Journal of the American Geriatrics Society最新文献

Background: The optimal blood pressure (BP) target for older adults with hypertension remains controversial, particularly among those with advanced age, frailty, or polypharmacy. This study estimated the individualized net benefit of intensive BP lowering among community-dwelling older adults in the Systolic Blood Pressure Intervention Trial (SPRINT).

Methods: Among 5143 SPRINT participants age ≥ 65 years, Cox models were internally validated to predict an absolute difference in risk between treating to a systolic BP target of < 120 versus < 140 mm Hg for all-cause death, cardiovascular outcomes, cognitive outcomes, and serious adverse events. Treatment effects were combined using simulated preference weights into individualized net benefits, representing the weighted sum of risk differences across outcomes. Net benefits were compared across categories of age (65-74 vs. ≥ 75 years), SPRINT-derived frailty status (fit, less fit, and frail), and polypharmacy (≥ 5 medications).

Results: When simulating preferences for participants who view the benefits of BP lowering (reduction in death, cardiovascular events, and cognitive impairment) as much more important than treatment-related harms (e.g., acute kidney injury and syncope), the median net benefit from intensive BP lowering was 4 percentage points (IQR: 3-6), and 100% had a positive net benefit favoring intensive BP lowering. When simulating benefits and harms to have similar, intermediate importance, the median net benefit was 1 percentage point (IQR: 0-2), and 85% had a positive net benefit. Participants with advanced age and frailty had greater net benefits from intensive BP lowering despite experiencing more harm in both simulations, and those with polypharmacy had greater net benefits when benefits were viewed as much more important than harms (p < 0.001 for all comparisons).

Conclusions: Among community-dwelling older adults with hypertension in SPRINT, almost all participants had a net benefit that favored a systolic BP target of < 120 mm Hg, but the magnitude of net benefit varied according to estimated risks and simulated preferences.

Background: Comprehensive geriatric assessment (CGA), an operational model of integrated care, has become a fundamental component of healthcare delivery models for older adults. It is a multidimensional diagnostic process intended to determine a frail elderly person's medical, psychosocial, and functional capabilities and limitations to develop an integrated care plan. The aim of this systematic review and meta-analysis was to update and synthesize the totality of research evidence related to the effectiveness of home-based CGA compared with usual care among community-dwelling at-risk older adults. A secondary aim of the review was to characterize the components of CGA delivered across the included studies.

Methods: CENTRAL, MEDLINE, Embase, CINAHL, trial registers (WHO ICTRP, ClinicalTrials.gov, and McMaster Aging Portal), and gray literature were searched. Two independent reviewers conducted screening, data extraction, quality appraisal, and applied the Grading of Recommendations, Assessment, Development, and Evaluations framework to quantify the certainty of evidence. Meta-analyses were performed in Review Manager 5.4. The primary outcome was functional status.

Results: Twenty-two trials recruiting 7219 community-dwelling older adults were included. Home-based CGA resulted in improved functional status at 6-24 months (standardized mean difference [SMD] 0.17, 95% confidence interval [CI] 0.09-0.25), at 12 months (SMD 0.24, 95% CI 0.02-0.47), and at 24 months (SMD 0.11, 95% CI 0.01-0.22); an increased health-related quality of life (HRQoL) at 6-24 and 12 months; a reduction in mortality at 36 months; a reduction in hospitalizations at 6-36 months; and improved patient satisfaction with care at 6-12 months. Home-based CGA resulted in little or no difference in nursing home admission, emergency department presentation, or adverse events. Intervention characteristics and multidisciplinary team composition varied across trials.

Conclusion: Home-based CGA improves clinical and process outcomes for community dwelling at-risk older adults. CGA delivered by a comprehensive multidisciplinary team enhances functional status among community-dwelling older adults.

