Journal of the American Geriatrics Society最新文献

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.

Background: Physical exercise is a key strategy for mitigating frailty and attenuating the decline in physical, cognitive, and psychological functions associated with frailty. This meta-analysis evaluated the effects of physical exercise programs on frailty and frailty-related outcomes in institutional settings.

Methods: A systematic search was conducted across CINAHL, Cochrane Library, PubMed, EMBASE, OVID Medline, and two trial registration websites (ClinicalTrials.gov and WHO ICTRP). Randomized controlled trials investigating the influence of physical exercise on frail older adults residing in nursing homes were included in the analysis.

Results: A total of 20 out of 183 articles met the inclusion criteria for the final review. The final sample comprised 1701 participants. This meta-analysis demonstrated significant improvements in measures of frailty (p < 0.001), physical function (p < 0.001), and cognitive function (p = 0.04). This study's results reported improvements exceeding the minimal clinical important difference (MCID) for several key outcomes, including the Fried frailty phenotype, physical functions (the Sit-to-Stands Test, the Time Up and Go Test, the Short Physical Performance Battery, and the Gait speed), and cognitive function as measured by the Mini-Mental State Examination. In contrast, improvements in handgrip strength, functional reach, and the Montreal Cognitive Assessment did not reach the MCID threshold. Subgroup analyses revealed that interventions involving ≥ 3 sessions/week for ≥ 15 weeks, totaling > 2000 min were associated with notable enhancements in overall functions.

Conclusions: In summary, our results indicate that a sustained and intensive physical exercise intervention may improve measures of frailty, physical and cognitive function in frail older nursing home residents.

Background: Elder mistreatment (EM) is pervasive yet under-identified. The Detection of Elder abuse Through Emergency Care Technicians (DETECT) tool was developed to improve EM identification and reporting among emergency medical technicians. This study explores clinician perspectives on adapting DETECT for use in home-based primary care (HBPC).

Methods: A qualitative study was conducted using semi-structured interviews and focus groups with HBPC clinicians (N = 16) across seven intervention sites. Discussions focused on barriers and facilitators to EM identification and response, engagement with Adult Protective Services (APS), and recommendations for adapting DETECT. Thematic analysis was performed.

Results: Three themes emerged: (1) EM as an overlooked priority-clinicians recognized EM as critical but lacked standardized screening tools and protocols; (2) Barriers and facilitators to screening and response-time constraints, complexity of EM cases, and APS hesitancy were barriers, while continuity of care and team-based approaches were facilitators; (3) Recommended DETECT adaptations-clinicians suggested modifications to item phrasing, an emphasis on tracking observations over time, and a scoring system incorporating safety risk levels.

Conclusions: HBPC clinicians support a standardized EM screening tool and emphasize the need for flexibility in reporting and response. Findings will inform modifications to DETECT that align with HBPC workflows and improve EM identification while maintaining patient-clinician relationships.

Background: Rib fractures are common and increase mortality in older adult patients. Early surgical stabilization of rib fractures (SSRF), < 72 h from admission, has been shown to improve outcomes in younger patients. We hypothesize that patients ≥ 65 years requiring SSRF will have improved outcomes with early SSRF.

Methods: This was a retrospective cohort analysis of patients ≥ 65 years between 1/1/2018 and 12/31/2022 who underwent SSRF and were captured in the National Trauma Data Bank. Patients who died within 24 h were excluded. Demographic and injury characteristics, comorbidities, hospital events and discharge dispositions were captured. Study groups were early (< 72 h) versus late SSRF. Primary outcomes were hospital length of stay (HLOS), intensive care unit LOS (ILOS), duration of mechanical ventilation (DMV), and mortality. With early SSRF as the reference group, multivariable analysis was conducted.

Results: Five thousand one hundred twenty-nine patients met inclusion criteria. Three thousand seventy (59.8%) underwent early SSRF and 2059 (40.1%) underwent late SSRF. Early SSRF was associated with shorter HLOS (9 vs. 14 days), ILOS (6 vs. 9 days), and DMV (5 vs. 9 days) (all p < 0.001). There was no difference in mortality (4.7% vs. 5.3%, p = 0.23). Early fixation was associated with fewer complications including unplanned intubation (6.6% vs. 13.5%), tracheostomy (1.9% vs. 5.3%), acute respiratory distress syndrome (0.9% vs. 1.7%), and pneumonia (0.2% vs. 0.7%) (all p < 0.001). On multivariable analysis, HLOS, ILOS, and DMV increased with late fixation (all p < 0.001).

Conclusion: Early SSRF is associated with improved outcomes and fewer complications in older adult patients with rib fractures. Further study will guide treatment protocols for the growing population of older adult trauma patients.

Background: In January 2018, South Korea introduced the cognitive support grade (CSG) within its long-term care insurance (LTCI) system, expanding eligibility for adult day services (ADS) to older adults with mild dementia. This study evaluates the policy's impact on reducing institutional care use and public expenditure using national claims data.

Methods: This study employed an interrupted time series (ITS) design to evaluate the population-level impact of the 2018 policy reform using monthly aggregated data between January 2015 and December 2018. To explore heterogeneity in policy effects, subgroup analyses were conducted using various characteristics.

Results: Following the policy reform, the share of population with ADS eligibility increased by 54.0 percentage points (95% CI: 49.6 to 58.4), followed by a 6.66-day rise in actual ADS uptake (95% CI: 5.11 to 8.21) and a 2.22-day reduction in institutional care use (95% CI: -4.03 to -0.412). Total public insurer costs remained unchanged, as reduced institutional care expenditures were largely offset by increased HCBS costs. Subgroup analyses suggested that ADS was most effective among individuals with coexisting informal care support.

Conclusions: The findings suggest that ADS may function as a complement to-rather than a substitute for-informal care and is associated with reduced institutionalization risk. Optimizing ADS delivery to match caregiving capacity may further enhance effectiveness.

Introduction: Embedded pragmatic clinical trials are an ideal way to develop and evaluate evidence-based interventions in the nursing home (NH) environment to facilitate streamlining implementation after study completion. However, there is minimal information available about the necessary and sufficient conditions of "difference makers" for robust implementation of pragmatic interventions in the NH setting.

Methods: The "Aligning Patient Preferences-a Role Offering Alzheimer's patients, Caregivers, and Healthcare Providers Education and Support" (APPROACHES) embedded pragmatic trial is designed to test and evaluate a staff-led advance care planning (ACP) intervention for residents with dementia in 128 NHs (64 intervention, 64 control). Coincidence Analysis, a case-based approach to data analysis that draws upon Boolean algebra and set theory, was applied to identify key difference-makers for robust implementation. This analysis focused on the 44 intervention NHs that implemented at least one of two implementation processes: site visits and/or monthly calls.

Results: Eighteen of 44 (41%) sites in the analysis robustly implemented the APPROACHES intervention as reflected by > 75% of residents having a documented ACP conversation. The Coincidence Analysis revealed two pathways directly linked with robust pragmatic implementation: (1) no executive director turnover during the observation period combined with site participation in monthly calls with peers; and (2) higher rates of baseline hospitalization (3.96-7.0 per 1000 resident-days alive) combined with a low number of certified beds. In contrast, leadership instability as reflected by administrator turnover, high number of certified beds, and a lack of participation in monthly calls with peers was associated with poorer performance.

Discussion: Findings from this study suggest that leadership stability and engagement with peers were essential drivers of robust implementation of the APPROACHES ACP Specialist intervention. Coincidence Analysis is a useful tool for understanding how implementation conditions are associated with robust implementation in embedded pragmatic clinical trials.