Journal of the American Geriatrics Society最新文献

Background: Early serious illness communication (SIC) has numerous benefits for patients with cardiopulmonary illnesses, yet engaging patients in this complex, iterative communication process is challenging due to constraints on clinician time, limited clinician training in these conversations, and a lack of patient readiness. This study reports secondary SIC outcomes of a previously reported clinical trial.

Methods: In a randomized clinical trial of a nurse and social worker palliative telecare team, one visit with the nurse and/or social worker focused on SIC using a protocolized guide. Participants were at high risk of hospitalization or death, had poor health status, and chronic obstructive pulmonary disease and/or heart failure or interstitial lung disease. Documented SIC, advance directive (AD) completion, and the four-item readiness to engage in advance care planning scale (ACP-4) were measured at baseline and 6 months. Differences in change between intervention and usual care were analyzed using linear models and linear mixed models.

Results: The 306 participants were on average 68.9 years, 90.2% male, 80.1% White, with multiple comorbidities (mean of 7.6). All outcomes were similar at baseline. ACP-4 increased more in the intervention group at 6 months compared to usual care (difference in change scores: 0.49; 95% CI 0.22-0.66, p < 0.001). Documented SIC at 6 months was higher in the intervention group compared to usual care (122/154, 79.2% vs. 7/152, 4.6%); adjusted difference in proportions 74.6% (95% CI 67.3-81.9, p < 0.001). The difference in proportion of participants with an AD at 6 months was not significant; adjusted difference in proportions, 0.01%, (95% CI -0.04-0.07, p = 0.64).

Conclusions: After participation in a telephonic, protocolized SIC intervention, documented SIC increased, and readiness to engage in ACP increased. Future research should evaluate how documented SIC is used and the effect of SIC on downstream outcomes of healthcare decisions and patient well-being.

Trial registration: ClinicalTrials.gov NCT02713347, https://clinicaltrials.gov/ct2/show/NCT02713347.

Background: Ambulatory care is critical in delivering interventions for dementia and mild cognitive impairment (MCI), from basic services to novel therapeutics. Yet, little is known regarding how community-dwelling persons with dementia/MCI interact with clinicians in outpatient ambulatory settings. We assessed associations of dementia/MCI with outpatient ambulatory evaluation and management (E&M) visits.

Methods: We included 2116 community-dwelling participants in Rush Alzheimer's Disease Center cohorts, with linked fee-for-service Medicare claims. Annually from 2011 to 2019, cohort neuropsychologic evaluations classified participants as dementia, MCI, or no cognitive impairment (NCI). Across groups, we compared annual probability of visiting providers and number of E&M visits, using repeated measures logistic or generalized Poisson mixed effects models.

Results: Across 8672 person-years (PY) of follow-up, the mean age was 82 (SD 7.6) years; 77% of PYs were among females and 24% among Black participants. Controlling for demographics and comorbidity, the annual predicted probability of primary care visits was high in all groups (86%-92%). Although there were few visits with dementia-related specialists, we found a higher probability of these visits among those with dementia (15%) and MCI (17%) than NCI (12%; p = 0.009, dementia vs. NCI; p < 0.001, MCI vs. NCI). There were striking differences in visits to other medical specialties: the mean number of annual visits was 40% lower for those with dementia (p < 0.001) and 10% lower for MCI (p < 0.001) than NCI. Overall, dementia and MCI were associated with 19% (p < 0.001) and 4% (p = 0.005) fewer E&M visits, respectively, compared to NCI.

Conclusions: Older adults with dementia and MCI interact with primary care providers regularly and are more likely to use dementia-related specialists than those with NCI. Yet, we found lower utilization of other medical specialties, without compensatory increases in primary care, leading to fewer overall E&M visits, even in MCI. Together, the findings may suggest lost opportunities to address the scope of health issues in vulnerable groups.

Background: Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been shown to improve renal and cardiovascular outcomes in patients with type 2 diabetes. Limited evidence exists about the efficacy and safety of SGLT2 inhibitors in patients with frailty.

Methods: This was a post hoc pooled, participant-level data analysis of the CANVAS Program (CANVAS and CANVAS-R) and the CREDENCE trial. We examined the effect of canagliflozin on: (1) Major adverse cardiovascular events (MACE), (2) Cardiovascular mortality, (3) all-cause mortality, and (4) key safety outcomes. Frailty was defined by a Frailty Index (FI) based on a deficit accumulation approach (FI > 0.25: frail). Cox proportional-hazard models were used to estimate the efficacy and safety of canagliflozin overall and according to frailty status.

