreases in NH antipsychotic use do not appear to improve resident outcomes. Intensive initiatives focused predominantly on achieving a decrease in antipsychotic use may not be effective at improving mortality and hospitalization outcomes for residents with Alzheimer's disease and related dementias. These findings suggest the need for better strategies that incorporate safe and effective nonpharmacological or pharmacological alternatives for managing neuropsychiatric symptoms of dementia.