Kayla P. Carpenter, Fernanda Bellolio, Manuela Bartolacci, Molly M. Jeffery, Susan M. Bower, Lauren T. Southerland, Aidan F. Mullan, Jennifer L. Ridgeway
Background
The Geriatric Emergency Department (ED) guidelines recommend screening older adults for delirium using evidence-based screening tools, but these tools are often underutilized. We aimed to identify barriers and facilitators to implementing an electronic health record (EHR)-based delirium screening tool as intended.
Methods
This mixed methods and focused ethnographic study combined a review of structured delirium screening data with observations of real-time delirium screenings and semi-structured in-person interviews at an academic ED that previously implemented the Delirium Triage Screen (DTS) and Brief Confusion Assessment Method (bCAM) tool. Content analysis of field notes from observations and interview transcripts was guided by the Exploration, Preparation, Implementation, and Sustainment implementation framework.
Results
From a total of 40,818 ED visits, 6196 (15.2%) had incomplete screens (i.e., without fidelity). We observed 62 encounters, of which 25 (40.3%) screenings were implemented without fidelity due to (1) not asking the required screening questions, (2) assuming patient responses, or (3) not completing the screen due to uncertainty regarding a patient's baseline mentation. We conducted 32 interviews. Identified barriers included staff prioritization of other tasks (e.g., stroke code, cleaning patients), limited knowledge of the screen's importance and utility, and language discordance. Facilitators included care partners providing baseline mental status information and nurses prefacing the screening to increase patient engagement.
Conclusion
The fidelity of ED delirium screening is influenced by an interplay of environmental, patient, provider, and caregiver factors. Fidelity may be improved by focusing education on the importance of screening, training screeners on how to determine whether a patient's mentation is acutely changed, providing clear action steps when a patient screens positive, and addressing how to administer the delirium screen to patients who do not speak English fluently.
{"title":"Barriers and Facilitators to the Fidelity of Delirium Screening in the Emergency Department: An Ethnographic Approach","authors":"Kayla P. Carpenter, Fernanda Bellolio, Manuela Bartolacci, Molly M. Jeffery, Susan M. Bower, Lauren T. Southerland, Aidan F. Mullan, Jennifer L. Ridgeway","doi":"10.1111/jgs.70142","DOIUrl":"10.1111/jgs.70142","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>The Geriatric Emergency Department (ED) guidelines recommend screening older adults for delirium using evidence-based screening tools, but these tools are often underutilized. We aimed to identify barriers and facilitators to implementing an electronic health record (EHR)-based delirium screening tool as intended.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This mixed methods and focused ethnographic study combined a review of structured delirium screening data with observations of real-time delirium screenings and semi-structured in-person interviews at an academic ED that previously implemented the Delirium Triage Screen (DTS) and Brief Confusion Assessment Method (bCAM) tool. Content analysis of field notes from observations and interview transcripts was guided by the Exploration, Preparation, Implementation, and Sustainment implementation framework.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>From a total of 40,818 ED visits, 6196 (15.2%) had incomplete screens (i.e., without fidelity). We observed 62 encounters, of which 25 (40.3%) screenings were implemented without fidelity due to (1) not asking the required screening questions, (2) assuming patient responses, or (3) not completing the screen due to uncertainty regarding a patient's baseline mentation. We conducted 32 interviews. Identified barriers included staff prioritization of other tasks (e.g., stroke code, cleaning patients), limited knowledge of the screen's importance and utility, and language discordance. Facilitators included care partners providing baseline mental status information and nurses prefacing the screening to increase patient engagement.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>The fidelity of ED delirium screening is influenced by an interplay of environmental, patient, provider, and caregiver factors. Fidelity may be improved by focusing education on the importance of screening, training screeners on how to determine whether a patient's mentation is acutely changed, providing clear action steps when a patient screens positive, and addressing how to administer the delirium screen to patients who do not speak English fluently.</p>\u0000 </section>\u0000 </div>","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"74 1","pages":"43-54"},"PeriodicalIF":4.5,"publicationDate":"2025-10-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145226581","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Anita Chary, Sumin Yoon, Victor Lara, Annika Bhananker, Michelle Suh, Kei Ouchi, Maura Kennedy, Aanand D. Naik
Background
Over half of the people with dementia visit the emergency department (ED) each year. Little is known about how people with dementia and their care partners conceptualize or communicate about health outcome goals or care preferences during acute care episodes.
Participants and Setting
We conducted interviews with 14 Hispanic people with dementia and 19 care partners recruited from a public safety net hospital system in the southeastern United States. Participants were community-dwelling and had recently visited the ED.
Methods
We used a qualitative study design informed by phenomenology and guided by the patient priorities care (PPC) framework. Interviews elicited patients' health priorities, including their care preferences and health outcome goals, as well as their experiences communicating with ED and hospital care teams. We used a deductive content analysis to identify health priorities and inductive thematic analysis regarding communication experiences.
Results
We identified three key themes. First, participants' health priorities were grounded in values of maintaining social connection and independence. Second, hospitalizations were distressing, disorienting, and physically burdensome for both patients and care partners, leading to preferences to avoid admission whenever possible. Third, communication with ED and hospital teams felt unidirectional, with care plans delivered rather than discussed. Participants felt that care preferences were rarely elicited or incorporated into clinical decision-making.
Conclusions
Hospital admission is a critical decision point during acute care episodes for people with dementia. Incorporating brief conversations about health priorities at this juncture may improve alignment between emergency care and what matters most to patients and care partners. Adapting existing frameworks like PPC for time-pressured acute care settings may help promote shared decision-making about hospital admission.
