Journal of the American Geriatrics Society最新文献

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: 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: 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.

Hospice use (2011-2021) for decedents with cancer and dementia by ethnic and racial groups.

Background: Gabapentinoid-related peripheral edema may prompt loop diuretic prescribing. Nursing home (NH) residents may be especially prone to this prescribing cascade. We estimated the incidence and identified predictors of the gabapentinoid-loop diuretic prescribing cascade in NHs.

Methods: We conducted a retrospective cohort study using 2016-2022 Medicare claims linked with Minimum Data Set assessments. We identified residents aged ≥ 66 years who initiated gabapentinoids in NHs and who had no evidence of loop diuretic use, heart failure, or renal insufficiency during the prior 6 months. The outcome was loop diuretic initiation within 90 days of gabapentinoid initiation. Using multivariable Poisson regression models, we estimated adjusted risk ratios (aRR) with 95% robust confidence intervals to identify predictors. We used pooled logistic regression models to examine the relationship between time-varying gabapentinoid dose and loop diuretic initiation risk.

Results: Among 23,544 residents, 994 (4.2%) experienced a prescribing cascade at a median of 36 days (IQR 15-61) after gabapentinoid initiation. Risk was higher with age 86-90 years (aRR = 1.60) or ≥ 91 years (aRR = 1.38); a diagnosis of chronic pain or fibromyalgia (aRR = 1.16), or diabetes (aRR = 1.23); and receipt of potassium-sparing diuretics (aRR = 1.53), thiazide diuretics (aRR = 1.27), or 15 or more unique medications (aRR = 1.18). Higher (versus lower) weekly gabapentin dose during follow-up was associated with a 1.45 times higher prescribing cascade risk over 13 weeks. Those with Alzheimer's Disease and Related Dementias (aRR = 0.79), or moderate (aRR = 0.72) to severe cognitive impairment (aRR = 0.59) had a lower risk versus those with intact cognition.

Conclusions: Approximately 1 in 20 NH residents who initiate gabapentinoids receives a loop diuretic within 3 months. Potentially modifiable predictors included existing polypharmacy and titrating gabapentinoid doses. NH clinicians should monitor for edema soon after gabapentinoid initiation and consider dose reductions or discontinuation before adding a loop diuretic.

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.