Journal of the American Geriatrics Society最新文献

Background: People with dementia have high rates of emergency department (ED) and hospital utilization, high mortality and costs, and other poor outcomes. To successfully impact the care trajectories of these patients, health care systems must pragmatically identify the correct target population. This study described patterns of ED utilization by people with dementia and explored the accuracy of administrative data models to predict mortality and costs.

Methods: Retrospective cohort study of a 20% random sample of Traditional Medicare (TM) beneficiaries with dementia, age ≥ 66 years, and an index ED visit in 2018. One-year mortality and high costs were described, and associations with the timing of prior hospitalizations examined. As a preliminary step to evaluate models based on administrative data only, C-statistics were used to examine the accuracy of eight multivariate models, stratified by the setting of care before and after an ED visit.

Results: The majority of the 250,343 person cohort of individuals with dementia resided in the community before their index ED encounter (83.9%) rather than in a nursing home (NH, 16.1%), and 34.4% required hospitalization. One-year mortality by location varied from 18.4% (community before and after ED visit) to 47% (admitted NH residents). One-year mortality was 40.3% for those hospitalized within the past month, and 26.2% for those hospitalized 6+ months before the ED encounter. C-statistics were less than or equal to 0.72 for seven multivariate models, and 0.81 for the model examining high costs for NH residents discharged back to their NH.

Conclusions: Mortality and costs for people with dementia vary by location of care before and after ED encounters, as well as by timing of prior hospitalizations. However, multivariate models using only administrative data lack accuracy, suggesting the need to add pragmatically selected clinical data and/or other measures to better identify the "right patients, at the right time".

Background: Older adults with chronic insomnia often use benzodiazepine receptor agonists (BZRAs) despite known associated risks and non-pharmacological alternatives such as cognitive behavioral therapy for insomnia (CBTI). CBTI reduces insomnia severity and could potentially improve other outcomes such as the impact of pain on daily activities, even when BZRAs are deprescribed. Yet concerns that deprescribing may worsen pain (which is often comorbid with insomnia) can be a barrier to engagement in BZRA deprescribing. This study examined changes in pain outcomes associated with deprescribing BZRAs in the context of concurrent CBTI.

Methods: Secondary data analysis was conducted using data from a randomized clinical trial that successfully decreased BZRA use in older adults. Participants (n = 188), who were largely older (68% ≥ 65 years, 55 ≤ range ≤ 91) and male (65%), completed CBTI concurrently with a deprescribing intervention (blinded encapsulated BZRA taper or open pill cutter taper). Participants completed the Brief Pain Inventory (BPI) at baseline, one week posttreatment (1 WK), and at a six-month (6 M) follow-up. Analyses included mixed effects models among all participants and a subset aged 65+ as well as comparison of model results to minimal clinically important difference (MCID) thresholds.

Results: Mixed effects models demonstrated that pain severity did not change significantly over time, broadly or in participants aged ≥ 65 years. Significant reductions in pain interference in day-to-day living at 1 WK were observed broadly, although these reductions did not meet the MCID threshold and were no longer significant at 6 M follow-up.

Conclusions: Combined BZRA deprescribing and CBTI did not meaningfully worsen pain in older adults. These results highlight the opportunity for using a combination of CBTI and deprescribing methods in patients with insomnia and comorbid pain, as well as a need for additional interventions to specifically address pain in older adults with chronic insomnia.

Background: Geriatric patients awaiting medical admission frequently experience extended emergency department (ED) stays and receive care in ED hallways. While prolonged ED stays are associated with increased delirium and mortality, the effect of placement in hallways remains unknown. This study's objective was to assess whether prolonged ED hallway exposure is associated with incident delirium and severe agitation in older adults and older persons living with dementia (PLWD).

Methods: We conducted a multi-site retrospective cohort database study between January 1, 2022 and December 31, 2023 of older adults (age 65+) without prevalent delirium admitted to a general medicine service with an ED stay > 8 h. Patients were dichotomized into two groups: > 8 or < 8 h of care in ED hallways. Our primary outcome was incident delirium and severe agitation (a composite outcome of ICD-10 code for delirium, positive nursing screen, use of parenteral antipsychotics, and/or physical restraints) after admission request. Secondary outcomes included hospital length of stay, inpatient and 30-day mortality, and 30-day ED revisit and readmission. We employed mixed-effect logistic regression models, independent of and mediated by history of dementia and adjusted for additional confounders.

Results: Our sample included 11,105 patients (median age 77, 51% female), with 2299 in the hallway group and 8806 in the non-hallway group. Prolonged ED hallway exposure was not associated with delirium and severe agitation for our general geriatric cohort (OR 0.87 [0.53-1.42]) but was for PLWD (OR 1.48 [1.03-2.13]). We observed no association between hallway care and our secondary outcomes except that the hallway group was associated with lower 30-day readmission (OR 0.69 [0.52-0.92]).

