Journal of the American Geriatrics Society最新文献

Background: The utilization of Annual Wellness Visits (AWVs), preventive healthcare visits covered by Medicare Part B, has grown steadily since their inception in 2011. However, longitudinal patterns and variations in use across enrollees, providers, and clinics remain poorly understood.

Objective: This study aimed to analyze AWV usage trends from 2018 to 2022 among a sizable cohort of Medicare beneficiaries, employing electronic health record (EHR) data. The goal was to assess AWV frequency and explore variations across enrollees, providers, and clinics.

Design: This retrospective observational study utilized EHR data from Medicare beneficiaries aged 66 and above, receiving continuous primary care from 2018 to 2022 (N = 24,549). Enrollees were classified into three categories based on their AWV utilization over a 5-year period: low users (0-1 AWVs), moderate users (2-3 AWVs), and regular users (4-5 AWVs). AWV usage patterns were examined across individual demographics and provider/clinic characteristics using multilevel regression models.

Key results: Over the 2018-2022 period, 58.6% were regular AWV users, 27.7% were moderate users, and 13.7% were low users. Differences in primary care providers and clinics accounted for 56.4% (95% CI, 45.3%-66.9%) of the variation between low and regular users. Among enrollees who visited the same providers and clinics, individuals were less likely to be regular users of AWVs if they were 85 and older, Hispanic, from socioeconomically disadvantaged areas, or had multiple comorbidities.

Conclusions: The majority of Medicare beneficiaries in the study engaged with AWVs, with 86% having two or more over the 5-year period. These findings underscore the broad acceptance of AWVs among beneficiaries but also show that clinic and provider factors influence usage, especially among older, minoritized, and socioeconomically disadvantaged populations. Interventions at the provider and clinic levels are necessary to further improve AWV uptake, particularly for vulnerable groups.

Frailty is a syndrome that can inform clinical treatments and interventions for older adults. Although implementation of frailty across medical subspecialties has the potential to improve care for the aging population, its uptake has been heterogenous. While frailty assessment is highly integrated into certain medical subspecialties, other subspecialties have only recently begun to consider frailty in the context of patient care. In order to advance the field of frailty-informed care, we aim to detail what is known about frailty within the subspecialties of internal medicine. In doing so, we highlight cross-disciplinary approaches that can enhance our understanding of frailty, focusing on ways to improve the implementation of frailty measures, as well as develop potential interventional strategies to mitigate frailty within these subspecialties. This has important implications for the clinical care of the aging population and can help guide future research.

Background: People with cognitive impairment commonly use central nervous system-active potentially inappropriate medications (CNS-PIM), increasing risk of adverse outcomes. Patient portals may be a promising tool for facilitating medication-related conversations. Little is known about portal use by this population related to medications.

Objective: To target portal interventions, we sought to identify individuals with cognitive impairment and CNS-PIM exposure who discussed medications through the portal and to determine how frequently their messages described possible adverse effects.

Methods: We used electronic health record (EHR) data from an academic health system in Maryland (Site 1) from 2017 to 2022 and pharmacy and EHR data from an integrated health system in Colorado (Site 2) in 2022 to identify people with cognitive impairment and CNS-PIM exposure who communicated about medications through the portal. At Site 1, message threads were manually categorized based on content. At Site 2, messages were categorized using natural language processing (NLP).

Results: The Site 1 cohort included 5543 patients aged ≥65 with cognitive impairment and ≥2 outpatient visits from 2017 to 2022. Over half (n = 3072; 55%) had CNS-PIM prescriptions. Most with CNS-PIM prescriptions had portal use (n = 1987; 65%); 1320 (66%) of those patients sent messages during possible CNS-PIM exposure. Coding of a 5% random sample of message threads revealed that 3% mentioned CNS-PIM and possible adverse effects, while 8% mentioned possible adverse effects without referencing CNS-PIM. At Site 2, 4270 people had cognitive impairment and CNS-PIM exposure in 2022; of these, 1984 (46%) had portal use and 1768 (41%) sent medication-related messages during CNS-PIM exposure. NLP identified 663 (8%) messages that mentioned CNS-PIM and possible adverse effects, while 726 (41%) mentioned possible adverse effects without referencing CNS-PIM.