{"title":"A Qualitative Study of Health Priorities of People With Dementia and Care Partners in Emergency Department and Hospital Care in a Public Safety-Net Setting","authors":"Anita Chary, Sumin Yoon, Victor Lara, Annika Bhananker, Michelle Suh, Kei Ouchi, Maura Kennedy, Aanand D. Naik","doi":"10.1111/jgs.70136","DOIUrl":"10.1111/jgs.70136","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Over half of the people with dementia visit the emergency department (ED) each year. Little is known about how people with dementia and their care partners conceptualize or communicate about health outcome goals or care preferences during acute care episodes.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Participants and Setting</h3>\u0000 \u0000 <p>We conducted interviews with 14 Hispanic people with dementia and 19 care partners recruited from a public safety net hospital system in the southeastern United States. Participants were community-dwelling and had recently visited the ED.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We used a qualitative study design informed by phenomenology and guided by the patient priorities care (PPC) framework. Interviews elicited patients' health priorities, including their care preferences and health outcome goals, as well as their experiences communicating with ED and hospital care teams. We used a deductive content analysis to identify health priorities and inductive thematic analysis regarding communication experiences.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>We identified three key themes. First, participants' health priorities were grounded in values of maintaining social connection and independence. Second, hospitalizations were distressing, disorienting, and physically burdensome for both patients and care partners, leading to preferences to avoid admission whenever possible. Third, communication with ED and hospital teams felt unidirectional, with care plans delivered rather than discussed. Participants felt that care preferences were rarely elicited or incorporated into clinical decision-making.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Hospital admission is a critical decision point during acute care episodes for people with dementia. Incorporating brief conversations about health priorities at this juncture may improve alignment between emergency care and what matters most to patients and care partners. Adapting existing frameworks like PPC for time-pressured acute care settings may help promote shared decision-making about hospital admission.</p>\u0000 </section>\u0000 </div>","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"73 12","pages":"3719-3728"},"PeriodicalIF":4.5,"publicationDate":"2025-10-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12748019/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145226549","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<p>We read with great interest the article by Hetherington-Rauth et al., which highlights the prognostic utility of automated CT-derived muscle area and density across anatomical regions in older men [<span>1</span>]. The findings underscore the value of automated opportunistic imaging for assessing sarcopenia and mortality risk in aging populations [<span>2</span>].</p><p>We commend the study's analysis and emphasis on functional outcomes, including grip strength, leg power, and walking speed. Nonetheless, the interpretation of results may benefit from a more thorough consideration of age as a potential residual confounder. Older participants naturally face a higher 10-year mortality risk. While age was included as a covariate, muscle size and density are strongly inversely correlated with age. Without accounting for age through matching or stratification, especially with the benefit of having a large cohort, the observed association between muscle metrics and mortality may be confounded by age.</p><p>Propensity score matching or age-stratified subgroup analyses could have further strengthened causal inference and minimized residual confounding. This is especially pertinent since the survival analyses showed consistent associations across regions—but without deeper exploration of whether these held across narrower age bands. It remains unclear whether poorer muscle metrics are independently predictive of mortality or simply reflect age-related risk of mortality.</p><p>From the health economic angle, where the cost of healthcare consumption is a pertinent marker of health in a given population, the authors could also consider analyzing, by decade bands of age, the association of muscle size and density with 1-year mortality, hospital attendance, or mean sick days, which would allow readers to better appreciate the impact of muscle size and quality on shorter term health-related outcomes. These parameters, with the strength of sample size, would allow more emphasis on muscle health in health promotion policies.</p><p>It was good of the authors to highlight differences with previous studies. The contrary findings regarding the association between muscle density and leg power in Korean older adults [<span>3</span>] compared with the MrOS study participants highlight important ethnic and regional differences in the assessment, cut-offs, and variations in muscle strength, density, and intermuscular adipose tissue (IMAT) in different populations. Validation in diverse populations, especially older women and multi-ethnic Asian cohorts, is crucial for generalizability.</p><p>It would have been interesting for the authors to consider and highlight the associations between muscle mass, muscle function, muscle quality, and health-related outcomes [<span>4</span>]. With increasing emphasis on muscle quality as a measurement metric for muscle health [<span>5, 6</span>], future studies pertaining to muscle health should be encouraged to assess and present thes
我们怀着极大的兴趣阅读了hetherington - rath等人的文章，该文章强调了自动ct获得的老年男性肌肉面积和跨解剖区域密度的预后效用。研究结果强调了自动机会成像在评估老年人群肌肉减少症和死亡风险方面的价值[10]。我们赞扬该研究的分析和对功能结果的强调，包括握力、腿部力量和步行速度。尽管如此，对结果的解释可能受益于更彻底地考虑年龄作为潜在的残留混杂因素。年龄较大的参与者自然面临更高的10年死亡风险。虽然年龄是一个协变量，但肌肉大小和密度与年龄呈强烈的负相关。如果没有通过匹配或分层来考虑年龄，特别是考虑到有一个大队列的好处，观察到的肌肉指标和死亡率之间的关联可能会因年龄而混淆。倾向评分匹配或年龄分层亚组分析可以进一步加强因果推理和最小化残留混淆。这是特别相关的，因为生存分析显示了跨地区的一致关联，但没有深入探索这些是否适用于更窄的年龄范围。目前尚不清楚较差的肌肉指标是独立预测死亡率还是仅仅反映与年龄相关的死亡率风险。从健康经济学的角度来看，医疗保健消费成本是特定人群健康状况的相关标志，作者还可以考虑按年龄的十年来分析肌肉大小和密度与1年死亡率、住院率或平均病假的关系，这将使读者更好地了解肌肉大小和质量对短期健康相关结果的影响。随着样本量的增加，这些参数将使健康促进政策更加重视肌肉健康。作者很好地强调了与以往研究的差异。与mri研究参与者相比，韩国老年人肌肉密度和腿部力量之间的关系的相反发现突出了不同人群在肌肉力量、密度和肌间脂肪组织（IMAT）的评估、截止值和变化方面的重要种族和地区差异。在不同人群中进行验证，特别是老年妇女和多种族亚洲人群，对于普遍性至关重要。对于作者来说，考虑和强调肌肉质量、肌肉功能、肌肉质量和健康相关结果之间的联系是很有趣的。随着越来越多的人强调肌肉质量是肌肉健康的测量指标[5,6]，应该鼓励与肌肉健康有关的未来研究评估和呈现肌肉健康的这些组成部分，让读者全面了解这种日益被认可的健康状态的复杂性，这意味着无数的疾病。虽然对肌肉质量的评估方式仍然存在争议，但在文献中有更多的报道将允许进行回顾性评估，以帮助该领域的研究人员确定哪种方法的准确性最高。尽管如此，这项研究通过证明利用CT扫描进行的机会性自动评估可以产生与临床相关的肌肉健康见解，做出了有价值的贡献。将自动分割整合到放射学工作流程中，有望更早地识别肌肉减少症，但需要进一步的工作来确保这些关联在性别、种族和年龄层之间是稳健的。李峰谭和Frederick H. Koh构思并撰写了最初的手稿。所有作者都对原稿进行了修改和编辑。这份手稿没有赞助者。作者声明无利益冲突。本出版物与Megan hetherington - rath等人的相关信件相关联。要查看本文，请访问https://doi.org/10.1111/jgs.70129。
