Journal of the American Geriatrics Society最新文献

Background: In long-term care (LTC), the incidence of hip or vertebral fractures are eight times that in the community. Despite the wide availability of osteoporosis therapy, LTC residents are omitted from pivotal trials and not treated. Denosumab is a relatively new, monoclonal antibody therapy for osteoporosis treatment. Via a randomized trial, we sought to determine the safety and efficacy of denosumab in LTC residents.

Methods: We conducted a 2-year, double-blind, placebo-controlled, randomized clinical trial in 201 osteoporotic men and women aged ≥ 65 years, living in LTC communities. Participants with multimorbidity, dysmobility, and cognitive impairment were not excluded. The intervention was denosumab 60 mg subcutaneous every 6 months or placebo. Our primary outcome measures were hip and spine bone mineral density (BMD) improvement at 24 months. Secondary outcomes included BMD at other skeletal sites, function, and safety.

Results: We included 123 women and 78 men with a mean ± standard error age of 81.5 ± 0.6. Overall, 83% and 71% completed 12 and 24 months, respectively. Compared with placebo, the women receiving denosumab had a greater 24-month percent increase in spine (7.41 ± 0.93 vs. 2.15 + 0.56; p = 0.014), and total hip BMD (4.62 ± 0.62 vs. -0.19 ± 0.79; p = 0.007); and men in spine (7.91 ± 0.96 vs. 1.12 ± 1.13; p = 0.002) and total hip (3.74 ± 0.55 vs. 0.48 ± 0.74; p = 0.018). There were no significant differences in safety metrics.

Conclusions: Denosumab was a safe and effective therapy for improving BMD in osteoporotic older men and women with multiple comorbidities in LTC.

Introduction: COVID-19 survivors are at greater risk for new medical conditions. Among older adults, where multimorbidity and functional impairment are common, frailty measurement provides a tool for understanding how infection impacts future health beyond a one-disease-at-a-time approach. We investigated whether COVID-19 was associated with change in frailty among older Veterans.

Methods: Data were from the Veterans Affairs (VA) COVID-19 Observational Research Collaboratory, which extracted VA medical record data. We included Veterans who had COVID-19 from March 1, 2020, to April 30, 2021 and matched uninfected controls. We excluded those <50 years at index or did not survive 12 months after. Frailty was assessed at the index date and 12 months using the VA Frailty Index (VA-FI). We assessed the number of new VA-FI deficits over 12 months. Analysis was done by negative binomial regression adjusted for age, gender, race, ethnicity, and BMI. Coefficients are given as the ratio of the mean number of new deficits in COVID-19 cases versus controls during follow-up.

Results: We identified 91,338 COVID-19-infected Veterans and an equal number of matched controls. Median (IQR) age was 68.9 years (60.3-74.2), 5% were female, 71% were White, and baseline VA-FI was 0.16 (0.10, 0.26). Median (IQR) number of new deficits at 1 year was 1 (0-2) for infected and 0 (0-1) for uninfected controls. After adjustment, those with COVID-19 accrued 1.54 (95% CI 1.52-1.56) times more deficits than those who did not. The five most common new deficits were fatigue (9.7%), anemia (6.8%), muscle atrophy (6.5%), gait abnormality (6.2%), and arthritis (5.8%).

Discussion: We found a greater increase in frailty among older Veterans with COVID-19 compared with matched uninfected controls, suggesting that COVID-19 infection has long-term implications for vulnerability and disability among older adults. Functional impairments such as fatigue, impaired mobility, and joint pain may warrant specific attention in this population.

The "Stress Tests and Biomarkers of Resilience" conference, hosted by the American Geriatrics Society and the National Institute on Aging, marks the second in a series aimed at advancing the field of resilience science. Held on March 4-5, 2024, in Bethesda, Maryland, this conference built upon the foundational work from the first conference, which focused on defining resilience across various domains-physical, cognitive, and psychosocial. This year's gathering centered around three factors: the biology that underlies resilient outcomes; the social, environmental, genetic, and psychosocial factors that impact that resilience biology; and the biomarker testing and imaging that predicts resilient outcomes for older adults. The presentations and discussions around these topics were underscored by considerations around the many impacts of social determinants of health on resiliency interventions, and by advances in the modern training and research methodologies that influence data collection and experiment design.

Background: Hospital at Home (HaH) is a growing care model requiring significant investments. Critical to starting a program is estimating census and enrollments. The objective of this study was to compare expected versus actual consults, enrollments, and barriers in a novel HaH program.

Methods: This was an observational, retrospective cohort study at a single urban academic medical center. Adult inpatients considered for enrollment to HaH were included. Demographic data, diagnoses and outcomes data were extracted for HaH patients. Volume and outcomes of HaH consults were recorded, including reasons for ineligibility or a patient declining to enroll.