Conclusions: People with cognitive impairment and care partners frequently send portal messages about medications and possible adverse effects. Identifying such messages can help target deprescribing interventions.

Background/objectives: Leisure activities provide various health benefits for older adults. However, few studies have examined changes in leisure activities and health. This study aimed to determine the association among changes in leisure activities, subsequent all-cause mortality, and functional disability.

Methods: Using a longitudinal, prospective cohort design, we analyzed data from the Japan Gerontological Evaluation Study (JAGES) in 2010 and 2013 merged with government data on death and long-term care needs by 2020. Changes in leisure activity were defined as four-category exposure based on a question about leisure activities: those with leisure activities in both 2010 and 2013, those who started leisure activities in 2013, those without leisure activities in both 2010 and 2013 (reference group), and those who stopped leisure activities in 2013. All-cause mortality and functional disability were defined as onset during the 6-year follow-up from the 2013 survey. We applied the inverse probability of censoring and treatment-weighted methods for analyses using Cox proportional hazards models, where missingness was addressed using multiple imputation.

Results: The study included 38,125 participants with a mean age of 72.8 ± 5.5 years at baseline, and 46.9% were male. Among those without leisure activities between 2010 and 2013 and those who started leisure activities in 2013, mortality rates by 2020 were 28.6% and 21.1%, and functional disability rates were 24.6% and 18.1%, respectively; and in analyses with the inverse probability of censoring and treatment-weighted methods, the hazard ratio for mortality was 0.82 (95% confidence interval (CI), 0.75-0.90) and 0.89 (95% CI, 0.79-1.01) for functional disability, respectively.

Conclusion: Initiation of leisure activities among the older adults was associated with a lower risk of mortality and functional disability over the subsequent 6 years compared to older adults who did not report initiating any leisure activities.

Introduction: The Geriatric Emergency Care Applied Research Network 2.0-Advancing Dementia Care (GEAR 2.0-ADC) aims to advance research efforts to improve the emergency care of persons living with dementia (PLWDs).

Objective: To support this objective, GEAR 2.0-ADC convened a virtual consensus conference to prioritize emergency care research opportunities for PLWDs inclusive of perspectives of PLWDs to ensure identification of research gaps in response to their experiences and priorities. Inclusion of PLWDs as research partners is increasingly recognized as a best practice, however, approaches to facilitating consensus participation are lacking.

Methods: Best practices for supporting the engagement of PLWDs in a consensus conference, applied across its three phases (pre-conference, during the conference, and post-conference), include: establishing a learning environment focused on research priorities before the event, presenting information in ways that align with participants' learning preferences while accommodating cognitive impairments, and providing multiple opportunities and methods for gathering post-conference feedback from PLWDs.

Results: These strategies were identified by PLWDs and care partners (CPs) through semi-structured interviews, who were involved in the convening process, aimed at exploring ways to enhance facilitation techniques for participants.

Conclusion: Additionally, these summarized insights aim to encourage the use of community-engaged approaches in discussions and consensus-building around research priorities in emergency care, particularly for PLWDs and their CPs.

Background: The decision-making process between autologous hematopoietic stem cell transplant (autoHSCT) and less-intensive treatments necessitates shared decision-making between older patients with hematological malignancies and healthcare providers. However, there is limited knowledge from both perspectives. This qualitative study aimed to comprehensively understand the experiences of shared decision-making regarding autoHSCT among older patients with hematological malignancies and physicians.

Methods: Older patients and physicians were recruited from the hematology department at one of the affiliated general hospitals of Wuhan University. They participated in semi-structured, in-depth face-to-face individual interviews from August 2022 to March 2023. The interviews explored their experiences with shared decision-making about autoHSCT. Interviews were transcribed verbatim and analyzed using Colaizzi's phenomenological method.

Results: Thirteen older patients and eight physicians were recruited. Two themes were identified: (1) Factors influencing AutoHSCT recommendations and decision-making: Seven factors were categorized into three groups: physician-driven factors (pretransplant assessments, experience-based judgment, and communication approaches), patient-driven factors (perceived benefits and risks, financial challenges, and family involvement), and mutual trust between patients and physicians, which is a bidirectional factor relying on both physicians' trust and the active participation of patients in the decision-making process. (2) Treatment planning and outcome expectations: Regardless of treatment choices, patients focused on engaging in self-management and prioritizing quality of life, and maintaining hope for positive outcomes.