{"title":"Comment on: Associations of CT Muscle Area and Density With Functional Outcomes and Mortality Across Anatomical Regions in Older Men","authors":"Li Feng Tan, Xizhen Low, Frederick H. Koh","doi":"10.1111/jgs.70133","DOIUrl":"10.1111/jgs.70133","url":null,"abstract":"<p>We read with great interest the article by Hetherington-Rauth et al., which highlights the prognostic utility of automated CT-derived muscle area and density across anatomical regions in older men [<span>1</span>]. The findings underscore the value of automated opportunistic imaging for assessing sarcopenia and mortality risk in aging populations [<span>2</span>].</p><p>We commend the study's analysis and emphasis on functional outcomes, including grip strength, leg power, and walking speed. Nonetheless, the interpretation of results may benefit from a more thorough consideration of age as a potential residual confounder. Older participants naturally face a higher 10-year mortality risk. While age was included as a covariate, muscle size and density are strongly inversely correlated with age. Without accounting for age through matching or stratification, especially with the benefit of having a large cohort, the observed association between muscle metrics and mortality may be confounded by age.</p><p>Propensity score matching or age-stratified subgroup analyses could have further strengthened causal inference and minimized residual confounding. This is especially pertinent since the survival analyses showed consistent associations across regions—but without deeper exploration of whether these held across narrower age bands. It remains unclear whether poorer muscle metrics are independently predictive of mortality or simply reflect age-related risk of mortality.</p><p>From the health economic angle, where the cost of healthcare consumption is a pertinent marker of health in a given population, the authors could also consider analyzing, by decade bands of age, the association of muscle size and density with 1-year mortality, hospital attendance, or mean sick days, which would allow readers to better appreciate the impact of muscle size and quality on shorter term health-related outcomes. These parameters, with the strength of sample size, would allow more emphasis on muscle health in health promotion policies.</p><p>It was good of the authors to highlight differences with previous studies. The contrary findings regarding the association between muscle density and leg power in Korean older adults [<span>3</span>] compared with the MrOS study participants highlight important ethnic and regional differences in the assessment, cut-offs, and variations in muscle strength, density, and intermuscular adipose tissue (IMAT) in different populations. Validation in diverse populations, especially older women and multi-ethnic Asian cohorts, is crucial for generalizability.</p><p>It would have been interesting for the authors to consider and highlight the associations between muscle mass, muscle function, muscle quality, and health-related outcomes [<span>4</span>]. With increasing emphasis on muscle quality as a measurement metric for muscle health [<span>5, 6</span>], future studies pertaining to muscle health should be encouraged to assess and present thes","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"74 1","pages":"286-287"},"PeriodicalIF":4.5,"publicationDate":"2025-10-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://agsjournals.onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.70133","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145226568","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Megan Hetherington-Rauth, Ashley A. Weaver, Peggy M. Cawthon
<p>We appreciate Tan et al.'s interest and comment on our recent manuscript, “Associations of CT Muscle Area and Density With Functional Outcomes and Mortality Across Anatomical Regions in Older Men” [<span>1</span>]. They raise an important question about the role of age in the relationship of muscle area and density with risk of mortality. Although all models were adjusted for age, we acknowledge that standard covariate adjustment may not fully address or disentangle the confounding influence of age.</p><p>In response to the comments, we performed additional analyses to assess age as a potential effect modifier. We examined interactions between age and both muscle area and muscle density at two trunk levels (Trunk-L1 and Trunk-L3) and in the right (Thigh-RT) and left (Thigh-LT) thigh, using Cox proportional hazards models with age modeled both continuously and in tertiles. We also conducted age-stratified subgroup analyses based on age tertiles of our sample.</p><p>Figure 1 presents hazard ratios (HRs) (95% CI) per standard deviation increase in muscle density and area for 10-year all-cause mortality, stratified by age tertile and anatomical region. No significant age interactions were observed when age was modeled as a continuous variable (<i>p</i>-interaction > 0.05), and similar HRs were found across all the age tertiles, as indicated by overlapping 95% CIs. However, some region-specific patterns emerged. Trunk muscle density at both Trunk-L1 and Trunk-L3 was most strongly associated with lower mortality risk in the youngest age tertile, with weaker associations in older tertiles, although no statistically significant interaction was detected (<i>p</i>-interaction > 0.05). In contrast, thigh muscle density was most strongly associated with mortality in the middle tertile, with a significantly greater effect than in the youngest tertile for the Thigh-RT (<i>p</i>-interaction = 0.006) and a borderline difference for the Thigh-LT (<i>p</i>-interaction = 0.06). Unlike muscle density, muscle area was not significantly associated with mortality in the overall sample or within most age tertiles, except for the Thigh-RT, where a significant association was observed only in the youngest tertile and the full cohort.</p><p>These findings suggest that the impact of muscle density on mortality risk varies by both anatomical region and stage of aging. The stronger association observed in the youngest-old age tertile for trunk muscles, but in the middle-old age tertile for thigh muscles, may reflect differences in the onset and progression of age-related muscle quality decline across regions. Lumbar paraspinal muscles are particularly vulnerable to early degenerative changes, such as fat infiltration, even in relatively healthy adults, likely due to their sensitivity to disuse and neuromuscular dysfunction [<span>2, 3</span>]. As a result, lower muscle density in the trunk, primarily driven by decreased muscle density of the paraspinal muscles, may s
{"title":"Reply to Comment on: Associations of CT Muscle Area and Density With Functional Outcomes and Mortality Across Anatomical Regions in Older Men","authors":"Megan Hetherington-Rauth, Ashley A. Weaver, Peggy M. Cawthon","doi":"10.1111/jgs.70129","DOIUrl":"10.1111/jgs.70129","url":null,"abstract":"<p>We appreciate Tan et al.'s interest and comment on our recent manuscript, “Associations of CT Muscle Area and Density With Functional Outcomes and Mortality Across Anatomical Regions in Older Men” [<span>1</span>]. They raise an important question about the role of age in the relationship of muscle area and density with risk of mortality. Although all models were adjusted for age, we acknowledge that standard covariate adjustment may not fully address or disentangle the confounding influence of age.</p><p>In response to the comments, we performed additional analyses to assess age as a potential effect modifier. We examined interactions between age and both muscle area and muscle density at two trunk levels (Trunk-L1 and Trunk-L3) and in the right (Thigh-RT) and left (Thigh-LT) thigh, using Cox proportional hazards models with age modeled both continuously and in tertiles. We also conducted age-stratified subgroup analyses based on age tertiles of our sample.</p><p>Figure 1 presents hazard ratios (HRs) (95% CI) per standard deviation increase in muscle density and area for 10-year all-cause mortality, stratified by age tertile and anatomical region. No significant age interactions were observed when age was modeled as a continuous variable (<i>p</i>-interaction > 0.05), and similar HRs were found across all the age tertiles, as indicated by overlapping 95% CIs. However, some region-specific patterns emerged. Trunk muscle density at both Trunk-L1 and Trunk-L3 was most strongly associated with lower mortality risk in the youngest age tertile, with weaker associations in older tertiles, although no statistically significant interaction was detected (<i>p</i>-interaction > 0.05). In contrast, thigh muscle density was most strongly associated with mortality in the middle tertile, with a significantly greater effect than in the youngest tertile for the Thigh-RT (<i>p</i>-interaction = 0.006) and a borderline difference for the Thigh-LT (<i>p</i>-interaction = 0.06). Unlike muscle density, muscle area was not significantly associated with mortality in the overall sample or within most age tertiles, except for the Thigh-RT, where a significant association was observed only in the youngest tertile and the full cohort.</p><p>These findings suggest that the impact of muscle density on mortality risk varies by both anatomical region and stage of aging. The stronger association observed in the youngest-old age tertile for trunk muscles, but in the middle-old age tertile for thigh muscles, may reflect differences in the onset and progression of age-related muscle quality decline across regions. Lumbar paraspinal muscles are particularly vulnerable to early degenerative changes, such as fat infiltration, even in relatively healthy adults, likely due to their sensitivity to disuse and neuromuscular dysfunction [<span>2, 3</span>]. As a result, lower muscle density in the trunk, primarily driven by decreased muscle density of the paraspinal muscles, may s","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"74 1","pages":"288-289"},"PeriodicalIF":4.5,"publicationDate":"2025-10-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://agsjournals.onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.70129","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145226564","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Yohanes A. Wondimkun, Gillian E. Caughey, Maria C. Inacio, Tracy Air, Catherine Lang, Michelle Hogan, Janet K. Sluggett
