Journal of the American Geriatrics Society最新文献

Background: The Motivational Interviewing for Fall Prevention (MI-FP) study aimed to engage older adults in fall prevention strategies. We report on the feasibility, intervention fidelity, and preliminary impact of MI-FP.

Methods: We conducted a pilot randomized controlled trial to test MI-FP among older (age ≥ 65) primary care patients at high fall risk in a Pacific Northwest clinic in the United States. The intervention group received up to eight motivational interviewing (MI) sessions by MI practitioners over 6 months and the control group received standard care. Feasibility was defined as ≥75% retention and ≥75% reporting satisfaction at 6 months. Intervention fidelity was assessed by meeting pre-determined MI proficiency standards using MI Treatment Integrity (MITI 4.2) coding scheme, and ≥75% of the intervention group completing ≥6 MI sessions. Preliminary impact was assessed at 6 and 12 months for changes in concern about falling, readiness to engage in fall prevention, fall prevention behaviors, physical function, and fall rates between groups.

Results: Participants (n = 200) had a mean age of 80 years and 67% were female. The overall retention rate was 75.0% (n = 150). Among 81.3% (n = 122) who reported satisfaction, 82.8% were satisfied (n = 101). The intervention group had significantly lower retention than the control group at 6 months (68.3% vs. 81.8%, p = 0.04). A proficient MI intervention was delivered, but only 57.4% (n = 58) engaged in ≥6 MI sessions. The preliminary impact of the intervention showed promising trends, but there were no significant differences by group for any outcome measure at 6 or 12 months (p > 0.05).

Conclusions: Virtual MI-FP may improve accessibility for older adults to discuss fall prevention, but future studies are needed to improve retention and intervention completion.

Background: Data on patients aged 90 or older are rare. This study aims to describe clinical characteristics, treatment strategies, and clinical outcomes (rates of VTE recurrence, major bleeding, and mortality), during the first 3 months of anticoagulant treatment for VTE, depending on the treatment period.

Methods: We analyzed data from RIETE, an ongoing global observational registry of patients with objectively confirmed acute VTE, grouped in 5-year intervals (2004-2008, 2009-2013, 2014-2018, and 2019-2023).

Results: Among 3477 patients aged 90 or older, clinical characteristics have changed over time (less heart failure, more dementia), with an increase in PE diagnoses from 57% in 2004-2008 to 69% in 2019-2023 (p-trends <0.001), but of lower severity. For long-term therapy, there was an increase in patients receiving DOACs (p-trends <0.001), with a decrease in patients on VKAs (p-trends <0.001). Mortality and fatal PE respectively showed a temporal trend: 19% and 4% in 2004-2008 to 15% (p-trends 0.026) and 2% (p-trends 0.002) in 2019-2023. In multivariable analyses, fatal PE declined from 2004 to 2023 (HR: 0.91; 95% CI: 0.87-0.96). Compared with VKAs, receiving LMWH during the first 3 months of anticoagulation was associated with a higher risk of major bleeding (HR: 1.91; 95% CI: 1.16-3.14) and death (HR: 2.20; 95% CI: 1.71-2.82). The effect seems to be the opposite for DOACs (HR: 0.50; 95% CI: 0.20-1.30 for major bleeding; HR: 0.86; 95% CI: 0.57-1.28 for all-cause death).

Conclusions: Fatal PE declined from 2004 to 2023, despite an increase in the diagnosis of PE. Since the arrival of DOACs, there seems to be better management of the therapeutic and diagnostic aspects of VTE in this population, underlining the need for further research on patients aged 90 or older.

Background: Subjective memory complaints (SMCs) refer to memory concerns reported by an individual, regardless of objective test impairment. We conducted a study to evaluate the association of SMCs with serum biomarkers of neurodegeneration, including neurofilament light chain (NfL), glial fibrillary acidic protein (GFAP), and total tau (t-tau). In addition, we evaluated the association of SMCs with the rate of cognitive decline.

Methods: This study included 1096 individuals participating in the Chicago Health and Aging Project, with data on SMCs, neurodegenerative biomarkers (NfL, GFAP, and t-tau), and global cognitive scores. The SMC score ranges from 0 to 8 and higher scores reflect more memory complaints. Linear regression models were developed to investigate the association of SMCs with serum biomarkers, adjusted by age, sex, race, education, and APOE e4. Linear mixed-effects models were used to examine the independent association of SMCs with cognitive decline in a multivariable model that was additionally adjusted by biomarkers of neurodegeneration.

