Association between the levels of urinary cell cycle biomarkers and non-recovery of renal function among critically ill geriatric patients with acute kidney injury

The lack of early renal function recovery among geriatric patients with acute kidney injury (AKI) in the intensive care unit (ICU) is a commonly observed and acknowledged poor prognostic factor, especially for older adults. However, no reliable prognostic biomarker is available for identifying individuals at risk of renal non-recovery or mortality in older adults. In this prospective observational cohort study, we enrolled critically ill older adults (aged ≥ 60 years) with AKI from the ICU and followed their disease progression. The primary endpoint was renal non-recovery within seven days of follow-up, while the secondary endpoint was the determinants of 30-day mortality after AKI. We assessed the predictive accuracy using receiver operating characteristic curves and performed between-group comparisons using the log-rank test. Among 209 older adults, 117 (56.0%) experienced renal recovery. Multiple regression analysis revealed that urine levels of tissue inhibitor of metalloproteinase-2 (TIMP-2) multiplied by insulin-like growth factor-binding protein 7 (IGFBP7) ([TIMP-2]*[IGFBP7]), AKI stages 2-3, and the Acute Physiology and Chronic Health Evaluation (APACHE II) score were independently associated with renal non-recovery. The regression model incorporating [TIMP-2]*[IGFBP7] demonstrated a fair predictive value (AUC 0.774, p < 0.001), with the optimal threshold set at 0.81 (ng/mL)2/1000. When [TIMP-2]*[IGFBP7] was combined with AKI severity and the APACHE score, the AUC increased to 0.851. In conclusion, urine [TIMP-2]*[IGFBP7] is a reliable biomarker associated with renal non-recovery in critically ill older adults, and its predictive efficacy can be further enhanced when combined with AKI severity and the APACHE score.

Integrated approach to reducing polypharmacy in older people: exploring the role of oxidative stress and antioxidant potential therapy

Increased life expectancy, attributed to improved access to healthcare and drug development, has led to an increase in multimorbidity, a key contributor to polypharmacy. Polypharmacy is characterised by its association with a variety of adverse events in the older persons. The mechanisms involved in the development of age-related chronic diseases are largely unknown; however, altered redox homeostasis due to ageing is one of the main theories. In this context, the present review explores the development and interaction between different age-related diseases, mainly linked by oxidative stress. In addition, drug interactions in the treatment of various diseases are described, emphasising that the holistic management of older people and their pathologies should prevail over the individual treatment of each condition.

Academic Detailing as a Health Information Technology Implementation Method: Supporting the Design and Implementation of an Emergency Department-Based Clinical Decision Support Tool to Prevent Future Falls

BACKGROUND

Clinical decision support (CDS) tools that incorporate machine learning-derived content have the potential to transform clinical care by augmenting clinicians' expertise. To realize this potential, such tools must be designed to fit the dynamic work systems of the clinicians who use them. We propose the use of academic detailing-personal visits to clinicians by an expert in a specific health IT tool-as a method for both ensuring the correct understanding of that tool and its evidence base and identifying factors influencing the tool's implementation.

OBJECTIVE

This study aimed to assess academic detailing as a method for simultaneously ensuring the correct understanding of an emergency department-based CDS tool to prevent future falls and identifying factors impacting clinicians' use of the tool through an analysis of the resultant qualitative data.

METHODS

Previously, our team designed a CDS tool to identify patients aged 65 years and older who are at the highest risk of future falls and prompt an interruptive alert to clinicians, suggesting the patient be referred to a mobility and falls clinic for an evidence-based preventative intervention. We conducted 10-minute academic detailing interviews (n=16) with resident emergency medicine physicians and advanced practice providers who had encountered our CDS tool in practice. We conducted an inductive, team-based content analysis to identify factors that influenced clinicians' use of the CDS tool.

RESULTS

The following categories of factors that impacted clinicians' use of the CDS were identified: (1) aspects of the CDS tool's design (2) clinicians' understanding (or misunderstanding) of the CDS or referral process, (3) the busy nature of the emergency department environment, (4) clinicians' perceptions of the patient and their associated fall risk, and (5) the opacity of the referral process. Additionally, clinician education was done to address any misconceptions about the CDS tool or referral process, for example, demonstrating how simple it is to place a referral via the CDS and clarifying which clinic the referral goes to.

CONCLUSIONS

Our study demonstrates the use of academic detailing for supporting the implementation of health information technologies, allowing us to identify factors that impacted clinicians' use of the CDS while concurrently educating clinicians to ensure the correct understanding of the CDS tool and intervention. Thus, academic detailing can inform both real-time adjustments of a tool's implementation, for example, refinement of the language used to introduce the tool, and larger scale redesign of the CDS tool to better fit the dynamic work environment of clinicians.

Laparoscopic Cholecystectomy vs Endoscopic Retrograde Cholangiopancreatography With Sphincterotomy in Elderly Patients With Acute Gallstone Pancreatitis

BACKGROUND

Gallstone pancreatitis (GSP) is common in elderly patients and carries worse outcomes. Laparoscopic cholecystectomy (LC) is recommended for prevention of recurrent GSP. In frail populations, an endoscopic retrograde cholangiopancreatography with sphincterotomy (ERCP-s) is an alternative. Management guidelines of GSP in the elderly are lacking. This study aimed to investigate and compare management strategies for GSP in the elderly.

MATERIALS AND METHODS

A retrospective comparison of outcome of patients aged ≥65 years with first presentation of GSP treated either with (1) LC only, (2) ERCP-s, (3) ERCP-S followed by LC, or (4) no intervention.

RESULTS

216 patients were included. Median age was 76 years (interquartile range 70-83). Most (80%, n = 172) had mild pancreatitis, whilst 12% (n = 26) had severe disease. 24% (n = 55) were treated with ERCP-s; 40% (n = 87) underwent LC alone; 11% (n = 23) had ERCP-s followed by LC; and 25% (n = 55) received no intervention. Patients without intervention were older (P < .001) and frailer (P < .001). The LC-only group had lower post-procedure re-admission rates of 6% (n = 5) compared to 27% (n = 14) for ERCP-s, 33% (n = 7) for ERCP-S + LC, and 31% (n = 17) for the no intervention group (P = .0001). Biliary cause mortality was highest in the no intervention group (n = 11, 20%).

CONCLUSION

Laparoscopic cholecystectomy represents the gold standard for elderly patients with GSP.

Factors Impacting Chinese Older Adults' Intention to Prevent COVID-19 in the Post-COVID-19 Pandemic Era: Survey Study

BACKGROUND

Understanding the factors influencing individuals' health decisions is a dynamic research question. Particularly, after China announced the deregulation of the COVID-19 epidemic, health risks escalated rapidly. The convergence of "no longer controlled" viruses and the infodemic has created a distinctive social period during which multiple factors may have influenced people's decision-making. Among these factors, the precautionary intentions of older individuals, as a susceptible health group, deserve special attention.

OBJECTIVE

This study aims to examine the intention of older adults to engage in preventive behaviors and the influencing factors, including social, media, and individual factors, within the context of the postepidemic era. Drawing upon the structural influence model of communication, this study tests the potential mediating roles of 3 different types of media exposure between cognitive and structural social capital and protective behavior intention, as well as the moderating role of negative emotions between social capital and media exposure.

METHODS

In this study, a web survey was used to collect self-reported quantitative data on social capital, media exposure, negative emotions, and the intention to prevent COVID-19 among older adults aged ≥60 years (N=399) in China.

RESULTS

The results indicate that cognitive social capital significantly influenced protective behavior intention (P<.001), with cell phone exposure playing an additional impactful role (P<.001). By contrast, newspaper and radio exposure and television exposure mediated the influence of structural social capital on protective behavior intention (P<.001). Furthermore, negative emotions played a moderating role in the relationship between cognitive social capital and cell phone exposure (P<.001).

CONCLUSIONS

This study suggests that using tailored communication strategies across various media channels can effectively raise health awareness among older adults dealing with major pandemics in China, considering their diverse social capital characteristics and emotional states.

The business case for hospital mobility programs in the veterans health care system: Results from multi-hospital implementation of the STRIDE program

OBJECTIVE

To conduct a business case analysis for Department of Veterans Affairs (VA) program STRIDE (ASsisTed EaRly MobIlization for hospitalizeD older VEterans), which was designed to address immobility for hospitalized older adults.

DATA SOURCES AND STUDY SETTING

This was a secondary analysis of primary data from a VA 8-hospital implementation trial conducted by the Function and Independence Quality Enhancement Research Initiative (QUERI). In partnership with VA operational partners, we estimated resources needed for program delivery in and out of the VA as well as national implementation facilitation in the VA. A scenario analysis using wage data from the Bureau of Labor Statistics informs implementation decisions outside the VA.

STUDY DESIGN

This budget impact analysis compared delivery and implementation costs for two implementation strategies (Replicating Effective Programs [REP]+CONNECT and REP-only). To simulate national budget scenarios for implementation, we estimated the number of eligible hospitalizations nationally and varied key parameters (e.g., enrollment rates) to evaluate the impact of uncertainty.

DATA COLLECTION

Personnel time and implementation outcomes were collected from hospitals (2017-2019). Hospital average daily census and wage data were estimated as of 2022 to improve relevance to future implementation.

