Journal of the American Geriatrics Society最新文献

Objective: The COVID-19 pandemic prompted a rapid shift to remote healthcare. In response, the Veteran Health Administration's (VHA) Gerofit clinical exercise program began providing supervised, group-based exercise sessions three times weekly via real-time video for older Veterans. The longer-term benefits of such remote programs, particularly their impact on mobility and physical function, remain unclear. This analysis evaluates whether the Gerofit to Home (GTH) model of care improves physical performance in older veterans with multiple chronic conditions.

Design: This is a retrospective, quality improvement analysis of national data collected in the VHA GTH program from April 2020 to December 2022. Physical function assessments (PFA) including the 2-min step test, 30-s chair stand test, 5 times sit to stand, and the 30-s arm curl test were completed at baseline, 3 months, 6 months, and 1 year time points. To assess functional trajectories for the PFAs, repeated measures ANCOVA, as implemented under mixed models, was applied, adjusting for age, gender, and race.

Results: The overall GTH sample included 626 older veterans (mean age of 75 ± 6.8 years). All PFA measures showed similar longitudinal trajectories, with significant improvements from baseline to 1 year (p < 0.01). Each follow-up differed significantly from baseline (ps < 0.01), and clinically meaningful gains were achieved and sustained across all assessments.

Conclusion: The GTH program demonstrates that remotely delivered, medically supervised group exercise-integrated within a national healthcare system-can produce and sustain meaningful improvements in physical function for older adults. As one of the first large-scale, health care system-supported remote exercise programs for older adults, GTH offers a novel, scalable model for delivering effective, accessible care to high-risk populations.

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: 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.

Background: Gabapentinoid-related peripheral edema may prompt loop diuretic prescribing. Nursing home (NH) residents may be especially prone to this prescribing cascade. We estimated the incidence and identified predictors of the gabapentinoid-loop diuretic prescribing cascade in NHs.

Methods: We conducted a retrospective cohort study using 2016-2022 Medicare claims linked with Minimum Data Set assessments. We identified residents aged ≥ 66 years who initiated gabapentinoids in NHs and who had no evidence of loop diuretic use, heart failure, or renal insufficiency during the prior 6 months. The outcome was loop diuretic initiation within 90 days of gabapentinoid initiation. Using multivariable Poisson regression models, we estimated adjusted risk ratios (aRR) with 95% robust confidence intervals to identify predictors. We used pooled logistic regression models to examine the relationship between time-varying gabapentinoid dose and loop diuretic initiation risk.

Results: Among 23,544 residents, 994 (4.2%) experienced a prescribing cascade at a median of 36 days (IQR 15-61) after gabapentinoid initiation. Risk was higher with age 86-90 years (aRR = 1.60) or ≥ 91 years (aRR = 1.38); a diagnosis of chronic pain or fibromyalgia (aRR = 1.16), or diabetes (aRR = 1.23); and receipt of potassium-sparing diuretics (aRR = 1.53), thiazide diuretics (aRR = 1.27), or 15 or more unique medications (aRR = 1.18). Higher (versus lower) weekly gabapentin dose during follow-up was associated with a 1.45 times higher prescribing cascade risk over 13 weeks. Those with Alzheimer's Disease and Related Dementias (aRR = 0.79), or moderate (aRR = 0.72) to severe cognitive impairment (aRR = 0.59) had a lower risk versus those with intact cognition.

Conclusions: Approximately 1 in 20 NH residents who initiate gabapentinoids receives a loop diuretic within 3 months. Potentially modifiable predictors included existing polypharmacy and titrating gabapentinoid doses. NH clinicians should monitor for edema soon after gabapentinoid initiation and consider dose reductions or discontinuation before adding a loop diuretic.

Background: Older adults often struggle to find footwear suitable for their clinical needs, thus affecting mobility, safety, and quality of life. Proper footwear is important due to fall risk, balance impairments, knee osteoarthritis (OA), hallux rigidus, plantar fasciitis, diabetic neuropathy, and limb length discrepancies (LLDs). Barriers such as inadequate clinical guidance and limited patient understanding persist. This paper provides updated, evidence-based recommendations for these challenges.

Methods: A topic review was conducted to evaluate shoe wear characteristics that address geriatric needs. Recommendations were synthesized from more than 45 years of clinical experience in physical therapy and categorized by clinical conditions. Evidence identified effective shoe features, including sole stiffness, tread patterns, heel elevation, and orthotic modifications to improve function, reduce pain, and reduce fall risk.

Results: Balance and fall risk: Shoes with wide soles, medium-firm materials, low heels, and high collars improved stability and reduced postural sway. Cupped, rigid insoles enhanced dynamic control, while treaded rubber outsoles minimized slipping. Knee OA: Flexible shoes with laterally wedged insoles and minimal heel lift reduced medial knee loads and pain. Supportive shoes and medially wedged insoles decreased lateral knee loads and pain. Hallux rigidus/bunions: Rocker-bottom shoes and stiffer soles accommodate deformities, improving function and comfort. Plantar fasciitis: Orthoses, supportive therapies, and stretching regimens were efficacious. Diabetic neuropathy: Rigid rocker soles and custom insoles reduced plantar pressure and ulcer recurrence. LLDs: Gradual shoe lift introduction alleviated low back pain. General recommendations: Properly fitted, comfortable shoes with moderately firm insoles, slip-resistant outsoles, and secure fastening mechanisms improve safety and function.

Conclusions: Footwear significantly impacts the mobility, safety, and well-being of older adults. Tailored recommendations enhance pain management, independence, and fall prevention. Providers should involve patients in decisions and counsel against the use of slippers or excessively elevated heels.