Journal of the American Geriatrics Society最新文献

Background: Artificial Intelligence (AI) applications in healthcare have significant potential to address the unmet needs of older adults. To successfully adopt and implement AI in the care of older adults, it is critical to understand stakeholders' perspectives. We sought to explore the perceived benefits and concerns among stakeholders about AI applications in caring for older adults.

Methods: We conducted individual semi-structured interviews with five groups of stakeholders: older adults and caregivers, clinicians, health system and health insurance plan leaders (payers), investors, and technology developers. Interviews asked about the perceived role of AI in the care of older adults, the perceived benefits and concerns regarding AI, and suggestions for mitigating the concerns. Interviews were audio recorded and transcribed verbatim. We used thematic content analysis to code the transcripts.

Results: Overall, 49 participants completed interviews: older adults/caregivers (n = 15), clinicians (n = 15), payers (n = 8), investors (n = 5), and technology developers (n = 6). We identified three themes. (1). Stakeholders reported multiple benefits of AI and identified several roles for its use in the care of older adults. (2). Stakeholders expressed concerns about AI, including worsening social isolation, high cost, propagating ageism, goal misalignment, and scams/misuse of AI; views on privacy concerns were mixed. (3). Stakeholders suggested potential solutions, such as setting appropriate guardrails, to mitigate concerns about AI.

Conclusions: Given the complexity and significant unmet needs among older adults, AI's potential benefits and harms are both heightened in this population. Appropriate guardrails are needed to leverage the benefits of AI while mitigating potential harms. Our findings have implications for technology developers to design innovations that align with the stakeholders' perceived roles for AI, for regulatory bodies to incorporate stakeholders' concerns when developing AI regulations, and for health systems and end-users of technology to critically evaluate a product regarding its affordability and impact on social isolation and ageism.

Background: Recent payment reforms in the United States have been credited with reducing the use of institutional post-acute care (PAC) after total knee arthroplasty (TKA) and total hip arthroplasty (THA). This dual-country study of Canada and the United States compares longitudinal trends in discharge to institutional PAC after primary TKA or THA.

Methods: We conducted serial cross-sectional analyses to compare discharge to institutional PAC trends among adults aged ≥ 66 years undergoing primary TKA or THA in the United States and Canada from 2013 to 2019. Patient-level data were obtained from population-based Medicare claims in the United States and analogous datasets in Ontario. Discharge trends were assessed using standardized differences and linear regression models to evaluate relative changes over time.

Results: Patients receiving TKA (2,308,001) and THA (1,234,149) in the United States and Ontario (106,721 and 53,371, respectively) were similar in age (73-74 years) and sex (~60% female). The absolute reduction in institutional PAC discharge over time for TKA was greater in the United States (slope = -3.59) than in Canada (slope = -0.53) (p < 0.0001), but relative reductions (slope = -8.78 in the United States, slope = -6.99 in Canada) were statistically similar (p = 0.08). THA showed a similar trend of absolute reductions; however, the relative reduction trend in the United States (slope = -9.98) was steeper than in Canada (slope = -6.46) (p = 0.0009).

Conclusions: The US payment reforms from 2013 to 2019 were associated with a greater impact on reducing institutional PAC utilization for THA than for TKA.

Background: Older adults frequently present to the Emergency Department (ED). In response, a Swiss university hospital introduced age-friendly interventions and achieved Geriatric Emergency Department Accreditation (GEDA) by the American College of Emergency Physicians (ACEP). However, the impact of previously introduced interventions and the reasons behind emergency clinicians' varying uptake or lack of continued use remain unclear. To further improve patient outcomes, conducting a contextual analysis to identify implementation barriers and facilitators is crucial, followed by the development of tailored implementation strategies supporting the sustainable uptake of all age-friendly program elements. The project's overall aim is to systematically promote the uptake and sustainable re-implementation of the existing age-friendly ED program. The first study phase outlined in this protocol ("Phase A") focuses on 2 key objectives: (1) to assess current age-friendly interventions in the ED and identify barriers and facilitators affecting their reach, adoption, implementation, and maintenance; (2) to develop tailored implementation strategies for re-implementing program elements.

Methods: This project uses a modified implementation mapping in 5 Steps across 2 Phases. Phase A includes Steps 1-4: (1) conducting a contextual analysis using a mixed-methods design combining observations, interviews, patient chart reviews, E-survey and a Gemba walk; (2) identifying expected intervention and implementation outcomes, performance objectives; (3) adapting, extending, or developing tailored implementation strategies based on the Expert Recommendations for Implementing Change taxonomy; and (4) co-designing an implementation protocol to guide re-implementation. The follow-up Phase B will involve the re-implementation of the intervention elements and co-designing the evaluation protocol (Step 5) for the implementation process.

Conclusion: Age-friendly EDs are essential for person-centered emergency care, enhancing safety and quality of care for older adults. This study will provide insights into adaptable, evidence-informed implementation strategies that support behavioral change among emergency clinicians to increase patient reach and sustainability of age-friendly interventions for complex ED settings.

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.

In the early 20th century, Geriatric Medicine emerged as a specialty with a focus on improving the health and quality of life of older adults. Almost since inception, geriatricians have worked in collaboration with other medical specialties and health professionals to achieve this goal. This focus on collaboration has led to innovations that are improving care for older adults across settings of care, some of which are being led by other specialties (e.g., the Geriatric Surgery Verification Program). In 2015, Geriatric Medicine began to recruit fellows through the National Resident Matching Program (NRMP), and data from the past 10 years (2015-2024) reflect stable recruitment into the field with approximately 300 fellows entering geriatrics fellowship annually. The field has been innovative in its efforts to create training pathways that support physicians to complete geriatrics fellowship, including national pilots that combine geriatrics and palliative care training and offer clinical geriatrics experiences during internal and family medicine residency training underway at the Accreditation Council for Graduate Medical Education. In research, the field has contributed to extending our collective healthspan, championed inclusion of older adults in all research, and led efforts to develop investigators who are focused on the geriatrics aspects of their research. Opportunities for geriatricians to build on the foundations they have laid include leading Age-Friendly Health Systems and artificial intelligence into healthcare implementation with a continued focus on partnering with others to achieve meaningful change in the health and well-being of others.

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.

Social drivers of health (SDOH) impact health outcomes across the lifespan, with distinct effects on the health and well-being of older adults. SDOH contribute to outcomes of particular importance to older adults, including physical and cognitive functioning and aging in place, highlighting the critical importance of addressing SDOH as part of comprehensive, patient-centered geriatrics care. Yet, there is limited guidance on best practices for the integration of SDOH into healthcare, particularly in subspecialty clinical settings such as geriatrics. Existing geriatrics frameworks, including Age-Friendly Health Systems and the Geriatrics 5Ms, provide an opportunity to incorporate SDOH concepts, as they are naturally aligned with models of social and medical care integration. Building on existing frameworks, we propose a novel conceptual model that integrates SDOH across the geriatrics care continuum, including practical guidance for geriatrics healthcare professionals to proactively incorporate SDOH into Age-Friendly care.