PRINCIPAL FINDINGS

Average implementation costs were $9450 for REP+CONNECT and $5622 for REP-only; average program delivery costs were less than $30 per participant in both VA and non-VA hospital settings. Number of walks had the most impact on delivery costs and ranged from 1 to 5 walks per participant. In sensitivity analyses, cost increased to $35 per participant if a physical therapist assistant conducts the walks. Among study hospitals, mean enrollment rates were higher among the REP+CONNECT hospitals (12%) than the REP-only hospitals (4%) and VA implementation costs ranged from $66 to $100 per enrolled.

CONCLUSIONS

STRIDE is a low-cost intervention, and program participation has the biggest impact on the resources needed for delivering STRIDE.

TRIAL REGISTRATION

ClinicalsTrials.gov NCT03300336. Prospectively registered on 3 October 2017.

Medical care priorities of community-dwelling older adults according to three dimensions of quality of life: Quality of daily living, satisfaction and happiness from birth to death, and human vitality

AIM

Although the maintenance and improvement of quality of life (QoL) through holistic care are important in geriatric medical care, care priorities might differ depending on three essential aspects of QoL: the quality of daily living, satisfaction and happiness from birth to death, and human vitality, which are "Seikatsu," "Jinsei," "Seimei" in Japanese, respectively. We aimed to clarify these priorities in terms of medical care and examined how the definitions of QoL affected these priorities' rankings.

METHODS

This cross-sectional study involved community-dwelling older adults aged ≥65 years living in Kashiwa City, Chiba Prefecture, Japan. The number of participants was 1550 (mean age, 76.1 ± 5.8 years; 699 women [45.1%]). A self-administered questionnaire distributed in advance was used to rank 12 items sought in medical care. Participants were randomly assigned to one of three groups and sent the corresponding questionnaire, which differed only in the definition of QoL.

RESULTS

The top priorities for medical care were "effective treatment of illness," "improvement of physical function," and "maintaining a high level of activity." When QoL was defined as "the quality of daily living, satisfaction and happiness from birth to death, and human vitality," participants were significantly more likely to rank QoL improvement as one of the top three items (adjusted odds ratio, 1.46; 95% confidence interval, 1.03-2.05).

CONCLUSIONS

As a medical care priority, older adults desire improvement of multidimensional elements of life, including human vitality. Health care providers should consider this when making medical care decisions. Geriatr Gerontol Int 2024; ••: ••-••.

Association Between Sleep Efficiency Variability and Cognition Among Older Adults: Cross-Sectional Accelerometer Study

Background

Sleep efficiency is often used as a measure of sleep quality. Getting sufficiently high-quality sleep has been associated with better cognitive function among older adults; however, the relationship between day-to-day sleep quality variability and cognition has not been well-established.

Objective

We aimed to determine the relationship between day-to-day sleep efficiency variability and cognitive function among older adults, using accelerometer data and 3 cognitive tests.

Methods

We included older adults aged >65 years with at least 5 days of accelerometer wear time from the National Health and Nutrition Examination Survey (NHANES) who completed the Digit Symbol Substitution Test (DSST), the Consortium to Establish a Registry for Alzheimer's Disease Word-Learning subtest (CERAD-WL), and the Animal Fluency Test (AFT). Sleep efficiency was derived using a data-driven machine learning algorithm. We examined associations between sleep efficiency variability and scores on each cognitive test adjusted for age, sex, education, household income, marital status, depressive symptoms, diabetes, smoking habits, alcohol consumption, arthritis, heart disease, prior heart attack, prior stroke, activities of daily living, and instrumental activities of daily living. Associations between average sleep efficiency and each cognitive test score were further examined for comparison purposes.

Results

A total of 1074 older adults from the NHANES were included in this study. Older adults with low average sleep efficiency exhibited higher levels of sleep efficiency variability (Pearson r=-0.63). After adjusting for confounding factors, greater average sleep efficiency was associated with higher scores on the DSST (per 10% increase, β=2.25, 95% CI 0.61 to 3.90) and AFT (per 10% increase, β=.91, 95% CI 0.27 to 1.56). Greater sleep efficiency variability was univariably associated with worse cognitive function based on the DSST (per 10% increase, β=-3.34, 95% CI -5.33 to -1.34), CERAD-WL (per 10% increase, β=-1.00, 95% CI -1.79 to -0.21), and AFT (per 10% increase, β=-1.02, 95% CI -1.68 to -0.36). In fully adjusted models, greater sleep efficiency variability remained associated with lower DSST (per 10% increase, β=-2.01, 95% CI -3.62 to -0.40) and AFT (per 10% increase, β=-.84, 95% CI -1.47 to -0.21) scores but not CERAD-WL (per 10% increase, β=-.65, 95% CI -1.39 to 0.08) scores.

Conclusions

Targeting consistency in sleep quality may be useful for interventions seeking to preserve cognitive function among older adults.

Association between atherosclerosis and height loss among older individuals

Atherosclerosis and height loss are each reportedly associated with cardiovascular disease. However, no studies have found an association between atherosclerosis and height loss. A retrospective study of 2435 individuals aged 60-89 years who underwent annual health check-ups was conducted. Atherosclerosis was defined as carotid intima-media thickness (CIMT) ≥ 1.1 mm. Height loss was defined as being in the highest quintile of height decrease per year, as in our previous studies. Among study participants, 555 were diagnosed as having atherosclerosis. Independent of known cardiovascular risk factors, atherosclerosis was positively associated with height loss. The adjusted odds ratio (OR) was 1.46 (95% confidence interval, 1.15, 1.83). Essentially the same associations were observed for men and women. The adjusted OR (95% CI) was 1.43 (1.01, 2.04) for men and 1.46 (1.07, 1.99) for women. Among older individuals, atherosclerosis is associated with height loss. This result can help clarify the mechanism underlying the association between height loss and cardiovascular disease.

Brief Report: Relationship Between Adiposity and Biomarkers of Aging and Frailty Among Adults Aging With HIV

BACKGROUND

This study examined the relationships among adiposity, handgrip, physical function, inflammation (ie, senescence-associated secretory phenotype chemokines as biomarkers of aging and frailty), and sex hormones in aging people with HIV.

METHODS

This cross-sectional exploratory study included 150 people with HIV aged ≥40 years (67.3% of participants were male). Our measures included (1) body mass index and waist circumference as measures of adiposity; (2) handgrip as a measure of muscle strength; (3) short physical performance battery as a measure of physical function; (4) interleukin-6, tumor necrosis factor alpha receptor II, high sensitivity C-reactive protein, C-X-C motif chemokine 10, and C-X3-C motif chemokine ligand 1 also known as fractalkine as senescence-associated secretory phenotype chemokines; and (5) free testosterone, estradiol, sex hormone-binding globulin, and dehydroepiandrosterone as sex hormones. Quantile regression analyses were used to identify relationships among inflammatory markers and hormones with age, adiposity, handgrip, and physical function.

RESULTS

Overall, 74% (n = 111) of participants were classified as overweight or obese and 53.3% (n = 80) presented with abdominal obesity. After controlling for age and sex, body mass index was positively associated with estradiol (β = 0.043, P < 0.01), and waist circumference was positively associated with high sensitivity C-reactive protein (β = 2.151, P < 0.01). After controlling for sex, age was positively associated with C-X-C motif chemokine 10 (β = 0.024, P = 0.03) and tumor necrosis factor alpha receptor II (β = 2.205, P = 0.01). After controlling for age and sex, short physical performance battery was negatively associated with dehydroepiandrosterone (β = -0.004, P = 0.01); no statistically significant associations were observed for handgrip.

CONCLUSION

Adiposity levels and aging were associated with inflammation (ie, C-X-C motif chemokine 10, tumor necrosis factor alpha receptor II, and high sensitivity C-reactive protein) among people with HIV aged 40 years and older.

Validating claims-based definitions for deprescribing: Bridging the gap between clinical and administrative data

BACKGROUND

Limited research has evaluated the validity of claims-based definitions for deprescribing.

OBJECTIVES

Evaluate the validity of claims-based definitions of deprescribing against electronic health records (EHRs) for deprescribing of benzodiazepines (BZDs) after a fall-related hospitalization.

METHODS

We used a novel data linkage between Medicare fee-for-service (FFS) and Part D with our health system's EHR. We identified patients aged ≥66 years with a fall-related hospitalization, continuous enrollment in Medicare FFS and Part D for 6 months pre- and post-hospitalization, and ≥2 BZD fills in the 6 months pre-hospitalization. Using a standardized EHR abstraction tool, we adjudicated deprescribing for a sub-sample with a fall-related hospitalization at UNC. We evaluated the validity of claims-based deprescribing definitions (e.g., gaps in supply, dosage reductions) versus chart review using sensitivity and specificity.

RESULTS

Among 257 patients in the overall sample, 44% were aged 66-74 years, 35% had Medicare low-income subsidy, 79% were female. Among claims-based definitions using gaps in supply, the prevalence of BZD deprescribing ranged from 8.2% (no refills) to 36.6% (30-day gap). When incorporating dosage, the prevalence ranged from 55.3% to 65.8%. Among the validation sub-sample (n = 47), approximately one-third had BZDs deprescribed in the EHR. Compared to EHR, gaps in supply from claims had good sensitivity, but poor specificity. Incorporating dosage increased sensitivity, but worsened specificity.

CONCLUSIONS

The sensitivity of claims-based definitions for deprescribing of BZDs was low; however, the specificity of a 90-day gap was >90%. Replication in other EHRs and for other low-value medications is needed to guide future deprescribing research.

