Journal of the American Geriatrics Society最新文献

Background: Previous studies on the relationship between prediabetes, HbA1c and cognitive trajectories show mixed results. Therefore, we investigated the association of prediabetes, diabetes and HbA1c with change in global and domain-specific cognitive scores in cognitively unimpaired (CU) adults, as well as the potential effect modification by sex or age.

Methods: This longitudinal study included 4236 CU persons aged ≥ 50 years from the population-based Mayo Clinic Study of Aging. We ran linear mixed-effect models with baseline prediabetes, diabetes and HbA1c predicting longitudinal global and domain-specific (i.e., memory, language, attention/executive function, and visuospatial skills) cognitive z-scores and raw scores. Models were adjusted for age, sex, education, medical comorbidity, repeated cognitive testing, and ApoEɛ4. We additionally ran models with sex and age interactions.

Results: Compared to normoglycemic individuals, individuals with prediabetes and diabetes showed poorer performance on cognitive tests, i.e., TMT-B, category fluency, and block design subtest over time. Additionally, the presence of prediabetes, diabetes, longer diabetes duration and higher HbA1c were associated with faster global and domain-specific cognitive decline over a median follow-up of 6.4 years (range 1-19). Three-way interactions showed that the effect of diabetes on decline in global cognition, attention and visuospatial domains was more pronounced in women than in men. Age did not modify the effect of diabetes or higher HbA1c on cognition.

Conclusions: The results suggest that prediabetes and diabetes significantly shorten the timeframe before a potentially clinically noticeable change in global and domain-specific cognition is reached. Thus, lifestyle modification to reverse prediabetes and prevent diabetes could potentially reduce the rate of cognitive decline in aging populations. The findings differed by sex (i.e., the effect of diabetes on decline in global cognition, attention and visuospatial domains was more pronounced in women than men).

Background: Functional impairment (FI) is a key criterion for diagnosing dementia. However, subtle functional changes may occur during preclinical and prodromal phases but may not be accurately characterized. Furthermore, research linking FI to Alzheimer disease (AD) biofluid biomarkers is limited. Here we examined cross-sectional associations between cerebrospinal fluid (CSF) AD biomarkers and persistent versus transient FI in dementia-free older adults, and the longitudinal association of FI with incident dementia.

Methods: Data from 1000 participants (age 72.9 ± 7.0; 45.2% female; 62.8% MCI) from the Alzheimer's Disease Neuroimaging Initiative were analyzed. CSF biomarkers included p-tau181, Aβ42, and ptau-181/Aβ42 ratio. Three Functional Activities Questionnaire items of "preparing a hot beverage," "preparing a balanced meal," and "shopping alone" were identified by factor analysis as assessing function rather than cognition directly. Persistent-FI was operationalized as FI present at> two-thirds of pre-dementia visits. Comparator groups included Transient-FI and No-FI. Linear regression modeled the association between FI status and baseline biomarker levels, while Cox regression assessed the association between FI and incident dementia. Models adjusted for age, sex, education, APOE-ε4 status, and MMSE.

Results: Compared to No-FI, Persistent-FI was associated with lower Aβ42 (Beta = -8.93; 95% CI: -13.56 to -4.03; p < 0.001), higher p-tau181 (Beta = 10.81; 95% CI: 0.44-22.26; p = 0.041), and ptau181/Aβ42 ratio (Beta = 21.66; 95% CI: 7.02-38.31; p = 0.003). In contrast, Transient-FI showed no significant associations. APOE-ε4 carrier status was more prevalent in the Persistent-FI group compared to No-FI (p = 0.009), but not in Transient-FI (p = 0.931). Compared to No-FI, Persistent-FI had a 6.66-fold greater dementia incidence rate (95% CI: 4.98-8.91, p < 0.001), while Transient-FI had a 1.72-fold greater incidence rate (95% CI: 1.09-2.72, p = 0.021).

Conclusions: Findings extend the limited research on the association of FI with CSF AD biomarkers in dementia-free populations. Operationalizing FI-related risk by persistence enhances prognostication, identifying individuals with greater AD pathology and progression risk. This approach could enhance screening, early detection, and risk stratification, informing timely interventions before dementia onset.

Background: Dementia-the seventh leading cause of death globally-is most prevalent in Asia, home to over half of those affected. Yet, palliative approaches to dementia, endorsed by the World Health Organization (WHO) Global Action Plan on the Public Health Response to Dementia, and focused on improving quality of life through a holistic and person-centered approach, are largely absent in the region.

Methods: We reviewed the available literature related to end-of-life experiences with advanced dementia from countries in the WHO South-east Asian and Western Pacific regions. We used the Consolidated Framework for Implementation Research to synthesize barriers and facilitators to implementing a palliative approach to dementia and propose a research agenda.

Results: Broad barriers identified in the outer setting of the implementation framework include sociocultural values and a lack of supportive policies, guidelines, and financing. Within the inner setting of the healthcare system, challenges stem from underdeveloped long-term care infrastructure, limited professional training, and gaps in equity and person-centeredness. At the individual level, barriers include low dementia literacy and limited uptake of advance care planning. Potential facilitators were growing digital fluency and established community norms around caring for older adults at home.

Conclusions: Based on our review, we propose a research agenda prioritizing partnering with individuals with dementia and their caregivers, especially in low- and middle-income countries, de-implementing low-value interventions and implementing community-level palliative care models, leveraging technological innovations, and developing core evaluation metrics to advance WHO's action plan and foster culturally relevant and effective interventions tailored to the region's unique needs.

