Journal of the American Geriatrics Society最新文献

Background: Rib fractures are common and increase mortality in older adult patients. Early surgical stabilization of rib fractures (SSRF), < 72 h from admission, has been shown to improve outcomes in younger patients. We hypothesize that patients ≥ 65 years requiring SSRF will have improved outcomes with early SSRF.

Methods: This was a retrospective cohort analysis of patients ≥ 65 years between 1/1/2018 and 12/31/2022 who underwent SSRF and were captured in the National Trauma Data Bank. Patients who died within 24 h were excluded. Demographic and injury characteristics, comorbidities, hospital events and discharge dispositions were captured. Study groups were early (< 72 h) versus late SSRF. Primary outcomes were hospital length of stay (HLOS), intensive care unit LOS (ILOS), duration of mechanical ventilation (DMV), and mortality. With early SSRF as the reference group, multivariable analysis was conducted.

Results: Five thousand one hundred twenty-nine patients met inclusion criteria. Three thousand seventy (59.8%) underwent early SSRF and 2059 (40.1%) underwent late SSRF. Early SSRF was associated with shorter HLOS (9 vs. 14 days), ILOS (6 vs. 9 days), and DMV (5 vs. 9 days) (all p < 0.001). There was no difference in mortality (4.7% vs. 5.3%, p = 0.23). Early fixation was associated with fewer complications including unplanned intubation (6.6% vs. 13.5%), tracheostomy (1.9% vs. 5.3%), acute respiratory distress syndrome (0.9% vs. 1.7%), and pneumonia (0.2% vs. 0.7%) (all p < 0.001). On multivariable analysis, HLOS, ILOS, and DMV increased with late fixation (all p < 0.001).

Conclusion: Early SSRF is associated with improved outcomes and fewer complications in older adult patients with rib fractures. Further study will guide treatment protocols for the growing population of older adult trauma patients.

Background: In January 2018, South Korea introduced the cognitive support grade (CSG) within its long-term care insurance (LTCI) system, expanding eligibility for adult day services (ADS) to older adults with mild dementia. This study evaluates the policy's impact on reducing institutional care use and public expenditure using national claims data.

Methods: This study employed an interrupted time series (ITS) design to evaluate the population-level impact of the 2018 policy reform using monthly aggregated data between January 2015 and December 2018. To explore heterogeneity in policy effects, subgroup analyses were conducted using various characteristics.

Results: Following the policy reform, the share of population with ADS eligibility increased by 54.0 percentage points (95% CI: 49.6 to 58.4), followed by a 6.66-day rise in actual ADS uptake (95% CI: 5.11 to 8.21) and a 2.22-day reduction in institutional care use (95% CI: -4.03 to -0.412). Total public insurer costs remained unchanged, as reduced institutional care expenditures were largely offset by increased HCBS costs. Subgroup analyses suggested that ADS was most effective among individuals with coexisting informal care support.

Conclusions: The findings suggest that ADS may function as a complement to-rather than a substitute for-informal care and is associated with reduced institutionalization risk. Optimizing ADS delivery to match caregiving capacity may further enhance effectiveness.

Introduction: Although frailty is considered a potentially modifiable risk factor for dementia, its influence on health outcomes in individuals with established dementia remains unclear. This study aims to systematize the current evidence to understand the impact of frailty on the development of adverse outcomes in older adults with dementia.

Methodology: We conducted a systematic review to investigate which adverse outcomes in 65 years or older adults with dementia are influenced by frailty. A comprehensive search was conducted across three databases-MEDLINE, EMBASE, and Cochrane-to identify relevant studies addressing this research question as of November 2024. Studies were considered for inclusion if they were observational studies or clinical trials involving individuals with dementia, assessed frailty within this population, and documented adverse health outcomes. Two independent and blinded researchers performed screening, data extraction, and risk of bias assessment. PROSPERO register CRD42024543327.

Results: Our search identified 5891 articles, from which 12 were included after screening and eligibility assessment (n = 172,025 participants). Alzheimer's disease was the most studied type of dementia, and the prevalence of frailty ranged from 8% to 65.9%. The reported adverse outcomes associated with frailty in patients suffering from dementia were mortality, institutionalization, functional and cognitive decline, neuropsychiatric symptoms, reduced quality of life, caregiver burden, and hospitalization.

Discussion: Understanding frailty in older adults with dementia may inform improved care strategies. Our findings suggest that higher levels of frailty are associated with an increased risk of adverse health outcomes.

Background: An international consensus is still lacking on the best operational definition of Sarcopenia in hospitalized older adults. The main objective of this study was to use the EWGSOP2 guidelines in hospitalized old subjects to test its predictivity for adverse clinical outcomes and to evaluate its step-by-step capability to predict unfavorable clinical events.

Participants and setting: Three hundred and seventeen men and two hundred and eighty seven women, aged 65 to 99 years, consecutively admitted to the Department of Geriatrics at the University Hospital of Verona.