<p>We thank the authors of the Letters to the Editor, “<i>The (hypo)glycemic iceberg in long-term care: Steering beyond hospital admissions</i>” [<span>1</span>] and “<i>Enhancing glycemic risk assessment in long-term care: suggestions for future research</i>” [<span>2</span>] for their thoughtful comments on our recent study “<i>Factors associated with hospitalization for hypoglycemia and hyperglycemia among older people in long-term care facilities</i>” [<span>3</span>].</p><p>We agree that our reported rates of hospitalization for hypoglycemia and hyperglycemia likely underestimate the actual burden of these complications among older adults in long-term care facilities (LTCFs). As noted in the article, our main finding was based on a primary diagnosis for a hospital visit and the incidence of these outcomes tripled when both primary and/or secondary diagnoses were considered. The authors of both letters have highlighted the importance of considering cases managed in LTCFs, undocumented events (including nocturnal or asymptomatic events), and atypically presenting hypoglycemic events, such as delirium, falls, and sudden death. Studies using continuous glucose monitoring have identified episodes of hypoglycemia that are often missed both symptomatically and by conventional monitoring [<span>4</span>]. All hypoglycemic events, including asymptomatic episodes, have detrimental physical and cognitive effects [<span>5</span>]. But it is a well-taken point that while our study sheds light on the most severe glycemic events, comprehensive assessments of hypoglycemia and hyperglycemia, including the use of continuous glucose monitoring, may be needed to fully understand the extent of risk and improve diabetes outcomes in LTCFs.</p><p>We agree with Xu et al.'s [<span>2</span>] suggestion regarding the importance of examining glycated hemoglobin (HbA1c) measures. Examining the relationship between HbA1c levels and the acute complications observed in our study could have enhanced our understanding of the risk factors for these complications in LTCFs. However, HbA1c may not accurately reflect current glycemic levels in older adults, potentially due to marked glucose variability and multiple comorbidities that alter erythrocyte lifespan and turnover (e.g., renal disease) [<span>6</span>]. Management of type 2 diabetes in LTCFs also requires a person-centered approach that considers the older person's life expectancy, functional level and cognitive impairment, goals of care, diabetes symptoms, and quality of life, meaning a less stringent approach to lowering HbA1c may be preferable for some residents.</p><p>We also acknowledge the importance of including Aboriginal people when studying diabetes management and its complications, given the high burden of this disease in this population (i.e., three times higher disease prevalence) [<span>7</span>], which was noted by Xu et al. [<span>2</span>]. However, studies using the data source employed for our study tha
{"title":"Reply to Comments on Factors Associated With Hospitalization for Hypoglycemia and Hyperglycemia Among Older People in Long-Term Care Facilities","authors":"Yohanes A. Wondimkun, Gillian E. Caughey, Maria C. Inacio, Tracy Air, Catherine Lang, Michelle Hogan, Janet K. Sluggett","doi":"10.1111/jgs.70131","DOIUrl":"10.1111/jgs.70131","url":null,"abstract":"<p>We thank the authors of the Letters to the Editor, “<i>The (hypo)glycemic iceberg in long-term care: Steering beyond hospital admissions</i>” [<span>1</span>] and “<i>Enhancing glycemic risk assessment in long-term care: suggestions for future research</i>” [<span>2</span>] for their thoughtful comments on our recent study “<i>Factors associated with hospitalization for hypoglycemia and hyperglycemia among older people in long-term care facilities</i>” [<span>3</span>].</p><p>We agree that our reported rates of hospitalization for hypoglycemia and hyperglycemia likely underestimate the actual burden of these complications among older adults in long-term care facilities (LTCFs). As noted in the article, our main finding was based on a primary diagnosis for a hospital visit and the incidence of these outcomes tripled when both primary and/or secondary diagnoses were considered. The authors of both letters have highlighted the importance of considering cases managed in LTCFs, undocumented events (including nocturnal or asymptomatic events), and atypically presenting hypoglycemic events, such as delirium, falls, and sudden death. Studies using continuous glucose monitoring have identified episodes of hypoglycemia that are often missed both symptomatically and by conventional monitoring [<span>4</span>]. All hypoglycemic events, including asymptomatic episodes, have detrimental physical and cognitive effects [<span>5</span>]. But it is a well-taken point that while our study sheds light on the most severe glycemic events, comprehensive assessments of hypoglycemia and hyperglycemia, including the use of continuous glucose monitoring, may be needed to fully understand the extent of risk and improve diabetes outcomes in LTCFs.</p><p>We agree with Xu et al.'s [<span>2</span>] suggestion regarding the importance of examining glycated hemoglobin (HbA1c) measures. Examining the relationship between HbA1c levels and the acute complications observed in our study could have enhanced our understanding of the risk factors for these complications in LTCFs. However, HbA1c may not accurately reflect current glycemic levels in older adults, potentially due to marked glucose variability and multiple comorbidities that alter erythrocyte lifespan and turnover (e.g., renal disease) [<span>6</span>]. Management of type 2 diabetes in LTCFs also requires a person-centered approach that considers the older person's life expectancy, functional level and cognitive impairment, goals of care, diabetes symptoms, and quality of life, meaning a less stringent approach to lowering HbA1c may be preferable for some residents.</p><p>We also acknowledge the importance of including Aboriginal people when studying diabetes management and its complications, given the high burden of this disease in this population (i.e., three times higher disease prevalence) [<span>7</span>], which was noted by Xu et al. [<span>2</span>]. However, studies using the data source employed for our study tha","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"74 1","pages":"284-285"},"PeriodicalIF":4.5,"publicationDate":"2025-10-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://agsjournals.onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.70131","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145208812","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Bart Spaetgens, Nordin M. J. Hanssen, Daisy J. A. Janssen
