Journal of the American Geriatrics Society最新文献

Background: Cognitive aging and dementia are major public health challenges in India's aging population. This study examines associations between cognition and neurodegenerative biomarkers among community-dwelling older adults using data from the Longitudinal Aging Study in India-Diagnostic Assessment of Dementia (LASI-DAD) Wave 2.

Methods: LASI-DAD Wave 2 included 4635 participants aged ≥ 60 years. Cognitive assessments covered memory, executive function, language, and visuospatial abilities. Age-, sex-, and education-adjusted cut-offs identified low cognitive performance. Blood biomarkers, including total tau, phosphorylated tau-181 (pTau-181), neurofilament light chain (NfL), glial fibrillary acidic protein (GFAP), and β-amyloid (Aβ42/Aβ40 ratio) were collected and log-transformed. Generalized linear model (GLM) adjusted for demographic and clinical variables were used to examine the associations between biomarker levels and poor cognitive performance.

Results: Median participant age was 70 years (IQR: 66-76); 54.6% were female. Poor cognitive performance was present in 828 (27.6%) participants. Higher NfL (Median 27.2 vs. 21.8 pg/mL, p < 0.001), GFAP (Median 120.4 vs. 102.9 pg/mL, p < 0.001) and p-Tau 181 (Median 37.5 vs. 35.4, p = 0.003) were associated with poor cognition. In GLM, NfL (RR: 1.411, 95% CI 1.162-1.714, p = 0.001), GFAP (RR: 1.425, 95% CI 1.147-1.769, p = 0.003) were associated with poor cognition, while Aβ42/Aβ40 ratio total tau and p-Tau 181 were not (adjusted for age, sex, body mass index, serum creatinine, hypertension, diabetes, heart disease and stroke). Additionally, higher NfL and GFAP were associated with poor performance in most cognitive domains, except recognition memory. Higher Aβ42/Aβ40 ratio with poor recognition memory, higher p-Tau 181 with lower orientation scores, and lower total tau with lower recognition memory and visuospatial score.

Conclusion: Among older Indian adults, elevated NfL and GFAP levels were strongly associated with poor cognitive performance. These biomarkers could aid future dementia screening and prognostication efforts. Longitudinal studies are needed to validate their role in large-scale screening programs.

Background: Barriers to advance care planning intervention implementation and impact on outcomes at the patient, clinician, and health system levels are well-documented. Understanding practice-level variation in implementation and outcomes could elucidate relevant contextual factors and potential strategies for improving future implementation. We therefore examined practice variation and associations between processes and outcomes in the pragmatic trial of SHARING Choices, a primary care advance care planning (ACP) and communication intervention for older adults.

Methods: We conducted an explanatory sequential mixed-methods analysis of quantitative variation among intervention practices in trial processes and outcomes, and qualitative interview analysis of ACP facilitators' perceptions of variation in implementation. We evaluated variation in key processes: (1) reach (phone contact between ACP facilitator and patient/family) and (2) uptake (facilitator-led ACP conversations) and outcomes: (1) new electronic health record (EHR)-documented advance directives (ADs) at 12 months and (2) receipt of potentially burdensome care within 6 months of death for Maryland residents with serious illness who died. We examined practice-level correlations among processes and outcomes.

Results: Variation among practices was substantial for key processes (ACP facilitator reach and uptake) and outcomes (new EHR AD documentation and potentially burdensome care at end of life; all p < 0.01). Processes of reach and uptake were significantly correlated with the outcome of new EHR AD documentation but not with potentially burdensome care at end of life. ACP facilitators perceived variation in practice engagement with the intervention related to practice relationships and teams, relative priority of ACP, and resources such as space.

Conclusions: Practice variation in processes and mixed associations with outcomes highlight pragmatic trial implementation challenges and the impact and complexity of ACP. Future ACP trials should consider accounting for and evaluating practice variation in study design, implementation, and analysis.

Background: Assessment of physical performance in older adults is critical for injury prevention and rehabilitation. Such an assessment remains indispensable for authentic health management, facilitating proper tracking of health condition progression and implementation of tailored interventions. This study aimed to develop and evaluate a digital health tool that empowers older adults to independently assess comprehensive physical performance, including balance, mobility, lower-limb strength, and cardiorespiratory endurance.

Participants and setting: This was a cross-sectional study employing a user-centered design approach conducted at Samsung Medical Center. Thirty community-dwelling older adults aged ≥ 65 years were included.

Methods: A self-administered mobile application with a wearable sensor guided older adults to evaluate and understand their functional performance components. Usability was evaluated using a System Usability Scale (SUS), user experience questionnaires, and open-ended feedback. Preliminary validity was assessed by comparing professional assessments with self-assessments of physical performance.

Results: The tool achieved acceptable usability (mean SUS 69.0 ± 14.84), with most participants (> 95%) perceiving the tool to be necessary and useful for health management, and 86.2% confirming home feasibility. Participants valued their understanding of functional capacity, increased motivation for health management, and enhanced willingness to engage in physical activity. Self-assessments of cardiorespiratory endurance and balance showed moderate concordance with professional measurements (r = 0.5-0.6) with no significant mean differences.