Methods: All patients underwent a complete geriatric assessment, clinical evaluation, and for the diagnosis of Sarcopenia, the EWGSOP2 guidelines were applied. As clinical outcomes, length of hospital stay, fall risk, and subjects' quality of life were considered.

Results: Among 604 hospitalized older patients, 56.0% presented with a SARC-F score suggestive of a risk for Sarcopenia. Patients at risk for Sarcopenia, and with available handgrip strength data, in 85.5% of cases also presented probable Sarcopenia. Among patients with probable Sarcopenia, and with available body composition data, 83.1% were confirmed with Sarcopenia, with a general prevalence of Sarcopenia of 22%. The shortest average length of hospitalization was in non-sarcopenic patients, with a median of 11 days, whereas dynapenic and sarcopenic subjects have respectively a median of 12 and 13 days of hospitalization, with significant differences also after adjustment for age, nutritional status and comorbidity. After dividing the patients into negative or positive for each diagnostic step of the EWGSOP2 algorithm, we found, for each step of the algorithm, a progressively greater association with adverse clinical outcomes.

Conclusions: EWGSOP2 algorithm is a valid tool even in hospitalized older patients, and each step enhances the predictivity of the algorithm; however, SARC-F and muscle strength can still be valuable tools for negative clinical outcomes when body composition data are not available.

Background: Resident-to-resident aggression (RRA) in long-term care settings is widespread with the potential for serious detrimental outcomes. However, few evidence-based training, intervention, and implementation strategies exist. The objective was to evaluate intervention process outcomes (knowledge), and proximal and distal outcomes (increased recognition, documentation, and reporting) in assisted living facilities.

Methods: Staff reported on RRA with respect to 930 residents (495 intervention and 435 usual care) from 14 New York assisted living facilities (7 per group). Data were collected at baseline, 6 and 12 months. Intervention site staff received training, while usual care staff did not. Knowledge outcomes were measured using two 10-item scales. Recognition and documentation for care planning were measured on an ongoing basis in real time, and longitudinal reporting of past two-week events through a structured interview. Mixed models were used to evaluate continuous knowledge variables. Outcome evaluation was conducted on an intent-to-treat basis using Poisson regressions for longitudinal count data measuring recognition/documentation and reporting.

Results: A total of 238, 263, and 217 staff attended Modules 1-3, respectively. There was a statistically significant increase in knowledge post-training, controlling for pre-training levels (estimated mean = 1.37, 95% CI, 1.11-1.62, p < 0.001 for Module 1 and estimated mean = 0.46, 95% CI, 0.21-0.70, p < 0.001 for Module 2). The program statistically significantly increased recognition and documentation of RRA in real time (estimated log mean = 4.34, 95% CI, 1.22-7.45, p = 0.006); there were 92 incidents reported by intervention group staff as contrasted with one in the usual care group. In terms of longitudinal reporting of events using a structured interview, a significant between-group difference was observed (estimate = 0.64, 95% CI, 0.18-1.09, p = 0.006).

Conclusions: The training intervention was demonstrated as effective in enhancing knowledge, recognition/documentation, and reporting of RRA in assisted living, replicating findings in nursing homes. It is recommended that this program be disseminated in long-term care facilities.

Trial registration: Clinical Trials.gov identifier: NCT03383289 registered December 26, 2017. The first subject was enrolled May 26, 2018; the last subject was enrolled August 2022; follow-up data collection was completed June 5, 2023.

Background: Hospitalization rates from nursing homes (NHs) have gained traction as pragmatic quality measures that can be derived from claims data. However, claims-based hospitalization measures do not account for clinical complexity and the extent to which they reflect quality of care or quality of transfer decision making is unknown. We aim to examine agreement between a claims-based measure of potentially avoidable hospitalizations and expert clinician review of transfer decision making and care quality.

Methods: We randomly selected 252 hospital transfers across eight Veterans Administration (VA) NHs, known as Community Living Centers (CLCs). Eleven expert clinicians independently completed Structured Implicit Reviews (SIRs) of medical records to assess: (1) whether the transfer decision was appropriate (i.e., hospital was the lowest safe level-of-care given the resident's acute condition); (2) quality of care for evaluation or treatment of the acute change (adequate management of acute change), (3) quality of care for chronic conditions and preventing decline. We used VA Corporate Data Warehouse (CDW) data to determine a claims-based measure of potentially avoidable hospitalization.

Results: CDW data were available for 242 VA hospitalizations. The claims-based measure categorized 29 (12%) hospitalizations as potentially avoidable; only 2 of which matched the 20 SIR identified as inappropriate decisions to transfer. Furthermore, the claims-based measure flagged only 5 of 33 cases rated as inadequate treatment of acute decline and 6 of 17 rated as poor quality of chronic disease or preventive care.

Conclusions: In a geographically diverse sample of CLC transfers, independent clinical experts' judgments of transfer decision appropriateness, quality of care for acute decline, and quality of chronic care differ from a claims-based potentially avoidable hospitalizations measure. Findings underscore the need for nuanced clinical consideration of hospitalization metrics for assessing quality and for understanding which aspects of care should be addressed to safely reduce NH transfers to hospitals.