Journal of the American Geriatrics Society最新文献

Sankey diagram of agreement between dischareg summary, discharge instructions, and patient provided reasoning for chronic medication changes made during hospitalization.

Background: Outcome measurement instruments (OMIs) are important for evaluating intervention effectiveness and quality. However, adopting OMIs remains challenging. This study aimed to select OMIs for a core outcome set (COS) for use in studies focusing on adherence to appropriate polypharmacy in older people.

Methods: A list of OMIs for COS outcomes and their feasibility information was compiled from the literature to select one OMI per outcome. Two rounds of Delphi questionnaires containing a range of OMIs were distributed to experts [academics, healthcare professionals (HCPs), journal editors and methodologists] who were asked to select OMIs for a subsequent consensus meeting using 'Yes', 'No', or 'Uncertain'. The Delphi results were discussed and OMIs were voted on (Yes: important and No: unimportant) in a consensus meeting with experts and an interview with a public member. An OMI was included if ≥ 80% of participants voted on it as critical and ≤ 20% voted it as unimportant.

Results: Twenty-one OMIs were presented to experts (Round 1, n = 42; Round 2, n = 39) in the Delphi exercise to achieve consensus on nine OMIs. Following the consensus meeting and interview (experts, n = 5; public participants, n = 1), agreement was achieved to select four OMIs: the Adherence to Refills and Medications Scale (ARMS, 100%); Multimorbidity Treatment Burden Questionnaire (MTBQ, 100%); Medication-Related Burden Quality of Life questionnaire (MRB-QoL, 83.3%); and 'the number of undesired consequences of the intervention that result from administering multiple medications in older people (83.3%)' for measuring medication adherence across multiple medications (subjective); treatment burden; health-related quality of life (HRQoL) and adverse events and side effects (AEs and SEs), respectively. No agreement was reached regarding cost-effectiveness and healthcare utilization.

Conclusion: This study selected OMIs for use with a COS in studies to improve adherence to appropriate polypharmacy in older people. Future research should identify appropriate OMIs for the remaining outcomes.

Background: Despite longstanding concern about an increase in use of invasive mechanical ventilation among persons living with dementia (PLWD), no studies have examined trends in mechanical ventilation use among PLWD in Veterans Affairs (VA) facilities. In this study, we aimed to (1) identify recent trends in use of mechanical ventilation among Veteran PLWD and (2) assess mortality trends of those who received mechanical ventilation.

Methods: In this retrospective national cohort study of all VA medical hospitalizations of Veteran PLWD ≥ 65 years from 2010 to 2019, we used data from the VA Corporate Data Warehouse and defined dementia using a VA-sanctioned list of dementia diagnosis codes. We calculated the percentage of hospitalizations with mechanical ventilation use during the study period and used linear regression to determine a temporal trend. We calculated in-hospital and one-year mortality for hospitalizations of Veteran PLWD involving mechanical ventilation and used linear regression (predictor: time; outcome: mortality) to describe mortality trends.

Results: Our cohort included 702,989 hospitalizations at 126 VA medical centers involving 251,545 unique Veteran PLWD. Hospitalized Veteran PLWD were 97.9% male, 89.7% non-Hispanic/Latino, and 72.7% White. Mechanical ventilation use decreased from 1.7% of hospitalizations in 2010 to 1.1% in 2019. Annual in-hospital mortality among those PLWD who received mechanical ventilation decreased from 45.9% in 2010 to 38.0% in 2019 and one-year mortality decreased from 73.4% in 2010 to 70.2% in 2018.

Conclusions: The use of mechanical ventilation in hospitalizations of Veteran PLWD was lower than seen in non-VA facilities and decreased from 2010 to 2019. Among hospitalized Veteran PLWD who received mechanical ventilation, in-hospital and one-year mortality remained high throughout the study period but decreased over time. These descriptive mortality decreases may be attributable to patient selection or improved mechanical ventilation practices. Further research should examine patient- and system-level factors to explain observed trends.

Background: As the population ages, kidney transplantation (KT) is increasingly considered for older adults with advanced chronic kidney disease (CKD). However, frailty, cognitive impairment, and malnutrition complicate transplant decision-making. A Comprehensive Geriatric Assessment (CGA) offers a multidimensional approach, but the relative contribution of individual CGA domains to transplant eligibility and receipt remains unclear.

Methods: We conducted a retrospective observational study of 164 older adults with advanced CKD seeking KT and underwent CGA by a geriatrician at an urban academic center from September 2021 to July 2024. Associations between CGA domains and KT listing and receipt were evaluated using logistic regression analyses, adjusting for age and other clinical covariates.

Results: Of the 164 participants, 139 (84.8%) were listed, and 24 (17.3%) received KT among them. While higher levels of functional status, as measured by activities of daily living (ADL), were associated with KT listing, instrumental ADL and gait speed were significantly associated with transplantation. Even after adjusting for age, better cognitive function, as assessed through clinical evaluation and Montreal Cognitive Assessment (MoCA), was also positively associated with both outcomes. Age-adjusted nutritional status was independently associated with transplant listing eligibility.

Conclusions: Individual domains of CGA, particularly physical function, cognition, and nutrition, are independently associated with KT decision-making among older adults. Incorporating focused geriatric assessments into kidney transplant evaluation may improve risk stratification and reduce disparities in transplant access.

