Journal of the American Geriatrics Society最新文献

Background: Anticholinergic burden refers to the cumulative anticholinergic effect of all medications taken by an individual. Anticholinergic burden scales help identify patients at risk of anticholinergic adverse effects and guide prescribing. However, substantial variation exists between scales, with no gold standard identified. This variability may contribute to inconsistent risk assessment, suboptimal prescribing, and adverse outcomes.

Aim: To systematically review available anticholinergic burden scales and their variability in medication lists, development strategies and scoring methods. As a secondary objective, the clinical outcomes associated with each scale were summarized.

Methods: A systematic search was conducted up to January 2025. Studies proposing novel or updated anticholinergic burden scales were included. Two reviewers independently performed study selection, data extraction, and quality assessment, using a custom tool based on expert consensus and principles of scale development. Findings were narratively synthesized.

Results: From 10,969 identified records, 21 studies met inclusion criteria. Medications included per scale ranged from 27 to 217, with 74% of high-potency drugs scored inconsistently. Variability was influenced by geographical origin and methodology, with literature review followed by expert opinion the most common method of development. Dosage consideration, among others, was inconsistent across scales, affecting clinical relevance. Clinical outcome studies reflected such inconsistencies.

Conclusion: No gold standard anticholinergic burden scale was identified. Scales with broader drug coverage and accounting for individual variability appeared more clinically relevant. This review highlights the need for a clinically accessible, universal scoring system to better address the risks associated with anticholinergic polypharmacy.

Background: People living with dementia frequently use Medicare skilled home health care and have unique usage patterns as compared to people without dementia, but little is known about variation in measured quality of home health care received by this population.

Methods: Using 2021 Medicare Fee-for-Service Claims data, we examined receipt of high-quality home health (i.e., care from an agency with a star rating > 3.5) as determined by two publicly available measures: the Quality of Patient Care Star Rating (based on standardized clinical status measures) and the Patient Survey Star Rating (based on satisfaction with care reported by patients or caregivers). For each quality measure, we mapped the county-level high-quality-home health agency utilization rate among people living with dementia and compared differences in utilization of high-quality home health agencies by dementia status.

Results: We found significant county-level variability in utilization of high-quality home health. When quality was operationalized based on clinical status measures (i.e., Quality of Patient Care Star Rating), dementia patients did not receive care from lower quality agencies. However, when quality was operationalized based on satisfaction with care (i.e., Patient Survey Star Ratings), people living with dementia were less likely than those without dementia to receive care from high-quality home health agencies.

Conclusions: These findings highlight variability in receipt of high-quality home health care among people living with dementia nationally and suggest a need for further investigation as to what constitutes high-quality home health care in this population. To ensure home health meets the unique care needs of people living with dementia, policy makers should work to ensure quality measures are better aligned with the needs of people living with dementia, incentivize access to high-quality home health care where services are limited, and promote systems to improve family caregiver identification and engagement with home health care.

Background: Socioeconomically disadvantaged neighborhoods disproportionately include minority and poor populations that are often underrepresented in clinical trials. Our objective was to determine whether recruitment and retention of participants differ based on neighborhood disadvantage.

Methods: In a multi-center clinical trial that included 86 primary care practices within 10 US health care systems in 9 states, outreach to 140,850 patients led to enrollment of 5451 persons, 70 or older, at high risk for serious fall injuries. Multiple indicators of recruitment and retention were evaluated. Neighborhood disadvantage was defined as the highest quintile of scores on the state area deprivation index.

Results: Patients who lived in a disadvantaged neighborhood were less likely to return a screening postcard (risk ratio [RR] [95% CI]: 0.88 [0.85-0.91]) than their non-disadvantaged counterparts, but they were more likely to have a positive screen (RR [95% CI]: 1.05 [1.00-1.09], p = 0.047). The likelihood of study enrollment (RR [95% CI]: 0.79 [0.70-0.90]) was substantially lower among patients living in a disadvantaged neighborhood. Among enrolled participants, a significantly higher percentage of those living in a disadvantaged neighborhood, relative to their non-disadvantaged counterparts, were Black (10.6 vs. 4.8), had a high school education or less (36.7 vs. 21.6), and were less affluent (21.8 vs. 13.8). After study enrollment, participants who lived in a disadvantaged neighborhood had a higher likelihood of death (adjusted RR [95% CI]: 2.64 [1.76-3.98]) and refused interviews (adjusted RR [95% CI]: 2.15 [1.20-3.85]), but not study withdrawal (adjusted RR [95% CI]: 0.94 [0.63-1.39]) or loss to follow-up (adjusted RR [95% CI]: 1.18 [0.84-1.65]).

Conclusion: In this large multi-center clinical trial of older persons, living in a socioeconomically disadvantaged neighborhood was associated with diminished yields in both recruitment and retention. Assessing neighborhood disadvantage and implementing targeted strategies may improve recruitment and retention of diverse populations of older persons in clinical trials.

Background: Monitoring the dementia care quality is key for healthcare services. Dementia care quality indicators (QIs) have been reported in the literature, fragmented by setting or stage of care. We aimed to conduct an umbrella review (review of systematic reviews) to identify, evaluate, and summarize dementia care QIs throughout the disease trajectory.

Methods: We conducted an umbrella review reporting the development, review, or testing of dementia care QIs. We used a structured search in MEDLINE (Ovid), PsycINFO (EBSCO), Cochrane Library, and LILACS. Two researchers independently screened titles, abstracts, and full-texts. QIs from included articles were extracted by one reviewer and checked by a second one. The AMSTAR 2 and AIRE tools were used to assess the methodological quality of reviews and QIs, respectively. Included QIs were categorized and coded based on their stage of care (initial assessment after diagnosis, follow-up and treatment, and end-of-life), type of indicator (structure, process, outcome), and specific aspects of care measured.