<p>We read with interest the study by Wondimkun et al. [<span>1</span>] examining hospitalizations for hypoglycemia and hyperglycemia among older adults newly admitted to long-term care facilities (LTCFs). The study provides important insights into risk factors for severe glycemic events in this vulnerable population, using high-quality, population-based registry data.</p><p>While the reported incidence of hospital admissions appears low, 1.0% for hypoglycemia and 0.5% for hyperglycemia in the year following LTCF entry, these figures, as the authors acknowledge, reflect only the most severe cases and, in our view, substantially underestimate the true burden of glycemic dysregulation in LTCFs. Many hypo- and hyperglycemic events are managed within the facility by nursing home staff and are not coded as primary reasons for hospitalization. Especially in frail older adults, symptoms such as delirium, falls, atypical behavior, or, even more concerning, cases of unwitnessed or unexpected death in bed may reflect underlying glycemic instability that remains undocumented in hospital data. Notably, the authors' own sensitivity analysis, which includes secondary diagnoses, suggests a threefold increase in the incidence of hospitalizations, reinforcing that many events were misclassified or coincided with other illnesses.</p><p>This raises broader concerns. First, glycemic events in LTCFs are rarely isolated episodes. More often, they reflect underlying frailty or transitions in health status that warrant a reassessment of care goals. These vulnerabilities may also explain why previous dysglycemic episodes, identified as key predictors in the study, frequently precede new hospitalizations. In many cases, such events serve as warning signs of broader care mismatches, including nutritional issues, medication burden, underlying illness or infection, or cognitive deterioration [<span>2</span>]. Studies from U.S. nursing homes reinforce this concern, showing substantial rates of hypoglycemia, particularly among residents using insulin or sulfonylureas [<span>3, 4</span>]. While such episodes may often not lead to hospitalization, they contribute to physical and cognitive decline, emergency transfers, and distress for both residents and staff. This aligns with Wondimkun et al., who reported that insulin and sulfonylureas significantly increased the risk of hypoglycemia-related hospitalizations, with insulin additionally linked to hyperglycemia admissions.</p><p>To address these issues, broader surveillance strategies are urgently needed. These should incorporate nursing documentation, structured reporting of adverse glycemic events, and, where feasible given emerging staffing shortages, the use of continuous glucose monitoring to better capture fluctuations in glucose levels. This is particularly relevant for residents with dementia or limited communication abilities, who in the present study were found to be at increased risk of hospitalization. These individua
我们饶有兴趣地阅读了Wondimkun等人的研究，研究了新入住长期护理机构（ltcf）的老年人的低血糖和高血糖住院情况。该研究使用高质量的、基于人群的登记数据，为易感人群中严重血糖事件的危险因素提供了重要的见解。虽然报告的住院率似乎很低，在LTCF进入后的一年中，低血糖率为1.0%，高血糖率为0.5%，但作者承认，这些数字仅反映了最严重的病例，并且在我们看来，大大低估了LTCF中血糖失调的真正负担。许多低血糖和高血糖事件是由养老院的工作人员在设施内处理的，不被编码为住院的主要原因。特别是在身体虚弱的老年人中，诸如谵妄、跌倒、不典型行为，甚至更令人担忧的是，在床上未被目击或意外死亡的病例可能反映了医院资料中未记载的潜在血糖不稳定。值得注意的是，作者自己的敏感性分析（包括二次诊断）表明，住院率增加了三倍，这强化了许多事件被错误分类或与其他疾病同时发生。这引发了更广泛的担忧。首先，ltcf的血糖事件很少是孤立事件。更常见的是，它们反映了潜在的脆弱或健康状况的转变，需要重新评估护理目标。这些弱点也可以解释为什么以前的血糖异常发作，在研究中被确定为关键的预测因素，经常在新的住院治疗之前。在许多情况下，这些事件是更广泛的护理不匹配的警告信号，包括营养问题、药物负担、潜在疾病或感染，或认知恶化。来自美国养老院的研究强化了这一担忧，表明低血糖率很高，特别是在使用胰岛素或磺脲类药物的居民中[3,4]。虽然这种情况通常不会导致住院，但它们会导致身体和认知能力下降，导致紧急转移，并使居民和工作人员感到痛苦。这与Wondimkun等人的报告一致，他们报道胰岛素和磺脲类药物显著增加低血糖相关住院的风险，胰岛素还与高血糖住院有关。为了解决这些问题，迫切需要更广泛的监测战略。这些措施应包括护理文件、不良血糖事件的结构化报告，以及在人员短缺的情况下，使用连续血糖监测来更好地捕捉血糖水平的波动。这对患有痴呆症或沟通能力有限的居民尤其重要，在目前的研究中发现，他们住院的风险更高。这些患者通常不能表现出典型的症状，导致护理团队将低血糖或高血糖的症状误解为与其他疾病有关。胰岛素或磺脲类药物的使用与住院之间的密切联系也对临床实践有影响。它加强了目前在虚弱的老年人中减少高风险药物的努力，并与美国糖尿病协会2025年老年人护理标准的建议保持一致，该标准得到了AGS[6]的认可。然而，在常规实践中的实施仍然参差不齐，因为临床医生在修改方案时经常面临不确定性，特别是在缺乏明确的、具体的指导的情况下。虽然ADA标准认识到LTCF居民的独特需求，但它们并没有提供具体的、可操作的建议。说明的事实是，HbA1c目标仍然相对接近于一般人群的目标。强调个性化护理目标，但缺乏实施工具，如针对LTCF量身定制的监测协议或药物算法，这反映了LTCF人群的知识有限。这使得临床医生缺乏做出安全、循证决策所需的结构。更好地了解关键的促进因素和障碍，包括患者的观点，可以为制定有针对性的策略提供信息，以支持老年人减少糖尿病药物的处方[7,8]。我们认为需要在LTCF患者中进行一项试验，以确定SGLT2抑制剂是否可以安全地替代胰岛素或磺脲类药物，减少低血糖和心力衰竭事件。因此，Wondimkun等人的研究结果不仅告诉我们对风险的理解，而且应该作为行动的呼吁。LTCF的进入是一个关键的转折点，为积极的药物审查、简化方案、将血糖目标与预期寿命、合并症负担和患者偏好相结合提供了一个窗口。 将其转化为实践将需要开发和评估实用工具，例如入院时的结构化风险评估，磺脲类药物和胰岛素的处方清单，以及血糖监测方案，以支持长期慢性糖尿病中心一致的以人为本的糖尿病护理。Wondimkun等人阐明了长期护理中（低）血糖冰山的一角。他们的研究为在这种情况下更全面的糖尿病管理奠定了基础。为了改善结果，我们现在必须从住院转向更早的识别、更安全的处方和真正以人为本的护理。虽然还有很多工作要做，但方向已经确定。巴特·斯帕特根斯：构思，写作-原稿。诺丁·m·j·汉森：写作——审查、编辑、验证。Daisy J. A. Janssen：监督，写作-审查和编辑，验证。这项工作没有收到任何资金。上述利益冲突与本手稿的构思、写作或提交无关。获得了诺和诺德、拜耳和勃林格殷格翰的酬金。其他作者声明没有利益冲突。本出版物链接到Yohanes a . Wondimkun等人的相关信件。要查看本文，请访问https://doi.org/10.1111/jgs.70131。
{"title":"The (Hypo)glycemic Iceberg in Long-Term Care: Steering Beyond Hospital Admissions","authors":"Bart Spaetgens, Nordin M. J. Hanssen, Daisy J. A. Janssen","doi":"10.1111/jgs.70125","DOIUrl":"10.1111/jgs.70125","url":null,"abstract":"<p>We read with interest the study by Wondimkun et al. [<span>1</span>] examining hospitalizations for hypoglycemia and hyperglycemia among older adults newly admitted to long-term care facilities (LTCFs). The study provides important insights into risk factors for severe glycemic events in this vulnerable population, using high-quality, population-based registry data.</p><p>While the reported incidence of hospital admissions appears low, 1.0% for hypoglycemia and 0.5% for hyperglycemia in the year following LTCF entry, these figures, as the authors acknowledge, reflect only the most severe cases and, in our view, substantially underestimate the true burden of glycemic dysregulation in LTCFs. Many hypo- and hyperglycemic events are managed within the facility by nursing home staff and are not coded as primary reasons for hospitalization. Especially in frail older adults, symptoms such as delirium, falls, atypical behavior, or, even more concerning, cases of unwitnessed or unexpected death in bed may reflect underlying glycemic instability that remains undocumented in hospital data. Notably, the authors' own sensitivity analysis, which includes secondary diagnoses, suggests a threefold increase in the incidence of hospitalizations, reinforcing that many events were misclassified or coincided with other illnesses.</p><p>This raises broader concerns. First, glycemic events in LTCFs are rarely isolated episodes. More often, they reflect underlying frailty or transitions in health status that warrant a reassessment of care goals. These vulnerabilities may also explain why previous dysglycemic episodes, identified as key predictors in the study, frequently precede new hospitalizations. In many cases, such events serve as warning signs of broader care mismatches, including nutritional issues, medication burden, underlying illness or infection, or cognitive deterioration [<span>2</span>]. Studies from U.S. nursing homes reinforce this concern, showing substantial rates of hypoglycemia, particularly among residents using insulin or sulfonylureas [<span>3, 4</span>]. While such episodes may often not lead to hospitalization, they contribute to physical and cognitive decline, emergency transfers, and distress for both residents and staff. This aligns with Wondimkun et al., who reported that insulin and sulfonylureas significantly increased the risk of hypoglycemia-related hospitalizations, with insulin additionally linked to hyperglycemia admissions.</p><p>To address these issues, broader surveillance strategies are urgently needed. These should incorporate nursing documentation, structured reporting of adverse glycemic events, and, where feasible given emerging staffing shortages, the use of continuous glucose monitoring to better capture fluctuations in glucose levels. This is particularly relevant for residents with dementia or limited communication abilities, who in the present study were found to be at increased risk of hospitalization. These individua","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"74 1","pages":"280-281"},"PeriodicalIF":4.5,"publicationDate":"2025-10-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://agsjournals.onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.70125","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145208782","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