Background: Reports of neuropsychiatric symptoms (NPS) from informants, often patients' caregivers and families, and from clinicians are both important for accurate detection of symptoms. However, informant/caregiver report and clinician assessments of NPS often differ.

Methods: We examined agreement between informant/caregiver and clinician report of NPS in the National Alzheimer's Coordinating Center Uniform Data Set. Participants were age ≥ 50 at baseline with mild cognitive impairment (MCI) or dementia (N = 27,225). At each visit, informants reported NPS using the Neuropsychiatric Inventory questionnaire (NPI-Q). Study clinicians provided clinical assessment per study protocol. Agreement between informant report and clinician judgment was assessed using Cohen's kappa statistic. Associations between agreement in reporting for each NPS and participant/informant characteristics were examined using random-effects logistic regressions.

Results: At baseline, participants were on average 72.9 ± 9.4 years old, 49% male, 76% non-Hispanic White, with 14.8 ± 3.6 years of schooling. Average follow-up was 4.0 ± 2.5 years. Informants were 63.7 ± 13.2 years old, 31% male, with 15.4 ± 2.8 years of schooling. 60% of informants were spouse/partner of the participant. Informants were more likely than clinicians to report the presence of all symptoms except for hallucinations. Agreement between informant and clinician reports of all symptoms was lower in patients with more severe dementia. Over time, agreement between informant and clinician reports of apathy increased. Agreement between informant and clinician reporting of NPS differed by participant's sex and race/ethnicity. Informants who had lower frequency of contact and more distant relationships with the participant were more likely to agree with clinicians' reporting.

Conclusions: Understanding differences between informant and clinician reports of NPS in dementia is essential in obtaining a more complete, accurate picture of behavioral challenges patients face. Considering patient and informant characteristics and dynamics between them would help clinicians better understand potential biases that may affect the accuracy of reported NPS and better manage and treat the symptoms.

Background: Trauma centers are implementing geriatric-focused processes of care, including geriatric consult services, to improve outcomes for injured older adults. We hypothesized that trauma centers with a geriatric consult service would have more geriatric-focused processes of care and improved hospital-level mortality for injured older adults.

Methods: We surveyed US trauma centers regarding compliance with geriatric-focused processes of care, including presence of geriatric consult service, palliative care consult service, geriatric pharmacists, screening for frailty, screening for potentially inappropriate home medications, and anticoagulation reversal protocols. Using Trauma Quality Improvement Program data, we calculated hospital-level observed-to-expected (O:E) mortality for patients aged ≥ 65 years treated at surveyed trauma centers, controlling for patient demographics, comorbidities, and injury severity. High-mortality hospitals were defined as those in the highest quartile of O:E ratio for mortality. Multivariable logistic regression was performed to assess the association of geriatric consult service availability with high-mortality hospitals while controlling for other hospital-level characteristics, including trauma verification level, number of beds, geriatric trauma volume, teaching status, and compliance with other geriatric-focused processes of care.

Results: Geriatric consult services were available at 49 of the 145 included trauma centers (34%). Hospitals with geriatric consult services were more likely to have Level I verification (61% vs. 12%, p < 0.001), standardized processes for assessing frailty (43% vs. 15%, p < 0.001), and geriatric pharmacists (55% vs. 33%, p = 0.012). On unadjusted analysis, hospitals with a geriatric consult service were less likely to have higher-than-expected mortality (17% vs. 44%, p = 0.009). On multivariable logistic regression, the presence of a geriatric consult service was associated with decreased odds of higher-than-expected mortality (OR 0.20, 95% CI 0.05-0.73, p = 0.015).

Conclusions: Trauma centers with geriatric consult services have improved hospital-level mortality for injured older adults and have more processes in place to manage these patients. Additional trauma centers should consider implementing a geriatric consult service.

Background: Opioid use disorder (OUD) among older adults is a fast-growing public health problem. However, little is known about treatment outcomes among older adults in office-based buprenorphine programs. Thus, our objective was to examine how age is associated with buprenorphine treatment outcomes among adults with OUD who initiate buprenorphine treatment in primary care.

Methods: This was a retrospective cohort study of all adults with OUD who initiated buprenorphine at an office-based treatment program in the Bronx, NY between June 1, 2015 and December 31, 2017. Using cox proportional hazards analysis and logistic regression models, the primary outcome was buprenorphine treatment retention based on electronic health record (EHR) prescription orders. The main independent variable was age at initiation of buprenorphine treatment, categorized as age < 40, age 40-49, age 50-59, and age ≥ 60. Covariates included patient demographics, cannabis use at treatment intake, and history of OUD treatment with methadone.

Results: The cohort included 239 patients of which 70 (29%) were age 50-59 and 24 (10%) were age ≥ 60. Compared to being age < 40, being age 50-59 was associated with a 27% decreased risk of treatment discontinuation (aHR of 0.63; 95% CI, 0.42-0.95) and greater odds of treatment retention at 1 year (aOR 2.23, 95% CI, 1.15-4.67) and 2 years (aOR 2.20; 95% CI, 1.03-4.74). Compared to being age < 40, being age ≥ 60 had similar, but nonsignificant findings.

Conclusions: In office-based buprenorphine treatment, being age 50-59 was associated with more than 25% decreased risk of treatment discontinuation and over twice the odds of long-term retention in treatment than adults age < 40. While not statistically significant, likely due to their smaller sample size, adults aged ≥ 60 had similar findings. These findings highlight the success of buprenorphine treatment for OUD once it is initiated in adults over age 50.