Journal of the American Geriatrics Society最新文献

Background and objectives: Deprescribing is a key strategy for optimizing therapeutic plans in multimorbid or complex chronic patients. Despite its long-standing use, further studies are needed to validate health outcomes and support its routine clinical integration. This project aims to assess the impact of applying LESS-CHRON criteria in terms of therapeutic and anticholinergic burden, as well as to describe potentially inappropriate medications (PIMs) more often involved in chronic treatments of patients with multimorbidity or those with complex health needs across two care settings: institutionalized and outpatients.

Methods: A quasi-experimental, multicenter, pre-post intervention cohort study was conducted in several phases (screening, intervention, and follow-up at 3 and 6 months after inclusion). The study included two cohorts: outpatients and institutionalized patients. The main variable was the percentage reduction in medication use. Additionally, the deprescribing success rate, reasons for non-acceptance (barriers to deprescribing), anticholinergic burden, and non-pharmacological variables were analyzed.

Results: Four hundred and sixty patients (229 outpatients, 231 institutionalized) with a mean age of 84.5 (SD: 7.9) years were included. Demographic, clinical, and pharmacological data were collected. Deprescribing opportunities were identified using the LESS-CHRON criteria, and recommendations were assessed by medical teams. Follow-up evaluations were conducted after 3 months. A total of 960 PIMs were identified, of which 542 medications were successfully deprescribed (345 patients), with an acceptance rate of 56.46%, showing no significant differences between cohorts. The overall therapeutic burden was reduced by 10.73% (SD: 10.68). The main barriers to deprescribing were clinical decisions (69.86%) and patient/family refusal (11.72%). After 3 months, at least one deprescribed drug was reintroduced in 61 patients. The mean deprescribing success rate was 87.10%, which was significantly higher in institutionalized patients (p < 0.05), and the anticholinergic burden was significantly reduced (p < 0.001).

Conclusion: The LESS-CHRON tool effectively identified deprescribing opportunities, reducing both medication burden and anticholinergic load. Institutionalized patients had a higher deprescribing success rate. However, clinical judgment and patient preferences remain key barriers to successful implementation.

Objectives: Frailty is a common condition in community-dwelling older adults with high health and socioeconomic implications. However, primary care-led randomized trials have been scarcely tested.

Design: Multicenter cluster randomized clinical trial.

Setting and participants: Two hundred and seventy-three community-dwelling older adults recruited from 12 Spanish primary care centers.

Inclusion criteria: independence in basic activities of daily living and either prefrailty/frailty using the frailty phenotype or gait speed < 0.8 m/s.

Methods: Participants were randomized 1:1 by clusters to the intervention or the control group, each cluster being a different primary care center.

Intervention: Physical exercise program, nutritional recommendations, and frailty training to primary care professionals. Interventions were conducted based on the guidelines of the "Consensus document on the prevention of frailty in older adults," updated in 2022, from the Spanish Health Ministry.

Control: Usual care.

Main outcome: Improvement in one category of the frailty phenotype or one point in the Short Physical Performance Battery (SPPB) at 12 and 32 weeks. under Intention-to-treat analysis was conducted.

Results: Mean age 78.1 years, 68.4% female. 25.7% were frail and 74.3% prefrail or with a gait speed lower than 0.8 m/s. The percentage of participants improving the main outcome at week 12 for the intervention and control groups were 70.4% and 49.5%, respectively, absolute risk reduction (ARR) 20.9% (95% confidence interval [CI] 7.3%-34.5%; p < 0.01; n = 191), number needed to treat (NNT) 4.8 (95% CI 2.9-13.6). At 32 weeks of follow-up 81.7% and 51.9% of the intervention and control group improved, respectively, ARR 29.8% (95% CI 13.8%-45.7%; p < 0.001; n = 134), NNT 3.4 (95% CI 2.2-7.2).

Conclusions and implications: A primary care-led intervention consisting of a physical exercise program, nutritional recommendations, and training in frailty was feasible and effective for improving frailty status or physical function in community-dwelling older adults with prefrailty or frailty.

Trial registration: clinicaltrial.gov: NCT05002439 (18/JUN/2021).

Background: Falls are a leading cause of injury and death in older adults (age ≥ 65 years). The onset of the COVID-19 pandemic in the United States (US) marked a transition into a period of greater social isolation to curb the spread of disease. The pandemic additionally greatly strained the US healthcare system. As a result, older adults participated in less physical activity and experienced greater hesitancy to seek medical care in an effort to minimize their risk of infection. They additionally may have experienced delays and incomplete access to such care. It is possible that such changes worsened frailty and increased vulnerability to falls and fall-related sequelae among this population. We hypothesized that the COVID-19 pandemic led to an increase in fall-related fatalities generally and an increase in fall-related fatalities that occurred in the home.

