Journal of the American Geriatrics Society最新文献

Background: Medication use complexity is associated with non-adherence, hospitalizations, and lower quality of life. It is most frequently measured with the Medication Regimen Complexity Index (MRCI). This instrument estimates the complexity of a patient's medication regimen, taking into account the pharmaceutical dosage forms and routes, dosage frequency, and instructions for use. This instrument was, however, developed without patient experience data and may overlook patient perspectives. Therefore, this study aimed to identify older patients' perspectives on medication use complexity.

Methods: This qualitative study used semi-structured interviews among patients aged ≥ 70 years using ≥ 5 chronic medications, recruited at community pharmacies and a geriatric outpatient clinic. After medication reconciliation, open-ended questions about the patient's medication use and four hypothetical medication regimens with similar MRCI scores but different schemes were discussed. Interviews were transcribed verbatim and coded independently by two researchers. Inductive and deductive thematic analysis using NVivo was applied to explore themes influencing medication use complexity according to patients.

Results: Sixteen patients were included (median age, 76; 56% female; median number of medications including OTC, 14). Four themes were identified, of which three are medication-related themes: medication characteristics, preparation for administration, and administration regimen. Factors that reduced medication use complexity included identification by medication appearance, use of medication aids or multidose drug dispensing systems, and development of routines. Factors that increased complexity included alterations in medication appearance or routine. The fourth theme was user-related and focused on the complexity of medication use in the context of an individual patient's attitudes and beliefs regarding medication and healthcare.

Conclusion: This study identified many themes that can influence medication use complexity for older patients, including new themes beyond those measured by the MRCI. Individualized assessments may better address patient-specific challenges in medication use, ultimately enhancing the potential effectiveness of complexity-reducing interventions.

Advanced chronic diseases, or multicomplexity in older adults presents unique challenges. Transthyretin cardiac amyloidosis (ATTR-CA) is one such scenario where heart failure is a common presentation, and management remains challenging. We describe the challenges involved in the diagnosis of ATTR-CA in older adults, which has implications on treatment options. We discuss the application of comprehensive geriatric assessment (CGA) and shared decision making (SDM) in the context of these challenges. Based on geriatric medicine principles, an innovative framework for applying SDM in ATTR-CA patients is proposed, including consideration of the patient priorities care approach. The proposed framework emphasizes assessing functionality, frailty, and life expectancy to help categorize risk. This framework can be applied in various advanced chronic diseases or multicomplexity. Based on risk categorization, treatment burden, and alignment with values and preferences, management pathways are suggested for each risk category. Incorporating CGA and SDM, the proposed framework supports patient-centered care, ensuring that clinical recommendations are tailored to each older adult's unique needs and goals. In ATTR-CA, a collaboration between cardiology and geriatric medicine provides significant value in managing older adults. The need to prevent age-related bias in clinical decision-making exists across all health conditions, and the proposed framework allows for a thorough evaluation of multimorbidity, frailty, disability, and patient preferences. While ATTR-CA is used as a prototype, this integrated approach can be applied across all health conditions and is essential for delivering holistic care, improving communication, and aligning treatment plans with patient values.

Background: Disturbances in sleep-wake homeostasis (Process S) and circadian rhythm (Process C) are common precipitants of delirium, especially among older hospitalized adults. We conducted a systematic review and meta-analysis to test whether four sleep-modulation agents-melatonin, ramelteon, suvorexant, and lemborexant-lower delirium incidence or shorten its duration in hospitalized patients, with stratified analyses by drug class, age, and surgical status.

Methods: We systematically searched PubMed, Embase, and CENTRAL through March 2025. We included randomized controlled trials (RCTs) and observational studies assessing delirium prevention with melatonin, ramelteon, suvorexant, and lemborexant in hospitalized adults (≥ 18 years), compared to placebo or standard care. Data synthesis was performed separately for RCTs and observational studies using random-effects models. Meta-regression was used to explore effect modifiers. Risk of bias was assessed using RoB2/ROBINS-I tools. Certainty of evidence was graded using the GRADE assessment.