Background: Voluntary accreditation is a prevalent structural signal of high quality in healthcare, yet its association with improved quality measures remains contested. In the U.S. hospice sector, the value of accreditation as an oversight mechanism warrants rigorous investigation, given its role in Medicare's "deemed status" program. The objective of this study is to determine the association between a hospice gaining accreditation and its performance on quality measures.

Methods: We conducted a retrospective, longitudinal study of U.S. hospices from 2016 to 2023. Using facility fixed-effects models, we estimated the change in quality measures associated with accreditation. The sample included a national panel of Medicare-certified hospices with publicly reported quality data. The primary independent variable was accreditation status. Dependent variables were four CMS quality measures: the Admission Composite Process Measure, Hospice Visits in the Last Days of Life, the Hospice Care Index, and the overall Hospice Star Rating.

Results: Gaining accreditation was associated with divergent quality outcomes: a significant improvement in clinical service intensity at the end of life, but a significant decline in the quality of administrative processes at admission. Accreditation was not associated with star rating.

Conclusions: Hospice accreditation does not appear to function as a mechanism for comprehensive quality improvement. Instead, our results suggest that organizations may strategically prioritize performance on surveyor-visible metrics, sometimes at the expense of other care processes. These findings suggest accreditation should be viewed as a domain-specific signal rather than a comprehensive proxy for superior hospice quality.

Background: Elder mistreatment (EM) is pervasive yet under-identified. The Detection of Elder abuse Through Emergency Care Technicians (DETECT) tool was developed to improve EM identification and reporting among emergency medical technicians. This study explores clinician perspectives on adapting DETECT for use in home-based primary care (HBPC).

Methods: A qualitative study was conducted using semi-structured interviews and focus groups with HBPC clinicians (N = 16) across seven intervention sites. Discussions focused on barriers and facilitators to EM identification and response, engagement with Adult Protective Services (APS), and recommendations for adapting DETECT. Thematic analysis was performed.

Results: Three themes emerged: (1) EM as an overlooked priority-clinicians recognized EM as critical but lacked standardized screening tools and protocols; (2) Barriers and facilitators to screening and response-time constraints, complexity of EM cases, and APS hesitancy were barriers, while continuity of care and team-based approaches were facilitators; (3) Recommended DETECT adaptations-clinicians suggested modifications to item phrasing, an emphasis on tracking observations over time, and a scoring system incorporating safety risk levels.

Conclusions: HBPC clinicians support a standardized EM screening tool and emphasize the need for flexibility in reporting and response. Findings will inform modifications to DETECT that align with HBPC workflows and improve EM identification while maintaining patient-clinician relationships.

Background: Rib fractures are common and increase mortality in older adult patients. Early surgical stabilization of rib fractures (SSRF), < 72 h from admission, has been shown to improve outcomes in younger patients. We hypothesize that patients ≥ 65 years requiring SSRF will have improved outcomes with early SSRF.

Methods: This was a retrospective cohort analysis of patients ≥ 65 years between 1/1/2018 and 12/31/2022 who underwent SSRF and were captured in the National Trauma Data Bank. Patients who died within 24 h were excluded. Demographic and injury characteristics, comorbidities, hospital events and discharge dispositions were captured. Study groups were early (< 72 h) versus late SSRF. Primary outcomes were hospital length of stay (HLOS), intensive care unit LOS (ILOS), duration of mechanical ventilation (DMV), and mortality. With early SSRF as the reference group, multivariable analysis was conducted.

Results: Five thousand one hundred twenty-nine patients met inclusion criteria. Three thousand seventy (59.8%) underwent early SSRF and 2059 (40.1%) underwent late SSRF. Early SSRF was associated with shorter HLOS (9 vs. 14 days), ILOS (6 vs. 9 days), and DMV (5 vs. 9 days) (all p < 0.001). There was no difference in mortality (4.7% vs. 5.3%, p = 0.23). Early fixation was associated with fewer complications including unplanned intubation (6.6% vs. 13.5%), tracheostomy (1.9% vs. 5.3%), acute respiratory distress syndrome (0.9% vs. 1.7%), and pneumonia (0.2% vs. 0.7%) (all p < 0.001). On multivariable analysis, HLOS, ILOS, and DMV increased with late fixation (all p < 0.001).

Conclusion: Early SSRF is associated with improved outcomes and fewer complications in older adult patients with rib fractures. Further study will guide treatment protocols for the growing population of older adult trauma patients.

Background: In January 2018, South Korea introduced the cognitive support grade (CSG) within its long-term care insurance (LTCI) system, expanding eligibility for adult day services (ADS) to older adults with mild dementia. This study evaluates the policy's impact on reducing institutional care use and public expenditure using national claims data.

Methods: This study employed an interrupted time series (ITS) design to evaluate the population-level impact of the 2018 policy reform using monthly aggregated data between January 2015 and December 2018. To explore heterogeneity in policy effects, subgroup analyses were conducted using various characteristics.

Results: Following the policy reform, the share of population with ADS eligibility increased by 54.0 percentage points (95% CI: 49.6 to 58.4), followed by a 6.66-day rise in actual ADS uptake (95% CI: 5.11 to 8.21) and a 2.22-day reduction in institutional care use (95% CI: -4.03 to -0.412). Total public insurer costs remained unchanged, as reduced institutional care expenditures were largely offset by increased HCBS costs. Subgroup analyses suggested that ADS was most effective among individuals with coexisting informal care support.

Conclusions: The findings suggest that ADS may function as a complement to-rather than a substitute for-informal care and is associated with reduced institutionalization risk. Optimizing ADS delivery to match caregiving capacity may further enhance effectiveness.