Results: Over the first year of implementation, 248 patients enrolled. The average daily census (ADC) grew over months 1-6, then plateaued at a mean of 4.4 patients during month 10, with an overall ADC range from 0 to 7 patients. From months 7 to 12, there were 724 consults for a home hospital assessment, of which 22.5% (163/724) of patients were enrolled, 21.8% (158/724) declined to enroll, 29.3% (212/724) were ineligible for the program, and 26.4% (191/724) had consults that were deferred until the time of discharge and never explicitly consented or refused. The most common reasons for program ineligibility were complex care needs, insurance status, and not meeting inpatient status. The most common reasons patients declined to enroll were a preference to remain in the brick-and-mortar hospital and home conditions not suitable for HaH.

Conclusions: This retrospective, cohort study defines the challenges of enrolling patients in an HaH program and provides areas for other programs to examine as they start or grow a program.

Background: Exposure to central nervous system (CNS)-active polypharmacy-overlapping exposure to three or more CNS-active medications-is potentially harmful yet common among persons living with dementia (PLWD). The extent to which these medications are prescribed to community-dwelling PLWD by individual clinicians versus distributed across multiple prescribers is unclear.

Methods: We identified community-dwelling Medicare beneficiaries with a dementia diagnosis and Medicare Parts A, B, and D coverage for at least one month in 2019. Using fill date and days' supply for prescriptions filled between January 1, 2019 and December 31, 2019, we identified beneficiaries exposed to CNS-active polypharmacy (i.e., >30 days of overlapping exposure to three or more antidepressant, antipsychotic, antiseizure, benzodiazepine, opioid, nonbenzodiazepine benzodiazepine receptor agonists, or skeletal muscle relaxant medications). We examined the number and type of clinicians who contributed to polypharmacy person-days among PLWD.

Results: The cohort included 955,074 PLWD who were primarily female (64.0%), were White (78.5%), and had a mean age of 83.4 years (standard deviation 8.0). Notably, 14.3% were exposed to CNS-active polypharmacy. At the person level, 24.6% of PLWD experienced polypharmacy prescribed by a single clinician. Considering total days of exposure, 45.3% of polypharmacy person-days were prescribed by a single clinician. Primary care physicians prescribed 63.0% of polypharmacy person-days and accounted for the plurality of days for all seven medication classes, followed by psychiatrists for antipsychotics and benzodiazepines and primary care advanced practice providers (APPs) for antidepressants and antiseizure medications.

Conclusion: In this cross-sectional analysis of Medicare claims data, primary care clinicians (both physicians and APPs) prescribed the majority of medications that contributed to CNS-active polypharmacy for PLWD. Future research is needed to identify strategies to support primary care clinicians in appropriate prescribing of CNS-active medications to PLWD.

Background: Motor signs may herald incident dementia and allow the earlier detection of high-risk individuals and the timely implementation of preventive interventions. The current study was performed to investigate the prognostic properties of motor signs with respect to incident dementia with Lewy bodies (DLB) in older adults with mild cognitive impairment (MCI). Emphasis was placed on sex differences. The specificity of these associations was explored.

Methods: We analyzed data from the National Alzheimer's Coordinating Center Uniform Data Set. Participants 55 + years old with a diagnosis of MCI were included in the analysis. Those with Parkinson's disease (PD) or other parkinsonian disorders at baseline and those with PD dementia at follow-up were excluded. UPDRS III was used to assess the presence or absence of motor signs in nine domains: hypophonia; masked facies; resting tremor; action/postural tremor; rigidity; bradykinesia; impaired chair rise; impaired posture/gait; postural instability. Αdjusted Cox proportional hazards models featuring sex by motor sign interactions were estimated.

Results: Throughout the average follow-up of 3.7 ± 3.1 years, among 4623 individuals with MCI, 2211 progressed to dementia (66 of whom converted to DLB). Masked facies [HR = 4.21 (1.74-10.18)], resting tremor [HR = 4.71 (1.44-15.40)], and bradykinesia [HR = 3.43 (1.82-6.45)] exclusively increased the risk of DLB. The HR of DLB was approximately 15 times greater in women compared to men with masked facies. Impaired posture-gait (approximately 10 times) and resting tremor (approximately 8.5 times) exhibited a similar trend (prominent risk-conferring properties in women compared to men) but failed to achieve statistical significance. Rigidity and hypophonia elevated the risk of other dementia entities, as well. The remaining motor features were not related to incident dementia of any type.

Conclusions: Specific motor signs may herald DLB among individuals with MCI. Different associations may exist between masked facies, impaired posture-gait, resting tremor, and incident DLB in men versus women.

Background: Older adults often require surgical care and are at elevated risk of delirium. We explored delirium risk profiles across the population of U.S. older adults who underwent one of 10 common noncardiac surgeries.

Methods: We analyzed Health and Retirement Study (HRS) participants linked with Medicare billing data who underwent the following 10 noncardiac surgeries from 2000 to 2018 at age 65 or more: total knee arthroplasty (TKA), total hip arthroplasty (THA), spine surgery, cholecystectomy, colorectal surgery, hernia repair (ventral, umbilical, or incisional), endarterectomy, prostatectomy, transurethral resection of the prostate (TURP), and hysterectomy. Demographic and health covariates were obtained from the HRS dataset. Latent cognitive ability was calculated from cognitive testing, proxy reports, and demographics at the preoperative HRS interview. We compared standardized differences for delirium risk factors across the 10 surgeries and qualitatively clustered them into phenotypical subgroups.