Systemic failures in nursing home care-A scoping study

Nursing homes (also referred to as residential aged care facilities, or long-term care facilities) cater for older people on a respite or long-term basis for those who are no longer able to live independently at home. Globally the sector struggles to meet societal expectations since it is torn between three competing agendas-meeting the needs of residents, meeting the demands of regulators, and meeting the financial imperatives of nursing home proprietors. Competing demands indicate that the system lacks a clear understanding of its purpose-without a clearly understood purpose any system will become dysfunctional overall and across all its levels of organisation. This scoping study aims to summarise and synthesise what is already known about the systemic function and failures in the nursing home system, and the impact this has on the wider health and aged care system.

METHOD

MEDLINE, EMBASE, PSYCHINFO, CINAHL and SCOPUS were searched using the terms: (nursing home care OR residential aged care OR nursing home) AND (organisational failure OR institutional failure OR systemic failure), limited to English language articles, including all years up to the end of February 2021. In addition, we used snowballing of article references and Google searches of the grey literature. System-focused articles were defined as those that explored how an issue at one system level impacted other system levels, or how an issue impacted at least two different agents at the same system level.

RESULT

Thirty-eight articles addressed systemic issues as defined in four different contexts: United States (14), Canada (2), Australia (11) and European countries (11). Only four studies reported whole-of-system findings, whereas the remaining 34 more narrowly addressed systemic features of specific nursing home issues. The thematic analysis identified 29 key systemic issues across five system layers which consistently appear across every country/health system context. The negative outcomes of these systemic failings include: high rates of regulatory reprimands for unacceptable or unsafe practices; dissatisfaction in care experiences on the part of residents, families, and care staff-including a fear of being sent to a nursing home; and the perception amongst staff that nursing homes are not preferred places to work.

CONCLUSIONS

The key issues affecting nursing home residents, and the care home sector more generally, are systemic in nature arising from two key issues: first, the lack of shared agreement on the care home system's purpose; and second, the lack of clear governance and accountability frameworks for system regulation and performance at a national level. Addressing these two key issues must be the starting point for any 'real' nursing home system redesign that can achieve a seamlessly integrated system that delivers the outcomes nursing home residents and their families expect. 'Systems thinking' is required to simultaneously improve care quality and outcomes for residents, strengthen regulation and accountability, and enable financial viability.

Proton pump inhibitors and risk of severe COVID-19 in older people

INTRODUCTION

Severe acute respiratory syndrome coronavirus 2 is a viral respiratory infection that can cause systemic disorders and lead to death, particularly in older people. Proton pump inhibitors (PPIs) increase the risk of enteric and lung infections. Considering the broad use of PPIs in older people, the potential role of PPIs in COVID-19 could be of dramatic significance. The objective of our study was to evaluate the link between PPIs and severe COVID-19 in older people.

METHOD

We performed a retrospective cohort study, including all patients aged ≥65, hospitalised for a diagnosis of COVID-19. Epidemiological, clinical and biological data were extracted and we performed an Inverse Probability of Treatment Weighing method based on a propensity score.

RESULTS

From March 2020 to February 2021, a total of 834 patients were included, with a median age of 83 and 52.8% were male. A total of 410 patients had a PPIs prescription, 358 (87.3%) were long-term PPIs-users and 52 (12.7%) were recent PPIs-users. Among PPIs-users, 163 (39.8%) patients developed severe COVID-19 versus 113 (26.7%) in PPIs-non users (odds ratio (OR) = 1.59 [1.18-2.14]; P < 0.05). Moreover, the double dose PPI-users had a higher risk of developing severe COVID-19 (OR = 3.36 [1.17-9.66]; P < 0.05) than the full dose PPI-users (OR = 2.15 [1.22-3.76]; P < 0.05) and the half dose PPI-users (OR = 1.64 [1.13-2.37]; P < 0.05).

CONCLUSION

Our study reports evidence that the use of PPIs was associated with an increased risk of severe COVID-19 in older people.

Implementation of frailty screening for older people living with HIV in Brighton, UK

OBJECTIVES

To evaluate the implementation of frailty screening in people living with HIV (PLWH) in a large urban cohort of patients in Brighton, UK.

METHODS

Focus group discussions with HIV professionals and PLWH interviews helped inform the design and implementation of the frailty screening pathway in the clinic. Data were collected from PLWH aged over 60 years attending their HIV annual health check from July 2021 to January 2023 (n = 590), who were screened for frailty by nurses using the FRAIL scale. We assessed the proportions of PLWH who screened as frail, prefrail or robust and compared patient characteristics across groups. All PLWH identified as frail were offered a comprehensive geriatric assessment delivered by a combined HIV geriatric clinic, and uptake was recorded.

RESULTS

A total of 456/590 (77.3%) PLWH aged over 60 years were screened for frailty. Median age and time since HIV diagnosis (range) for those screened were 66 (60-99) years and 21 (0-32) years, respectively. In total, 56 (12.1%) of those screened were identified as frail, 118 (25.9%) as prefrail and 282 (61.8%) as robust. A total of 10/56 (18%) people identified as frail declined an appointment in the geriatric clinic. Compared with non-frail individuals, frail PLWH had been living with HIV for longer and had a greater number of comorbidities and comedications but were not chronologically older.

CONCLUSIONS

Implementing frailty screening in PLWH over 60 years old is feasible in a large cohort of PLWH, as recommended by the European AIDS Clinical Society. More research is needed to determine if frailty screening can improve clinical outcomes of older PLWH and the use of the comprehensive geriatric assessment within HIV services.

The Impact of Frailty, Oropharyngeal Dysphagia and Malnutrition on Mortality in Older Patients Hospitalized for Covid-19

COVID-19 hospital mortality is higher among older patients through as yet little-known factors. We aimed to assess the effect of frailty (FR), oropharyngeal dysphagia (OD) and malnutrition (MN) on mortality in hospitalized COVID-19 older patients. Prospective cohort study of older patients (>70 years) with COVID-19 admitted to a general hospital from April 2020 to January 2021. Patients were evaluated on admission, discharge and at 1- and 3-months follow up. FR was assessed with FRAIL-VIG, OD with Volume-Viscosity Swallowing Test and MN with GLIM criteria. Clinical characteristics and outcomes, including intra-hospital, 1- and 3-month mortality, were analyzed. 258 patients were included (82.5±7.6 years; 58.9% women); 66.7% had FR (mild 28.7%, moderate 27.1% and severe 10.9%); 65.4%, OD and 50.6%, MN. OD prevalence increased from non-FR patients through the severity levels of FR: mild, moderate and severe (29.8%, 71.6%, 90.0%, 96.2%; p<0.0001, respectively), but not that of MN (50.6%, 47.1%, 52.5%, 56.0%). Mortality over the whole study significantly increased across FR categories (9.3% non-FR; 23.0% mild; 35.7% moderate; 75.0% severe; p<.001). Functionality (Barthel pre-admission, HR=0.983, CI-95%:0.973-0.993; p=0.001), OD (HR=2.953, CI-95%:0.970-8.989; p=0.057) and MN (HR=4.279, CI-95%:1.658-11.049; p=0.003) were independent risk factors for intra-hospital mortality. FR, OD and MN are highly prevalent conditions in older patients hospitalized with COVID-19. Functionality, OD and MN were independent risk factors for intra-hospital mortality.

Perceptions about Aging and Ageism from 14 Cross-sectional Cohorts of Undergraduate Dental Students

BACKGROUND

Although positive and negative views of aging and older adults exist, how undergraduate dental students imagine their lives to be as they grow older remains to be fully explored. This study aimed at determining the self-perceived views of being 65, 75, or 85 y of age, as expressed by undergraduate dental students at the University of British Columbia (UBC), Vancouver, Canada.

METHODS

A 14-y cross-sectional study design was utilized involving third-year undergraduate dental students at UBC's Faculty of Dentistry. Brief individual essays (150 words) encompassing students' self-perceived views were gathered as part of a dental geriatric course from 2009 to 2022; however, essays were not mandatory. Saldaña's inductive coding and thematic analysis of textual data were used. Themes and categories of information were identified and matched with their excerpts while aiming for data saturation.

RESULTS

Over the 14-y period, 657 students were enrolled in UBC's undergraduate dental geriatric course, and 561 essays were collected. Inductive coding and thematic analysis identified 5 main themes and 11 categories. While themes included "oral health, general health, and the mind" and "me, myself, and familial relationships," the categories focused on "(un)able bodies" and "general health." Positive views about the aging process were shared, while less optimistic ideas-and even ageism-were apparent when students saw themselves as not employable or living in isolation. Positive and negative views were not bound by the students' academic year but might have been influenced by the COVID-19 pandemic.

CONCLUSION

Although the number of older adults already surpasses the number of children in many countries, ageism appears to have permeated through students' views of 3 older ages. More positive yet realistic views of growing older were also shared. Follow-up studies are needed to explore the impact of dental education on decreasing ageism.

KNOWLEDGE TRANSFER STATEMENT

As the proportion of older adults in the global population steadily grows, it is important to educate heath care providers about normal and pathologic aging to avoid ageism-stereotypes, prejudices, and discrimination against older adults. This cross-sectional study involved 14 cohorts of undergraduate dental students exploring their self-perceived views of growing older. Although positive and negative views of aging were shared, dental education must focus on decreasing ageism.

