Journal of the American Geriatrics Society最新文献

Background: Unmet social and caregiving needs can make caregiving for a person with dementia more difficult. Although national policy encourages adoption of systematic screening for health-related social risks (HRSRs) in clinical settings, the accuracy of these risk-based screening tools for detecting unmet social needs is unknown.

Methods: We used baseline data from dementia caregivers (N = 343) enrolled in a randomized controlled trial evaluating CommunityRx-Dementia, a social care intervention conducted on Chicago's South Side. We assessed caregivers' (1) unmet social and caregiving needs by querying need for 14 resource types and (2) HRSRs using the Center for Medicare & Medicaid Services (CMS) Accountable Health Communities (AHC) screening tool. Using unmet social needs as the reference, we examined the sensitivity of the AHC tool to detect food, housing, and transportation needs. Analyses were stratified by gender.

Results: Most caregivers were women (78%), non-Hispanic (96%), Black (81%), partnered (58%) and had an annual household income ≥$50K (64%). Unmet social and caregiving needs were similarly prevalent among women and men caregivers (87% had ≥1 need, 43% had ≥5 needs). HRSRs were also prevalent. The most common HRSR was lack of social support (45%). Housing instability, difficulty with utilities and having any HRSRs were significantly more prevalent among women (all p < 0.05). The AHC screener had low sensitivity for detecting unmet food (39%, 95% confidence interval [CI]: 27%-53%), housing (42%, 95% CI: 31%-53%), and transportation (22%, 95% CI: 14%-31%) needs. Sensitivity did not differ by gender for food (41% for women and 30% for men, p = 0.72) or housing (44% for women and 29% for men, p = 0.37) needs. For transportation needs, sensitivity was 27% for women versus 0% for men (p = 0.01).

Conclusions: Men and women caregivers have high rates of unmet social needs that are often missed by the CMS-recommended risk-based screening method. Findings indicate a role for need-based screening in implementing social care.

Background: Emergency department (ED) visits at end-of-life may cause financial strain and serve as a marker of inadequate access to community services and health care. We sought to examine end-of-life ED use, total healthcare spending, and out-of-pocket spending in a nationally representative sample.

Methods: Using Medicare Current Beneficiary Survey data, we conducted a pooled cross-sectional analysis of Medicare beneficiaries aged 65+ years with a date of death between July 1, 2015 and December 31, 2021. Our primary outcomes were ED visits, total healthcare spending, and out-of-pocket spending in the 7, 30, 90, and 180 days preceding death. We estimated a series of zero-inflated negative binomial models identifying patient characteristics associated with the primary outcomes.

Results: Among 3812 older adult decedents, 610 (16%), 1207 (31.7%), 1582 (41.5%), and 1787 (46.9%) Medicare beneficiaries had ED visits in the final 7, 30, 90, and 180 days, respectively, of life. For Medicare beneficiaries with at least one ED visit in the final 30 days of life, the median total and out-of-pocket costs were, respectively, $12,500 and $308, compared, respectively, with $278 and $94 for those without any ED visits (p < 0.001 for both comparisons). Having a diagnosis of dementia (odds ratio [OR] 0.71; 95% confidence interval [CI] 0.51-0.99; p = 0.04) and being on hospice status during the year of death (OR 0.56; 95% CI 0.48-0.66; p = <0.001) were associated with a decreased likelihood of having an ED visit. Having dementia was associated with a decreased likelihood of having any healthcare spending (OR 0.50; 95% CI 0.36-0.71; p = 0.001) and any out-of-pocket spending (OR 0.51; 95% CI 0.36-0.72; p = <0.001).

Conclusions: One in three older adults visit the ED in the last month of life, and approximately one in two utilize ED services in the last half-year of life, with evidence of associated considerable total and out-of-pocket spending.

Background: A prescribing cascade occurs when medication causes an adverse drug reaction (ADR) that leads to the prescription of additional medication. Prescribing cascades can cause excess medication burden, which is of particular concern in older adults. This study aims to identify and quantify potentially problematic prescribing cascades relevant for clinical practice.

Methods: A mixed-methods study was conducted. First, prescribing cascades were identified through literature search. An expert panel (n = 16) of pharmacists and physicians assessed whether these prescribing cascades were potentially problematic. Next, a cohort study quantified potentially problematic prescribing cascades in adults using Dutch community pharmacy data for the period 2015-2020. Additionally, the influence of multiple medications potentially causing the same ADR was evaluated. Prescription sequence symmetry analysis was used to calculate adjusted sequence ratios (aSRs), adjusting for temporal prescribing trends. An aSR >1.0 indicates the occurrence of a prescribing cascade. In a subgroup analysis, aSRs were calculated for older adults.

Results: Seventy-six prescribing cascades were identified in literature and three were provided by experts. Of these, 66 (83.5%) were considered potentially problematic. A significant positive aSR for the medication sequence was found for 41 (62.1%) of these prescribing cascades. The highest aSR was found for amiodarone potentially causing hypothyroidism treated with thyroid hormones (4.63 [95% confidence interval 4.40-4.85]), based on 565 incident users. The biggest population (n = 34,645) was found for angiotensin converting enzyme-inhibitors potentially causing urinary tract infections treated with antibiotics. Regarding four potential ADRs, the aSRs were higher for people using multiple medications that cause the same ADR as compared to people using only one of those medications. Among older adults the aSRs remained significant for 37 prescribing cascades.

Conclusion: An overview was generated of potentially problematic prescribing cascades relevant for clinical practice. These results can support healthcare providers to intervene and reduce medication burden for older adults.

Background: Current guidelines for the diagnosis and treatment of pericarditis refer to the general adult population. Few and fragmentary data regarding recurrent pericarditis in older adults exist.