Results: We analyzed 7424 older adults (mean age 76 ± 6 years, 45% male). Endarterectomy patients presented with the highest burden of nearly all health and cognitive factors, implying higher delirium risk (e.g., stroke, 22%; depressive symptoms, 30%; high school or less education, 73%; frailty, 42%; lowest latent cognitive ability). A second "general surgery" phenotype, including cholecystectomy, colorectal, and hernia surgery patients, experienced more frailty (29%-32%) and depressive symptoms (24%-26%), with moderate comorbidity burden. A third "pain" phenotype, which included TKA, THA, and spine surgery patients, commonly reported moderate or severe pain (47%-53%) and impairment in activities of daily living (ADL, 23%-30%), but fewer comorbid medical conditions. The remaining surgery types (hysterectomy, prostatectomy, TURP) were not phenotypically grouped and generally had lower risk features for delirium.

Conclusion: In an epidemiological cohort of US older adults, we identified clinically meaningful heterogeneity in delirium risk profiles across different surgical types, which may have implications for delirium risk stratification and delirium prevention or treatment.

Background: Older adults with advanced cancer experience functional disability that warrants rehabilitation services; however, evidence indicates inconsistencies in referral. The purpose was to (1) identify predictors of geriatric assessment (GA)-driven referrals to rehabilitation services and (2) explore associations between referral and change in function, health-related quality of life (HRQoL), and overall survival among older adults with advanced cancer.

Methods: This was a secondary analysis (NCT020107443, UG1CA189961) of a nationwide GA clinical trial. Patients were older adults with advanced cancer who had at least one GA-defined physical performance or functional status impairment. Primary outcomes were oncologist-initiated discussion about or referral to rehabilitation services after the GA (Aim 1) and decline in activities of daily living (ADL), Instrumental ADL (IADL), and HRQoL within 3 months, and overall survival at 1 year (Exploratory Aims). Analyses included multivariable logistic regression and Cox proportional hazards models. Demographic and clinical factors were controlled for by using 1:1 propensity score matching.

Results: In total 265 patients were analyzed. After adjustment, impaired cognition (odds ratio [OR] = 2.25, p = 0.01), Karnofsky score indicating disability (OR = 2.86, p < 0.01), and receipt of monoclonal antibodies (OR = 1.95, p = 0.04) were associated with higher odds of referral. In contrast, polypharmacy was associated with lower odds of referral (OR = 0.31, p < 0.01). Referred patients were less likely to decline in ADL (OR 0.30, p = 0.07) and IADL (OR 0.64, p = 0.35), but more likely to decline in HRQoL (OR 1.20, p = 0.67) and have worse survival (HR 1.18, p = 0.62).

Conclusions: Cancer treatment, polypharmacy, cognition, and disability status likely influence oncologists' decision to refer for rehabilitation. Referral was not independently associated with change in functional disability, HRQoL, or survival. Future studies should evaluate patients' utilization of rehabilitation services post-referral and determine whether dose/timing of rehabilitation services influence clinical outcomes.

Background: Obesity indices reflect not only fat mass but also muscle mass and nutritional status in older people. Therefore, they may not accurately reflect prognosis. This study aimed to investigate associations between a body shape index (ABSI), body mass index (BMI), and mortality in the general older population.

Methods: This nationwide observational longitudinal study included individuals aged between 65 and 74 years who underwent annual health checkups between 2008 and 2014. Exposures of interest were ABSI and BMI, and the primary outcome was all-cause mortality. Association between the ABSI and BMI quartile (Q1-4) and mortality was assessed using Cox regression analysis. A restricted cubic spline was also used to investigate nonlinear associations. The missing values were imputed using multiple imputation by chained equations.

Results: Among 315,215 participants, 5074 died during a median follow-up period of 42.5 (interquartile range: 26.2-59.3) months. Compared with ABSI Q1, ABSI Q3 and Q4 were associated with increased risk of mortality, with the adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of 1.13 (1.05-1.22) and 1.23 (1.13-1.35), respectively. Compared with BMI Q3, BMI Q1 and Q2 were associated with an increased risk of mortality, with aHRs and 95% CIs of 1.51 (1.39-1.65) and 1.12 (1.03-1.22), respectively. The impacts of these indices were greater in male than in female. The heatmap of the aHR for mortality by continuous ABSI and BMI showed that higher ABSI was consistently associated with higher mortality risk regardless of BMI, and that the combination of low BMI and high ABSI was strongly associated with increased mortality risk.

Conclusions: High ABSI and low BMI are additively associated with the risk of all-cause mortality in the general older population in Japan. Combination of ABSI and BMI is useful for evaluating mortality risk in older people.