States have increased their use of managed care organizations to cover long-term services and supports (LTSS) to rebalance use from nursing homes to home and community-based settings. We study the impact of managed long-term services and supports (MLTSS) programs on long-stay Medicaid nursing home visits.
Methods
We used the minimum data set (MDS) 3.0 and master beneficiary summary files (MBSF) from 2011 to 2021 to identify 3,685,771 older adults aged 65 and above with long-stay nursing home visits. Using a staggered difference-in-differences (DiD) regression design, we compared individuals in states that implemented MLTSS programs with individuals in states that did not implement MLTSS.
Results
Although overall Medicaid nursing home enrollment for older adults decreased from 2011 to 2021, states implementing MLTSS experienced a 5.83% decrease in their share of older adults residing in long-stay nursing homes relative to states that did not implement MLTSS. We observed no significant changes in the share of residents with low care needs due to MLTSS.
Conclusion
The findings of this study suggest MLTSS programs can potentially fulfill states' objectives of rebalancing Medicaid LTSS use from nursing homes to home and community-based settings, but further design changes may be necessary to target low-care nursing home residents.
{"title":"Impact of Managed Long-Term Services and Supports on Nursing Home Use","authors":"Deepon Bhaumik, David C. Grabowski","doi":"10.1111/jgs.70144","DOIUrl":"10.1111/jgs.70144","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>States have increased their use of managed care organizations to cover long-term services and supports (LTSS) to rebalance use from nursing homes to home and community-based settings. We study the impact of managed long-term services and supports (MLTSS) programs on long-stay Medicaid nursing home visits.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We used the minimum data set (MDS) 3.0 and master beneficiary summary files (MBSF) from 2011 to 2021 to identify 3,685,771 older adults aged 65 and above with long-stay nursing home visits. Using a staggered difference-in-differences (DiD) regression design, we compared individuals in states that implemented MLTSS programs with individuals in states that did not implement MLTSS.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Although overall Medicaid nursing home enrollment for older adults decreased from 2011 to 2021, states implementing MLTSS experienced a 5.83% decrease in their share of older adults residing in long-stay nursing homes relative to states that did not implement MLTSS. We observed no significant changes in the share of residents with low care needs due to MLTSS.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>The findings of this study suggest MLTSS programs can potentially fulfill states' objectives of rebalancing Medicaid LTSS use from nursing homes to home and community-based settings, but further design changes may be necessary to target low-care nursing home residents.</p>\u0000 </section>\u0000 </div>","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"74 1","pages":"205-209"},"PeriodicalIF":4.5,"publicationDate":"2025-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145193879","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Amanda A. Geppert, Sara Kim, Donna Tong, Jane L. Holl, Maria Lucia L. Madariaga
<p>There is strong evidence that prehabilitation (prehab) before surgery in frail, older adult patients improves perioperative outcomes, yet only 10%–30% of eligible patients adhere to prehab programs [<span>1-3</span>]. We hypothesize that the lack of “end” user (e.g., patient, caregiver) engagement in the design of prehab programs contributes to poor adherence and describe the first application of user-centered, participatory, co-design [<span>4, 5</span>] principles to a prehab program for frail, older adult Thoracic Surgery patients.</p><p>Patients/caregivers in the thoracic surgery clinic waiting room were invited to participate in a brief (5–10 min) interview to gather feedback on individual components of low-fidelity, early prototypes (e.g., hand-drawn pictures) of a prehab program. Three phases of interviews, with new participants at each phase, were conducted with continuous data analysis to inform the next iteration of the prototype (Table 1). For Phase 1, participants were shown an initial prototype of an Apple Watch (with daily exercise reminders and recording physical activity) and multiple formats (e.g., handout, cards, video) of physical activities (e.g., tai chi, walking, Zumba) for patients to perform. For Phase 2, the prototype consisted of the Apple Watch, a prescription for prehab, and a 13-page, single-sided, <i>flipbook</i> that was branded with the hospital name and included evidence of the benefits of the exercises from professional societies; a page for each exercise with step-by-step directions; a daily tracking log; and a brief guide on the use of the Apple Watch. For Phase 3, a near final prototype (Apple Watch, prescription, and <i>flipbook</i> with additional refinements to the exercise directions and a “Safety Tips” page) was reviewed by participants and the University of Chicago Health Literacy and Office of Diversity, Equity and Inclusion team. Participants were also asked about their receptivity to wearing the Apple Watch and receiving a daily exercise reminder. Finally, content and layout refinements were made by the study team in alignment with design criteria prioritized by patients and caregivers. The study was approved by the University of Chicago IRB22-1679.</p><p>A total of 19 patients and 4 caregivers (<i>n</i> = 23) participated in the interviews (participation rate 96%, 23/24). Feedback from Phase 1 participants (<i>n</i> = 9) indicated a desire for (1) a “booklet” that is institutionally “branded” to convey quality and includes a limited number of exercises with evidence of patient benefit and is ordered by difficulty and (2) a “prescription” for prehab. Phase 2 participants (<i>n</i> = 3) endorsed the <i>flipbook</i> (booklet), found the exercise directions simple enough to complete at home, and requested more information about needed equipment. Phase 3 participants (<i>n</i> = 11) offered nuanced feedback about the content, order, and directions of the exercises (e.g., how to address poor balance or
{"title":"Application of Participatory Design to Co-Design a Thoracic Surgery Prehabilitation Program","authors":"Amanda A. Geppert, Sara Kim, Donna Tong, Jane L. Holl, Maria Lucia L. Madariaga","doi":"10.1111/jgs.70141","DOIUrl":"10.1111/jgs.70141","url":null,"abstract":"<p>There is strong evidence that prehabilitation (prehab) before surgery in frail, older adult patients improves perioperative outcomes, yet only 10%–30% of eligible patients adhere to prehab programs [<span>1-3</span>]. We hypothesize that the lack of “end” user (e.g., patient, caregiver) engagement in the design of prehab programs contributes to poor adherence and describe the first application of user-centered, participatory, co-design [<span>4, 5</span>] principles to a prehab program for frail, older adult Thoracic Surgery patients.</p><p>Patients/caregivers in the thoracic surgery clinic waiting room were invited to participate in a brief (5–10 min) interview to gather feedback on individual components of low-fidelity, early prototypes (e.g., hand-drawn pictures) of a prehab program. Three phases of interviews, with new participants at each phase, were conducted with continuous data analysis to inform the next iteration of the prototype (Table 1). For Phase 1, participants were shown an initial prototype of an Apple Watch (with daily exercise reminders and recording physical activity) and multiple formats (e.g., handout, cards, video) of physical activities (e.g., tai chi, walking, Zumba) for patients to perform. For Phase 2, the prototype consisted of the Apple Watch, a prescription for prehab, and a 13-page, single-sided, <i>flipbook</i> that was branded with the hospital name and included evidence of the benefits of the exercises from professional societies; a page for each exercise with step-by-step directions; a daily tracking log; and a brief guide on the use of the Apple Watch. For Phase 3, a near final prototype (Apple Watch, prescription, and <i>flipbook</i> with additional refinements to the exercise directions and a “Safety Tips” page) was reviewed by participants and the University of Chicago Health Literacy and Office of Diversity, Equity and Inclusion team. Participants were also asked about their receptivity to wearing the Apple Watch and receiving a daily exercise reminder. Finally, content and layout refinements were made by the study team in alignment with design criteria prioritized by patients and caregivers. The study was approved by the University of Chicago IRB22-1679.