Journal of the American Geriatrics Society最新文献

Background: Surgical resection is the primary treatment modality for colorectal cancer. Prehabilitation is about enhancing the patient's physiological capacity preoperatively to reduce the risk of treatment-related complications. Clear definitions of the modality, content, and duration of prehabilitation, including its components such as nutrition, exercise, and psychological support, are lacking. Some review articles have proposed that a multimodal approach may yield the best overall outcomes, but the clinical efficacy of such an approach requires further exploration.

Objective: This study consisted of a systematic review and meta-analysis to investigate the effectiveness of multimodal prehabilitation programs for patients undergoing colorectal surgery.

Methods: We searched PubMed, Embase, CINAHL, and the Cochrane Library from inception to August 5, 2023, without language or publication period restrictions. The included studies were randomized controlled trials, prospective studies, or retrospective studies that examined the effectiveness of multimodal prehabilitation programs for patients undergoing colorectal surgery. A random-effects model was used for data analysis.

Results: This study included 14 articles that analyzed data from 2314 patients who underwent colorectal cancer surgery. In comparisons against a control group, multimodal prehabilitation significantly reduced the length of hospital stay ([mean difference; MD] = -2.47 days, 95% confidence interval [CI] [-3.56, -1.39]), postoperative complication rate (odds ratio; [OR] = 0.74, 95% CI [0.59, 0.94]), and time to the first passage of flatus (MD = -0.43 days, 95% CI [-0.66, -0.20]).

Conclusion: Multimodal prehabilitation interventions before colorectal cancer surgery reduce hospital stay lengths, lower complication rates, and promote bowel recovery, particularly in older populations.

Background: Psychological resilience has been characterized as the ability to recover from stressful life events. Not well studied is whether self-reported measures of psychological resilience are associated with physical function recovery. Therefore, we examined the association of self-reported psychological resilience with longitudinal physical function before and after an acute care encounter.

Methods: This analysis includes a national cohort (n = 272) of Veterans (≥ 70 years) with advanced chronic kidney disease who had physical function measures before and after an acute care encounter (emergency department visit, hospitalization). At enrollment, self-reported psychological resilience was assessed via the Brief Resilience Scale (BRS) (range 1-5, higher scores indicate greater resilience). BRS scores were categorized as Low, Moderate, and High psychological resilience. Physical function was ascertained at enrollment, approximately every 8 weeks, and immediately following an acute care encounter using the Life-Space Assessment (LSA) (range 0-120, higher scores reflect greater mobility). Linear models for longitudinal data were used to estimate differences in physical function over time by psychological resilience group.

Results: Physical function levels differed by resilience group both before and after the acute care encounter. Although all resilience groups had the lowest LSA scores immediately following the acute care encounter, differences were seen by resilience group (Low: 38.5, Moderate: 44.9, High: 52.5). Differences remained during recovery at the first post-encounter follow-up (Low: 43.6, Moderate: 49.0, High: 57.5). At the second post-encounter follow-up, only the High resilience group displayed a continued increase in physical function (estimated mean difference of 11.6 (95% CI 1.5, 21.8, p = 0.02) vs. Moderate and 17.7 (95% CI 4.2, 31.3, p = 0.01) vs. Low).

Conclusion: Self-reported psychological resilience was associated with physical function levels before and after an acute care encounter. The BRS may be a useful tool to identify older adults who are less likely to recover after an acute health event.

Background: Older adults with multiple chronic conditions face significant challenges with their health. Patient Priorities Care (PPC) is an Age-Friendly approach that explores 'what matters' by identifying values, care preferences, and health priorities, and aligning healthcare based on patients' health outcome goals.

Methods: Patient priorities care was implemented in four clinical settings (Hospital in Home, a transitional care case management program and in two embedded clinics within specialty care settings) within a large academically affiliated Veteran Affairs hospital system. During the pilot phase, the structured PPC approach was deployed through multiple modalities within specialty practices, including telehealth, and descriptive measures were evaluated. During the evaluation phase, clinical process measures related to care alignment were assessed, and clinicians' perspectives on PPC were explored through semi-structured interviews, which were then coded and analyzed for themes.