Identifying and Managing Frailty: A Survey of UK Healthcare Professionals

Frailty is a common condition that leads to multiple adverse outcomes. Frailty should be identified and managed in a holistic, evidence-based and patient-centered way. We aimed to understand how UK healthcare professionals (HCPs) identify and manage frailty in comparison with UK Fit for Frailty guidelines, their frailty training, their confidence in providing support and organizational pathways for this. An online mixed-methods survey was distributed to UK HCPs supporting older people through professional bodies, special interest groups, key contacts, and social media. From 137 responses, HCPs valued frailty assessment but used a mixture of tools that varied by profession. HCPs felt confident managing frailty and referred older people to a wide range of supportive services, but acknowledged a lack of formalized training opportunities, systems, and pathways for frailty management. Clearer pathways, more training, and stronger interprofessional communication, appropriate to each setting, may further support HCPs in frailty management.

Effects of medication management in geriatric patients who have fallen: results of the EMMA mixed-methods study

BACKGROUND

comprehensive medication management (CMM) can reduce medication-related risks of falling. However, knowledge about inter-individual treatment effects and patient-related barriers remains scarce.

OBJECTIVE

to gain in-depth insights into how geriatric patients who have fallen view their medication-related risks of falling and to identify effects and barriers of a CMM in preventing falls.

DESIGN

complementary mixed-methods pre-post study, based on an embedded quasi-experimental model.

SETTING

geriatric fracture centre.

METHODS

qualitative, semi-structured interviews framed the CMM intervention, including a follow-up period of 12 weeks. Interviews explored themes of falling, medication-related risks, post-discharge acceptability and sustainability of interventions using qualitative content analysis. Optimisation of pharmacotherapy was assessed via changes in the weighted and summated Medication Appropriateness Index (MAI) score, number of fall-risk-increasing drugs (FRID) and potentially inappropriate medications (PIM) according to the Fit fOR The Aged and PRISCUS lists using parametric testing.

RESULTS

thirty community-dwelling patients aged ≥65 years, taking ≥5 drugs and admitted after an injurious fall were recruited. The MAI was significantly reduced, but number of FRID and PIM remained largely unchanged. Many patients were open to medication reduction/discontinuation, but expressed fear when it came to their personal medication. Psychosocial issues and pain increased the number of indications. Safe alternatives for FRID were frequently not available. Psychosocial burden of living alone, fear, lack of supportive care and insomnia increased after discharge.

CONCLUSION

as patients' individual attitudes towards trauma and medication were not predictable, an individual and longitudinal CMM is required. A standardised approach is not helpful in this population.

Association of body mass index with long-term outcomes in older adults hospitalized for COVID-19: an observational study

Both underweight and obesity have been associated with poor prognosis in COVID-19. In an older populations of patients hospitalized for SARS-CoV-2 infection, we aimed to evaluate the association between body mass index (BMI) and short and long-term prognosis. Among 434 consecutive patients aged ≥ 70 years and hospitalized for suspected COVID-19 at a university hospital, 219 patients (median age of 83 years, 53% male) testing positive for COVID-19 and for whom BMI was recorded at admission, agreed to participate. Among them, 39 had a BMI < 20 kg/m2, 73 had a BMI between 20 and 24.9 kg/m2 and 107 had a BMI ≥ 25 kg/m2. After adjustment for confounders, BMI < 20 kg/m2 was associated with a higher risk of one-year mortality (hazard ratio (HR) [95% confidence interval]: 1.75 [1.00-3.05], p = 0.048), while BMI ≥ 25 kg/m2 was not (HR: 1.04 [0.64-1.69], p = 0.9). However, BMI was linearly correlated with both in-hospital acute respiratory failure (p = 0.02) and cardiovascular events (p = 0.07). In this cohort of older patients hospitalized for COVID-19, low BMI, rather than high BMI, appears as an independent risk factor for death after COVID-19. The pathophysiological patterns underlying this excess mortality remain to be elucidated.

The Effect of a Hip Fragility Pathway on Outcomes of Ground Level Falls in the Elderly

Fragility hip fractures result from low energy mechanisms and are associated with morbidity and mortality, especially in the elderly. We examined outcomes 2 years before and after implementation of a fragility fracture program. The pathway involves emergency department clearance and admission by a medical service with orthopedic consultation. Demographics include age, gender, fracture location, injury severity score (ISS), and ASA. Outcomes include DVT/PE, mortality, disposition, non-operative rate, ICU admission, time to surgery (TTS), length of stay (LOS), and admission service. 777 patients were included (383 PRE/394 POS). POS patients were slightly younger. Trauma admission decreased and LOS and TTS increased. There were no other demographic or outcome differences. Although TTS increased, it remained under 48 hours. Length of stay increase was possibly a reflection of COVID-19. Decreased trauma admission demonstrates pathway adherence. Further studies need to be conducted to verify that quality care can be maintained after initiation of a hip fragility pathway.

Identifying Predictive Risk Factors for Future Cognitive Impairment Among Chinese Older Adults: Longitudinal Prediction Study

Background

The societal burden of cognitive impairment in China has prompted researchers to develop clinical prediction models aimed at making risk assessments that enable preventative interventions. However, it is unclear what types of risk factors best predict future cognitive impairment, if known risk factors make equally accurate predictions across different socioeconomic groups, and if existing prediction models are equally accurate across different subpopulations.

Objective

This paper aimed to identify which domain of health information best predicts future cognitive impairment among Chinese older adults and to examine if discrepancies exist in predictive ability across different population subsets.

Methods

Using data from the Chinese Longitudinal Healthy Longevity Survey, we quantified the ability of demographics, instrumental activities of daily living, activities of daily living, cognitive tests, social factors and hobbies, psychological factors, diet, exercise and sleep, chronic diseases, and 3 recently published logistic regression-based prediction models to predict 3-year risk of cognitive impairment in the general Chinese population and among male, female, rural-dwelling, urban-dwelling, educated, and not formally educated older adults. Predictive ability was quantified using the area under the receiver operating characteristic curve (AUC) and sensitivity-specificity curves through 20 repeats of 10-fold cross-validation.

Results

A total of 4047 participants were included in the study, of which 337 (8.3%) developed cognitive impairment 3 years after baseline data collection. The risk factor groups with the best predictive ability in the general population were demographics (AUC 0.78, 95% CI 0.77-0.78), cognitive tests (AUC 0.72, 95% CI 0.72-0.73), and instrumental activities of daily living (AUC 0.71, 95% CI 0.70-0.71). Demographics, cognitive tests, instrumental activities of daily living, and all 3 recreated prediction models had significantly higher AUCs when making predictions among female older adults compared to male older adults and among older adults with no formal education compared to those with some education.

Conclusions

This study suggests that demographics, cognitive tests, and instrumental activities of daily living are the most useful risk factors for predicting future cognitive impairment among Chinese older adults. However, the most predictive risk factors and existing models have lower predictive power among male, urban-dwelling, and educated older adults. More efforts are needed to ensure that equally accurate risk assessments can be conducted across different socioeconomic groups in China.

Application of the Geriatric Trauma Outcome Score in a Rural Setting

OBJECTIVE

To retrospectively apply the Geriatric Trauma Outcome (GTO) score to the patient population of a rural South Central Appalachian level 1 trauma center and identify the potential utility of the GTO score in guiding goals of care discussions.

METHODS

Trauma registry data was extracted for 5,627 patients aged 65+ from 2017 to 2021. GTO score was calculated for each patient. Descriptive statistics were calculated for age, Injury Severity Score (ISS), GTO score, receipt of red blood cells, discharge status, and code status. A simple logistic regression model was used to determine the relationship between GTO score and discharge status. The probability of mortality was then calculated using GTO score, and the distribution of code status among patients with ≤50, 51-75%, and >75% probability of mortality was examined.

RESULTS

For every 10-point increase in GTO score, odds of mortality increased by 79% (OR = 1.79; P < .001). Patients had an estimated 50% probability of mortality with a GTO score of 156, 75% with 174, and 99% with a score of 234, respectively. Seventeen patients had a GTO score associated with >75% probability of mortality. Of those 17 patients, four retained a full code status.

CONCLUSIONS

Our analysis demonstrates that the GTO score is a validated measure in a rural setting and can be an easily calculated metric to help determine a geriatric patient's probability of mortality following a trauma. The results of our study also found that GTO score can be used to inform goals of care discussions with patients.

Aging in Heart Failure: Embracing Biology Over Chronology: JACC Family Series

Age is among the most potent risk factors for developing heart failure and is strongly associated with adverse outcomes. As the global population continues to age and the prevalence of heart failure rises, understanding the role of aging in the development and progression of this chronic disease is essential. Although chronologic age is on a fixed course, biological aging is more variable and potentially modifiable in patients with heart failure. This review describes the current knowledge on mechanisms of biological aging that contribute to the pathogenesis of heart failure. The discussion focuses on 3 hallmarks of aging-impaired proteostasis, mitochondrial dysfunction, and deregulated nutrient sensing-that are currently being targeted in therapeutic development for older adults with heart failure. In assessing existing and emerging therapeutic strategies, the review also enumerates the importance of incorporating geriatric conditions into the management of older adults with heart failure and in ongoing clinical trials.

