Journal of the American Geriatrics Society最新文献

Background

Research has revealed dementia disparities among underserved older adults. Built upon standard-Reducing Disability in Alzheimer's Disease (s-RDAD), Innovations in Dementia Empowerment and Action (IDEA) is designed and culturally tailored for underserved communities through an empowerment stigma-reduction cognitive-behavioral intervention and tested with sexual and gender minority (SGM) adults and care partners.

Methods

The study is a 2-arm (IDEA and s-RDAD), single-blind, randomized controlled trial (RCT) with a staggered multiple baseline design. With 161 dyads (person living with dementia/care partner), the aim of the study is to compare the two arms via between and within group differences on primary (physical activity) and secondary outcomes (e.g., quality of life, physical functioning, and resource literacy) at post-treatment, and 30 and 56 week follow-up.

Results

When comparing the two arm between-group differences, the IDEA care partners' community resource literacy was significantly higher at 30-week follow-up than for s-RDAD (contrast = 0.10, p = 0.005). While both intervention arms demonstrated efficacy with significant improvement in physical activity (contrast_IDEA = 0.10, p = 0.010; contrast_s-RDAD = 0.14, p < 0.001) and quality of life (contrast_IDEA = 0.06, p < 0.001; contrast_s-RDAD = 0.03, p = 0.035) for the person with dementia at post-treatment, positive treatment effects on physical activity (contrast_IDEA = 0.09, p = 0.032) and quality of life (contrast_IDEA = 0.03, p = 0.040) persisted at 30 weeks for IDEA but not for s-RDAD.

Conclusion

While both intervention arms were efficacious, IDEA demonstrated sustained efficacy. The cultural tailoring of interventions is promising to address disparities in dementia care and interventions in underserved communities. Future research is needed for the translation of this efficacious intervention to the larger community.

Clinicaltrials.gov identifier: NCT03550131

Background

The Perioperative Optimization of Senior Health (POSH) clinic was established to address vulnerabilities and improve outcomes in frail older patients. This study describes the results of comprehensive perioperative optimization by the POSH interdisciplinary team (IDT) in patients who underwent colorectal surgery.

Methods

Frail patients planned for colorectal surgery and enrolled in the POSH clinic (10/2021–09/2023) were retrospectively identified. Descriptive statistics were used to summarize the findings of preoperative geriatric assessment and postoperative outcomes. Outcomes were compared with a contemporary propensity-matched cohort using chi-squared analysis and two-sample t-tests for categorical and continuous variables, respectively.

Results

Thirty-six patients with a median age of 80 years and a mean Charlson Comorbidity Index of 6.11 were planned for colorectal surgeries, most commonly colectomy (62.1%) and ostomy reversal (20.7%). Twenty-nine patients underwent surgical management after interdisciplinary optimization in the POSH clinic. The most common interventions recommended included advance care planning (86.2%), physical therapy (55.2%), and medication management (34.5%). Postoperatively, 75% of patients were discharged home, and there were no mortalities within 90 days. There were no significant differences in postoperative outcomes when compared to a contemporary propensity-matched cohort. The remaining seven patients enrolled in POSH did not undergo surgical management after surgery was deemed inconsistent with their goals of care, and three of these patients expired within 1 year of evaluation in POSH.

Conclusions

The POSH model provides high-risk patients with individualized risk stratification, comprehensive interdisciplinary strategies for risk mitigation, and alignment of care with patient goals. When elective colorectal surgery was within their goals of care, frail older adults safely underwent operative intervention after careful perioperative optimization. Future studies should include a mixed-method exploration of the patient perspective and a randomized controlled trial to quantify the impact of the POSH clinic on short- and long-term postoperative outcomes.

Introduction

Of the 6 million people living with dementia (PLWD) in the United States, half visit an emergency department (ED) annually. Little is known about the specific emergency care preferences and priorities of PLWD and their care partners. This descriptive qualitative study engaged PLWD and care partners to identify their ED care priorities and the factors that influence their overall evaluation of ED care.

Methods

We recruited PLWD receiving care in a large academic ED and their care partners to participate in individual or dyadic interviews. Interviews were analyzed using thematic analysis and member checking interviews were completed to confirm and expand on study findings.

Results

We conducted interviews with 55 participants (N = 19 PLWD, 24 care partners, 6 dyads). PLWD and care partners evaluated ED care experiences through a summative lens shaped by: (1) universal priorities common across all participants and (2) individual values that varied in importance and quality between individuals. Universal priorities included feeling respected, clear communication, and being informed about and involved in their emergency care decisions. Individual values included preferences around the who and how of decision-making, attention to cognitive health, and degree of escalation of care. Several contextual factors shaped the appraisal of ED visits including the timing of evaluation and nature of the precipitating event (acute/unknown cause vs. chronic/known or suspected cause).

Conclusion

Findings suggest that interpersonal interactions, including being informed about care and involved in decisions, strongly influence the evaluation of ED visits for PLWD. These findings can support the development of person-centered outcome measures capable of evaluating these priorities.