Inspiring Undergraduate Student Training in Alzheimer's Research (USTAR) aims to provide Underrepresented Minority (URM) undergraduate students with mentored didactic, clinical, and research experiences to stimulate interest in research related to Alzheimer's Disease and Related Dementias (ADRD). USTAR specifically focuses on social determinants of health (SDOH) as risk factors for ADRD minoritized populations. USTAR's scientific rationale is that URM undergraduates are less likely to enter the biomedical workforce. Addressing this disparity is important since minorities are disproportionally affected by ADRD, and URM scientists may deeply appreciate the sociocultural forces that create racial health disparities. USTAR unites faculty expertise from Thomas Jefferson University (TJU) and Delaware State University (DSU), a Historically Black College and University (HBCU). The faculty's work spans the full spectrum of ADRD research and care, including neuroscience, biology, gerontology, geriatrics, neurology, and geriatric psychiatry. The 20-month USTAR program will train two cohorts of 10 students. Across all USTAR activities, we emphasize the relationship between SDOH and cognition. USTAR's goals are to: (1) provide interdisciplinary ADRD-related research, educational, clinical, and community experiences; (2) enhance research skills via group research projects; (3) facilitate transition from undergraduate to graduate studies in science; and (4) evaluate USTAR's effectiveness. USTAR has the potential to increase diversity in the national workforce that conducts health disparities research pertaining to ADRD. This goal aligns with the National Institute on Aging's (NIA) mission to meet the nation's biomedical, behavioral, and clinical research needs and to ensure health equity for all Americans.

Background: Patient-facing chatbots can be used for administrative tasks, personalized care reminders, and overcoming transportation or geographic barriers in healthcare. Although some data suggest older adults see privacy as an ethical barrier to adopting digital technologies, little is known about privacy concerns regarding information shared with novel patient-facing chatbots. We sought to examine attitudes toward privacy based on age or other sociodemographic characteristics.

Methods: We conducted a sequential mixed methods study among patient users of a large healthcare system chatbot. We purposively oversampled by race and ethnicity to survey 3089 patient chatbot users online using de novo and validated items. Next, we conducted semi-structured interviews with users (n = 46) purposively sampled based on diversity or select survey responses. We used multivariable logistic regression to analyze survey data and modified grounded theory to analyze interviews. We integrated data using simultaneous visualization and triangulation.

Results: We received 617/3089 surveys (response rate, 20.0%). Overall, 370/597 (63.9%) expressed worry about the privacy of information shared with the chatbot. Logistic regression found that users ≥ 65 years were 26% points less likely to be worried about information privacy compared to those 18-34 years old (p < 0.001). We found less worry among Black, non-Hispanic users and among those with more than a four-year college degree. By integrating our survey and interview data, we observed that older adult users experienced a halo effect: they worried less because they saw the chatbot as associated with a trusted health system and experienced lower medical mistrust.

Conclusion: Contrary to some prior research, adults aged 65 and older expressed less concern about chatbot privacy than younger adults because of their trust in health care. To maintain this trust and build it among all users, health systems using patient-facing chatbots need to take active steps to maintain and communicate patient privacy protections.

Background: Patient trust in physicians is essential for effective end-of-life discussions. Little is known about how Chinese older adults' trust in physicians relates to their end-of-life care discussions and care setting preferences.

Objective: To examine the association between medical trust among Chinese older adults and their views on end-of-life discussions and care setting preferences.

Design: Secondary analysis of longitudinal cohort data from the Population Study of Chinese Elderly (PINE) using linear mixed-effects logistic and multinomial logistic regressions, adjusting for covariates. Predicted probabilities of outcome measures were reported.

Participants: A total of 2192 Chinese older adult immigrants in greater Chicago participated in the PINE study from 2017 to 2020.

Main measures: Outcome variables encompass four dimensions of end-of-life care planning: (1) beliefs about the importance of discussions with family; (2) discussions of end-of-life options with family; (3) preference for counseling with a healthcare provider as a resource; and (4) preferred place of care. The main independent variable was trust in physicians. Covariates included age, sex, education, income, years in the United States, living children, self-rated health, and medical conditions.

Key results: Respondents with strong trust were less likely to consider end-of-life discussions with family important (AOR = 0.70, 95% CI: 0.55-0.88). Those with strong trust were more likely than those with weak trust to value counseling with a healthcare provider for end-of-life discussions with family (AOR = 5.86, 95% CI: 4.65-7.38). Moderate trust was associated with a preference for end-of-life care in a hospital (AOR = 1.63, 95% CI: 1.30-2.05) over home care, relative to weak trust.

Conclusions: Older Chinese immigrants with strong trust tended to place less emphasis on end-of-life discussions with family and favored one-on-one counseling with a healthcare provider for end-of-life discussion. Patient education and family engagement in end-of-life discussions led by trusted healthcare providers may be promising approaches to ensure goal-concordant care for this population.