Exploring trajectories of functional decline and recovery among older adults: a data-driven approach

Independently performing activities of daily living (ADLs) is vital for maintaining one's quality of life. Losing this ability can significantly impact an individual's overall health status, including their mental health and social well-being. Aging is an important factor contributing to the loss of ADL abilities, and our study focuses on investigating the trajectories of functional decline and recovery in older adults. Employing trajectory analytics methodologies, this research delves into the intricate dynamics of ADL pathways, unveiling their complexity, diversity, and inherent characteristics. The study leverages a substantial dataset encompassing ADL assessments of nursing home residents with diverse disability profiles in the United States. The investigation begins by transforming these assessments into sequences of disability combinations, followed by applying various statistical measures, indicators, and visual analytics. Valuable insights are gained into the typical disability states, transitions, and patterns over time. The results also indicate that while predicting the progression of ADL disabilities presents manageable challenges, the duration of these states proves more complicated. Our findings hold significant potential for improving healthcare decision-making by enabling clinicians to anticipate possible patterns, develop targeted and effective interventions that support older patients in preserving their independence, and enhance overall care quality.

Cardiac Rehabilitation During the COVID-19 Pandemic and the Potential for Digital Technology to Support Physical Activity Maintenance: Qualitative Study

BACKGROUND

Social distancing from the COVID-19 pandemic may have decreased engagement in cardiac rehabilitation (CR) and may have had possible consequences on post-CR exercise maintenance. The increased use of technology as an adaptation may benefit post-CR participants via wearables and social media. Thus, we sought to explore the possible relationships of both the pandemic and technology on post-CR exercise maintenance.

OBJECTIVE

This study aimed to (1) understand CR participation during the COVID-19 pandemic, (2) identify perceived barriers and facilitators to physical activity after CR completion, and (3) assess willingness to use technology and social media to support physical activity needs among older adults with cardiovascular disease.

METHODS

We recruited participants aged 55 years and older in 3 different CR programs offered at both public and private hospitals in Northern California. We conducted individual interviews on CR experiences, physical activity, and potential for using technology. We used thematic analysis to synthesize the data.

RESULTS

In total, 22 participants (n=9, 41% female participants; mean age 73, SD 8 years) completed in-depth interviews. Themes from participants' feedback included the following: (1) anxiety and frustration about the wait for CR caused by COVID-19 conditions, (2) positive and safe participant experience once in CR during the pandemic, (3) greater attention needed to patients after completion of CR, (4) notable demand for technology during the pandemic and after completion of CR, and (5) social media networking during the CR program considered valuable if training is provided.

CONCLUSIONS

Individuals who completed CR identified shared concerns about continuing physical activity despite having positive experiences during the CR program. There were significant challenges during the pandemic and heightened concerns for safety and health. The idea of providing support by leveraging digital technology (wearable devices and social media for social support) resonated as a potential solution to help bridge the gap from CR to more independent physical activity. More attention is needed to help individuals experience a tailored and safe transition to home to maintain physical activity among those who complete CR.

User-Friendly Chatbot to Mitigate the Psychological Stress of Older Adults During the COVID-19 Pandemic: Development and Usability Study

BACKGROUND

To safeguard the most vulnerable individuals during the COVID-19 pandemic, numerous governments enforced measures such as stay-at-home orders, social distancing, and self-isolation. These social restrictions had a particularly negative effect on older adults, as they are more vulnerable and experience increased loneliness, which has various adverse effects, including increasing the risk of mental health problems and mortality. Chatbots can potentially reduce loneliness and provide companionship during a pandemic. However, existing chatbots do not cater to the specific needs of older adult populations.

OBJECTIVE

We aimed to develop a user-friendly chatbot tailored to the specific needs of older adults with anxiety or depressive disorders during the COVID-19 pandemic and to examine their perspectives on mental health chatbot use. The primary research objective was to investigate whether chatbots can mitigate the psychological stress of older adults during COVID-19.

METHODS

Participants were older adults belonging to two age groups (≥65 years and <65 years) from a psychiatric outpatient department who had been diagnosed with depressive or anxiety disorders by certified psychiatrists according to the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) criteria. The participants were required to use mobile phones, have internet access, and possess literacy skills. The chatbot's content includes monitoring and tracking health data and providing health information. Participants had access to the chatbot for at least 4 weeks. Self-report questionnaires for loneliness, depression, and anxiety were administered before and after chatbot use. The participants also rated their attitudes toward the chatbot.

RESULTS

A total of 35 participants (mean age 65.21, SD 7.51 years) were enrolled in the trial, comprising 74% (n=26) female and 26% (n=9) male participants. The participants demonstrated a high utilization rate during the intervention, with over 82% engaging with the chatbot daily. Loneliness significantly improved in the older group ≥65 years. This group also responded positively to the chatbot, as evidenced by changes in University of California Los Angeles Loneliness Scale scores, suggesting that this demographic can derive benefits from chatbot interaction. Conversely, the younger group, <65 years, exhibited no significant changes in loneliness after the intervention. Both the older and younger age groups provided good scores in relation to chatbot design with respect to usability (mean scores of 6.33 and 6.05, respectively) and satisfaction (mean scores of 5.33 and 5.15, respectively), rated on a 7-point Likert scale.

CONCLUSIONS

The chatbot interface was found to be user-friendly and demonstrated promising results among participants 65 years and older who were receiving care at psychiatric outpatient clinics and experiencing relatively stable symptoms of depression and anxiety. The chatbot not only provided caring companionship but also showed the potential to alleviate loneliness during the challenging circumstances of a pandemic.

Association between sarcopenia and hearing impairment in middle-aged and elderly people in China: a prospective cohort study

This study used longitudinal data from CHARLS 2011-2018 for cross-sectional and longitudinal analyses to investigate the relationship between sarcopenia and hearing impairment in middle-aged and elderly adults in China. The study selected 9723 participants aged 45 years and older from CHARLS 2011 and followed up in 2015 and 2018. Binary logistic regression and cox proportional risk regression models were used for testing. The results of the study showed that in the cross-sectional analysis, probable sarcopenia was significantly associated with hearing impairment compared with the group without sarcopenia [OR (95% CI) 0.342 (1.187, 1.669), p < 0.001], but sarcopenia was not significantly associated with hearing impairment. In the longitudinal analysis, middle-aged and elderly adults with sarcopenia [HR (95% CI) 0.354 (1.043, 1.945), p < 0.01] were more likely to have hearing impairment than those with probable sarcopenia and without sarcopenia. Probable sarcopenia was strongly associated with hearing impairment in middle-aged and elderly adults, whereas sarcopenia was a strong predictor of hearing impairment over the next 7 years. The results of this study emphasize the urgent need for measures to address sarcopenia in order to prevent and delay the decline in hearing function.

Palliative care for older adults with cardiovascular disease

Heart disease is the number one cause of death in the United States. Advanced cardiac conditions, such as heart failure, are characterized by severe symptoms, recurrent hospitalizations, limited/uncertain prognosis, decreased quality of life, and high levels of caregiver burden. The burden of heart failure is highest in older adults, for whom cardiovascular symptoms are layered on existing age-related problems such as geriatric syndromes, polypharmacy, depression, frailty, inadequate social support, decreased representation in clinical trials, and aging caregivers. Deliberate integration of outpatient and interdisciplinary geriatrics, palliative care, and cardiovascular care are essential for this special population. Life-prolonging and quality of life-focused approaches to managing cardiovascular disease are not mutually exclusive; many cardiology medications and treatments prolong life while also improving symptom burden. Symptom management, a cornerstone of palliative care, is therefore not only complementary to life-prolonging cardiology treatments, but also integral to optimized daily cardiovascular care. In this review, we aim to summarize relevant literature and provide practical tools that can be used by primary care clinicians, geriatricians, cardiologists and palliative care clinicians to optimize holistic outpatient care for adults who are aging with heart disease. While palliative care is appropriate for any age or stage of illness, we will focus on older adults with heart disease, and the nuances of managing their symptoms, goals of care, and quality of life.

Dentition and weight status in community-dwelling older adults

BACKGROUND/OBJECTIVE

Tooth loss is common among older adults and can affect dietary intake and weight status. This study investigated associations between dentition status and body mass index (BMI) in older adults.

MATERIALS AND METHODS

This was a cross-sectional study of data from a convenience sample of older adults (65-89 years) treated at an urban U.S. dental school clinic. Clinical and demographic data were obtained from electronic health records. Dentition status was determined based on data from odontograms. Multinomial logistic regression was used to estimate the odds ratio (OR) and 95% confidence interval (CI) of having a non-normal weight status for each measure of dentition status, after adjusting for covariates.

RESULTS

Patients (n = 1765) were 54.1% female, 51.5% White, 41.6% African American and 22.5% Hispanic/Latino. The median (interquartile range [IQR]) age was 71 (67.0-75.0) years; the mean (±SD) BMI was 28.5 (±5.7) kg/m2 ; 72.5% were overweight or obese. The median (IQR) number of remaining teeth was 20.0 (13.0-24.0); the median numbers of anterior and posterior occluding pairs of teeth were 5.0 (2.0-6.0) and 2.0 (0.0-5.0), respectively; and 44.9% had a functional dentition (≥21 teeth). Having a higher number of remaining teeth and more posterior occluding pairs were associated with lower odds of obesity (OR = 0.980, 95% CI = 0.964, 0.997, p = .022 and OR = 0.931, 95% CI = 0.885, 0.980, p = .006, respectively). Lack of a functional dentition was associated with higher odds of obesity (OR = 1.400, 95% CI = 1.078, 1.818, p = .012), after controlling for covariates.

CONCLUSION

Older adults with tooth loss - especially loss of posterior occlusion and lack of a functional dentition - were more likely to be obese than of normal weight.