Background

Previous studies on the relationship between prediabetes, HbA1c and cognitive trajectories show mixed results. Therefore, we investigated the association of prediabetes, diabetes and HbA1c with change in global and domain-specific cognitive scores in cognitively unimpaired (CU) adults, as well as the potential effect modification by sex or age.

Methods

This longitudinal study included 4236 CU persons aged ≥ 50 years from the population-based Mayo Clinic Study of Aging. We ran linear mixed-effect models with baseline prediabetes, diabetes and HbA1c predicting longitudinal global and domain-specific (i.e., memory, language, attention/executive function, and visuospatial skills) cognitive z-scores and raw scores. Models were adjusted for age, sex, education, medical comorbidity, repeated cognitive testing, and ApoEɛ4. We additionally ran models with sex and age interactions.

Results

Compared to normoglycemic individuals, individuals with prediabetes and diabetes showed poorer performance on cognitive tests, i.e., TMT-B, category fluency, and block design subtest over time. Additionally, the presence of prediabetes, diabetes, longer diabetes duration and higher HbA1c were associated with faster global and domain-specific cognitive decline over a median follow-up of 6.4 years (range 1–19). Three-way interactions showed that the effect of diabetes on decline in global cognition, attention and visuospatial domains was more pronounced in women than in men. Age did not modify the effect of diabetes or higher HbA1c on cognition.

Conclusions

The results suggest that prediabetes and diabetes significantly shorten the timeframe before a potentially clinically noticeable change in global and domain-specific cognition is reached. Thus, lifestyle modification to reverse prediabetes and prevent diabetes could potentially reduce the rate of cognitive decline in aging populations. The findings differed by sex (i.e., the effect of diabetes on decline in global cognition, attention and visuospatial domains was more pronounced in women than men).

Background

Older adults frequently present to the Emergency Department (ED). In response, a Swiss university hospital introduced age-friendly interventions and achieved Geriatric Emergency Department Accreditation (GEDA) by the American College of Emergency Physicians (ACEP). However, the impact of previously introduced interventions and the reasons behind emergency clinicians' varying uptake or lack of continued use remain unclear. To further improve patient outcomes, conducting a contextual analysis to identify implementation barriers and facilitators is crucial, followed by the development of tailored implementation strategies supporting the sustainable uptake of all age-friendly program elements. The project's overall aim is to systematically promote the uptake and sustainable re-implementation of the existing age-friendly ED program. The first study phase outlined in this protocol (“Phase A”) focuses on 2 key objectives: (1) to assess current age-friendly interventions in the ED and identify barriers and facilitators affecting their reach, adoption, implementation, and maintenance; (2) to develop tailored implementation strategies for re-implementing program elements.

Methods

This project uses a modified implementation mapping in 5 Steps across 2 Phases. Phase A includes Steps 1–4: (1) conducting a contextual analysis using a mixed-methods design combining observations, interviews, patient chart reviews, E-survey and a Gemba walk; (2) identifying expected intervention and implementation outcomes, performance objectives; (3) adapting, extending, or developing tailored implementation strategies based on the Expert Recommendations for Implementing Change taxonomy; and (4) co-designing an implementation protocol to guide re-implementation. The follow-up Phase B will involve the re-implementation of the intervention elements and co-designing the evaluation protocol (Step 5) for the implementation process.

Conclusion

Age-friendly EDs are essential for person-centered emergency care, enhancing safety and quality of care for older adults. This study will provide insights into adaptable, evidence-informed implementation strategies that support behavioral change among emergency clinicians to increase patient reach and sustainability of age-friendly interventions for complex ED settings.

Background

Voluntary accreditation is a prevalent structural signal of high quality in healthcare, yet its association with improved quality measures remains contested. In the U.S. hospice sector, the value of accreditation as an oversight mechanism warrants rigorous investigation, given its role in Medicare's “deemed status” program. The objective of this study is to determine the association between a hospice gaining accreditation and its performance on quality measures.

Methods

We conducted a retrospective, longitudinal study of U.S. hospices from 2016 to 2023. Using facility fixed-effects models, we estimated the change in quality measures associated with accreditation. The sample included a national panel of Medicare-certified hospices with publicly reported quality data. The primary independent variable was accreditation status. Dependent variables were four CMS quality measures: the Admission Composite Process Measure, Hospice Visits in the Last Days of Life, the Hospice Care Index, and the overall Hospice Star Rating.

Results

Gaining accreditation was associated with divergent quality outcomes: a significant improvement in clinical service intensity at the end of life, but a significant decline in the quality of administrative processes at admission. Accreditation was not associated with star rating.

Conclusions

Hospice accreditation does not appear to function as a mechanism for comprehensive quality improvement. Instead, our results suggest that organizations may strategically prioritize performance on surveyor-visible metrics, sometimes at the expense of other care processes. These findings suggest accreditation should be viewed as a domain-specific signal rather than a comprehensive proxy for superior hospice quality.

Background

Gabapentinoid-related peripheral edema may prompt loop diuretic prescribing. Nursing home (NH) residents may be especially prone to this prescribing cascade. We estimated the incidence and identified predictors of the gabapentinoid-loop diuretic prescribing cascade in NHs.