</p><p>A total of 19 patients and 4 caregivers (<i>n</i> = 23) participated in the interviews (participation rate 96%, 23/24). Feedback from Phase 1 participants (<i>n</i> = 9) indicated a desire for (1) a “booklet” that is institutionally “branded” to convey quality and includes a limited number of exercises with evidence of patient benefit and is ordered by difficulty and (2) a “prescription” for prehab. Phase 2 participants (<i>n</i> = 3) endorsed the <i>flipbook</i> (booklet), found the exercise directions simple enough to complete at home, and requested more information about needed equipment. Phase 3 participants (<i>n</i> = 11) offered nuanced feedback about the content, order, and directions of the exercises (e.g., how to address poor balance or ","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"73 12","pages":"3919-3921"},"PeriodicalIF":4.5,"publicationDate":"2025-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12748017/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145202540","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Claire E. Donnelly, Nicholas A. Rattray, Mindy E. Flanagan, Jennifer L. Myers, Ashley L. Schwartzkopf, Caroline B. Madrigal, Cathy C. Schubert, Marianne Shaughnessy, Jane A. Driver, Shivani K. Jindal, Dawn M. Bravata
<div> <section> <h3> Background</h3> <p>The Coordinated Transitional Care (CTraC) program is an evidence-based, nurse-driven, low-cost intervention that improves transitional care for geriatric patients following hospital admission. CTraC reduces readmissions and enhances outcomes for older Veterans with chronic conditions or minimal caregiver support.</p> </section> <section> <h3> Objectives</h3> <p>This program evaluation was a component of the US Department of Veterans Affairs (VA) Geriatric Learning Health System initiative, which seeks to support community-dwelling older Veterans as they transition from hospital to home. We examined CTraC's operation across diverse hospital settings and identified critical transitional processes and contextual factors supporting patients transitioning from hospital to home. Our goal was to identify lessons to support the widespread deployment of CTraC systemwide.</p> </section> <section> <h3> Design</h3> <p>Semi-structured interviews were conducted with CTraC nurses at 11 VA hospitals. Qualitative data explored program set-up, protocol use, data tracking, program challenges and successes, and readmission reduction strategies. Comparison matrices were developed within a rapid qualitative analysis approach.</p> </section> <section> <h3> Results</h3> <p>CTraC nurses act as the point person for Veterans, address concerns, provide guidance, and resolve potential issues before escalation. Five themes emerged on CTraC alleviating gaps in transitional care and the program's organizational factors impacting implementation and sustainment. Nurses identified and addressed problems, including medication issues, follow-up appointment scheduling, in-home safety issues, and handling tasks overlooked by other clinicians. Interviews indicated variation in CTraC nurses' ability to track data, integrate CTraC into existing systems, and communicate program effectiveness with leadership. Sustainability challenges (e.g., facility decommissioning CTraC due to limited leadership awareness of program effectiveness) highlighted the need for enhanced data infrastructure and analytic support to report program efficacy.</p> </section> <section> <h3> Conclusions</h3> <p>Adaptation and feedback-driven refinement are critical to expanding CTraC's impact and promoting sustainment. Strengthening data feedback support and workforce resources may enable CTraC to sustain its adaptive, patient-centered approach to transitional care for Veterans.</
{"title":"Perspectives of Nurses in the VA Coordinated Transitional Care (CTraC) Program: A Qualitative Study","authors":"Claire E. Donnelly, Nicholas A. Rattray, Mindy E. Flanagan, Jennifer L. Myers, Ashley L. Schwartzkopf, Caroline B. Madrigal, Cathy C. Schubert, Marianne Shaughnessy, Jane A. Driver, Shivani K. Jindal, Dawn M. Bravata","doi":"10.1111/jgs.70110","DOIUrl":"10.1111/jgs.70110","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>The Coordinated Transitional Care (CTraC) program is an evidence-based, nurse-driven, low-cost intervention that improves transitional care for geriatric patients following hospital admission. CTraC reduces readmissions and enhances outcomes for older Veterans with chronic conditions or minimal caregiver support.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>This program evaluation was a component of the US Department of Veterans Affairs (VA) Geriatric Learning Health System initiative, which seeks to support community-dwelling older Veterans as they transition from hospital to home. We examined CTraC's operation across diverse hospital settings and identified critical transitional processes and contextual factors supporting patients transitioning from hospital to home. Our goal was to identify lessons to support the widespread deployment of CTraC systemwide.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Design</h3>\u0000 \u0000 <p>Semi-structured interviews were conducted with CTraC nurses at 11 VA hospitals. Qualitative data explored program set-up, protocol use, data tracking, program challenges and successes, and readmission reduction strategies. Comparison matrices were developed within a rapid qualitative analysis approach.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>CTraC nurses act as the point person for Veterans, address concerns, provide guidance, and resolve potential issues before escalation. Five themes emerged on CTraC alleviating gaps in transitional care and the program's organizational factors impacting implementation and sustainment. Nurses identified and addressed problems, including medication issues, follow-up appointment scheduling, in-home safety issues, and handling tasks overlooked by other clinicians. Interviews indicated variation in CTraC nurses' ability to track data, integrate CTraC into existing systems, and communicate program effectiveness with leadership. Sustainability challenges (e.g., facility decommissioning CTraC due to limited leadership awareness of program effectiveness) highlighted the need for enhanced data infrastructure and analytic support to report program efficacy.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Adaptation and feedback-driven refinement are critical to expanding CTraC's impact and promoting sustainment. Strengthening data feedback support and workforce resources may enable CTraC to sustain its adaptive, patient-centered approach to transitional care for Veterans.</","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"73 12","pages":"3860-3869"},"PeriodicalIF":4.5,"publicationDate":"2025-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12748012/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145193801","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Alan P. Pan, Kathryn Agarwal, Thomas Potter, Karim Borei, Sara Nowakowski, Courtenay R. Bruce, George E. Taffet, Farhaan S. Vahidy
Background
Underlying socio-economic and health burden may variably impact delirium presentation among older adults. We characterized differences in patient factors related to social marginalization and studied their effects on delirium occurrence and hospital outcomes.