Conclusions: Prolonged ED hallway care was not associated with delirium and severe agitation in a general geriatric cohort but was for older PLWD. Prospective research is needed to determine if hospitals should consider prioritizing PLWD for rooms.

The Reducing Inflammation for Greater Health Trial's (RIGHT) study is a single-center, randomized, double-blind, placebo-controlled trial designed to test whether clazkizumab, an interleukin-6 (IL-6) inhibitor, can improve or slow decline in physical, cognitive, and vascular function in older adults, when compared to a placebo. The trial will enroll participants meeting the following inclusion criteria: (1) ≥ 70 years of age, (2) with low to moderate physical function, defined as self-reported difficulty walking 1/4 mile or climbing a flight of stairs, but able to walk 400 m at baseline exam, (3) usual walking speed between ≥ 0.44 and < 1.0 m/s on a 4-m walk or a body mass index of ≥ 28 kg/m², (4) average IL-6 level between 2.0 and 30 pg/mL on two tests, and (5) no active infection, cancer, or other serious health conditions. Clazakizumab, a monoclonal antibody targeting IL-6, 5 mg via subcutaneous injection every 4 weeks for 24 weeks compared to a placebo. The primary outcome will be walking speed over 400 m. Secondary outcomes include other measures of physical function (short physical performance battery, oxygen consumption with walking on a treadmill, fatigability), cognitive function, vascular stiffness and endothelial function, IL-6 and C-reactive protein levels, other markers of inflammation, safety, and tolerability. Findings will evaluate acceptability, safety and 6-months change in mobility and other outcomes. The study was approved by the IRB and is registered with ClinicalTrials.gov (NCT05727384). The RIGHT study will inform the geroscience hypothesis that modifying aging itself will lead to improvement in multiple aspects of health.

Background: Assessment of physical performance in older adults is critical for injury prevention and rehabilitation. Such an assessment remains indispensable for authentic health management, facilitating proper tracking of health condition progression and implementation of tailored interventions. This study aimed to develop and evaluate a digital health tool that empowers older adults to independently assess comprehensive physical performance, including balance, mobility, lower-limb strength, and cardiorespiratory endurance.

Participants and setting: This was a cross-sectional study employing a user-centered design approach conducted at Samsung Medical Center. Thirty community-dwelling older adults aged ≥ 65 years were included.

Methods: A self-administered mobile application with a wearable sensor guided older adults to evaluate and understand their functional performance components. Usability was evaluated using a System Usability Scale (SUS), user experience questionnaires, and open-ended feedback. Preliminary validity was assessed by comparing professional assessments with self-assessments of physical performance.

Results: The tool achieved acceptable usability (mean SUS 69.0 ± 14.84), with most participants (> 95%) perceiving the tool to be necessary and useful for health management, and 86.2% confirming home feasibility. Participants valued their understanding of functional capacity, increased motivation for health management, and enhanced willingness to engage in physical activity. Self-assessments of cardiorespiratory endurance and balance showed moderate concordance with professional measurements (r = 0.5-0.6) with no significant mean differences.

Conclusion: The tool provides self-directed, comprehensive assessments and delivers intuitive comparative data against age- and sex-matched norms, thereby enabling autonomous health management. Despite variable user experience, the tool demonstrated acceptable usability, with most participants recognizing its utility and perceiving the potential for home use. Further refinements in usability, accuracy, and technical simplification are needed. With these improvements, the tool could harness these assessment results to deliver tailored exercise programs and evolve into a comprehensive prevention and rehabilitation resource for older adults.

Background: Program of All-Inclusive Care for the Elderly (PACE) is comprised of diverse organizations serving different populations that aim to deliver care aligned with what matters most to older adults with multiple chronic conditions but often focus on diseases, social, or functional concerns in isolation. Patient Priorities Care (PPC) provides an evidence-based approach to elicit and align care with what matters most.

Methods: The National PACE Association launched a year-long PPC Learning Community (LC) with diverse PACE organizations (PO) across the United States. PO members met monthly to build understanding of PPC, share learnings, implement PPC in their programs, and disseminate lessons to the broader community.

Results: The LC supported PPC uptake into five of six participating POs and as well as the LC's lead's PO. A total of 889 participants received PPC, and 410 staff members were trained. Learning Community members presented in national meetings and created a PPC Guidebook with guidance on training, implementation, and evaluation in this model of care. Members felt the LC built community and promoted accountability through shared learning and feedback. Challenges included limited time for self-directed learning, provider engagement barriers, and the need for continued support for uptake and sustainability.

Conclusions: The LC catalyzed integration of What Matters Most into the PACE model of care using PPC, laying the groundwork for broader adoption. Future peer learning opportunities can ensure sustained momentum and assess impact on utilization, staff satisfaction, and total cost of care.