Methods

We conducted a retrospective cohort study using 2016–2022 Medicare claims linked with Minimum Data Set assessments. We identified residents aged ≥ 66 years who initiated gabapentinoids in NHs and who had no evidence of loop diuretic use, heart failure, or renal insufficiency during the prior 6 months. The outcome was loop diuretic initiation within 90 days of gabapentinoid initiation. Using multivariable Poisson regression models, we estimated adjusted risk ratios (aRR) with 95% robust confidence intervals to identify predictors. We used pooled logistic regression models to examine the relationship between time-varying gabapentinoid dose and loop diuretic initiation risk.

Results

Among 23,544 residents, 994 (4.2%) experienced a prescribing cascade at a median of 36 days (IQR 15–61) after gabapentinoid initiation. Risk was higher with age 86–90 years (aRR = 1.60) or ≥ 91 years (aRR = 1.38); a diagnosis of chronic pain or fibromyalgia (aRR = 1.16), or diabetes (aRR = 1.23); and receipt of potassium-sparing diuretics (aRR = 1.53), thiazide diuretics (aRR = 1.27), or 15 or more unique medications (aRR = 1.18). Higher (versus lower) weekly gabapentin dose during follow-up was associated with a 1.45 times higher prescribing cascade risk over 13 weeks. Those with Alzheimer's Disease and Related Dementias (aRR = 0.79), or moderate (aRR = 0.72) to severe cognitive impairment (aRR = 0.59) had a lower risk versus those with intact cognition.

Conclusions

Approximately 1 in 20 NH residents who initiate gabapentinoids receives a loop diuretic within 3 months. Potentially modifiable predictors included existing polypharmacy and titrating gabapentinoid doses. NH clinicians should monitor for edema soon after gabapentinoid initiation and consider dose reductions or discontinuation before adding a loop diuretic.

Background

Artificial Intelligence (AI) applications in healthcare have significant potential to address the unmet needs of older adults. To successfully adopt and implement AI in the care of older adults, it is critical to understand stakeholders' perspectives. We sought to explore the perceived benefits and concerns among stakeholders about AI applications in caring for older adults.

Methods

We conducted individual semi-structured interviews with five groups of stakeholders: older adults and caregivers, clinicians, health system and health insurance plan leaders (payers), investors, and technology developers. Interviews asked about the perceived role of AI in the care of older adults, the perceived benefits and concerns regarding AI, and suggestions for mitigating the concerns. Interviews were audio recorded and transcribed verbatim. We used thematic content analysis to code the transcripts.

Results

Overall, 49 participants completed interviews: older adults/caregivers (n = 15), clinicians (n = 15), payers (n = 8), investors (n = 5), and technology developers (n = 6). We identified three themes. (1). Stakeholders reported multiple benefits of AI and identified several roles for its use in the care of older adults. (2). Stakeholders expressed concerns about AI, including worsening social isolation, high cost, propagating ageism, goal misalignment, and scams/misuse of AI; views on privacy concerns were mixed. (3). Stakeholders suggested potential solutions, such as setting appropriate guardrails, to mitigate concerns about AI.

Conclusions

Given the complexity and significant unmet needs among older adults, AI's potential benefits and harms are both heightened in this population. Appropriate guardrails are needed to leverage the benefits of AI while mitigating potential harms. Our findings have implications for technology developers to design innovations that align with the stakeholders' perceived roles for AI, for regulatory bodies to incorporate stakeholders' concerns when developing AI regulations, and for health systems and end-users of technology to critically evaluate a product regarding its affordability and impact on social isolation and ageism.

Background

Sarcopenic obesity is a condition characterized by decreased muscle mass and strength along with an increased body fat percentage. While previous studies have separately examined the relationship between sarcopenia and obesity with urinary incontinence (UI), this study aimed to evaluate the combined impact of sarcopenic obesity on UI.

Methods

This study included 1147 female patients aged ≥ 60 years who attended a geriatrics outpatient clinic between November 2012 and June 2024. Body composition was assessed using bioimpedance analysis (BIA), and muscle strength was measured by handgrip strength. The skeletal muscle mass index (SMMI) was adjusted for body weight. Sarcopenic obesity was defined using population-specific threshold values, incorporating low muscle strength, low muscle mass, and high fat percentage. Patients were classified into four groups: non-sarcopenic non-obese, sarcopenic non-obese, sarcopenic obese, and non-sarcopenic obese. The prevalence of UI and its association with these phenotypes was analyzed using multivariable logistic regression.

Results

The mean age was 74 ± 7 years. The prevalence of sarcopenic obesity was 20%, while the prevalence of UI was 49%. UI was observed in 57% of the 230 patients with sarcopenic obesity. A significant difference in UI prevalence was found among phenotypic groups (p < 0.001). In multivariable regression analysis, sarcopenic obesity was independently associated with UI (OR: 1.82, 95% CI: 1.16–2.85, p = 0.009). Other phenotypes were not significantly associated.

Conclusions

Sarcopenic obesity is more strongly associated with UI than sarcopenia or obesity alone. Early identification and targeted interventions may play a crucial role in mitigating the effects of UI or reducing its incidence.