Journal of the American Geriatrics Society最新文献

Background: Identifying priority challenges of older adults with chronic obstructive pulmonary disease (COPD) is critical to designing interventions aimed at improving their well-being and independence.

Objective: To prioritize challenges of older adults with COPD and those who care for them to guide refinement of a telephonic nurse coach intervention for patients with COPD and their family caregivers (EPIC: Empowering People to Independence in COPD).

Design: Multiphase study guided by Baltes Theory of Successful Aging and the 5Ms Framework: Phase 1: Nominal group technique (NGT), a structured process of prioritizing responses to a question through group consensus. Phase 2: Rapid qualitative analysis. Phase 3: Intervention mapping and refinement.

Setting: Ambulatory, virtual.

Participants: Older adults with COPD, family caregivers, clinic staff (nurses, respiratory therapists), clinicians (physicians, nurse practitioners), and health system leaders.

Results: NGT sessions were conducted by constituency group with 37 participants (n = 7 patients, n = 6 family caregivers, n = 8 clinic staff, n = 9 clinicians, n = 7 health system leaders) (Phase 1). Participants generated 92 statements across five themes (Phase 2): (1) "Barriers to care", (2) "Family caregiver needs", (3) "Functional status and mobility issues", (4) "Illness understanding", and (5) "COPD care complexities". Supplemental oxygen challenges emerged as a critical problem, and prioritized challenges differed by group. Patients and clinic staff prioritized "Functional status and mobility issues", family caregivers prioritized "Family caregiver needs", and clinicians and health system leaders prioritized "COPD care complexities". Intervention mapping (Phase 3) guided EPIC refinement focused on meeting patient priorities of independence and mobility but accounting for all priorities.

Conclusions: Diverse constituency groups identified priority challenges for older adults with COPD. Functional status and mobility issues, particularly related to supplemental oxygen, emerged as patient prioritized challenges.

Implications: Patient-centered interventions for older adults with COPD must account for their prioritized functional and supplemental oxygen needs and explore diverse constituent perspectives to facilitate intervention enrichment.

Background: Primary care can be an important setting for communication and advance care planning (ACP), including for those with dementia and their families. The study objective was to explore experiences with a pragmatic trial of a communication and ACP intervention, SHARING Choices, in primary care for older adults with and without dementia.

Methods: We conducted qualitative interviews using tailored semi-structured guides with three groups: ACP facilitators who conducted the intervention; clinicians, managers, and administrators from sites randomized to the intervention; and patients and families who met with ACP facilitators. We used thematic analysis to identify and synthesize emergent themes based on key Consolidated Framework for Implementation Research concepts and Proctor's Implementation Outcomes, triangulating the three groups' perspectives.

Results: We identified five key themes. For acceptability, perceptions of the intervention were mostly positive, although some components were not generally implemented. For adoption, respondents perceived that ACP facilitators mainly focused on conducting ACP, although facilitators often did not implement the ADRD and family engagement aspects with the ACP. For relational connections, ACP facilitator-practice and clinician communication and engagement were key to how the intervention was implemented. For adaptability, ACP facilitators and health systems adapted how the ACP facilitation component was implemented to local preferences and over time, given the pragmatic nature of the trial. And, for sustainability, ACP facilitators and clinicians/managers/facilitators were positive that the intervention should be continued but noted barriers to its sustainability. Patients and families generally did not recall the intervention.

Conclusions: ACP facilitators and clinicians, managers, and administrators had positive perceptions of the ACP facilitator component of the intervention in this pragmatic trial with adaptation to local preferences. However, engaging those with dementia and families was more challenging in the implementation of this intervention.

Background: Gait performance can provide valuable insights into cognitive functioning in older adult and may be used to screen for cognitive impairment. However, the optimal test condition and spatiotemporal parameter for accuracy have not yet been determined. This study aims to determine the gait measure with the highest accuracy identifying cognitive decline.

Methods: A total of 711 participants were recruited, including 332 cognitively healthy individuals, 264 with mild cognitive impairment (MCI), and 115 with dementia, with a mean age of 72 years (interquartile range 69-76), and 43% (n = 307) of women. The participants underwent gait assessment in three different conditions, including a single task and dual tasks of counting backward by ones and naming animals.

