Journal of the American Geriatrics Society最新文献

Background and objectives: Deprescribing is a key strategy for optimizing therapeutic plans in multimorbid or complex chronic patients. Despite its long-standing use, further studies are needed to validate health outcomes and support its routine clinical integration. This project aims to assess the impact of applying LESS-CHRON criteria in terms of therapeutic and anticholinergic burden, as well as to describe potentially inappropriate medications (PIMs) more often involved in chronic treatments of patients with multimorbidity or those with complex health needs across two care settings: institutionalized and outpatients.

Methods: A quasi-experimental, multicenter, pre-post intervention cohort study was conducted in several phases (screening, intervention, and follow-up at 3 and 6 months after inclusion). The study included two cohorts: outpatients and institutionalized patients. The main variable was the percentage reduction in medication use. Additionally, the deprescribing success rate, reasons for non-acceptance (barriers to deprescribing), anticholinergic burden, and non-pharmacological variables were analyzed.

Results: Four hundred and sixty patients (229 outpatients, 231 institutionalized) with a mean age of 84.5 (SD: 7.9) years were included. Demographic, clinical, and pharmacological data were collected. Deprescribing opportunities were identified using the LESS-CHRON criteria, and recommendations were assessed by medical teams. Follow-up evaluations were conducted after 3 months. A total of 960 PIMs were identified, of which 542 medications were successfully deprescribed (345 patients), with an acceptance rate of 56.46%, showing no significant differences between cohorts. The overall therapeutic burden was reduced by 10.73% (SD: 10.68). The main barriers to deprescribing were clinical decisions (69.86%) and patient/family refusal (11.72%). After 3 months, at least one deprescribed drug was reintroduced in 61 patients. The mean deprescribing success rate was 87.10%, which was significantly higher in institutionalized patients (p < 0.05), and the anticholinergic burden was significantly reduced (p < 0.001).

Conclusion: The LESS-CHRON tool effectively identified deprescribing opportunities, reducing both medication burden and anticholinergic load. Institutionalized patients had a higher deprescribing success rate. However, clinical judgment and patient preferences remain key barriers to successful implementation.

Objectives: Frailty is a common condition in community-dwelling older adults with high health and socioeconomic implications. However, primary care-led randomized trials have been scarcely tested.

Design: Multicenter cluster randomized clinical trial.

Setting and participants: Two hundred and seventy-three community-dwelling older adults recruited from 12 Spanish primary care centers.

Inclusion criteria: independence in basic activities of daily living and either prefrailty/frailty using the frailty phenotype or gait speed < 0.8 m/s.

Methods: Participants were randomized 1:1 by clusters to the intervention or the control group, each cluster being a different primary care center.

Intervention: Physical exercise program, nutritional recommendations, and frailty training to primary care professionals. Interventions were conducted based on the guidelines of the "Consensus document on the prevention of frailty in older adults," updated in 2022, from the Spanish Health Ministry.

Control: Usual care.

Main outcome: Improvement in one category of the frailty phenotype or one point in the Short Physical Performance Battery (SPPB) at 12 and 32 weeks. under Intention-to-treat analysis was conducted.

Results: Mean age 78.1 years, 68.4% female. 25.7% were frail and 74.3% prefrail or with a gait speed lower than 0.8 m/s. The percentage of participants improving the main outcome at week 12 for the intervention and control groups were 70.4% and 49.5%, respectively, absolute risk reduction (ARR) 20.9% (95% confidence interval [CI] 7.3%-34.5%; p < 0.01; n = 191), number needed to treat (NNT) 4.8 (95% CI 2.9-13.6). At 32 weeks of follow-up 81.7% and 51.9% of the intervention and control group improved, respectively, ARR 29.8% (95% CI 13.8%-45.7%; p < 0.001; n = 134), NNT 3.4 (95% CI 2.2-7.2).

Conclusions and implications: A primary care-led intervention consisting of a physical exercise program, nutritional recommendations, and training in frailty was feasible and effective for improving frailty status or physical function in community-dwelling older adults with prefrailty or frailty.

Trial registration: clinicaltrial.gov: NCT05002439 (18/JUN/2021).

Background: Central nervous system (CNS)-active polypharmacy is associated with increased risks such as impaired cognition and falls. In 2021, CNS-active polypharmacy was added as a Medicare Part D display measure to monitor for this risk. Enrollees in the Medicare Part D Medication Therapy Management program are at increased risk of CNS-active polypharmacy and are offered comprehensive medication reviews (CMRs) to optimize their medication management and reduce medication-related safety risks.

Objective: Evaluate the association of CMRs with CNS-active medication discontinuation among Medication Therapy Management enrollees in 2021.

Methods: Observational study applying inverse probability of treatment weights to compare the time until discontinuation of at least one medication contributing to CNS-active polypharmacy in CMR recipients versus non-recipients in 2021 using 5% Medicare fee-for-service claims and enrollment data.

