Journal of the American Geriatrics Society最新文献

With almost 90% of Americans expressing a desire to age in place in their home, many health systems and communities are challenged to provide the right resources, at the right time, to support What Matters to older adults. In the Department of Veterans Affairs (VA), approximately 50% of Veterans enrolled in VA health care are aged 65 and older, driving an imperative to provide timely, Age-Friendly care through a broad continuum of services. VA has taken a multifaceted approach to shift Long-Term Services and Supports to promote aging in place through innovation pilots, expansion of Home and Community Based Services (HCBS) and adoption of Age-Friendly Health Systems (AFHS) practices [or "framework"]. VA is spreading geriatrics knowledge throughout the clinician and trainee workforce, improving skills and practices across all disciplines and care settings. The framework of AFHS creates a shared language to support transitions across ambulatory, hospital, emergency department, home care, and nursing home settings. Through these efforts, VA is reimagining geriatrics, providing an example of the type of care all older adults want and deserve. Since March 2020, 375 care settings across 132/139 (95%) VA parent facilities have earned AFHS recognition. By incorporating AFHS into the infrastructure of the healthcare system, clinicians are prepared to address What Matters across clinical settings and address common geriatric syndromes. Leaders in a variety of health systems can learn from VA efforts to provide a continuum of Age-Friendly programs and services that promote independence, function, well-being and aging in place.

Background: Elderly population is increasing in high-income countries. For instance, by 2050, 21.4% of the United States population is expected to be 65+, thus making advance care planning (ACP) increasingly important. We aim to identify predictors of ACP completion in 11 high-income countries and explore relationships between ACP and utilization factors.

Method: Using the 2021 International Health Policy (IHP) survey data, we assessed the relationship between sociodemographic factors, healthcare utilization, and ACP. The primary outcome variable was a composite of three ACP activities. A generalized linear mixed model (GLMM) was used to identify predictors of ACP completion.

Results: Analyses included 18,677 older adults who answered at least one ACP question. Only 5126 (27.4%) reported completion of three ACP activities. Germany (64.7%) showed the highest completion rates, while Sweden (5.0%) and France (5.0%) showed the lowest completion rates. Predictors of ACP completion identified in the GLMM were: increasing age (incidence rate ratio [IRR] range between 1.2 and 1.5), completion of high school education or more (IRR: 1.1, 95% CI: 1.1-1.1), higher income (IRR: 1.1, 95% CI: 1.1-1.2), presence of two or more health conditions (IRR: 1.1, 95% CI: 1.0-1.1), hospital stay in the past 2 years (IRR: 1.1, 95% CI: 1.1-1.1), and access to quality primary care (IRR: 1.0, 95% CI: 1.0-1.1). Male gender (IRR: 0.9, 95% CI: 0.8-0.9) had a negative association with ACP activity completion.

Conclusion: Several patient-specific and health system utilization factors were identified as predictors of ACP activity completion, which clinicians and policymakers could use to enhance ACP completion.

Background: Community-dwelling older adults are at high risk for unmet social service needs. We describe a novel partnership embedding county services case managers in the Emergency Department (ED) to connect older adults to community services alongside their medical care.

Methods: Setting: A medium-sized urban ED with 55,000 patient visits a year.

Intervention: Case managers from the Franklin County, Ohio Office on Aging (OA) were embedded within the ED. The OA team worked with the ED social work team to identify community-dwelling older patients, perform an in-person intake assessment, and initiate needed community services (including home-delivered meals, emergency response systems, house repairs, and transportation). Program logic model and development are reported in detail.

Results: From June to December 2023, there were 7284 ED visits for adults ≥60 years old. Referrals to the OA case manager ranged from 1 to 13 per day. The OA case managers performed 252 full intake assessments on unique patients. The population was 51% men. Only 11% (n = 28) were currently connected to OA services, and of those already connected 29% (n = 8) needed increased services. Of the remaining unconnected patients (n = 224), 8% (n = 20) were not county residents and the OA team connected them with other county OAs. Half 53% (n = 120) were accepting of services and had services from the OA or other community health programs initiated during the ED visit. The OA team made three new Adult Protective Services referrals and one referral to the long-term care ombudsman. The program did not increase ED length of stay or hospital admission rates.

Conclusions: Embedding county service enrollment within a community ED is a cost neutral intervention that reached a population without previous services. Future plans include expansion of the program and evaluation of the program's ability to detect elder mistreatment and self-neglect.

Background: Recruiting older adults into clinical trials can be particularly challenging. Our objective was to determine if targeted web-based advertising is an effective recruitment strategy.

Methods: We compared the recruitment rates of traditional and targeted web-based methods for three representative clinical trials involving older adults. All studies utilized traditional recruitment methods initially, but shifted toward primarily targeted web-based advertising after experiencing slow recruitment rates.

Results: We found that web-based advertising reached more individuals compared to traditional methods. Compared to traditional methods, web-based methods also had at least twice the rate of expressed interest, completion of telephone and in-person screening, eligibility, and enrollment. Additionally, the proportion of individuals excluded after the telephone screening did not differ according to whether targeted web-based advertising (STAMINA: 51%; Berries and Steps: 62%; ISTIM: 20%) or traditional methods (STAMINA: 48%; Berries and Steps: 69%; ISTIM: 23%) were used within each study. Those recruited using web-based advertisements tended to be younger compared to traditional methods, but were similar in racial distribution and education.