Conclusions: The shared decision-making process for autoHSCT between older patients with hematological malignancies and physicians is shaped by physician-driven factors, patient-driven factors, and mutual trust. These findings provide a foundation for developing patient-centered care strategies, including decision aids and enhanced communication training for physicians, aimed at improving outcomes for older patients facing complex treatment choices. Future research should explore how these factors interact over time, through longitudinal studies, to assess their long-term impact on patient outcomes and quality of life.

Background: Events such as global pandemics can force rapid adoption of new modes of assessment. We describe the evaluation of a modified neuropsychological assessment for web and telephone administration.

Methods: Telephone and video conferencing-based neuropsychological assessment procedures were developed and implemented within an ongoing observational study, the Successful Aging following Elective Surgery II (SAGES) study (N = 420 persons). Repeated cognitive assessments were used (N = 2008 observations). Analyses using latent variable psychometric methods were used to compare the measurement modes, and a nested validation sub-study (N = 100 persons) was used to test for measurement equivalence. We used item response theory methods to calibrate data collected by different assessment modes. Measurement equivalence was assessed with Bland-Altman plots and regression analysis.

Results: Only small differences were detected between in-person and video modes of assessment. The largest difference among factor loadings was shared for the Boston Naming Test and Visual Search and attention test, but the effects were very small (Cohen's q = 0.06) and not statistically significant (95% confidence interval on q, -0.06, +0.18). In terms of item difficulty differences between in-person and video, the Digit Span Backwards test was less difficult by video with a small-to-moderate effect size (Cohen's d of -0.28, 95% CI, -0.54, -0.01). The contrast of in-person and telephone assessment was larger, with telephone assessment being less difficult than in-person (largest shift in item difficulty for digit span backwards, d = -1.12 95% CI -1.35, -0.90). Calibrated scores from telephone and videoconference demonstrated good agreement (r = 0.72, 95% CI 0.61, 0.80), and the differences could be corrected with latent variable measurement models.

Conclusions: Videoconference based neuropsychological assessment can be as precise as in-person. Calibration of ability estimates using latent variable measurement models can address measurement differences and generate scores without evidence of systematic bias.

Background: Hospital-associated disability (HAD), a decline in the ability to perform activities of daily living (ADL) during hospitalization, is a modifiable target in integrated care for older adults. The aim of this study was to determine the impact of inpatient cardiac rehabilitation (CR) on the development of HAD in older patients with aortic stenosis undergoing transcatheter aortic valve implantation (TAVI).

Methods: Older patients undergoing TAVI were extracted from the Japanese nationwide database (JROAD-DPC) from April 2014 to March 2021 and were divided into patients receiving inpatient CR (CR group) and a non-CR group. HAD was defined as a decrease in the Barthel Index (BI) score ≥5 points at discharge compared with the score at admission.

Results: Of 19,789 eligible patients, 17,066 (86%) underwent inpatient CR. The overall prevalence of HAD was 9.6%, with a lower incidence in the CR group than in the non-CR group (8.8% vs. 14.2%, p < 0.001). Random forest analysis revealed key features associated with HAD risk including BI score at admission, inpatient CR participation, age, body mass index (BMI), and chronic kidney disease. The results of multivariate logistic regression analysis showed that participation in inpatient CR was associated with a lower odds ratio (OR) of HAD (OR, 0.62; 95% confidence interval, 0.54-0.70), with similar results in inverse probability of treatment weighting-adjusted logistic regression analyses (OR, 0.82; 95% confidence interval, 0.77-0.88). Analyses in subgroups of interest showed heterogeneity in the effects of inpatient CR with possible loss in patients with a BMI of <18.5 kg/m² or a BI score of less than 60 points at admission.

Conclusions: The data suggest a beneficial effect of inpatient CR participation on the prevention of HAD in older patients undergoing TAVI, but the effect may be limited in lean patients with disability for ADL before TAVI.