Journal of the American Geriatrics Society最新文献

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.

The Reducing Inflammation for Greater Health Trial's (RIGHT) study is a single-center, randomized, double-blind, placebo-controlled trial designed to test whether clazkizumab, an interleukin-6 (IL-6) inhibitor, can improve or slow decline in physical, cognitive, and vascular function in older adults, when compared to a placebo. The trial will enroll participants meeting the following inclusion criteria: (1) ≥ 70 years of age, (2) with low to moderate physical function, defined as self-reported difficulty walking 1/4 mile or climbing a flight of stairs, but able to walk 400 m at baseline exam, (3) usual walking speed between ≥ 0.44 and < 1.0 m/s on a 4-m walk or a body mass index of ≥ 28 kg/m², (4) average IL-6 level between 2.0 and 30 pg/mL on two tests, and (5) no active infection, cancer, or other serious health conditions. Clazakizumab, a monoclonal antibody targeting IL-6, 5 mg via subcutaneous injection every 4 weeks for 24 weeks compared to a placebo. The primary outcome will be walking speed over 400 m. Secondary outcomes include other measures of physical function (short physical performance battery, oxygen consumption with walking on a treadmill, fatigability), cognitive function, vascular stiffness and endothelial function, IL-6 and C-reactive protein levels, other markers of inflammation, safety, and tolerability. Findings will evaluate acceptability, safety and 6-months change in mobility and other outcomes. The study was approved by the IRB and is registered with ClinicalTrials.gov (NCT05727384). The RIGHT study will inform the geroscience hypothesis that modifying aging itself will lead to improvement in multiple aspects of health.

Objectives: To measure the association between initiating palliative care using the combined criteria of short survival expectations and increased care needs with acute healthcare utilization among community-dwelling people living with dementia.

Design: A population-level propensity-based overlap-weighted cohort study.

Setting: Ontario, Canada.

Participants: 50,961 community-dwelling people living with dementia between 2010 and 2023, with 1-year follow-up until 2024. We used moderate to severe dementia and the initiation of homecare services as proxies for short survival expectations and increased care needs, respectively. We used linked health administrative data with propensity-based overlap weighting on sociodemographic and clinical factors to address confounding by the indication to receive palliative care.

Exposures: Receipt of home-based palliative care within 30 days of homecare initiation.

Main outcome measures: Individual 1-year cause-specific hazards of emergency department (ED) use, hospitalization, and intensive care unit (ICU) admission.

Results: Palliative care was associated with a higher risk of hospitalization in the first 90 days (e.g., hazard ratio (HR) 1.43 at 30 days; 95% confidence interval (CI) 1.25-1.64), which was driven predominantly by hospitalization with palliative intent, but was no longer significantly different beyond 180 days, compared to not receiving palliative care. [Correction added on 31 January 2026, after first online publication: The preceding sentence has been revised in this version.] At 90 days, the cumulative incidence of hospitalization, death, or admission to a nursing home was approximately 20% among those receiving palliative care, compared to 15% in those not receiving palliative care. Although the overall absolute rate of ICU admission was low (0.01 ± 0.1 admissions per month), palliative care initiation was associated with a 186% higher risk in the first 30 days (HR 2.86; 95% CI 1.75-4.69) but not beyond 90 days. Palliative care was not associated with ED use over the following year (HR 1.02; 95% CI 0.72-1.45).

Conclusions: The current approach to delivering palliative care services for community-dwelling people living with dementia in Canada may paradoxically increase early acute care use, likely reflecting system gaps and unmet needs. Given the high prevalence of dementia, there is an urgent need to re-examine homecare delivery models.

Background: Resident-to-resident aggression (RRA) in long-term care settings is widespread with the potential for serious detrimental outcomes. However, few evidence-based training, intervention, and implementation strategies exist. The objective was to evaluate intervention process outcomes (knowledge), and proximal and distal outcomes (increased recognition, documentation, and reporting) in assisted living facilities.

Methods: Staff reported on RRA with respect to 930 residents (495 intervention and 435 usual care) from 14 New York assisted living facilities (7 per group). Data were collected at baseline, 6 and 12 months. Intervention site staff received training, while usual care staff did not. Knowledge outcomes were measured using two 10-item scales. Recognition and documentation for care planning were measured on an ongoing basis in real time, and longitudinal reporting of past two-week events through a structured interview. Mixed models were used to evaluate continuous knowledge variables. Outcome evaluation was conducted on an intent-to-treat basis using Poisson regressions for longitudinal count data measuring recognition/documentation and reporting.

