Journal of the American Geriatrics Society最新文献

Background: The COVID-19 pandemic presented unprecedented challenges to hospital system and critical care resources, leading to significant changes to operations and patient care. There are limited national data on these changes and instances of unsanctioned deviations from patient care, yet understanding the COVID response is key to future preparedness efforts. We sought to understand how hospitals and states navigated scarcity during COVID-19, particularly in the absence of a declaration of crisis standards of care.

Methods: Between February 2022 and September 2022 we conducted 34 interviews with 36 leaders of U.S. states' COVID-19 planning and response efforts. Interviews were transcribed verbatim and verified. We analyzed interviews using iterative inductive thematic analysis for descriptions of resource scarcity and changes to policies and procedures to prevent rationing lifesaving care.

Results: Nearly all participants described equipment and personnel scarcity in their home institution or state during COVID-19. Hospitals across regions and states developed formal and informal coordination processes for load and resource sharing in response to influxes of high-acuity patients, avoiding formal rationing of lifesaving resources in many regions. Participants also described unsanctioned patient triage, early discharge, and patients counseled to accept less aggressive care (e.g., premature transition to hospice) in states that had not declared crisis standards of care.

Conclusions: Extending limited resources and inter-institutional collaboration helped avoid formal rationing. Yet, patient care was unquestionably impacted due to scarcity, both real and perceived. Reports of using hospital triage protocols to deny patients lifesaving care outside of formally recognized crisis conditions and attempts to nudge patients to accept less-resource-intensive care are concerning. This may have had disproportionate effects on older adults, individuals with disabilities, and racial and ethnic minoritized groups. To avoid unsanctioned deviations from standard practice in future health emergencies, we recommend that transparent and equitable triage protocols are implemented with robust oversight.

Geriatric patients function as complex systems shaped by biological, psychological, functional, and social factors, generating new emergent properties of non-linear change, self-organization, phase transitions, and path dependence that produce clinical states guiding dynamic assessment, early detection, and cross-domain care.

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: In 2015, the Netherlands implemented long-term care (LTC) reforms to promote aging-in-place, potentially impacting nursing home (NH) access for older individuals with dementia. This study examines how the reform affected NH admission rates and waiting list prevalence for this population.

Methods: We performed interrupted time series analyses to evaluate trends in NH admissions (2011-2019, Statistics Netherlands) and waiting list prevalence (2013-2018, National Healthcare Institute) before and after the 2015 LTC reform. Incidence rate ratios (IRR) were calculated for monthly NH admission rates and waiting list prevalence.

Results: Among 270,706 older people with dementia, the reform was negatively associated with NH admission rates (IRR 0.610 [0.547-0.681]), halting the pre-reform decline and stabilizing the post-reform trend (IRR 1.001 [0.999-1.002]). The reform was positively associated with NH waiting list prevalence (IRR 1.159 [1.048-1.282]).

Conclusion: Among older Dutch people with dementia, the 2015 Dutch LTC reform was associated with fewer NH admissions and longer waiting lists. While stabilization of the NH admissions may reflect prioritization of persons with dementia within stricter eligibility criteria, the concurrent rise in waiting list prevalence suggests that institutional capacity did not keep pace with persistent need. As a result, many older people with dementia remain longer in the community, raising concerns regarding their health and safety as well as the burden on their informal caregivers.

Receiver Operating Characteristic Curve for the Modified Caregiver Strain Index predicting high Zarit-Burden Interview, showing excellent discrimination.

Background: Cannabis use is rising among adults, yet few users receive structured medical supervision. Older users face unique risks necessitating specialized oversight. Given their longitudinal relationships and detailed understanding of patients' health and goals, primary care providers are well-positioned to guide decisions and education about medical cannabis (MC). Further, because of their expertise in managing complex considerations of aging, geriatricians in particular are uniquely qualified to offer safe, evidence-informed guidance to older adults using MC. This led us to develop and implement a physician-led MC clinic embedded in a geriatric primary care practice.

Methods: A monthly, physician-led MC certification clinic was established to provide individualized evaluation, safety assessment, medication review, and counseling, with support from pharmacy and nursing. The clinic was shaped by the legal, regulatory, and clinical context. The demographic characteristics, medical and qualifying conditions, and medication profiles of patients with a MC clinic visit between Jan 1, 2022, and July 1, 2024, were evaluated retrospectively. Data was analyzed descriptively.

Results: In 30 months, 144 visits were completed. The population had a mean age of 65 years (SD 13.8), was 59.7% female, and diverse. There was high clinical complexity (mean 20.9 comorbid conditions, 14.7 medications). Pain was the predominant qualifying condition (88.9%), with anxiety (13.9%) and insomnia (11.8%) also common. Drug utilization reviews revealed a mean of 4.6 interactions per patient. Common medications included CNS depressants (66.0%), pain medications (59.0%), and psychiatric medications (56.9%).

Conclusions: This model demonstrates a feasible approach to integrating MC care into primary care for medically complex older adults. This integration prevents MC care fragmentation, provides thorough drug interaction screening, and supports informed MC risk-benefit assessment.

Background: Rapid increase in cardiometabolic diseases in India may contribute to increased incidence of late-life cognitive impairment. This study focuses on associations between baseline cardiometabolic risk factors and subsequent decline in cognitive function among older adults in India, leveraging data from two waves (Wave 1: 2017-2020, Wave 2: 2022-2024) of the Longitudinal Aging Study in India-Diagnostic Assessment of Dementia (LASI-DAD).

Methods: Analysis included longitudinal data of 1554 study participants. A summary measure of different cognitive functional domains was used. Cognitive decline was defined as annual decline in cognitive score ≥ 0.05 times the standard deviation of the summary score. Cardiometabolic risk was characterized using cardiovascular, metabolic, and inflammatory biomarkers. Multivariate, multinomial logistic regression analysis was used to examine the associations between cardiometabolic risk and cognitive decline.

Results: At baseline, 71.7% of the sample had elevated homocysteine levels, 44.4% had elevated blood pressure, 23% had elevated glycosylated hemoglobin (HbA1c), and 6.7% had elevated uric acid levels. Between the two waves, 34.8% experienced significant cognitive decline, while 35.6% died. Multivariate multinomial logistic regression showed significant cognitive decline was associated with elevated blood pressure [odds ratio (OR): 1.7, 95% confidence interval (CI) 1.3-2.2], elevated HbA1c (OR: 1.1, 95% CI: 1.0-1.2), being overweight (OR: 1.4, 95% CI: 1.0-2.0), and elevated uric acid level (OR: 1.2, 95% CI: 1.0-1.3). Those with hypertension had 1.5 times higher odds of mortality (95% confidence interval: 1.2-2.0), while those with diabetes mellitus or elevated pro-brain natriuretic peptide had 1.2 times (95% CI: 1.1-1.4), and 1.8 times (95% CI: 1.1-1.4) higher odds of mortality.

Conclusion: Cardiometabolic risk factors play a significant role in late-life cognitive decline and death among older Indians. These longitudinal relationships from LASI-DAD highlight potentially modifiable risk factors and inform potential prevention policies.

This scoping review provides key trends in the use of the Delphi method applied to geriatrics and gerontology research, and documents key information that can be used in the planning of future Delphi studies, like recruitment rates, number of Delphi rounds and panelists, attrition, consensus definitions, and stakeholders engaged.