Background: Diverticulitis accounts for over 300,000 hospitalizations annually in the United States and its incidence increases with age. Among older adults, diverticulitis is the fourth leading cause for emergency surgery. Older adults with multimorbidity and geriatric syndromes are often excluded from clinical studies, leaving a gap in the evidence needed to guide management. Here, we provide a clinically oriented review of the diagnosis and management of older adults with diverticulitis through the lens of age-friendly care.

Methods and results: We reviewed the literature describing the epidemiology, diagnosis, management, and prevention of diverticulitis in older adults. Due to age-related physiologic changes, the presence of geriatric syndromes, and multimorbidity, older adults with diverticulitis often present with atypical symptoms, variable laboratory findings, and are at higher risk for complications than younger patients. Guidelines support a more aggressive approach to diagnosis in this population, with lower threshold for obtaining diagnostic imaging. Antibiotics remain a mainstay of treatment for uncomplicated disease, and surgical management should be focused on severity of disease and the balance between the likelihood of improving quality of life and risks and burden of treatment.

Conclusions: Diverticulitis is a common disease that has a unique presentation among older individuals with limited evidence to guide management. Diagnosis and treatment should focus on what matters most to the patient, providing the most meaningful outcome possible within the context of multimorbidity, patient goals, symptom burden, and anticipated treatment outcomes.

The CONSORT 2010 statement is a guideline that provides an evidence-based checklist of minimum reporting standards for randomized trials. With the rapid growth of Artificial Intelligence (AI) based interventions in the past 10 years, the CONSORT-AI extension was created in 2020 to provide guidelines for AI-based randomized controlled trials (RCT). The Clin-STAR "Around the EQUATOR" series features existing reported standards while also highlighting the inherent complexities of research involving research of older participants. In this work, we propose that when designing AI-based RCTs involving older adults, researchers adopt a conceptual framework (CONSORT-AI-5Ms) designed around the 5Ms (Mind, Mobility, Medications, Matters most, and Multi-complexity) of Age-Friendly Healthcare Systems. Employing the 5Ms in this context, we provide a detailed rationale and include specific examples of challenges and potential solutions to maximize the impact and value of AI RCTs in an older adult population. By combining the original intent of CONSORT-AI with the 5Ms framework, CONSORT-AI-5Ms provides a patient-centered and equitable perspective to consider when designing AI-based RCTs to address the diverse needs and challenges associated with geriatric care.

Objective: The primary objective of this study was to assess the prescribing patterns of long acting injectable (LAI) antipsychotics in an older adult population. Secondary objectives were to determine if there were differences in treatment discontinuation rates between different LAI agents and race/ethnicity.

Methods: Merative MarketScan Multi-State Medicaid Databases (2017-2021) were used to identify patients 65 years or older who were prescribed a LAI antipsychotic. Pharmacy claims for LAI antipsychotics were referenced via National Drug Code (NDC) by brand/generic name and dose. International Classification of Diseases, 10th edition (ICD-10) codes were used to identify older adults diagnosed with schizophrenia, schizotypal or schizoaffective disorders. Those with dementia or related disorders were censored. Conditional associations between race/ethnicity and generation of LAI antipsychotics were investigated using logistic regression controlling for age, sex, and health plan. Cox proportional hazard regression was used to compare the distribution of time until treatment discontinuation among older adults across LAI antipsychotics.

Results: A total of 526 older adults (59% female) with an average age of 70.4 ± 5.5 years met inclusion for analysis. The most commonly used LAI antipsychotics included paliperidone palmitate-1 month formulation (~35%), haloperidol decanoate (~24%), and risperidone microspheres (~15%). Overall, approximately 32% received LAI first-generation antipsychotics and 68% received LAI second generation antipsychotics. Blacks (n = 204) received LAI first-generation antipsychotics more often than Whites (n = 283); (OR: 1.74, 95% [1.18, 2.56], p < 0.01). When controlling for age, sex, and race/ethnicity, LAI first-generation antipsychotics showed earlier discontinuation rates compared to LAI second-generation antipsychotics (HR: 2.12, 95% CI [1.45, 3.10], p < 0.001).

Conclusions: LAI first-generation antipsychotics showed treatment discontinuation significantly earlier compared to LAI second-generation antipsychotics. Furthermore, Blacks were prescribed LAI first-generation antipsychotics at a higher rate than Whites, which may contribute to poorer health outcomes. Futures studies are needed to establish a causal relationship.