Journal of the American Geriatrics Society最新文献

Background: This study aims to evaluate the add-on effects of oral Chinese herbal medicine (CHM) for mild cognitive impairment (MCI), when used in addition to donepezil compared to donepezil alone.

Methods: Randomized controlled trials comparing these treatments across all types of MCI were identified from nine databases and three registers until August 2023. Outcome measures were Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and adverse events (AEs). Methodological quality was assessed using Cochrane risk-of-bias tool, and evidence certainty was evaluated using the GRADE method.

Results: Involving 1611 participants across 20 studies, meta-analysis results indicate that oral CHM combined with donepezil significantly improved cognitive function in MCI patients compared to donepezil alone, as evidenced by MMSE (1.88 [1.52, 2.24], I² = 41%, 12 studies, 993 participants) and MoCA (MD: 2.01 [1.57, 2.44], I² = 52%, 11 studies, 854 participants). Eleven studies reported details of AEs, identifying gastrointestinal symptoms and insomnia as the most common symptoms. No significant difference in AEs frequency was found between the groups (RR: 0.91 [0.59, 1.39], I² = 4%, 11 studies, 808 participants). All 20 studies were evaluated as having "some concerns" regarding the overall risk of bias. The certainty of evidence for MMSE was "moderate" and "low" for MoCA. From frequently utilized herbs, two classical CHM formulae were identified: Kai xin san and Si wu decoction. The observed treatment effects of commonly used herbs may be exerted through multiple pharmacological mechanisms, including anti-inflammatory, anti-oxidative stress, anti-apoptotic actions, promotion of neuronal survival and modulation of the cholinergic system.

Conclusions: The concurrent use of oral CHM and donepezil appears to be more effective than donepezil alone in improving the cognitive function of MCI, without leading to an increase in AEs. While recognizing concerns of overall methodological quality, this combined therapy should be considered as an alternative option for clinical practice.

This is an exciting time in Geriatrics, with numerous opportunities in health care for Geriatrics specialists to innovate and lead. Geriatrics specialists should know how to implement innovative care models to lead healthcare changes in their organizations and effectively facilitate change management. We highlight a 10-step framework that Geriatrics specialists can leverage to quickly move their ideas from development to implementation at a system level. This framework adapts concepts from business management to provide a step-by-step guide to move from idea generation to implementation. We provide different practical examples that a Geriatrician can correlate to in their practice, including value proposition and business canvas model. Though small components of the business canvas model may vary based on organization and program/idea-specific needs, the outlined skills will establish Geriatrics specialists as leaders of change, a resource for education, and valued consultants to a health system that is in dire need of direction to improve the quality of care, and health outcomes, for older adults.

Background: The COVID-19 pandemic significantly affected the physical health of older adults around the world, causing day-to-day disruptions in routines and changes to usual patterns of mobility. Despite the passing of 2 years since vaccinations, older adults continue to experience detriments, including social isolation and reduced mobility. This study aims to understand how views of the COVID-19 pandemic are associated with life-space mobility-moving about the community. We hypothesize that endorsing stronger perspectives about the persistence of COVID-19 is correlated with reduced life-space mobility.

Methods: Survey data were collected via online questionnaire in October and November of 2022. Linear regression models were used to examine the relationship between five perspectives on the COVID-19 pandemic (e.g., agreeing that "I wish people would take COVID-19 more seriously") and life-space mobility, measured using a modified version of the life space assessment, in older adults (n = 510). Analyses were adjusted for demographic factors and mental and physical health indicators, including depressive symptoms and number of chronic conditions.

Results: In fully adjusted models, the study found that endorsing a stronger lingering impact of the COVID-19 pandemic across any of the five perspectives was associated with significantly lower life-space mobility.

Conclusions: The results of this study show that endorsing a stronger lingering impact of the COVID-19 pandemic is associated with reduced life-space mobility, which underscores the importance of designing public health strategies that carefully balance the safety concerns of older adults with opportunities for physical activity and social interaction.

Background: Older adults with severe aortic stenosis (AS) may receive care in a nursing home (NH) prior to undergoing transcatheter aortic valve replacement (TAVR). NH level of care can be used to stabilize medical conditions, to provide rehabilitation services, or for long-term care services. Our primary objective is to determine whether NH utilization pre-TAVR can be used to stratify patients at risk for higher mortality and poor disposition outcomes at 30 and 365 days post-TAVR.

Methods: We conducted a retrospective cohort study among Medicare beneficiaries who spent ≥1 day in an NH 6 months before TAVR (2011-2019). The intensity of NH utilization was categorized as low users (1-30 days), medium users (31-89 days), long-stay NH residents (≥ 100 days, with no more than a 10-day gap in care), and high post-acute rehabilitation patients (≥90 days, with more than a 10-day gap in care). The probabilities of death and disposition were estimated using multinomial logistic regression, adjusting for age, sex, and race.

Results: Among 15,581 patients, 9908 (63.6%) were low users, 4312 (27.7%) were medium users, 663 (4.3%) were high post-acute care rehab users, and 698 (4.4%) were long-stay NH residents before TAVR. High post-acute care rehabilitation patients were more likely to have dementia, weight loss, falls, and extensive dependence of activities of daily living (ADLs) as compared with low NH users. Mortality was the greatest in high post-acute care rehab users: 5.5% at 30 days, and 36.4% at 365 days. In contrast, low NH users had similar mortality rates compared with long-stay NH residents: 4.8% versus 4.8% at 30 days, and 24.9% versus 27.0% at 365 days.

Conclusion: Frequent bouts of post-acute rehabilitation before TAVR were associated with adverse outcomes, yet this metric may be helpful to determine which patients with severe AS could benefit from palliative and geriatric services.

Background: Advance care planning (ACP) has been reconceptualized as a health behavior. Action plans (APs), or patient-directed mini contracts, improve behavior change. However, no prior studies have assessed whether APs can increase ACP documentation and engagement.

Methods: We included English and Spanish-speaking primary care patients from San Francisco, ≥55 years of age, with ≥2 serious or chronic illnesses. Participants were in the intervention arm of the PREPAREforYOURcare.org trial and asked at baseline to choose 1 of 5 actions (e.g., choose a surrogate). At 6 months, we assessed whether participants completed their AP and if completion was associated with demographics, electronic health record (EHR) ACP documentation, and five-point ACP Engagement Survey scores. We used t-tests, chi-squared, multivariate analysis adjusted for baseline ACP and clustering by physician, and qualitative thematic analysis to explore reasons for non-completion.

Results: The mean age of 586 participants was 65 ± 10 years; 44.0% women, 45.9% Spanish-speaking, 31.4% had limited health literacy, and 43% completed an AP at 6 months; surrogate-related (47.4%), tell others about medical wishes (33.7%), ask clinicians questions (13.7%), and decide what matters most in life (5.2%). Participants with limited versus adequate health literacy were less likely to complete an AP (25.4% vs 35.9%, p = 0.01). Completing an AP was associated with greater ACP EMR documentation 49.8% vs 35.6%, p < 0.001 (adjusted odds ratio: 2.06; 95% CI [1.43-2.97]) and engagement (adjusted five-point scores [3.69; 95% CI 3.57-3.81 vs 3.10; 95% CI: 2.98-3.21], p < 0.001). Themes for non-completion included not being ready and logistical issues (e.g., surrogate deceased).

Conclusions: Among English and Spanish-speaking older adults, creating an ACP AP resulted in greater documentation and engagement. APs may help facilitate ACP behavior change as part of effective ACP interventions. Additional support may be needed for patients with limited health literacy and those facing logistical barriers.