Journal of the American Medical Directors Association最新文献

Objectives: Chronic diseases are a global health concern, and subjective life expectancy (SLE) is a novel concept increasingly linked to health outcomes. However, the relationship between chronic disease patterns and SLE remains unclear. This study aimed to examine these associations and to explore whether pain mediates them.

Design: Longitudinal study.

Setting and participants: Data were drawn from 4 waves of the China Health and Retirement Longitudinal Study (CHARLS), including 4774 participants aged 45 and older.

Methods: Chronic disease patterns were classified as none, preexisting, or new-onset based on reports across 2 consecutive waves. SLE was dichotomized as lower or higher. Weighted mixed-effects logistic regression models with nested random intercepts for communities and individuals were used to examine the association between chronic disease patterns and SLE, adjusting for baseline SLE. The delta method assessed whether pain mediated these associations.

Results: Most chronic diseases were significantly associated with lower SLE compared with those without such conditions, with exceptions of dyslipidemia, emotional/nervous/psychiatric diseases, and memory-related diseases. For several conditions including diabetes/high blood sugar, cancer, heart disease, kidney disease, chronic lung disease, and arthritis/rheumatism, new-onset conditions showed stronger associations with lower SLE than preexisting conditions. For stroke [odds ratio (OR), 0.54; 95% CI, 0.36-0.81 vs OR, 0.51; 95% CI, 0.34-0.76], preexisting conditions showed slightly stronger associations. Conversely, only preexisting conditions were significantly associated with lower SLE for hypertension, liver disease, stomach/digestive disease, and asthma. Pain served as a partial mediator in these associations.

Conclusions and implications: These findings offer new insights for policymakers and health care practitioners, highlighting the importance of implementing interventions during the early stages following diagnosis. Reducing and managing pain at this critical period may help prevent declines in SLE and support individuals' long-term well-being.

Objectives: To evaluate the effect of deprescribing interventions that explicitly targeted psychotropic medications on fall outcomes in older adults across community, inpatient, long-term care, and postdischarge settings.

Design: Systematic review and meta-analysis.

Setting and participants: Older adults (≥65 years).

Methods: We searched MEDLINE, Embase, Cochrane CENTRAL, Web of Science, and CINAHL from inception to June 2025. We included randomized controlled trials (RCTs) and high-quality nonrandomized studies of interventions (NRSIs) that compared structured deprescribing or medication-optimization interventions with an explicit psychotropic component against usual care in adults aged ≥65 years. Data were pooled using random-effects models (Restricted Maximum Likelihood estimator), and heterogeneity was quantified using the I² statistic. Subgroup analyses were performed based on intervention fidelity and clinical setting.

Results: A total of 18 studies (11 RCTs and 7 NRSIs) were included. In the primary analysis of long-term community RCTs (n = 1425), psychotropic-targeting deprescribing interventions did not significantly reduce the odds of falls [odds ratio (OR), 0.91; 95% CI, 0.59-1.39]. However, subgroup analysis indicated a significant reduction in falls for high-fidelity interventions (OR, 0.61; 95% CI, 0.41-0.91), whereas low-fidelity interventions showed no effect. In the inpatient setting, a meta-analysis of 5 NRSIs (n = 5972) demonstrated a significant reduction in falls (OR, 0.43; 95% CI, 0.19-0.96; P = .03). No significant reduction in falls was observed in the long-term care or postdischarge transitional care settings.

Conclusions and implications: Based on low to very low certainty evidence, psychotropic-targeting deprescribing interventions may reduce falls in inpatient settings and in high-fidelity community programs, whereas effects were not clearly demonstrated in other settings. These findings support its potential role as a targeted strategy and underscore the need for high-fidelity protocols and adequately powered trials tailored to specific care settings.

Objectives: Sarcopenia and frailty are closely linked geriatric syndromes, but how sarcopenia is associated with frailty's dynamic progression remains unclear. This study examined the association between sarcopenia and multistate frailty transitions in Chinese older adults.

Design: A longitudinal study.

Setting and participants: This study is based on data from 4 waves (2011-2018) of the China Health and Retirement Longitudinal Study (CHARLS), including 4621 adults aged ≥60 years.

Methods: Frailty status was classified as robust, prefrailty, or frailty using a 35-item frailty index. Sarcopenia (nonsarcopenia, possible sarcopenia, confirmed sarcopenia) was defined according to Asian Working Group for Sarcopenia 2019 (AWGS 2019) criteria. A continuous-time multistate Markov model estimated transition intensities and probabilities across frailty states. Hazard ratios (HRs) were obtained from models sequentially adjusted for related factors to quantify the associations between sarcopenia and specific frailty transitions.

Results: Among 4621 participants (mean age 67.3 years; 48.2% female), substantial transitions were observed between frailty states over 7 years of follow-up, with prefrailty being the most prevalent and dynamic state. Compared with nonsarcopenia, the HRs (95% CI) for confirmed sarcopenia were 1.29 (1.05, 1.57) for transitioning from robust to prefrailty and 1.20 (1.00, 1.43) for transitioning from prefrailty to frailty. Similar results were observed for possible sarcopenia. Among the 3 sarcopenia components, low muscle strength showed the strongest association with transitions indicating frailty deterioration, followed by low physical performance.

Conclusions and implications: Sarcopenia, regardless of severity, was associated with frailty progression in Chinese older adults, thereby identifying it as a key factor linked to frailty progression. These findings support early screening and targeted interventions to facilitate healthy aging.