Methods: We conducted an interrupted time series analysis using a regression model on monthly fall fatalities among older adults from January 2015 through December 2020. Fall fatality data were extracted from the Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research (CDC WONDER), along with the estimated annual population of US residents aged ≥ 65. The COVID-19 pandemic, defined as starting in the US in March 2020, was the interruption variable.

Results: There were 192,586 fall fatalities among older adults in the study period, with a mean of 2614 deaths per month ( $\sigma$  = 228.4) pre-pandemic, and 3051 deaths per month ( $\sigma$  = 215.1) post-pandemic onset. There was no statistically significant change in the incidence of all fall-related fatalities following pandemic onset. However, there was a 25% increase in incidence of fall-related fatalities that occurred within fall victims' homes, specifically (IRR = 1.25, 95% CI 1.14, 1.36).

Conclusion: There was a significant increase in fall-related fatalities within homes among older adults in the US after the onset of the COVID-19 pandemic. During pandemic type situations and times of social distancing, increased social supports and resources must be maintained for older adults to reduce the incidence of falls within the home and fall-related injuries.

Background: Central nervous system (CNS)-active polypharmacy is associated with increased risks such as impaired cognition and falls. In 2021, CNS-active polypharmacy was added as a Medicare Part D display measure to monitor for this risk. Enrollees in the Medicare Part D Medication Therapy Management program are at increased risk of CNS-active polypharmacy and are offered comprehensive medication reviews (CMRs) to optimize their medication management and reduce medication-related safety risks.

Objective: Evaluate the association of CMRs with CNS-active medication discontinuation among Medication Therapy Management enrollees in 2021.

Methods: Observational study applying inverse probability of treatment weights to compare the time until discontinuation of at least one medication contributing to CNS-active polypharmacy in CMR recipients versus non-recipients in 2021 using 5% Medicare fee-for-service claims and enrollment data.

Results: Of 2702 community-dwelling, Medication Therapy Management program enrollees ≥ 66 years of age with CNS-active polypharmacy, 969 (35.9%) were CMR recipients. Both CMR recipients and non-recipients were taking a median of four CNS-active medications. As compared to non-recipients pre-weighting, CMR recipients were more likely to use certain CNS-active medications, such as antidepressants, antiseizure medications, benzodiazepines, and nonbenzodiazepine sedative hypnotics and opioids. Compared to non-recipients pre-weighting, CMR recipients were also more likely to have more prescribers contributing to the CNS-active polypharmacy and to have a mix of prescriber types involved. Comparable numbers of CMR and non-CMR patients discontinued at least one CNS-active medication within 1 year (11.5% vs. 13.2%). In the weighted analyses, there was no difference in likelihood of discontinuation of at least one CNS-active medication between CMR recipients and non-recipients (hazard ratio = 1.03, 95% confidence interval = 0.94-1.12).

Conclusions: CMRs were not associated with reduced CNS-active polypharmacy in older adults in the first year that it served as a Part D Display measure. Future research is needed to better understand why and whether this continues.

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: Although dementia prevention is a global priority, few interventions have been successfully translated into public health and community settings. This study evaluated the effectiveness of a nudge-based communication strategy to promote Alzheimer's disease (AD) prevention on behavioral, cognitive, and provider-level outcomes in a real-world setting.

Methods: We conducted a pragmatic cluster-randomized trial across seven senior centers. Eligible participants were adults aged ≥ 60 with cognitive impairment but no dementia. Centers were randomized to intervention (n = 3) or control (n = 4) arms. All centers offered standard activities and provider training in dementia management. The intervention arm additionally received CULTIVAMENTE, a low-intensity, nudge-based communication strategy involving posters, brochures, and web-based content promoting AD prevention. Main outcomes included changes in a composite cognitive healthy behavior score, cognitive performance (memory and executive function), prevalence of mild-to-moderate cognitive impairment, and provider practices (AD prevention discussions and referrals). Analyses used intention-to-treat linear mixed models.

Results: Among 211 participants (mean age 74.8 ± 7.0 years; 80.5% women), after 6 months, those in the intervention group (n = 101) demonstrated greater improvement in cognitive healthy behaviors compared to control (SD difference = 0.15; 95% CI = 0.02-0.28; p = 0.021; 95.4% greater increase than control). Cognitive scores improved significantly in the intervention group (memory = 0.24; 95% CI = 0.07-0.41; memory-executive functioning = 0.21; 95% CI = 0.08-0.33), and mild-to-moderate cognitive impairment cases declined in the intervention group (from 70 to 67) compared to the control group (from 71 to 75; p < 0.001). Additionally, intervention participants were more likely to report increases in knowing how to prevent AD, having discussions about ways to prevent AD with providers, and receiving referrals to manage risk factors.

Conclusions: Embedding nudge-based messaging into senior centers improved dementia prevention behaviors, cognitive outcomes, and provider practices. These results support testing low-cost, scalable strategies in real-world settings to reduce dementia risk.