Quality and Accessibility of Home Assessment mHealth Apps for Community Living: Systematic Review

BACKGROUND

Home assessment is a critical component of successful home modifications, enabling individuals with functional limitations to age in place comfortably. A high-quality home assessment tool should facilitate a valid and reliable assessment involving health care and housing professionals, while also engaging and empowering consumers and their caregivers who may be dealing with multiple functional limitations. Unlike traditional paper-and-pencil assessments, which require extensive training and expert knowledge and can be alienating to consumers, mobile health (mHealth) apps have the potential to engage all parties involved, empowering and activating consumers to take action. However, little is known about which apps contain all the necessary functionality, quality appraisal, and accessibility.

OBJECTIVE

This study aimed to assess the functionality, overall quality, and accessibility of mHealth home assessment apps.

METHODS

mHealth apps enabling home assessment for aging in place were identified through a comprehensive search of scholarly articles, the Apple (iOS) and Google Play (Android) stores in the United States, and fnd.io. The search was conducted between November 2022 and January 2023 following a method adapted from PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Reviewers performed a content analysis of the mobile app features to evaluate their functionality, overall quality, and accessibility. The functionality assessment used a home assessment component matrix specifically developed for this study. For overall quality, the Mobile Application Rating Scale (MARS) was used to determine the apps' effectiveness in engaging and activating consumers and their caregivers. Accessibility was assessed using the Web Content Accessibility Guidelines (WCAG) 2.1 (A and AA levels). These 3 assessments were synthesized and visualized to provide a comprehensive evaluation.

RESULTS

A total of 698 apps were initially identified. After further screening, only 6 apps remained. Our review revealed that none of the apps used thoroughly tested assessment tools, offered all the functionality required for reliable home assessment, achieved the "good" quality threshold as measured by the MARS, or met the accessibility criteria when evaluated against WCAG 2.1. However, DIYModify received the highest scores in both the overall quality and accessibility assessments. The MapIt apps also showed significant potential due to their ability to measure the 3D environment and the inclusion of a desktop version that extends the app's functionality.

CONCLUSIONS

Our review revealed that there are very few apps available within the United States that possess the necessary functionality, engaging qualities, and accessibility to effectively activate consumers and their caregivers for successful home modification. Future app development should prioritize the integration of reliable and thoroughly tested assessment tools as the foundation of the development process. Furthermore, efforts should be made to enhance the overall quality and accessibility of these apps to better engage and empower consumers to take necessary actions to age in place.

Dementia Caregiver Experiences: Insights From a Telephone-Based Support Program

Dementia caregivers face daunting challenges as both the oldest subpopulation of those providing unpaid care and the most at risk of adverse health outcomes as a result of their role, including depression, anxiety, and increased mortality. To better understand the experiences and needs of dementia caregivers, a qualitative content analysis was conducted of secondary data extracted from call logs (N = 569) recorded by a provider-initiated, telephone-based support program. Experiences identified from the call logs were coded, categorized, and ranked to determine the most prevalent dementia caregiving-related experiences. Features of the program, particularly the semi-structured call format and directionality of calls, helped to uniquely capture common experiences of family caregivers and their day-to-day concerns. Findings from this analysis reflect the high prevalence of caregiver mental and emotional health-related concerns. This analysis supports the development of interventions that align with the experiences of dementia caregivers.

Effects of ageing and frailty on circulating monocyte and dendritic cell subsets

Ageing is associated with dysregulated immune responses, resulting in impaired resilience against infections and low-grade inflammation known as inflammageing. Frailty is a measurable condition in older adults characterized by decreased health and physical impairment. Dendritic cells (DCs) and monocytes play a crucial role in initiating and steering immune responses. To assess whether their frequencies and phenotypes in the blood are affected by ageing or frailty, we performed a flow cytometry study on monocyte and DC subsets in an immune ageing cohort. We included (n = 15 in each group) healthy young controls (HYC, median age 29 years), healthy older controls (HOC, 73 years) and Frail older controls (76 years). Monocyte subsets (classical, intermediate, non-classical) were identified by CD14 and CD16 expression, and DC subsets (conventional (c)DC1, cDC2, plasmacytoid (p)DC) by CD11c, CD1c, CD141 and CD303 expression. All subsets were checked for TLR2, TLR4, HLA-DR, CD86, PDL1, CCR7 and CD40 expression. We observed a lower proportion of pDCs in HOC compared to HYC. Additionally, we found higher expression of activation markers on classical and intermediate monocytes and on cDC2 in HOC compared to HYC. Frail participants had a higher expression of CD40 on classical and non-classical monocytes compared to the HOC group. We document a substantial effect of ageing on monocytes and DCs. Reduced pDCs in older people may underlie their impaired ability to counter viral infections, whereas enhanced expression of activation markers could indicate a state of inflammageing. Future studies could elucidate the functional consequences of CD40 upregulation with frailty.

[Barriers to entry into Ehpad since the Covid-19 crisis: a qualitative study of people over 65 in Marseille]

From the outset of the Covid-19 health crisis, residential care facilities for the dependent elderly (Ehpad) were faced with health and safety challenges. Strict infection prevention measures, such as visiting restrictions and the implementation of sanitary protocols, have been essential to protect residents. While Ehpad occupancy rates were stable before the health crisis, they fell sharply in the aftermath of Covid-19.

Will-to-Live and Self-Rated Health in Older Hospitalized Patients Are Not Predictive for Short-Term Mortality

Background: Self-assessed will-to-live and self-rated health are associated with long-term survival in community-dwelling older persons but have not been examined in frailer older patients in relation to short-term prognosis. The aim was to explore whether will-to-live and self-rated health are predictive for six-month mortality and can guide ceiling of treatment decisions in hospitalized patients in an acute geriatric ward. We included the Surprise Question as reference, being a well-established clinical tool for short-term prognostication. Methods: This multicentric prospective study included patients of 75 years and older admitted at acute geriatric wards of two Belgian hospitals. Will-to-live and self-rated health were scored on a Likert scale (0-5, 0-4) and assessed by junior geriatricians. The senior geriatricians answered the Surprise Question for clinical judgment of prognosis. Receiver-operator characteristic (ROC) curves were constructed to determine diagnostic accuracy. For time-dependent analysis, Cox regression was performed with adjustment for age and gender. Results: Of 93 included patients in the study, 69 were still alive after six months and 24 died, resulting in a six-month mortality of 26%. The mean age was 86 years (range 75-100), 67% of the patients were women. Median will-to-live and self-rated health were 3 (moderate and good). Both will-to-live and self-rated health were not predictive for six-month mortality (area under the ROC curve [AUC] 0.496, p = 0.951 for will-to-live; 0.447, p = 0.442 for self-rated health) as opposed to Surprise Question (AUC 0.793, p < 0.001). After correction for sex and age, the hazard ratio of six-month mortality was 0.92 for will-to-live (p = 0.667), 0.86 for self-rated health (p = 0.548), and 10.28 for Surprise Question (p < 0.001). Conclusion: Will-to-live and self-rated health are not predictive for six-month mortality in patients admitted to the acute geriatric ward, unlike prognostic tools such as Surprise Question. Clinical Trial Registration Number: B670202100792.

Emergency Palliative Care: Early Assessment of an Older Adult With a Fall and Hip Fracture

In this segment of the emergency department (ED) palliative care case series, we present a patient who arrives to the ED after a fall resulting in a hip fracture. He is also found to have hypernatremia and an acute kidney injury and develops delirium while in the ED awaiting an inpatient bed. The ED-based integrated geriatric palliative care program is consulted and performs a multidimensional assessment. The geriatric palliative care clinician facilitates discussion with his daughter about surgical intervention based on the patient's goals and values, diagnoses delirium, and worsening depression, creates a plan for delirium and pain management, and accelerates postdischarge planning.

Comparison of chronic kidney disease progression and associated complications between geriatric and non-geriatric groups

There is no consensus on the physiologic decline in estimated glomerular filtration rate (GFR) due to geriatric conditions related with the aging or chronic kidney disease (CKD) itself. In this study, we aimed to compare the CKD progression and associated complications in a large sample of geriatric and non-geriatric patients. The data of in 506 patients at age between 30 to 90 years and diagnosed with CKD at stage 2 and above (15 mL/min/1.73 m2 ≤ eGFR < 90 mL/min/1.73 m2) were collected retrospectively and compared among geriatric (>65 years old) and non-geriatric individuals. The rate of hypertension was higher in geriatrics compared to non-geriatrics (96.6% vs 91.9%, P = .04). Among laboratory findings, only PTH level was significantly lower and HCO3 concentration was higher in geriatrics compared to non-geriatrics (P = .02, P < .001, respectively). There was no significant difference in last measured eGFR (P = .99) while that measured 4 years ago was lower in geriatrics compared to that of non-geriatrics (P < .001). eGFR change was smaller in geriatrics compared to non-geriatrics (P < .001), and rate of progressive renal disease among non-geriatric group (39%) was found to be significantly higher than in the geriatrics (17.2%) (P < .001). The prevalence of hyperkalemia was lower in geriatrics at stage 3a (P = .02); prevalence of hyperparathyroidism was lower in those at stage 3b (P = .02) and lastly the acidosis was observed significantly lower in geriatric patients at stage 3a, 3b, and 4 compared to the non-geriatrics at corresponding stages (P < .001, P = .03, and P = .04, respectively). The eGFR change was significantly smaller in geriatrics at stage 3b and 4 (P < .001 and P = .04, respectively) while the rate of progressed renal disease was lower in geriatrics at stage 3a and 3b (21.1% vs 9.9%, P = .03 and 41.2% vs 11.1%, P < .001, respectively). eGFR change in 4-year period and the rates of progressive renal disease are higher in the non-geriatrics and also the prevalence of secondary complications of CKD, such as hyperparathyroidism, acidosis, and hyperkalemia, are higher in non-geriatrics. This may reflect that decline of GFR in geriatric individuals is at least partially related to physiological aging rather than kidney disease. Therefore, devising age related CKD definitions might be appropriate.

