Journal of the American Geriatrics Society最新文献

Background: This systematic review and meta-analysis aimed to evaluate the efficacy of mindfulness-based treatments for older people with mild cognitive impairment (MCI) who also experience depression and cognitive difficulties.

Methods: Seven databases were searched: PubMed, EBSCOhost, CINAHL Complete, Cochrane Library, ProQuest, Scopus, and Web of Science, up to July 2025. PRISMA guidelines, the Oxford Centre for Evidence-Based Medicine scale, the RoB 2 tool, and GRADEpro were employed to evaluate the methodological quality and evidence reliability. The review plan was pre-registered in the PROSPERO database (CRD420251080874).

Results: Initially, 1738 records were identified in the databases. Thirteen studies that met the inclusion criteria were included in the analysis. The PICOS framework was employed for the subsequent analysis. The meta-analysis indicated that participants receiving mindfulness therapies experienced a significant reduction in depression symptoms, as assessed by the Geriatric Depression Scale (GDS, p = 0.045). In contrast, the Montreal Cognitive Assessment (p = 0.061) and the Mini-Mental State Examination (p = 0.713) did not demonstrate statistically significant changes in cognitive ability.

Conclusions: The findings suggest that mindfulness-based training may reduce depressive symptoms in older individuals with MCI; however, the impact on cognitive abilities remains inconclusive.

Background: Medicare Advantage (MA) plans now cover 54% of all Medicare beneficiaries. However, MA is understudied in the nursing home population. We analyzed MA enrollment trends and resident and facility characteristics from 2010 through 2023.

Methods: We calculated the point prevalence of MA enrollment for long-stay nursing home residents, short-stay residents, and all other Medicare beneficiaries from 2010 to 2023, and compared variation in MA growth at the state level between long-stay residents and the general Medicare population. We analyzed how the composition of Traditional Medicare- and MA-enrolled long-stay residents changed over time, changes in special needs plan (SNP) enrollment, and nursing home quality for MA enrollees. We also tracked monthly MA enrollment rates among nursing home residents before and after they became long-stay.

Results: MA enrollment among long-stay residents increased from 12.9% in 2010 to 36.5% in 2023, a 183% increase, outpacing the growth rate among the overall Medicare population. There was substantial geographic variation in MA growth between long-stay residents and others across states. Enrollment in Institutional SNPs grew substantially, accounting for about 35% of MA enrollment among long-stay residents. Dual-Eligible SNP enrollment also accounted for a substantial proportion among MA long-stay residents, ranging between 12% and 20% across years. Long-stay residents covered by Traditional Medicare and MA showed comparable clinical characteristics and had similar shares residing in high-quality nursing homes. Disenrollment from MA sharply increased as beneficiaries entered nursing homes for long-term care.

Conclusions: The substantial growth in MA enrollment among long-stay nursing home residents, coupled with the notable geographic variation and disenrollment, underscores the importance of recognizing that not all beneficiary groups experience MA in the same way. Targeted monitoring is needed to ensure that MA plans adequately address the care needs of this high-risk population.

Background: This study investigates the willingness of older adults to participate in a hypothetical deprescribing clinical trial.

Methods: We conducted an online survey of adults aged 65+ years in Australia and the United States. Participants rated their willingness to enroll in a deprescribing trial, responding to the statement, "Research is conducted to assess the safety and effectiveness of stopping medicines. Imagine your doctor made you aware of a research trial aiming to help people stop one or more of their medicines. To what extent would you be willing to enroll in the study?" on a 6-point Likert scale with "Not at all willing (1)" and "Extremely willing (6)" as the scale anchors. Participants provided a brief free-text explanation. We dichotomized the outcome variable as willing (scores 4-6) and unwilling (scores 1-3) to enroll and conducted descriptive analyses, chi-square tests, and univariate and multivariate logistic regression models. Free-text responses were analyzed using content analysis, with descriptive statistics summarizing themes.