Results: Thirty-seven studies (27 RCTs, 10 observational) comprising 7845 patients were included. Among RCTs, melatonin (RR 0.94; 95% CI 0.72-1.22) and ramelteon (RR 0.63; 95% CI 0.39-1.03) showed no significant effect on delirium incidence, whereas orexin receptor antagonists were associated with a lower risk (RR 0.55; 95% CI 0.35-0.87). Evidence for a class difference was inconsistent across analytic approaches: a subgroup heterogeneity test suggested differential effects (interaction-p = 0.09), but the meta-regression found no between-class difference (p = 0.14). No other specific test for subgroup differences was statistically significant in RCTs. Meta-regression confirmed patient setting as a significant modifier in observational studies, but not in RCTs.

Conclusion: Sleep-wake pharmacotherapies may reduce incident delirium in hospitalized adults. In randomized trials, melatonin and ramelteon did not significantly reduce delirium incidence, whereas dual orexin receptor antagonists showed a possible benefit, but the meta-regression did not demonstrate a reliable between-class difference, and the evidence remains limited. Adequately powered randomized trials across inpatient settings are needed to clarify any true differences and define clinical relevance.

Background: Geriatric patients awaiting medical admission frequently experience extended emergency department (ED) stays and receive care in ED hallways. While prolonged ED stays are associated with increased delirium and mortality, the effect of placement in hallways remains unknown. This study's objective was to assess whether prolonged ED hallway exposure is associated with incident delirium and severe agitation in older adults and older persons living with dementia (PLWD).

Methods: We conducted a multi-site retrospective cohort database study between January 1, 2022 and December 31, 2023 of older adults (age 65+) without prevalent delirium admitted to a general medicine service with an ED stay > 8 h. Patients were dichotomized into two groups: > 8 or < 8 h of care in ED hallways. Our primary outcome was incident delirium and severe agitation (a composite outcome of ICD-10 code for delirium, positive nursing screen, use of parenteral antipsychotics, and/or physical restraints) after admission request. Secondary outcomes included hospital length of stay, inpatient and 30-day mortality, and 30-day ED revisit and readmission. We employed mixed-effect logistic regression models, independent of and mediated by history of dementia and adjusted for additional confounders.

Results: Our sample included 11,105 patients (median age 77, 51% female), with 2299 in the hallway group and 8806 in the non-hallway group. Prolonged ED hallway exposure was not associated with delirium and severe agitation for our general geriatric cohort (OR 0.87 [0.53-1.42]) but was for PLWD (OR 1.48 [1.03-2.13]). We observed no association between hallway care and our secondary outcomes except that the hallway group was associated with lower 30-day readmission (OR 0.69 [0.52-0.92]).

Conclusions: Prolonged ED hallway care was not associated with delirium and severe agitation in a general geriatric cohort but was for older PLWD. Prospective research is needed to determine if hospitals should consider prioritizing PLWD for rooms.

Background: Program of All-Inclusive Care for the Elderly (PACE) is comprised of diverse organizations serving different populations that aim to deliver care aligned with what matters most to older adults with multiple chronic conditions but often focus on diseases, social, or functional concerns in isolation. Patient Priorities Care (PPC) provides an evidence-based approach to elicit and align care with what matters most.

Methods: The National PACE Association launched a year-long PPC Learning Community (LC) with diverse PACE organizations (PO) across the United States. PO members met monthly to build understanding of PPC, share learnings, implement PPC in their programs, and disseminate lessons to the broader community.

Results: The LC supported PPC uptake into five of six participating POs and as well as the LC's lead's PO. A total of 889 participants received PPC, and 410 staff members were trained. Learning Community members presented in national meetings and created a PPC Guidebook with guidance on training, implementation, and evaluation in this model of care. Members felt the LC built community and promoted accountability through shared learning and feedback. Challenges included limited time for self-directed learning, provider engagement barriers, and the need for continued support for uptake and sustainability.

Conclusions: The LC catalyzed integration of What Matters Most into the PACE model of care using PPC, laying the groundwork for broader adoption. Future peer learning opportunities can ensure sustained momentum and assess impact on utilization, staff satisfaction, and total cost of care.

Background: The impact of vitamin D on fall incidence remains controversial. We studied the effect of 5 years of vitamin D₃ supplementation on the risk of falls in a double-blind, placebo-controlled randomized trial with generally healthy, community-dwelling men and women in Finland.

Methods: The study included 2495 participants, men aged ≥ 60 and women aged ≥ 65, who were randomized into three arms: 1600 IU/day or 3200 IU/day of vitamin D₃ or placebo. A random subgroup of 551 participants underwent more detailed examinations. Falls and fall-related injuries were collected with questionnaires at months 0, 12, 24, 36, and 60. General linear mixed models and generalized linear models were used for analyses.