Results: During the pilot phase, a total of 109 PPC conversations were conducted by telephone (48%), video (35%) and in-person (17%) across the four clinical settings. Participants were on average 80 ± 9 years old, white (89%), and male (94%). Multimorbidity (17 ± 8 chronic conditions per patient), cognitive impairment (39% of participants), and polypharmacy (15 ± 7 prescriptions per patient) were prevalent. During the evaluation phase, a total of 46 documented PPC conversations were reviewed. Clarifying preferences for life-sustaining treatment, modifying medications, and ordering durable medical equipment were the most common care alignment outcomes resulting from health priorities identification. Nine semi-structured interviews were conducted with clinicians responsible for continuing care alignment, and seven emergent themes were described, highlighting perceived barriers and promoters to utilizing the PPC framework.

Conclusion: PPC is an Age-Friendly approach to addressing 'what matters' that is feasible to implement in various clinical settings and through multiple modalities, including telehealth. Continuing to expand the delivery of conversations about 'what matters' is essential for developing and scaling Age-Friendly care.

Background: The impact of COVID-19 on physical function (PF) outcomes among older adults remains unclear. We examined the long-term association between COVID, PF, and Activities of Daily Living (ADLs) among women from the Women's Health Initiative (WHI).

Methods: Participants from the WHI who completed the COVID-19 survey (2021-2022) and annual survey (2022) were included. Self-reported data on COVID-19 testing and symptoms (2021-2022) were used. PF score and ADLs were evaluated pre- and post-COVID-19 survey by the 36-Item Short Form Survey PF subscale, the Lawton Instrumental Activities of Daily Living, and the Katz Index of Independence in ADL. Multivariable linear regression and logistic regression were used and adjusted for pre-COVID functioning to examine the association between COVID status, PF, and ADLs. The interaction between pre-COVID functioning and COVID status was tested.

Results: Among the 13,933 WHI participants, 71.4% were aged ≥ 80 years, and 88.6% were Non-Hispanic White. Only 8.7% tested positive for COVID-19 (n = 1210), with 35.1% having long COVID (n = 425). The most common long COVID symptoms were fatigue (18.2%), malaise (12.2%), memory problems (12.1%), and brain fog (11.2%). Women who tested COVID+ had lower PF scores (60 vs. 65, p = 0.045) and were less likely to be able to do all ADLs without help (74% vs. 79.2%, p = 0.015) compared to those who never tested COVID+. After controlling for covariates, post-COVID PF scores did not differ by COVID status (p = 0.30), although pre-COVID PF scores were significantly linked to post-COVID scores (p < 0.001). Similarly, the odds of being able to do all ADLs without any help did not differ by COVID status (p = 0.31), with pre-COVID ADLs significantly associated with post-COVID ADLs (p < 0.001).

Conclusions: In older women, after accounting for pre-COVID functional status, the association between long COVID and lower functioning became nonsignificant. Our findings highlight the importance of preserving physical functioning among older women.

Background/objective: Antimicrobial peptides have demonstrated promise as biomarkers for urinary tract infection (UTI) in older adults (age ≥ 65 years). However, it is unknown if urinary AMP levels also increase in asymptomatic bacteriuria. Our objective was to determine if AMP levels vary between older adult patients with and without asymptomatic bacteriuria.

Methods: This was a preplanned secondary analysis of older adults enrolled in a cross-sectional study of patients presenting to a family medicine clinic for a non-acute visit and without urinary symptoms. Asymptomatic bacteriuria was considered present if a patient had a positive culture defined as (> 10,000) colony-forming units (CFUs) of a single organism. All other culture results were considered negative. Urinalysis results are presented based on the presence/absence of asymptomatic bacteriuria. Urinary levels of 4 AMPs (human neutrophil peptides 1-3 (HNP 1-3), human alpha-defensin-5 (HD-5), human beta-defensin-2 (hBD-2), and cathelicidin (LL-37)) are reported as median and interquartile range. The Wilcoxon Rank Sum test was used to compare the log-transformed AMP values between the groups.

Results: The analytic cohort included 162 older adult patients; 18 (11%) had asymptomatic bacteriuria. Urinalysis results varied between asymptomatic older adult patients with positive asymptomatic bacteriuria and negative cultures, but AMP values did not differ (p > 0.2 for all four AMPs).

Conclusion: AMPs did not differ between asymptomatic older adult patients with positive and negative cultures in this secondary analysis. AMPs should be further studied as if they increase in older adults with symptomatic UTI, they may then be able to distinguish negative culture/asymptomatic bacteriuria from true infection where urinalysis cannot.