Methods
We conducted a 7-year retrospective analysis of older adults (aged ≥ 70 years) who systematically underwent screening for delirium at an 8-hospital healthcare system. Our primary exposure included patient characteristics related to demographics and social marginalization. Multivariable logistic regression models were built to identify factors associated with increased odds of delirium occurrence, either (1) present-on-admission (D-POA) or (2) hospital-acquired (HAD). Secondary outcomes included hospital length of stay, in-hospital mortality, and discharge disposition.
Results
A total of 260,200 older adults were screened for delirium (median [IQR] age in years: 78.0 [74.0–84.0]; female: 143,402 [55.1%]; non-Hispanic Black: 40,737 [15.8%]; Hispanic: 30,760 [11.9%]; median [IQR] Area Deprivation Index: 4.0 [2.0–6.0]; median [IQR] Charlson Comorbidity Index: 10.0 [8.0–13.0]). Rates of D-POA were 25.5% across all screened patients. Among patients delirium-free at admission, 10.4% later acquired HAD. In addition to known risk associations with older age and comorbidity burden, increased odds of D-POA were observed for non-Hispanic Black patients (aOR, 95% CI: 1.49, 1.44–1.54), Hispanic patients (aOR, 95% CI: 1.31, 1.26–1.36), higher ADI-defined socio-economic marginalization (aOR, 95% CI: 1.01, 1.00–1.01), and prior dementia (aOR: 6.53, 6.37–6.68). HAD risks were also higher for males (aOR, 95% CI: 1.07, 1.04–1.11), non-Hispanic Black patients (1.39, 1.32–1.46), Hispanic patients (aOR, 95% CI: 1.28, 1.21–1.35), residence in higher ADI neighborhoods (aOR, 95% CI: 1.02, 1.02–1.03), and prior dementia (aOR, 95% CI: 2.44, 2.34–2.53). Effects of delirium on poor hospital outcomes did not differ by socio-demographic sub-groups.
Conclusions
Delirium risks were higher among minoritized and socio-economically marginalized older adults. These findings present an opportunity to consider social marginalization as an important factor in delirium risk stratification.
{"title":"Social Disparities, Delirium Occurrence, and Related Outcomes Among Hospitalized Older Adults","authors":"Alan P. Pan, Kathryn Agarwal, Thomas Potter, Karim Borei, Sara Nowakowski, Courtenay R. Bruce, George E. Taffet, Farhaan S. Vahidy","doi":"10.1111/jgs.70137","DOIUrl":"10.1111/jgs.70137","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Underlying socio-economic and health burden may variably impact delirium presentation among older adults. We characterized differences in patient factors related to social marginalization and studied their effects on delirium occurrence and hospital outcomes.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We conducted a 7-year retrospective analysis of older adults (aged ≥ 70 years) who systematically underwent screening for delirium at an 8-hospital healthcare system. Our primary exposure included patient characteristics related to demographics and social marginalization. Multivariable logistic regression models were built to identify factors associated with increased odds of delirium occurrence, either (1) present-on-admission (D-POA) or (2) hospital-acquired (HAD). Secondary outcomes included hospital length of stay, in-hospital mortality, and discharge disposition.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>A total of 260,200 older adults were screened for delirium (median [IQR] age in years: 78.0 [74.0–84.0]; female: 143,402 [55.1%]; non-Hispanic Black: 40,737 [15.8%]; Hispanic: 30,760 [11.9%]; median [IQR] Area Deprivation Index: 4.0 [2.0–6.0]; median [IQR] Charlson Comorbidity Index: 10.0 [8.0–13.0]). Rates of D-POA were 25.5% across all screened patients. Among patients delirium-free at admission, 10.4% later acquired HAD. In addition to known risk associations with older age and comorbidity burden, increased odds of D-POA were observed for non-Hispanic Black patients (aOR, 95% CI: 1.49, 1.44–1.54), Hispanic patients (aOR, 95% CI: 1.31, 1.26–1.36), higher ADI-defined socio-economic marginalization (aOR, 95% CI: 1.01, 1.00–1.01), and prior dementia (aOR: 6.53, 6.37–6.68). HAD risks were also higher for males (aOR, 95% CI: 1.07, 1.04–1.11), non-Hispanic Black patients (1.39, 1.32–1.46), Hispanic patients (aOR, 95% CI: 1.28, 1.21–1.35), residence in higher ADI neighborhoods (aOR, 95% CI: 1.02, 1.02–1.03), and prior dementia (aOR, 95% CI: 2.44, 2.34–2.53). Effects of delirium on poor hospital outcomes did not differ by socio-demographic sub-groups.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Delirium risks were higher among minoritized and socio-economically marginalized older adults. These findings present an opportunity to consider social marginalization as an important factor in delirium risk stratification.</p>\u0000 </section>\u0000 </div>","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"73 12","pages":"3729-3737"},"PeriodicalIF":4.5,"publicationDate":"2025-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145193798","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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