Objective of the study: Given the absence of specific data in scientific literature, we hypothesized that there might be clinical, laboratory and outcome differences between young adults and older adults affected by idiopathic recurrent pericarditis.

Materials and methods: We performed an international multicentric retrospective cohort study analyzing data from patients affected by recurrent pericarditis (idiopathic or post-cardiac injury) and referring to tertiary referral centers. Clinical, laboratory, and outcome data were compared between patients younger than 65 years (controls) and patients aged 65 or older.

Results: One hundred and thirty-three older adults and 142 young adult controls were enrolled. Comorbidities, including chronic kidney diseases, atrial fibrillation, and diabetes, were more present in older adults. The presenting symptom was dyspnea in 54.1% of the older adults versus 10.6% in controls (p < 0.001); pain in 32.3% of the older adults versus 80.3% of the controls (p < 0.001). Fever higher than 38°C was present in 33.8% versus 53.5% (p = 0.001). Pleural effusion was more prevalent in the older adults (55.6% vs 34.5%, p < 0.001), as well as severe pericardial effusion (>20 mm) (24.1% vs 12.7%, p = 0.016) and pericardiocentesis (16.5% vs 8.5%, p = 0.042). Blood leukocyte counts were significantly lower in the older adults (mean + SE: 10,227 + 289/mm³ vs 11,208 + 285/mm³, p = 0.016). Concerning therapies, NSAIDS were used in 63.9% of the older adults versus 80.3% in the younger (p = 0.003), colchicine in 76.7% versus 87.3% (p = 0.023), corticosteroids in 49.6% versus 26.8% (p < 0.001), and anakinra in 14.3% versus 23.9% (p = 0.044).

Conclusions: Older adults affected by recurrent pericarditis show a different clinical pattern, with more frequent dyspnea, pleural effusion, severe pericardial effusion, and lower fever and lower leukocyte count, making the diagnosis sometimes challenging. They received significantly less NSAIDs and colchicine, likely due to comorbidities; they were also treated less commonly with anti-IL1 agents, and more frequently with corticosteroids.

Background: Antipsychotic and other psychotropic medication use is prevalent among community-dwelling older adults with dementia despite the potential for adverse effects. Two Centers for Medicare & Medicaid Services (CMS) initiatives, the National Partnership to Improve Dementia Care ("the Partnership") and the Five Star Quality Rating System for antipsychotic use reporting, have been successful in reducing antipsychotic use in nursing home residents. We assessed if these initiatives had a spillover effect in antipsychotic and other psychotropic medication use among community dwellers with dementia due to potential overlap in prescribers across settings.

Methods: Among community-dwelling older adults with dementia, we examined psychotropic medication class use (i.e., antipsychotics, antidepressants, anxiolytics, anticonvulsants/mood stabilizers, antidementia) in 2010-2017 Medicare fee-for-service claims using interrupted time series analyses across three periods ("Pre-Partnership": July 1, 2010 to March 31, 2012; "Post-Partnership": April 1, 2012 to January 31, 2015; "Five Star Quality Rating": February 1, 2015 to December 31, 2017).

Results: We included 1,289,401 community dwellers with dementia contributing 26,609,697 person-months. The mean age was 80 years, most were female (70%), approximately 80% were non-Hispanic Whites, 10% were non-Hispanic Blacks, and 5% were Hispanic ethnicity. Antipsychotic use was declining pre-Partnership (β = -0.06, 95% CI: -0.08, -0.05) and post-Partnership (β = -0.02, 95% CI: -0.02, -0.01). Post-Five Star Quality Rating, antipsychotic use remained stable with a nearly flat slope (β = -0.01, 95% CI: -0.01, 0.00). Anticonvulsant and antidepressant use increased and anxiolytic and antidementia medication use decreased among community-dwelling older adults with dementia.

Conclusions: These two CMS policies on antipsychotic use for nursing home residents were not associated with a spillover effect to community-dwelling older adults with dementia. Strategies to monitor the appropriateness of psychotropic medication use may be warranted for community-dwellers with dementia.

Background: Medicare Advantage (MA) plans must cover all telehealth services offered by Traditional Medicare (TM), but have flexibility to provide additional telehealth services. It is not known whether these flexibilities are associated with telehealth availability and use. In this study, we examined differences in telehealth availability and use between TM and MA beneficiaries.

Methods: This cross-sectional study analyzed beneficiaries who participated in the 2021 Medicare Current Beneficiary Survey. Our primary outcomes were telehealth availability and use, assessed both overall and by modality (telephone only, video only, and both). Our key independent variable was full-year enrollment in MA versus TM. Differences in outcomes between TM and MA beneficiaries were estimated using logistic regression models that adjusted for beneficiary characteristics. The analysis of telehealth availability included all beneficiaries in the sample, while the analysis of telehealth use was limited to those offered telehealth services. In a secondary analysis, we examined differences between TM and MA beneficiaries in the availability of technology that may enable telehealth use and experience using the internet to seek information.

Results: Among 8130 Medicare beneficiaries, MA beneficiaries were 2.9 (95% CI: 0.6-5.2) percentage points more likely to have a provider who offered telehealth services than TM beneficiaries, including both telephone and video options. However, MA beneficiaries were 3.5 (-6.7, -0.4) percentage points less likely to use telehealth services than TM beneficiaries. Video-only options were used less frequently among MA beneficiaries compared to those in TM (-2.7 [-5.1, -0.3]). Despite lower telehealth use, MA beneficiaries had comparable or higher rates of technology access and internet experience compared to TM beneficiaries.

Conclusion: Our findings suggest that greater access to telehealth services among MA beneficiaries did not translate into greater telehealth use. Future research is warranted to explore the underlying mechanisms behind lower use of telehealth services among MA beneficiaries.