Results: Gait performance was deteriorated as cognitive impairment progressed. The gait test performed during naming animals condition was the most accurate in differentiating between cognitive groups. Specifically, the naming animals gait speed was more accurate in discriminating control participants from those with cognitive impairment (area under the curve [AUC] = 76.9% for MCI and 99.7% for people with dementia with control group as reference). The coefficient of stride length variability while naming animals was the most effective parameter in discriminating between MCI and dementia groups (AUC = 96.7%).

Conclusions: The naming animals dual-task gait test can be a valuable assessment for screening cognitive impairment in older adults, regardless of their cognitive abilities. The test is useful in clinical settings for subjects with a range of cognitive profiles.

Background: Among older persons, neighborhood disadvantage is a granular and increasingly used social determinant of health and functional well-being. The frequency of transitions into or out of a disadvantaged neighborhood over time is not known. These transitions may occur when a person moves from one location to another or when the Neighborhood Atlas, the data source for the area deprivation index (ADI) that is used to identify disadvantaged neighborhoods at the census-block level, is updated.

Methods: From a prospective longitudinal study of community-living persons, aged 70 years or older in South Central Connecticut, neighborhood disadvantage was ascertained every 18 months for 22 years (from March 1998 to March 2020). ADI scores higher than the 80th state percentile were used to distinguish neighborhoods that were disadvantaged (81-100) from those that were not (1-80).

Results: At baseline, 205 (29.3%) of the 699 participants were living in a disadvantaged neighborhood. Changes in neighborhood disadvantage during 14 consecutive 18-month intervals were relatively uncommon, ranging from 1.5% to 11.8%. Nearly 80% of participants had no change in neighborhood disadvantage and less than 4% had more than one change over a median follow-up of more than 9 years. Overall, the rate of transitions into or out of neighborhood disadvantage was only 2.7 per 100 person-years. These transitions were most common when the Neighborhood Atlas was updated (2013, 2015, 2018, and 2020). Comparable results were observed when decile changes in ADI scores during the 18-month intervals were evaluated.

Conclusions: In longitudinal studies of older persons with extended follow-up, it may not be necessary to update information on disadvantaged neighborhoods in circumstances when it is possible, and the degree of misclassification of neighborhood disadvantage should be relatively low in circumstances when updated information cannot be obtained.

Background: Unmet need for home and community-based services (HCBS) may disparately impact older adults from racial and ethnic minoritized groups. We examined racial and ethnic differences in unmet need for HCBS among consumers ≥65 years using publicly funded HCBS.

Methods: We analyzed the National Core Indicators-Aging and Disability survey data (2015-2019) from 21,739 community-dwelling HCBS consumers aged ≥65 years in 23 participating states. Outcome measures included self-reported unmet need in six service types (i.e., personal care, homemaker/chore, delivered meals, adult day services, transportation, and caregiver support). Racial and ethnic groups included non-Hispanic Black, Asian, non-Hispanic White, Hispanic, and multiracial groups. Logistic regression models examined associations between race and ethnicity and unmet need, adjusting for sociodemographic, health, and HCBS program (i.e., Medicaid, Older Americans Act [OAA], Program for All-Inclusive Care for the Elderly [PACE]) characteristics, and use of specific service types.

Results: Among 21,739 respondents, 23.3% were Black, 3.4% were Asian, 10.8% were Hispanic, 58.8% were non-Hispanic White, and 3.7% were multiracial or identified with other races/ethnicities. Asian and Black consumers had higher odds of reporting unmet need in personal care than White consumers (adjusted odds ratio [aOR], 1.45, p value < 0.01; and aOR, 1.25, p < 0.001, respectively). Asian and Black consumers had significantly higher odds of unmet need in adult day services versus White consumers (aOR, 1.94, p < 0.001 and aOR, 1.39, p < 0.001, respectively). Black consumers had higher odds of unmet need versus non-Hispanic White consumers in meal delivery and caregiver support services (aOR, 1.29; p < 0.01; and aOR 1.26, p < 0.05, respectively). Race and ethnicity were not significantly associated with experiencing unmet need for homemaker/chore or transportation services.

Conclusions: Future research should identify driving forces in disparities in unmet need to develop culturally appropriate solutions.