Firearm Violence Involving Adults 65 and Older During the Novel Coronavirus Disease Pandemic

BACKGROUND

Rates of firearm violence (FV) surged during the COVID-19 pandemic. However, there is a paucity of data regarding older adults (OAs) (≥65 years old). This study aimed to evaluate patterns of FV against OAs before and after the COVID-19 pandemic, hypothesizing decreased firearm incidents, injuries, and deaths for OAs due to restricted social movement.

METHODS

Retrospective (2016-2021) data for OAs were obtained from the Gun Violence Archive. The rate of FV was weighted per 10,000 OAs using annual population data from the United States Census Bureau. Mann-Whitney U tests were performed to compare annual firearm incidence rates, number of OAs killed, and number of OAs injured from 2016-2020 to 2021.

RESULTS

From 944 OA-involved shootings, 842 died in 2021. The median total firearm incidents per month per 10,000 OAs decreased in 2021 vs 2016 (.65 vs .38, P < .001), 2017 (.63 vs .38, P < .001), 2018 (.61 vs .38, P < .001), 2019 (.39 vs .38, P = .003), and 2020 (.43 vs .38, P = .012). However, there was an increased median number of OAs killed in 2021 vs 2020 (.38 vs .38, P = .009), but no difference from 2016-2019 vs 2021 (all P > .05). The median number of firearm injuries decreased from 2017 to 2021 (.21 vs .19, P = .001) and 2020 to 2021 (.19 vs .19 P < .001).

DISCUSSION

Firearm incidents involving OAs decreased in 2021 compared to pre-pandemic years; however, there was a slight increase in deaths compared to 2020. This may reflect increased social isolation; however, future research is needed to understand why this occurred.

Development and Testing of the Foot Care Scale for Older Japanese Diabetic Patients

We aimed to develop and test the reliability and validity of a foot care self-management assessment tool for older Japanese patients with diabetes. In this cross-sectional observational study, which was carried out according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines, additional items were developed and selected to reflect older Japanese patients' needs a thorough investigation with experts in diabetes and geriatrics. A total of 200 older patients with diabetes in a foot care outpatient clinic were included in the study to finalize the scale items and verify the scale's reliability and validity. A factor analysis yielded a 4-factor, 9-item scale. Factors 1 to 4 were "skin condition" (3 items), "nail clipping" (2 items), "attention to wounds" (2 items), and "relationships with others" (2 items). The Cronbach's α coefficients for the 4 factors were .852, .900, .820, and .571, respectively. The overall scale was 0.797, indicating good internal consistency. Spearman's correlation coefficients for each of the 4 factors with the scale's total score showed good stability; all correlations were significant. In Japan's super-aged society, it is important to focus on foot care practices among older adults and to promote good foot care practices among early older adults so that they can practice self-care at home. Therefore, a scale for comprehensively evaluating foot care in elderly patients with diabetes is needed. The Foot Care Scale for Older Diabetics could be useful as a tool for assessing the ability to self-manage foot care in older Japanese patients with diabetes.

Validation of the Hospital Frailty Risk Score in older adults hospitalized with community-acquired pneumonia

AIM

Frailty results from age-associated declines in physiological reserve and function and is prevalent in older people. Our aim is to examine the association of the Hospital Frailty Risk Score (HFRS) with adverse events in older patients hospitalized with community-acquired pneumonia (CAP) and hypothesise that frailty is a comparable predictor of outcomes in CAP versus traditional severity indices such as CURB-65.

METHODS

Retrospective review of electronic medical records in patients ≥65 years with CAP admitted to a tertiary hospital from 1 January to 30 April 2021. Patients were identified using ICD codes for CAP and categorized as high risk (>15), intermediate risk (5-15) and low risk (<5) of frailty using the HFRS.

RESULTS

Of 429 patients with CAP, 53.8% male, mean age of 82.9 years, older patients (85 vs. 79.7 years, P < 0.001) were at higher risk of frailty. Using the HFRS, 47.6% were deemed at high risk, 35.9% at intermediate risk, and 16.6% at low risk of frailty. Multivariate logistic regression shows that HFRS was more strongly associated (≥7 days, OR 1.042, CI 1.017-1.069) than CURB-65 (OR 0.995, CI 0.810-1.222) with long hospital length of stay (LOS), while CURB-65 (Confusion, Urea >7mmol/L, Respiratory rate >30, Blood pressure, age => 65 years old) was more strongly associated with mortality at 30, 90 and 365 days, compared with the HFRS. Comparing the values for the area under the receiver operator characteristic curve, the HFRS was found to be a better predictor of long LOS, while CURB-65 remains a better predictor of mortality.

CONCLUSIONS

Patients with high risk of frailty have higher healthcare utilization and HFRS is a better predictor of long LOS than CURB-65 but CURB-65 was a better predictor of mortality. Geriatr Gerontol Int 2024; 24: 135-141.

Polypharmacy and risk of fractures in older adults: A systematic review

BACKGROUND

Fractures have serious health consequences in older adults. While some medications are individually associated with increased risk of falls and fractures, it is not clear if this holds true for the use of many medications (polypharmacy). We aimed to identify what is known about the association between polypharmacy and the risk of fractures in adults aged ≥65 and to examine the methods used to study this association.

METHODS

We conducted a systematic review with narrative synthesis of studies published up to October 2023 in PubMed, Embase, CINAHL, PsychINFO, Cochrane Library, Web of Science, and the grey literature. Two independent reviewers screened titles, abstracts, and full texts, then performed data extraction and quality assessment.

RESULTS

Among the 31 studies included, 11 different definitions of polypharmacy were used and were based on three medication counting methods (concurrent use 15/31, cumulative use over a period 6/31, daily average 3/31, and indeterminate 7/31). Overall, polypharmacy was frequent and associated with higher fracture risk. A dose-response relationship between increasing number of medications and increased risk of fractures was observed. However, only seven studies adjusted for major confounders (age, sex, and chronic disease). The quality of the studies ranged from poor to high.

CONCLUSIONS

Polypharmacy appears to be a relevant modifiable risk factor for fractures in older individuals that can easily be used to identify those at risk. The diversity of medication calculation methods and definitions of polypharmacy highlights the importance of a detailed methodology to understand and compare results.

Barriers and Enablers for Deprescribing Glucose-Lowering Treatment in Older Adults: A Systematic Review

OBJECTIVES

Overtreatment with glucose-lowering treatment (GLT) is frequent and a source of high morbidity and mortality in older adults with type 2 diabetes mellitus (T2DM). This study aimed to identify and synthesize barriers and enablers for deprescribing GLT in older adults (≥65 years) with T2DM.

DESIGN

Systematic review of qualitative and mixed-methods studies.

SETTING AND PARTICIPANTS

Older adults with T2DM, any participants [patients, health care providers (HCPs), caregivers], any settings.

METHODS

Two researchers (and a referred third researcher at all stages) independently screened original articles reporting qualitative and mixed-methods studies exploring barriers and enablers for deprescribing GLT in older adults published during 2010-2023, identified from MEDLINE, Embase, CINAHL, and gray literature. Quality of the included studies was assessed with the Mixed-Methods Appraisal Tool. Verbatim statements on barriers and enablers were extracted, and determinants of behaviors were identified with the Theoretical Domains Framework (TDF) version 2, and related intervention functions (targets for future interventions) were proposed according to the Behavior Change Wheel (BCW).

RESULTS

We identified only 4 studies from 2 countries (United States and the Netherlands), all recently published (2019-2023), that primarily reported barriers to GLT deprescribing from interviews or focus groups of patients or HCPs practicing outpatient medicine. Knowledge, fear, poor communication, inertia, and trust with HCPs were the main determinants of behaviors that influenced deprescribing, and education, training, persuasion and environmental restructuring were the main intervention functions for proposing future interventions. Studies did not cover financial aspects, physician characteristics, or caregiver and family viewpoints.

CONCLUSIONS AND IMPLICATIONS

The use of a behavioral theory and a validated implementation framework provided a comprehensive approach to identifying barriers and enablers for deprescribing GLT in older adults (≥65 years) with T2DM. The behavioral determinants identified may be useful in tailoring interventions to improve the implementation of GLT deprescribing in older adults in ambulatory settings.

Joe's Story: How a Capitated Payment Model Lets Me Be the Physician I Want to Be

For many years I cared for Joe, following him through diagnoses of strokes, end-stage renal disease, and metastatic prostate cancer. Gaining his trust, coordinating his care across specialist visits and hospitalizations, and helping him and his family clarify goals of care took an investment of time and relationship-building. I was able to spend this time with Joe, and all of my medically complex patients, because I had taken a job in a Program of All-Inclusive Care for the Elderly (PACE), a fully capitated model of care. With care organized around the patient instead of the visit, this payment model transformed my work life. As I reflect on the care that I provided for Joe over the years, I consider how health care organization and finance can either help or hinder our ability to provide patient-centered, coordinated, continuous care for our patients. Evolving payment models can help make space for family physicians to provide the robust primary care we are trained to deliver.