Objectives: The CHemical Restraints avOidance MEthodology (CHROME) was developed to help general physicians with quality prescribing of psychotropics for people with dementia (PwD). A new enhanced version (CHROME 2.0) was implemented and tested for improved outcomes.

Design: This was an observational, 13-month, prospective, 4-wave study.

Setting and participants: All residents with dementia at 10 Albertia nursing homes participated in the study.

Methods: Neuropsychiatric syndromes and psychotropic prescriptions were first reviewed by physicians to comply with CHROME, and at the third and fourth waves, with CHROME 2.0, which included more stringent diagnostic criteria, implementation of environmental adaptations, and nonpharmacologic therapies. Medical data were extracted from the centralized information technology management software.

Results: A total of 673 residents were eligible, of whom 410 PwD (mean age ± SD, 87.2 ± 7.3 years; 78.3% female) completed the study. Frequency of ≥1 neuropsychiatric diagnosis was reduced from 76.7% to 36.1%, and frequency of ≥1 psychotropic prescribing was reduced from 84.1% to 39.8%. The highest relative reduction was observed for typical antipsychotics (93.2%), followed by other hypnotics (90.7%), short-intermediate benzodiazepines (86.4%), atypical antipsychotics (67.6%), long benzodiazepines (64.3%), and antidepressants (48.9%). Improvement was observed in all neuropsychiatric symptoms (d = 0.37), particularly hallucinations (69.5%), apathy (64.0%), depression (59.1%), delusions (59.0%), and appetite/eating symptoms (57.5%). Frequency of ≥1 fall diminished from 11.5% to 6.6% (P < .005). Monthly psychotropic costs per 100 PwD were reduced from €6.506 to €2.429.

Conclusions and implications: A significant decrease in psychotropic medication can be achieved concurrently with a marked improvement in both neuropsychiatric symptoms and falls. Psychotropic overprescription seems related to a culture of overestimating the capabilities of psychotropics while underestimating the potential of psychosocial interventions and the need for human contact of PwD. CHROME's limitation of psychotropics for severe cases contributed to shifting from a drug-centered care paradigm to a psychosocially more humane and integrative one that seems cost-effective and replicable, and should be further researched and implemented.

Objectives: Advance care planning (ACP) is essential in supporting family caregivers of nursing home residents with dementia, but nursing home (NH) staff often lack training to engage in proactive ACP discussions. An embedded pragmatic clinical trial was conducted to test a structured ACP training for NH staff called the ACP Specialist Program. This study explores family caregivers' experiences related to discussions with the ACP Specialist, as well as needs and challenges in making ACP decisions for NH residents living with dementia.

Design: Qualitative interviews.

Setting and participants: 28 family caregivers of NH residents with dementia who had engaged in an ACP discussion with the ACP Specialist in the prior 3-month period.

Methods: Interviews were conducted, transcribed, and then coded by the research team using qualitative descriptive methods.

Results: Thirteen original codes were distilled into 8 codes reflecting 2 broad themes. The first theme focuses on family caregiver experiences as the surrogate decision maker and includes the surrogate's understanding of the surrogate decision-maker role; comfort with the role; challenges related to the role; and involvement of other family members. The second theme focuses on caregiver perspectives of ACP Specialists and the ACP discussion. It includes descriptions of the types of decisions in ACP conversations; the experience of support from the ACP Specialist; the role of the ACP Specialist as part of the NH team; and the role of other NH staff and clinicians in ACP.

Conclusion and implications: Family experiences were positive overall because they believed that the resident's situation, preferences, and needs were known and acted on by the staff. Their reports of needs and challenges reinforce the importance of ACP training programs like the ACP Specialist that promote routine conversations in the NH to support family decision makers for persons living with dementia.

Objectives: Reducing task demands early in the rehabilitation process to promote activity participation, followed by increasing those demands as functional exercise, may enhance the outcome of activities of daily living (ADL) for patients receiving home health therapy. This study examined the feasibility and preliminary effects of the Home-based Activity Reactivation Program (HARP), which combines compensatory and restorative approaches to calibrate task demands as an adjuvant to usual home health therapy, on ADL performance and physical functioning.

Design: A single-blind, pilot randomized controlled trial with repeated measures.

Setting and participants: Forty-seven home health patients (mean age = 82.3 ± 7.5 years) were randomized to receive either HARP and usual therapy (intervention group) or usual therapy alone (control group).

Methods: HARP was delivered in 6 weekly home visits, separate from usual therapy sessions. The primary outcome was the Motor Skills domain of the Assessment of Motor and Process Skills. Secondary outcomes included the Activity Measure for Post-Acute Care Home Health Short Form, Box and Block Test, Jebsen Hand Function Test, Timed-Up-and-Go Test, and Short Physical Performance Battery.

Results: HARP showed strong feasibility, achieving an 88% completion rate and 95% satisfaction among completers. No program-related severe adverse events were reported. However, the 2 groups did not differ in change scores for Motor Skills at the postintervention (estimate = -0.31 logits, P = .07) or at 1-month follow-up (estimate = 0.20 logits, P = .37). No significant between-group differences were observed over time for secondary outcomes.

Conclusions and implications: Although feasible and safe, adding HARP to usual therapy did not yield superior functional outcomes compared with usual therapy alone. Factors such as insufficient usual therapy visits, delays in HARP initiation, and potential practitioner bias may have influenced these results. These factors highlight inherent challenges of integrating and evaluating adjuvant interventions within real-world home health care.