Results: Of the 1096 individuals, 665 (60.7%) were female, 643 (58.7%) were African Americans, and the mean (SD) age at the baseline was 78.0 (5.8) years. Compared to individuals with fewer memory complaints (i.e., people in the first tertile of SMCs), those reporting more memory complaints (i.e., people in the third tertile of SMCs) had a 12.0% increase in serum concentrations of NfL and an 9.4% increase in GFAP. In addition, individuals reporting more memory complaints (i.e., those in the 3rd versus the 1st tertile of SMCs) had a faster rate of cognitive decline by 0.029 ( $\beta$ -0.029, 95% CI -0.046 to -0.013) standardized units per year.

Conclusions: Individuals who reported more memory complaints had higher levels of biomarkers of neurodegeneration and a faster rate of cognitive decline, suggesting that SMCs may be valuable for identifying people at high risk of cognitive impairment.

Background: Adults with Alzheimer's disease and Alzheimer's disease related dementias (ADRD) or frailty are susceptible to fractures. Opioid analgesics are frequently prescribed after fractures. Documenting post-fracture opioid discontinuation rates and predictors of discontinuation among adults with ADRD or frailty can inform clinical practice, identify potential disparities, and improve pain management guidelines. The objective of this paper was to investigate opioid discontinuation in opioid-naïve older adults who used opioids after an acute fracture.

Methods: This retrospective cohort study included opioid-naïve Medicare fee-for-service beneficiaries (N = 33,027) ≥65 years of age who filled an opioid prescription within 30 days of a vertebral, lower extremity, or upper extremity fracture from 2013 to 2018. Beneficiaries were classified according to ADRD (yes/no) and frailty (yes/no) status using validated claims-based algorithms. The primary outcome was opioid discontinuation, defined as a 30-day supply gap. We estimated discontinuation rates with the Kaplan-Meier method and identified predictors of opioid discontinuation using Cox proportional hazards regression.

Results: The 30-day opioid discontinuation rate was similar among non-frail beneficiaries without ADRD (81% [95% CI, 80%-81%]) and those who were non-frail with ADRD (83% [81%-84%]). Comparatively, 30-day discontinuation rates were lower among those with frailty and ADRD (76% [75%-77%]) and those with frailty alone (77% [75%-78%]). After adjusting for sociodemographic characteristics, health status, healthcare utilization, and calendar year, beneficiaries with both ADRD and frailty (HR, 0.90 [0.87-0.93]) and those with frailty alone (HR, 0.85 [0.82-0.89]), but not those with ADRD alone (HR, 1.06 [1.01-1.10]), were less likely to discontinue opioids compared with those without ADRD or frailty.

Conclusions and relevance: Our findings suggest that frailty, but not ADRD, was associated with a lower likelihood of opioid discontinuation among older adults who initiated opioids after an acute fracture. Further research is needed to understand how opioid deprescribing practices depend on patient and provider preferences.

This paper is an official position statement of the American Geriatrics Society (AGS) and updates the 2017 AGS position statement, Making Medical Treatment Decisions for Unbefriended Older Adults. In this updated position statement, the term "unbefriended" is replaced by "unrepresented" as a term that is more value-neutral, more accurately describes the circumstance in which a person without medical decision-making capacity does not have recognized surrogate representation, and better aligns with increasingly preferred terminology as reflected in recent medical literature. We define unrepresented older adults as those who (1) lack decisional capacity to provide informed consent for a particular medical treatment, (2) have not executed an advance directive that addresses the medical treatment at hand and lack capacity to do so, and (3) lack representation from a surrogate decision-maker (i.e., family, friend, or legally authorized surrogate). Making medical decisions on behalf of unrepresented older adults is exceptionally challenging and, given demographic trends, is likely to become increasingly common in the years ahead. The process of arriving at treatment decisions for this population should follow standards of procedural fairness and include capacity assessment, search for potential surrogates, team-based efforts to determine the patient's values and preferences, and steps to guard against bias. Proactive measures are needed to identify older adults at risk for becoming unrepresented. This position statement also calls for national efforts to reduce state-to-state variability in legal approaches for unrepresented patients.