Monitoring falls in residential aged care facilities: Agreement between falls incident reports and progress notes

OBJECTIVES

Accurate fall reporting is essential for assessing the effectiveness of fall prevention strategies. This study aimed to investigate the level of agreement between incident reports and resident progress notes as data sources for falls monitoring in residential aged care facilities.

METHODS

A retrospective observational study was conducted involving 46 older people from six residential aged care facilities who had consented to join the broader TOP UP trial. Fall events documented in the incident report system and resident progress notes over 12 months before randomisation were extracted by two independent reviewers using a standardised Excel form. Agreement between the two data collection methods was calculated using Cohen's kappa coefficient.

RESULTS

A total of 75 falls were recorded from 27 (59%) of the 46 participants who were 65% female, with an average age of 83 [SD 9] years. The incident reports captured 68 (90.7%) falls, while the progress notes captured 73 (97.3%) falls. Overall, there was a 75% agreement between falls recorded in progress notes and incident reports. Perfect agreement was identified for five facilities (n = 35), while one facility had a lower agreement rate of 29% (n = 11), which appeared to be attributable to staff shortages linked to the COVID-19 pandemic.

CONCLUSIONS

There was substantial agreement between incident reports and progress records. These findings support the use of incident reports for identifying falls in research or to investigate the effectiveness of fall prevention strategies in residential aged care facilities.

Integra at Home: A flexible continuum of in-home medical care for older adults with complex needs

BACKGROUND

As individuals age, they may need new strategies to manage exacerbations of chronic disease to maintain their dignity and independence. Many end up in a revolving cycle of emergency department visits, hospitalizations, and post-acute care. Support to stay at home, which is often their preference, becomes a challenge and varies with insurance coverage, location, and financial status. There are few home-based options sufficiently agile enough to respond when acute conditions arise particularly with exacerbations of chronic disease.

METHODS

In 2018, Integra designed a home-based option to treat acute exacerbations of chronic illness. A partnership with community paramedicine enabled faster response times and provided additional treatment tools. Using process improvement methodology, we developed "Integra at Home" workflows and team-based care. We counted averted emergency visits and hospitalizations, patient and staff satisfaction, and evidence of financial sustainability as a result of our program.

RESULTS

Integra successfully developed a suite of home-based services, including responses to acute problems, to address beneficiaries' fluctuating medical needs. Following responses to 415 acute events, 74% (N = 307) resulted in averted emergency department visits. Based on InterQual® criteria, 34% (N = 103) of averted visits would have qualified as an averted hospitalization. All 64 respondents to patient surveys (N = 170) stated they would recommend our program. The staff indicated the model is a better way of caring for patients with higher rewards than traditional settings. The average length of stay in hospice for patients referred from the program (N = 22) was 4 weeks.

CONCLUSIONS

Home-based care continuums are feasible, yet resources to manage acute exacerbations remain inadequate. To fill this gap, we created higher acuity services to respond to urgent needs and monitor symptoms between episodes. Amid successes and challenges, we are serving higher acuity older adults in Integra's home-based continuum model. We encourage further spread of longitudinal home-based acute care models.

Effect of number of medications on the risk of falls among community-dwelling older adults: A 3-year follow-up of the SONIC study

AIM

This study examined the association between the number of prescribed medications and falls among community-dwelling older adults.

METHODS

We conducted a geriatric comprehensive health-checkup on community-dwelling adults aged 69-91 years who participated in the Septuagenarians, Octogenarians, and Nonagenarians Investigation with Centenarians study. The final analysis of this study included 1,076 participants with complete data. The participants were divided into four groups based on the number of medications at baseline: 0, 1, 2-4, and ≥5. At the 3-year follow-up, the participants were asked whether they had fallen in the past year. Multivariable logistic regression analysis was performed to assess the relationship between the number of medications taken and falls after adjusting for confounding factors.

RESULTS

The prevalence rates of falls were 10.5%, 18.2%, 18.3%, and 19.8% in the no-medication, one-medication, comedication, and polypharmacy groups, respectively. In the one-medication prescription group, 59% of prescriptions were for fall-risk-increasing drugs (FRID). Multivariable analysis showed a significantly higher incidence of falls in the one-medication group (adjusted odds ratio [OR], 1.91; 95% confidence interval [CI], 1.04-3.54), co-medication (OR, 1.89; 95% CI, 1.09-3.29), and polypharmacy groups (OR, 1.94; 95% CI, 1.09-3.45) than in the no-medication group.

CONCLUSIONS

The study showed that polypharmacy, as well as just taking one medication, can affect the occurrence of falls. This suggests that in addition to the number of medications and polypharmacy, the type of medication, such as FRID, affects the risk of falls. Therefore, pharmacotherapy should consider the risk of falls in older adults when prescribing medications. Geriatr Gerontol Int 2024; 24: 306-310.

What Clinicians and Researchers Should Know About the Evolving Field of Advance Care Planning: a Narrative Review

Advance care planning (ACP) has been recognized as crucial by patients, families, and clinicians; however, different definitions and measurements have led to inconsistencies in practice and mixed evidence in the literature. This narrative review explores ACP's evolution, innovations, and outcomes using thematic analysis to synthesize data from randomized controlled trials, reviews, and editorials. Key findings include (1) ACP has evolved over the past several decades from a sole focus on code status and advance directive (AD) forms to a continuum of care planning over the life course focused on tailored preparation for patients and surrogate decision-makers and (2) ACP measurement has evolved from traditional outcome metrics, such as AD completion, to a comprehensive outcomes framework that includes behavior change theory, systems, implementation science, and a focus on surrogate outcomes. Since the recent development of an ACP consensus definition and outcomes framework, high-quality trials have reported mainly positive outcomes for interventions, especially for surrogates, which aligns with the patient desire to relieve decision-making burden for loved ones. Additionally, measurement of "clinically meaningful" ACP information, including documented goals of care discussions, is increasingly being integrated into electronic health records (EHR), and emerging, real-time assessments and natural language processing are enhancing ACP evaluation. To make things easier for patients, families, and care teams, clinicians and researchers can use and disseminate these evolved definitions; provide patients validated, easy-to-use tools that prime patients for conversations and decrease health disparities; use easy-to-access clinician training and simple scripts for interdisciplinary team members; and document patients' values and preferences in the medical record to capture clinically meaningful ACP so this information is available at the point of care. Future efforts should focus on efficient implementation, expanded reimbursement options, and seamless integration of EHR documentation to ensure ACP's continued evolution to better serve patients and their care partners.

Sex Differences Among Older Adults With Bipolar Disorder: Results From the Global Aging & Geriatric Experiments in Bipolar Disorder (GAGE-BD) Project

OBJECTIVE

Sex-specific research in adult bipolar disorder (BD) is sparse and even more so among those with older age bipolar disorder (OABD). Knowledge about sex differences across the bipolar lifespan is urgently needed to target and improve treatment. To address this gap, the current study examined sex differences in the domains of clinical presentation, general functioning, and mood symptoms among individuals with OABD.

METHODS

This Global Aging & Geriatric Experiments in Bipolar Disorder (GAGE-BD) study used data from 19 international studies including BD patients aged ≥50 years (N = 1,185: 645 women, 540 men).A comparison of mood symptoms between women and men was conducted initially using two-tailed t tests and then accounting for systematic differences between the contributing cohorts by performing generalized linear mixed models (GLMMs). Associations between sex and other clinical characteristics were examined using GLMM including: age, BD subtype, rapid cycling, psychiatric hospitalization, lifetime psychiatric comorbidity, and physical health comorbidity, with study cohort as a random intercept.

RESULTS

Regarding depressive mood symptoms, women had higher scores on anxiety and hypochondriasis items. Female sex was associated with more psychiatric hospitalizations and male sex with lifetime substance abuse disorders.

CONCLUSION

Our findings show important clinical sex differences and provide support that older age women experience a more severe course of BD, with higher rates of psychiatric hospitalization. The reasons for this may be biological, psychological, or social. These differences as well as underlying mechanisms should be a focus for healthcare professionals and need to be studied further.

An Evaluation of the National Early Warning Score 2 and the Laboratory Data Decision Tree Early Warning Score in Predicting Mortality in Geriatric Patients

BACKGROUND

Due to the high rate of geriatric patient visits, scoring systems are needed to predict increasing mortality rates.

OBJECTIVE

In this study, we aimed to investigate the in-hospital mortality prediction power of the National Early Warning Score 2 (NEWS2) and the Laboratory Data Decision Tree Early Warning Score (LDT-EWS), which consists of frequently performed laboratory parameters.

METHODS

We retrospectively analyzed 651 geriatric patients who visited the emergency department (ED), were not discharged on the same day from ED, and were hospitalized. The patients were categorized according to their in-hospital mortality status. The NEWS2 and LDT-EWS values of these patients were calculated and compared on the basis of deceased and living patients.

RESULTS

Median (interquartile range [IQR]) NEWS2 and LDT-EWS values of the 127 patients who died were found to be statistically significantly higher than those of the patients who survived (NEWS2: 5 [3-8] vs. 3 [1-5]; p < 0.001; LDT-EWS: 8 [7-10] vs. 6 [5-8]; p < 0.001). In the receiver operating characteristic curve analysis, the NEWS2, LDT-EWS, and NEWS2+LDT-EWS-formed by the sum of the two scoring systems-resulted in 0.717, 0.705, and 0.775 area under curve values, respectively.

CONCLUSIONS

The NEWS2 and LDT-EWS were found to be valuable for predicting in-hospital mortality in geriatric patients. The power of the NEWS2 to predict in-hospital mortality increased when used with the LDT-EWS.