Results: Of 2702 community-dwelling, Medication Therapy Management program enrollees ≥ 66 years of age with CNS-active polypharmacy, 969 (35.9%) were CMR recipients. Both CMR recipients and non-recipients were taking a median of four CNS-active medications. As compared to non-recipients pre-weighting, CMR recipients were more likely to use certain CNS-active medications, such as antidepressants, antiseizure medications, benzodiazepines, and nonbenzodiazepine sedative hypnotics and opioids. Compared to non-recipients pre-weighting, CMR recipients were also more likely to have more prescribers contributing to the CNS-active polypharmacy and to have a mix of prescriber types involved. Comparable numbers of CMR and non-CMR patients discontinued at least one CNS-active medication within 1 year (11.5% vs. 13.2%). In the weighted analyses, there was no difference in likelihood of discontinuation of at least one CNS-active medication between CMR recipients and non-recipients (hazard ratio = 1.03, 95% confidence interval = 0.94-1.12).

Conclusions: CMRs were not associated with reduced CNS-active polypharmacy in older adults in the first year that it served as a Part D Display measure. Future research is needed to better understand why and whether this continues.

Background: People with dementia have high rates of emergency department (ED) and hospital utilization, high mortality and costs, and other poor outcomes. To successfully impact the care trajectories of these patients, health care systems must pragmatically identify the correct target population. This study described patterns of ED utilization by people with dementia and explored the accuracy of administrative data models to predict mortality and costs.

Methods: Retrospective cohort study of a 20% random sample of Traditional Medicare (TM) beneficiaries with dementia, age ≥ 66 years, and an index ED visit in 2018. One-year mortality and high costs were described, and associations with the timing of prior hospitalizations examined. As a preliminary step to evaluate models based on administrative data only, C-statistics were used to examine the accuracy of eight multivariate models, stratified by the setting of care before and after an ED visit.

Results: The majority of the 250,343 person cohort of individuals with dementia resided in the community before their index ED encounter (83.9%) rather than in a nursing home (NH, 16.1%), and 34.4% required hospitalization. One-year mortality by location varied from 18.4% (community before and after ED visit) to 47% (admitted NH residents). One-year mortality was 40.3% for those hospitalized within the past month, and 26.2% for those hospitalized 6+ months before the ED encounter. C-statistics were less than or equal to 0.72 for seven multivariate models, and 0.81 for the model examining high costs for NH residents discharged back to their NH.

Conclusions: Mortality and costs for people with dementia vary by location of care before and after ED encounters, as well as by timing of prior hospitalizations. However, multivariate models using only administrative data lack accuracy, suggesting the need to add pragmatically selected clinical data and/or other measures to better identify the "right patients, at the right time".

Geriatric patients function as complex systems shaped by biological, psychological, functional, and social factors, generating new emergent properties of non-linear change, self-organization, phase transitions, and path dependence that produce clinical states guiding dynamic assessment, early detection, and cross-domain care.

ACE principles are implemented in the Geriatric Observation Unit through early intervention, interdisciplinary teamwork, mobility promotion, and continuous outcome review to improve care transitions and support at-risk older adults.

Background: Dementia affects over 6.5 million people in the United States. The centers for medicare & medicaid services (CMS) introduced the guiding an improving dementia experience (GUIDE) Model to standardize and address gaps in dementia care. Whereas social and educational interventions form a major part of dementia care management, certain patients require medical interventions, such as referrals and medication for behavioral issues. This study aims to describe the dementia care provided by nurse practitioner (NP) dementia care managers within the Cedars-Sinai C.A.R.E.S. Program, a CMS GUIDE Model site.

Methods: This retrospective observational study analyzed 394 people living with dementia enrolled in the Cedars-Sinai C.A.R.E.S. Program from July 2021 to October 2024. Patient demographics, dementia stage, and provided medical interventions were extracted from electronic health records. Logistic regression models assessed predictors of dementia care use.

Results: Among 394 enrolled patients, 51% received a specialty referral, 30% were initiated on medication, and 4% underwent laboratory testing. NPs commonly prescribed dementia-specific medications (21.6%) and antidepressants (12.4%) and referred patients to neurology (36.6%), psychiatry (14.5%), and occupational therapy (4.8%). Whereas no significant disparities in care delivery were observed, Black or African Americans with mild dementia (CDR ≤ 1) had higher odds of receiving any medical intervention (aOR = 2.69, 95% CI: 1.07-7.78, p = 0.046) and starting medications (aOR = 3.37, 95% CI: 1.52-7.56, p = 0.003) relative to their White counterparts. Patients residing in care facilities, including board-and-care homes and assisted living communities, were significantly less likely to receive referrals (aOR = 0.31, 95% CI: 0.09-0.88, p = 0.038).

Conclusion: As dementia care managers, NPs can support the diverse dementia care needs of enrolled patients with dementia. Integrating NPs into dementia care models, such as the CMS GUIDE Model, may enhance care quality and equity, particularly for populations with complex medical needs or those facing barriers to adequate dementia care.

This scoping review provides key trends in the use of the Delphi method applied to geriatrics and gerontology research, and documents key information that can be used in the planning of future Delphi studies, like recruitment rates, number of Delphi rounds and panelists, attrition, consensus definitions, and stakeholders engaged.