Results: A total of 238, 263, and 217 staff attended Modules 1-3, respectively. There was a statistically significant increase in knowledge post-training, controlling for pre-training levels (estimated mean = 1.37, 95% CI, 1.11-1.62, p < 0.001 for Module 1 and estimated mean = 0.46, 95% CI, 0.21-0.70, p < 0.001 for Module 2). The program statistically significantly increased recognition and documentation of RRA in real time (estimated log mean = 4.34, 95% CI, 1.22-7.45, p = 0.006); there were 92 incidents reported by intervention group staff as contrasted with one in the usual care group. In terms of longitudinal reporting of events using a structured interview, a significant between-group difference was observed (estimate = 0.64, 95% CI, 0.18-1.09, p = 0.006).

Conclusions: The training intervention was demonstrated as effective in enhancing knowledge, recognition/documentation, and reporting of RRA in assisted living, replicating findings in nursing homes. It is recommended that this program be disseminated in long-term care facilities.

Trial registration: Clinical Trials.gov identifier: NCT03383289 registered December 26, 2017. The first subject was enrolled May 26, 2018; the last subject was enrolled August 2022; follow-up data collection was completed June 5, 2023.

Introduction: Elevated concentrations of air pollutants in residential neighborhoods are associated with poorer survival, cognitive, and cardiovascular health among older adults. Older kidney transplant (KT) recipients may be more vulnerable due to chronic immunosuppression and age-related co-morbidities. Therefore, we quantified the associations between pollutant concentrations and post-KT outcomes among older recipients.

Methods: We identified older (age ≥ 55) Black and White KT recipients from the national registry (2003-2019) linked to Medicare claims. Annual pollutant concentrations (particulate matter ≤ 2.5 μm [PM_2.5], particulate matter ≤ 10 μm, [PM₁₀], nitrogen dioxide [NO₂], and sulfur dioxide [SO₂]) were obtained from the Center for Air, Climate and Energy Solutions, and matched by ZIP code and year of KT. We used shared frailty models (cluster = state) to estimate the adjusted hazard ratios (aHR) of mortality and death-censored graft failure (DCGF) and competing risk models with cluster-robust standard errors to estimate the adjusted subhazard ratios (aSHR) of dementia and stroke by pollutant concentrations.

Results: Among 42,199 older KT recipients, 38% were Black, 36% were female, and 82% received deceased donor KT. After adjustment, each standardized increase in pollutant concentrations was associated with significantly higher mortality risk: PM_2.5 (aHR = 1.08, 95% confidence interval [CI]: 1.07-1.10); PM₁₀ (aHR = 1.05, 95% CI: 1.03-1.07); NO₂ (aHR = 1.04, 95% CI: 1.02-1.06); SO₂ (aHR = 1.09, 95% CI: 1.08-1.11). Similarly, increasing pollutant concentrations were associated with a higher risk of DCGF. Additionally, there were no significant associations between increasing pollutant concentrations and incident dementia/stroke, except: increasing PM_2.5 and NO₂ concentrations were associated with a 3% (aSHR = 1.03, 95% CI: 1.00-1.07) and 4% higher risk of stroke (aSHR = 1.04, 95% CI: 1.02-1.07), respectively.

Conclusion: Residence in neighborhoods with high concentrations of ambient air pollutants can worsen patient and graft survival, as well as increase the risk of stroke among older KT recipients. Early screening and interventions targeting older recipients living in such neighborhoods may be crucial for preserving cognitive and cerebrovascular health, as well as improving longitudinal quality of life.

Background: Despite efforts to promote aging in place, millions of caregivers face decisions about whether a person living with dementia (PLwD) should move from home to another residential setting, such as a nursing home or assisted living facility. These decisions are frequently made during times of crisis, and caregivers report many unmet needs regarding decision making. Tools to support this decision making are lacking.

Methods: Focus groups of caregivers and an expert panel provided the content for a decision support tool. The tool was then iteratively reviewed with a new cohort of 53 caregivers, who participated in cognitive interviews and rated the tool's clarity, trustworthiness, and whether it made them more comfortable thinking about care transitions.

Results: In focus groups, caregivers highlighted the importance of understanding decision making in the context of the entire relationship between the caregiver and PLwD, and they repeatedly called attention to the role of guilt. The expert panel grappled with the ethical standing of the caregiver's well-being in decision making on behalf of the PLwD. The tool consists of two booklets. The first addresses the cognitive and emotional aspects of decision making and the second provides education. Over 95% of caregivers gave a rating of "Good" or "Very Good" for the booklets' clarity, ease of understanding, and trustworthiness. At least 80% agreed or strongly agreed that they were comfortable thinking about the issues and wanted to learn more.

Conclusions: A decision support tool for caregivers of PLwD that provides education about transitions in care site, along with support for the emotional aspects of decision making, is highly acceptable and supports caregivers' ability to engage with what can be a challenging topic.

This figure illustrates teaching strategies for the five domains of geriatric care, represented as the "5 M's": Medication, Mentation, Mobility, Multi-Complexity, and Matters Most. For each domain, Ms. T's clinical problems are listed with corresponding interventions.