Conclusion: The tool provides self-directed, comprehensive assessments and delivers intuitive comparative data against age- and sex-matched norms, thereby enabling autonomous health management. Despite variable user experience, the tool demonstrated acceptable usability, with most participants recognizing its utility and perceiving the potential for home use. Further refinements in usability, accuracy, and technical simplification are needed. With these improvements, the tool could harness these assessment results to deliver tailored exercise programs and evolve into a comprehensive prevention and rehabilitation resource for older adults.

Background: Medicare annual wellness visits (AWVs) are vital for older adults' preventive care, which was transitioned to telehealth modalities during COVID-19. This study examined primary care providers' perceptions of telehealth-delivered AWVs and explored the factors influencing telehealth implementation using the Practical Robust Implementation and Sustainability Model (PRISM).

Participants and setting: Twenty-five primary care providers from eight clinics within an integrated health system in the Midwestern United States were interviewed. Eligibility required having conducted at least one telehealth AWV for patients aged 65 or older between March 2023 and October 2023.

Methods: Semi-structured interviews lasting 30-45 min were conducted using purposeful sampling. Topics aligned with PRISM domains were addressed: program (telehealth utilization), recipient (organizational characteristics), external environment, and implementation infrastructure. Data were analyzed using NVivo software, using inductive and deductive thematic coding.

Results: Providers described telehealth AWV as flexible, convenient, and efficient. Benefits included shorter visit durations and the ability to observe patients' home environments. Challenges included difficulty conducting cognitive and mobility assessments, limitations in physical exams, and managing patients with hearing or visual impairments without caregiver support. Most providers did not perceive language as a major barrier, particularly for Spanish-speaking patients (Program domain). Providers noted that limited internet, device access, and lack of community technology support, especially in underserved areas, hindered telehealth use. They also emphasized the importance of maintaining reimbursement parity between telehealth and in-person visits (External Environment). Providers reported minimal formal training and inconsistent access to telehealth-equipped rooms, though support from colleagues and workflow adaptations helped address these limitations (Implementation Infrastructure). Staff support, particularly through pre-visit coordination, technical troubleshooting, and patient preparation, was crucial in implementing telehealth (Recipient).

Conclusion: This study provided valuable insights into the implementation of telehealth AWVs and underscored the importance of organizational support for sustainable telehealth practices in primary care settings.

Background: Analyzing longitudinal patient-reported outcomes (PROs) remains methodologically challenging, particularly in populations with high mortality rates during follow-up. Many PRO studies overlook this issue, potentially leading to biased estimates and limited clinical interpretability. We discuss various methods for analyzing patients who died during follow-up in PRO analyses and examine how these methods affect the interpretation of the study outcomes, using a clinical example in older patients with cancer.

Methods: For our clinical example, we included adults aged $\ge$  70 years with cancer from a prospective cohort. Quality of life (QoL) was assessed with the EuroQoL 5-Dimension (EQ-5D) tool at baseline and 6 and 12 months after treatment initiation. We applied six different methods: Four methods calculated absolute changes in mean scores; two methods estimated the proportion of patients with a changed QoL.

Results: Of the 1218 participants, 321 (26%) died within 12 months. Methods restricted to the 897 survivors at the end of follow-up lead to results that are difficult to interpret due to selection bias. In linear mixed models, EQ-5D scores are implicitly reconstructed for the 321 participants that died, creating a hypothetical view of QoL assuming no patients died. Alternative approaches, such as the "while-alive" strategy or composite endpoint strategies, treating death as the worst possible score on the EQ-5D, produce more complete views of the QoL.

Conclusions: The interpretation of longitudinal PROs strongly depends on the chosen method, associated estimands and how patients that died are addressed: different methods lead to different estimates and conclusions. Properly defining the research question and choosing the most appropriate method is essential for meaningful interpretations for clinicians and patients.

Background: An international consensus is still lacking on the best operational definition of Sarcopenia in hospitalized older adults. The main objective of this study was to use the EWGSOP2 guidelines in hospitalized old subjects to test its predictivity for adverse clinical outcomes and to evaluate its step-by-step capability to predict unfavorable clinical events.

Participants and setting: Three hundred and seventeen men and two hundred and eighty seven women, aged 65 to 99 years, consecutively admitted to the Department of Geriatrics at the University Hospital of Verona.

Methods: All patients underwent a complete geriatric assessment, clinical evaluation, and for the diagnosis of Sarcopenia, the EWGSOP2 guidelines were applied. As clinical outcomes, length of hospital stay, fall risk, and subjects' quality of life were considered.

Results: Among 604 hospitalized older patients, 56.0% presented with a SARC-F score suggestive of a risk for Sarcopenia. Patients at risk for Sarcopenia, and with available handgrip strength data, in 85.5% of cases also presented probable Sarcopenia. Among patients with probable Sarcopenia, and with available body composition data, 83.1% were confirmed with Sarcopenia, with a general prevalence of Sarcopenia of 22%. The shortest average length of hospitalization was in non-sarcopenic patients, with a median of 11 days, whereas dynapenic and sarcopenic subjects have respectively a median of 12 and 13 days of hospitalization, with significant differences also after adjustment for age, nutritional status and comorbidity. After dividing the patients into negative or positive for each diagnostic step of the EWGSOP2 algorithm, we found, for each step of the algorithm, a progressively greater association with adverse clinical outcomes.

Conclusions: EWGSOP2 algorithm is a valid tool even in hospitalized older patients, and each step enhances the predictivity of the algorithm; however, SARC-F and muscle strength can still be valuable tools for negative clinical outcomes when body composition data are not available.