Results: Over the 5-year follow-up, a similar fall risk of 55% and fall-injury risk of 11% were observed in the placebo, 1600 IU/day, and 3200 IU/day arms, with the mean number of falls and fall-injuries per person-year of 1.26 (95% CI 1.14-1.38) and 0.07 (95% CI 0.06-0.08), respectively. Age, sex, or BMI did not modify the results. In the random subgroup, the mean baseline serum 25(OH)D concentration was 75 nmol/L (SD 18). After 12 months, the concentrations were 73, 100, and 120 nmol/L in the placebo, 1600 IU/day, and 3200 IU/day arms, respectively.

Conclusions: Five-year vitamin D₃ supplementation of 1600 IU/day or 3200 IU/day did not affect the overall risk of falls or fall injuries among generally healthy, largely vitamin D sufficient men and women. The findings do not support the use of high vitamin D doses for fall prevention in such populations.

Trial registration: ClinicalTrials.gov: NCT01463813, https://clinicaltrials.gov/ct2/show/NCT01463813.

Background: Aging in a rural setting presents unique challenges including limited access to in-home care, lack of social support, language and cultural barriers, and the lack of transportation. We conducted a pilot study embedding community health workers (CHWs) into rural primary care teams to assist with implementation of the 4Ms of the Age-Friendly Health System: What Matters, Mentation, Medication, and Mobility.

Methods: The Connected Care for Older Adults model embeds CHWs in primary care and they conduct home visits to implement 4Ms protocols for patients 55 and older, living independently, and considered to be "medically frail" by a PCP, or meet criteria by the Edmonton Frail Scale. Patients complete the program in approximately 90 days. Feedback was collected from patients, caregivers, providers, and CHWs; health care impact was collected from electronic health records.

Results: We enrolled 388 patients from 79 PCPs at 7 clinics. Patients were 63% female with an average age of 77 years. Over 95% were public payer, 49% had been to the ED in the past 12 months, and 34% had been hospitalized. The program made a positive difference for 95% of responding patients (n = 120) and 100% of responding providers (n = 19) were "very satisfied" with the program. Clinicians cited the CHWs' ability to support resource connections, address social isolation and social needs, provide regular check-ins, and help to get patients and families engaged in care as positive components of the model. Early data suggests this program may reduce health care utilization.

Conclusions: Connected Care for Older Adults incorporates CHWs in primary care settings to deliver age-friendly care to rural, underserved adults 55 and older. Early findings and feedback from participating patients, caregivers, providers, and CHWs suggest that this is a promising approach to delivering age-friendly care.

Background: Older adults with chronic insomnia often use benzodiazepine receptor agonists (BZRAs) despite known associated risks and non-pharmacological alternatives such as cognitive behavioral therapy for insomnia (CBTI). CBTI reduces insomnia severity and could potentially improve other outcomes such as the impact of pain on daily activities, even when BZRAs are deprescribed. Yet concerns that deprescribing may worsen pain (which is often comorbid with insomnia) can be a barrier to engagement in BZRA deprescribing. This study examined changes in pain outcomes associated with deprescribing BZRAs in the context of concurrent CBTI.

Methods: Secondary data analysis was conducted using data from a randomized clinical trial that successfully decreased BZRA use in older adults. Participants (n = 188), who were largely older (68% ≥ 65 years, 55 ≤ range ≤ 91) and male (65%), completed CBTI concurrently with a deprescribing intervention (blinded encapsulated BZRA taper or open pill cutter taper). Participants completed the Brief Pain Inventory (BPI) at baseline, one week posttreatment (1 WK), and at a six-month (6 M) follow-up. Analyses included mixed effects models among all participants and a subset aged 65+ as well as comparison of model results to minimal clinically important difference (MCID) thresholds.

Results: Mixed effects models demonstrated that pain severity did not change significantly over time, broadly or in participants aged ≥ 65 years. Significant reductions in pain interference in day-to-day living at 1 WK were observed broadly, although these reductions did not meet the MCID threshold and were no longer significant at 6 M follow-up.

Conclusions: Combined BZRA deprescribing and CBTI did not meaningfully worsen pain in older adults. These results highlight the opportunity for using a combination of CBTI and deprescribing methods in patients with insomnia and comorbid pain, as well as a need for additional interventions to specifically address pain in older adults with chronic insomnia.