Results: Six systematic reviews were included, comprising 554 dementia care QIs that were synthesized into 120 QIs. 86 (72%) were classified as process, 20 (16%) as structure, and 14 (12%) as outcome indicators. 32 QIs (27%) are recommended exclusively for community settings, 7 (6%) for hospital settings, and 81 (67%) for more than one care setting. The 120 QIs are related to 60 different aspects of care, with advanced care planning and having an individualized healthcare plan being the most frequently quoted QIs. The quality of systematic reviews was low to critically low, and over a third of QIs were considered to have high methodological quality.

Conclusions: Our umbrella review synthesized a broad overview of dementia care QIs, facilitating healthcare organizations to monitor and improve areas in need. Future research should focus on validating these QIs in local contexts.

Background: Age-related hearing loss is common and a particularly prevalent disability among Veterans. In response, comprehensive hearing services are available within the Veterans Affairs (VA) integrated healthcare system. Severe hearing loss may pose distinct communication challenges inadequately addressed by hearing aids, but data suggest severe hearing loss is often not treated differently. We sought to identify barriers and facilitators to evidence-based and individualized management of severe hearing loss from the perspectives of VA clinicians and Veterans.

Methods: We used purposeful sampling to conduct remote semi-structured video interviews with 33 current VA clinicians encompassing multiple disciplines and 39 Veterans with severe hearing loss over approximately an 18 month period (May 2022 to December 2023). We analyzed qualitative data using content thematic analysis. Coding categories were summarized within each participant; then across all participants to yield clinician-specific and Veteran themes.

Results: In the sample of 33 VA clinicians (20 audiologists, 9 otolaryngologists and 4 primary care clinicians), the overarching theme of qualitative data is that hearing loss is undertreated in the Veteran population. Across clinician groups, the qualitative data revealed multi-level factors (system-, clinician-, and patient-level) that influence the delivery of hearing care and management for Veterans with severe hearing loss. Interviews revealed that efficient access and collaborative care facilitate evidence-based practice. Among Veterans, inadequately managed hearing loss impacts quality of life; lack of knowledge and misconceptions about hearing care options and system-level barriers influence Veterans' perceptions of their hearing care and management.

Conclusion: Although hearing care is available to Veterans, multi-level factors influence the delivery of hearing care and management for Veterans with severe hearing loss. Greater attention both in primary and specialty care is needed to ensure tailored treatments are available to Veterans with severe hearing loss across the integrated VA health care system.

Background: The long-term care (LTC) Data Cooperative is a National Institute on Aging-funded data resource that links skilled nursing facility (SNF) electronic health record (EHR) data with Medicare and Medicaid claims for use in comparative effectiveness and interventional research. Here we characterize the population of residents and SNFs represented in the LTC Data Cooperative and report on the completeness of key data elements.

Methods: We compared facility and resident characteristics between SNF participants in the LTC Data Cooperative in 2023 and all US SNFs. We examined frequencies and variation in documentation of key EHR data elements including resident census data, vital signs, blood glucose readings, medication administration records, and immunizations.

Results: The LTC Data Cooperative included 2557 SNFs in 48 states plus D.C. in 2023, or 17% of US SNFs. The LTC Data Cooperative population was generally similar to the national population with small differences including being slightly older (21.3% under age 65 vs. 23.8% in the national population); having fewer females (61.0% vs. 63.2%), fewer Black residents (15.1% vs. 17.5%); and fewer residents with dementia (45.5% vs. 47.2%). Data availability varied across SNFs, however most had relatively consistent documentation of key elements. The number of SNFs with vital sign records available on at least 80% of days ranged from 2248 SNFs for temperature documentation to 2303 SNFs for blood pressure documentation. Approximately 2300 SNFs (90%) had at least some medication administration records available, while 2485 SNFs (97%) had immunization records.

Conclusions: The LTC Data Cooperative offers novel EHR data capturing clinical measures not available in the Minimum Data Set or claims data on a SNF resident population that is comparable to the national population. Studies using these data can generate evidence to inform and improve clinical care and outcomes for older adults in the SNF setting.

Background: Transcatheter aortic valve replacement (TAVR) has become the standard treatment for severe aortic stenosis, particularly among very old adults, and long-term comprehensive management post-TAVR is becoming increasingly important. Although cardiac rehabilitation (CR) is strongly recommended for patients with heart failure (HF) or post-cardiac surgery, cohort studies evaluating the long-term efficacy of CR in patients who have undergone TAVR are scarce. This study aimed to examine the association between outpatient CR and long-term clinical outcomes post-TAVR utilizing a nationwide administrative claims database in Japan.

Methods: Among 46,885 patients who underwent TAVR between April 2014 and March 2021, 34,165 patients who participated in inpatient CR and were discharged alive were included. Patients were categorized by outpatient CR participation. After propensity score matching, the primary outcome, a composite of all-cause mortality and HF hospitalization, was compared over a 3-year period.

Results: Among the eligible patients, 29,552 (86.5%) were aged ≥ 80 years, and 22,805 (66.7%) were female. The participation rate in outpatient CR was 10.2%, with no observed increasing trend over the years. Advanced age, female sex, dementia, and multiple comorbidities were associated with non-participation in CR. The outpatient CR group exhibited reduced risk for the primary outcome (hazard ratio: 0.87, 95% confidence interval: 0.79-0.96) with a median follow-up of 734 days.

Conclusions: The participation rate in outpatient CR after TAVR remains low, with identifiable barriers in Japan. Participation was associated with improved outcomes, suggesting a beneficial management strategy for older patients post-TAVR.