Results: There were 2334 participants in the quantitative analysis and 2237 participants in the content analysis. Most were willing (n = 1705, 73%) rather than unwilling (n = 629, 27%) to enroll in a deprescribing trial (p < 0.001, 95% CI 0.712, 0.748). Over one-half of participants (n = 1252, 56%) expressed the "positive about deprescribing trials" domain, with Australian participants more likely to do so (AU 666 [60%] vs. US 586 [52%], p < 0.001). Participants (n = 1047, 47%) frequently reported at least one theme of the "concerns and hesitations" domain (n = 669, 30%) with US participants more frequently expressing negative views (US 273 [24%] vs. AU 211 [19%], p = 0.002) and reporting the "mistrust" theme (US 74 [7%] vs. AU 35 [3%], p < 0.001).

Conclusions: Older adults showed a willingness to engage in deprescribing trials, though concerns may affect enrollment. Clear communication of risks and benefits could support recruitment.

Background: Elder mistreatment (EM) is pervasive yet under-identified. The Detection of Elder abuse Through Emergency Care Technicians (DETECT) tool was developed to improve EM identification and reporting among emergency medical technicians. This study explores clinician perspectives on adapting DETECT for use in home-based primary care (HBPC).

Methods: A qualitative study was conducted using semi-structured interviews and focus groups with HBPC clinicians (N = 16) across seven intervention sites. Discussions focused on barriers and facilitators to EM identification and response, engagement with Adult Protective Services (APS), and recommendations for adapting DETECT. Thematic analysis was performed.

Results: Three themes emerged: (1) EM as an overlooked priority-clinicians recognized EM as critical but lacked standardized screening tools and protocols; (2) Barriers and facilitators to screening and response-time constraints, complexity of EM cases, and APS hesitancy were barriers, while continuity of care and team-based approaches were facilitators; (3) Recommended DETECT adaptations-clinicians suggested modifications to item phrasing, an emphasis on tracking observations over time, and a scoring system incorporating safety risk levels.

Conclusions: HBPC clinicians support a standardized EM screening tool and emphasize the need for flexibility in reporting and response. Findings will inform modifications to DETECT that align with HBPC workflows and improve EM identification while maintaining patient-clinician relationships.

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: Embedded pragmatic clinical trials are an ideal way to develop and evaluate evidence-based interventions in the nursing home (NH) environment to facilitate streamlining implementation after study completion. However, there is minimal information available about the necessary and sufficient conditions of "difference makers" for robust implementation of pragmatic interventions in the NH setting.

Methods: The "Aligning Patient Preferences-a Role Offering Alzheimer's patients, Caregivers, and Healthcare Providers Education and Support" (APPROACHES) embedded pragmatic trial is designed to test and evaluate a staff-led advance care planning (ACP) intervention for residents with dementia in 128 NHs (64 intervention, 64 control). Coincidence Analysis, a case-based approach to data analysis that draws upon Boolean algebra and set theory, was applied to identify key difference-makers for robust implementation. This analysis focused on the 44 intervention NHs that implemented at least one of two implementation processes: site visits and/or monthly calls.

Results: Eighteen of 44 (41%) sites in the analysis robustly implemented the APPROACHES intervention as reflected by > 75% of residents having a documented ACP conversation. The Coincidence Analysis revealed two pathways directly linked with robust pragmatic implementation: (1) no executive director turnover during the observation period combined with site participation in monthly calls with peers; and (2) higher rates of baseline hospitalization (3.96-7.0 per 1000 resident-days alive) combined with a low number of certified beds. In contrast, leadership instability as reflected by administrator turnover, high number of certified beds, and a lack of participation in monthly calls with peers was associated with poorer performance.

Discussion: Findings from this study suggest that leadership stability and engagement with peers were essential drivers of robust implementation of the APPROACHES ACP Specialist intervention. Coincidence Analysis is a useful tool for understanding how implementation conditions are associated with robust implementation in embedded pragmatic clinical trials.

Sankey diagram of agreement between dischareg summary, discharge instructions, and patient provided reasoning for chronic medication changes made during hospitalization.