Conclusion: Targeted web-based advertisements may be more effective in recruiting older adults for clinical trials at a faster rate than traditional recruitment methods, but need further evaluation of compatible study designs, potential population bias, and cost-effectiveness.

Background: Thyroid hormone is one of the most commonly prescribed medications in the United States. Misuse of and overtreatment with thyroid hormone is common in older adults and can lead to cardiovascular and skeletal adverse events. Even though deprescribing can reduce inappropriate care, no studies have yet explored specific barriers and facilitators to guide thyroid hormone deprescribing in older adults (defined as discontinuation of thyroid hormone when initiated without an appropriate indication or dose reduction in those overtreated).

Methods: We conducted semi-structured interviews with 19 endocrinologists, geriatricians, and primary care physicians who prescribe thyroid hormone. Interviews were completed between July 2020 and December 2021 via two-way video conferencing. We used both an inductive and deductive content analysis guided by the Theoretical Domains Framework to evaluate transcribed and coded participant responses. Thematic analysis characterized themes related to barriers and facilitators to thyroid hormone deprescribing practices in older adults.

Results: The most commonly reported barriers to thyroid hormone deprescribing were related to patient-level factors, followed by physician- and system-level factors. Patient factors included patients' perceived need for thyroid hormone use and patient anxiety/concerns about potential side effects related to thyroid hormone dose reduction, patient lack of knowledge, and misinformation regarding deprescribing. Physician- and system-level barriers included clinic visit time constraints, physician inertia, physician lack of knowledge about deprescribing, perceived lack of sufficient patient follow-up, and electronic health record limitations. The most prominent physician-reported facilitators to thyroid hormone deprescribing were effective physician-to-patient communication, and positive physician-patient relationship, including patients' trust in their treating physician.

Conclusion: Barriers and facilitators to thyroid hormone deprescribing in older adults were reported at multiple levels including patient-, physician-, and system-level factors. Interventions to improve thyroid hormone deprescribing in older adults should aim to improve patient education and expectations, increase multidisciplinary physician awareness, and overcome physician inertia.

Objective: This trial analyzes the effects of home-based isometric handgrip training (IHT) and aerobic exercise training (AET) on ambulatory and office blood pressure (BP) in older adults with high normal to established hypertension.

Methods: This randomized controlled trial included 84 participants (46 women, 71.1 ± 3.6 years, systolic BP [SBP] 137.1 ± 13.8 mmHg, diastolic BP [DBP] 80.8 ± 8.3 mmHg). Participants were randomized into IHT (n = 28), AET (n = 28), or usual medical care plus lifestyle advice (UC, n = 28). Participants performed IHT or AET three times/week for 8 weeks. IHT consisted of 4 × 45 s bilateral contractions at 50% of maximum voluntary contraction with 1-min rest between sets. AET consisted of walking 30 min at 50%-70% of estimated maximum oxygen consumption. UC received standardized medical care including lifestyle advice.

Results: Seventy-six participants completed the intervention: 27 in IHT, 26 in AET, and 23 in UC. At baseline, BP values were similar among groups. No differences were observed in 24-h ambulatory, daytime, and nighttime SBP and DBP in any group (p > 0.05). IHT and AET reduced office SBP (-8.0 ± 13.4 mmHg; p = 0.004; -5.6 ± 12.2 mmHg; p = 0.027, respectively). IHT reduced office DBP (-3.3 ± 7.4 mmHg; p = 0.024), but AET did not. No differences occurred in office BP in UC. There was no difference in office BP among groups (p > 0.05).

Conclusions: An 8-week home-based IHT and AET failed to reduce ambulatory SBP, while office SBP was reduced by 8/5 mmHg. Only IHT reduced office DBP by 3 mmHg. Thus, IHT and AET may be effective for lowering office BP in older adults with high normal to established hypertension.

Dementia is a syndrome characterized by cognitive changes which interfere with daily functioning. Neuropsychiatric symptoms (NPS) are also pervasive and may even occur prior to any noticeable cognitive decline. Still, NPS are less associated with the early stages of the disease course, despite mounting research evidence that NPS present early and often in several dementia syndromes, even in the absence of cognitive decline (i.e., mild behavioral impairment [MBI]). Primary care teams are at the forefront of dementia care, yet they frequently report insufficient training in dementia diagnosis and management. This poses a serious problem considering that timely diagnosis of dementia is critical for optimal outcomes and maximum efficacy of intervention. We provide a concise narrative review of four dementia syndromes (Alzheimer's disease, vascular dementia, dementia with Lewy bodies, and behavioral variant frontotemporal dementia) and their associated neuropsychiatric presentations, as well as at-a-glance clinical guides, to help primary care team members recognize possible prodromal neurodegenerative disease and to prompt further workup. We also review next steps in the management of dementia and symptoms of MBI for primary care team members. As evidenced by the NPS profiles of these dementia syndromes, subacute new onset of psychiatric symptoms in an older adult should prompt consideration of an emerging dementia process and possible further workup of such, even in the absence of cognitive decline.