Delirium is a complex neurocognitive disorder characterized by an acute disturbance in attention, awareness, and perception. It is a dangerous syndrome that is independently associated with higher rates of morbidity and mortality, inpatient complications, and is a predictor of long-term cognitive dysfunction. Although delirium can occur in persons of all ages, the prevalence among and impact on older adults is particularly significant. Current gold standard approaches for delirium include treating medical precipitants and physiological perturbations and optimizing the environment using multicomponent nonpharmacological interventions. Although these approaches are proven effective in preventing delirium, evidence has not shown them to significantly improve delirium once it occurs. The need for a safe, effective, and specific treatment for the phenotype of delirium itself is an urgent priority worldwide. The intervention described in this article, Attention and Awareness Through Movement technique followed by Movement To Capacity (AATM/MTC), targets cortical dysfunction through sustained sequential touch, cranial nerve stimulation, and muscular movement. It raises the tantalizing possibility that a specific method to reduce inattention and normalize arousal levels may not only be feasible but also safe and inexpensive. For these reasons, preliminary observations are described in the hope of stimulating interest in further exploration of this novel approach to delirium therapy.

Background: Few programs exist to support aging in place for older adults. Age Self Care is a novel program providing older adults with evidence-based information using group sessions embedded within the structure of a community-based organization (CBO) to facilitate behavior change and support aging in place. We report on a preliminary study of Age Self Care conducted in collaboration between the University of California, San Francisco (UCSF) Division of Geriatrics, At Home With Growing Older (AHWGO), and San Francisco Village (SF Village).

Methods: We recruited middle-income, community-dwelling adults aged 65+ from university outpatient clinics. Participants attended eight 90-min, video-based group sessions and enrolled in SF Village, a non-profit mutual support organization for older adults. Data collection included direct observations and a participant focus group. We used rapid analysis methods informed by the COM-B model (Capability, Opportunity, Motivation, Behavior Change) to assess behavior change.

Results: Fourteen participants completed the 8-week study (15 enrolled, 1 withdrew). Average attendance was 81% throughout the program. We found that 14 participants made concrete changes to optimize the ability to remain at home during the program. For example, participants engaged in evidence-based falls risk reduction activities such as decluttering and improving lighting. We identified three facilitators to behavior change. First, Age Self Care promoted self-management-the day-to-day management of health and chronic conditions by individuals-through education and community-based resources. Second, peer support empowered participants to take charge of their health, home environment, and social networks. Third, the online platform created a community and was a catalyst for social opportunity. We identified one non-modifiable barrier: pre-existing financial barriers hindered some behavior change.

Conclusions: In this preliminary study, Age Self Care facilitated behavior change, including minor home modifications, fall risk reduction, and engagement in social networks, all of which support aging in place.

Background: Frailty defined by the Cardiovascular Health Study (CHS) phenotype is associated with higher healthcare expenditures in community-dwelling Medicare beneficiaries after accounting for claims-based cost indicators. However, frailty assessment using the CHS phenotype is often not feasible in routine clinical practice. We evaluated whether frailty identified by the simple Study of Osteoporotic Fractures (SOF) phenotype is associated with subsequent incremental costs after accounting for claims-derived cost indicators.

Methods: Prospective study utilizing data from four cohort studies of older adults linked with Medicare claims composed of 8264 community-dwelling fee-for-service beneficiaries (4389 women, 3875 men). SOF Frailty Phenotype (three components: weight loss, poor energy, and inability to rise from chair five times without using arms) and CHS Frailty Phenotype (operationalized using five components) derived from cohort data. Participants were classified as robust, prefrail, or frail using each phenotype. Multimorbidity index (CMS Hierarchical Conditions Categories score) and Kim frailty indicator (approximating the deficit accumulation index) derived from claims. Annualized total and sector-specific healthcare costs ascertained for 36 months after frailty assessment.

Results: Average annualized total healthcare costs (2023 US dollars) were $15,021 in women and $15,711 in men. After accounting for claims-based multimorbidity and frailty indicators, average incremental costs of SOF phenotypic frailty (two or three components) versus robust (none) were $7142 in women and $5961 in men, only modestly lower than incremental costs of CHS phenotypic frailty ($9422 in women, $6479 in men). SOF phenotypic frailty in both sexes was associated with higher subsequent expenditures in the inpatient, skilled nursing facility, and home healthcare sectors.

Conclusions: As observed with CHS phenotypic frailty, SOF phenotypic frailty is associated with higher subsequent total and sector-specific expenditures after accounting for claims-derived indicators. The parsimonious SOF phenotype can be readily assessed in space-constrained and time-limited practice settings to improve identification of older adults at high risk of costly care.