Results: There were 14,543 participants (10,142 from the CANVAS Program, 4401 from the CREDENCE trial). Their mean age was 63.2 years; 35.3% were female. Frailty was present in 56% of the study participants. The benefits of canagliflozin were observed in both the frail and non-frail subgroups: HRs for MACE 0.80 (95% CI 0.70-0.90) in the frail versus 0.91 (95% CI 0.75-1.09) in the non-frail (p for interaction = 0.27); HRs for cardiovascular mortality 0.79 (95% CI 0.67-0.95) in the frail versus 0.94 (95% CI 0.70-1.27) in the non-frail (p for interaction = 0.38); HRs for all-cause mortality 0.81 (95% CI 0.70-0.94) in the frail versus 0.93 (95% CI 0.74-1.16) in the non-frail (p for interaction = 0.39). Adverse events were similar among frail and non-frail participants, except for osmotic diuresis (HRs 1.67, 95% CI 1.22-2.28 in the frail vs. 3.05, 95% CI 2.13-4.35 in the non-frail, p for interaction = 0.01).

Conclusions: Canagliflozin improved cardiovascular and mortality endpoints in participants with type 2 diabetes irrespective of frailty status, with a similar safety profile. Our findings, in addition to those from other recent studies, provide evidence to support the introduction of SGLT2 inhibitor therapy in patients perceived to be frail.

Trial registration: ClinicalTrials.gov CANVAS: NCT01032629; CANVAS-R: NCT01989754; CREDENCE: NCT02065791.

Background: Cataract extraction with intraocular lens insertion (CEIOL) is among the most frequently performed surgeries in the United States and is indicated for individuals with age-related cataracts causing visual impairment. The association between CEIOL and falls and hip fractures has been described, but there is a paucity of literature describing the association between CEIOL and various other common morbidity and mortality-increasing age-related traumatic injuries.

Methods: This retrospective cohort study utilized TriNetX, a health database, to access de-identified electronic medical records. Cohorts of patients aged 60 years and older were identified using diagnostic and procedural codes. Cohort 1 was defined as patients with age-related cataracts who underwent CEIOL within 10 years of documented diagnosis of cataracts. Cohort 2 was defined as patients with age-related cataracts who did not undergo CEIOL within 10 years of documented diagnosis of cataracts. Propensity score matching for demographics and other relevant comorbidities was completed. Chi-square analysis was performed, and data were reported as odds ratios with 95% confidence intervals. Outcomes analyzed included proximal humerus fracture, distal radius fracture, hip fracture, ankle fracture, fall, subdural hemorrhage, and epidural hemorrhage.

Results: Patients who underwent CEIOL demonstrated significantly lower odds of falls (p < 0.0001), proximal humerus fracture (p = 0.016), distal radius fracture (p = 0.0004), hip fracture (p < 0.0001), ankle fracture (p = 0.0002), subdural hemorrhage (p < 0.0001), and epidural hemorrhage (p = 0.006) as compared to patients with a documented diagnosis of age-related cataract without CEIOL.

Conclusions: CEIOL was significantly associated with decreased falls and reductions in major fall-related injuries among patients with age-related cataracts. These findings strongly support improved screening protocols to detect vision loss secondary to age-related cataracts, as this may decrease the incidence of common major fall-related injuries among patients with age-related cataracts.

Background: Recent evidence underscores the significant impact of social determinants of health (SDoH) on cardiovascular disease (CVD). However, available CVD risk assessment tools often neglect SDoH. This study aimed to integrate SDoH with traditional risk factors to predict CVD risk.

Methods: The data was sourced from the ASPirin in Reducing Events in the Elderly (ASPREE) longitudinal study, and its sub-study, the ASPREE Longitudinal Study of Older Persons (ALSOP). The study included 12,896 people (5884 men and 7012 women) aged 70 or older who were initially free of CVD, dementia, and independence-limiting physical disability. The participants were followed for a median of eight years. CVD risk was predicted using state-of-the-art machine learning (ML) and deep learning (DL) models: Random Survival Forest (RSF), Deepsurv, and Neural Multi-Task Logistic Regression (NMTLR), incorporating both SDoH and traditional CVD risk factors as candidate predictors. The permutation-based feature importance method was further utilized to assess the predictive potential of the candidate predictors.

Results: Among men, the RSF model achieved relatively good performance (C-index = 0.732, integrated brier score (IBS) = 0.071, 5-year and 10-year AUC = 0.657 and 0.676 respectively). For women, DeepSurv was the best-performing model (C-index = 0.670, IBS = 0.042, 5-year and 10-year AUC = 0.676 and 0.677 respectively). Regarding the contribution of the candidate predictors, for men, age, urine albumin-to-creatinine ratio, and smoking, along with SDoH variables, were identified as the most significant predictors of CVD. For women, SDoH variables, such as social network, living arrangement, and education, predicted CVD risk better than the traditional risk factors, with age being the exception.

Conclusion: SDoH can improve the accuracy of CVD risk prediction and emerge among the main predictors for CVD. The influence of SDoH was greater for women than for men, reflecting gender-specific impacts of SDoH.