Journal of the American Geriatrics Society最新文献

{"title":"Caring for dementia caregivers: How well does social risk screening reflect unmet needs?","authors":"Victoria A. Winslow MPH,&nbsp;Stacy Tessler Lindau MD,&nbsp;Elbert S. Huang MD,&nbsp;Spencer Asay BS,&nbsp;Amber E. Johnson MD,&nbsp;Soo Borson MD,&nbsp;Katherine Thompson MD,&nbsp;Jennifer A. Makelarski PhD","doi":"10.1111/jgs.19200","DOIUrl":"10.1111/jgs.19200","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Unmet social and caregiving needs can make caregiving for a person with dementia more difficult. Although national policy encourages adoption of systematic screening for health-related social risks (HRSRs) in clinical settings, the accuracy of these risk-based screening tools for detecting unmet social needs is unknown.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We used baseline data from dementia caregivers (<i>N</i> = 343) enrolled in a randomized controlled trial evaluating CommunityRx-Dementia, a social care intervention conducted on Chicago's South Side. We assessed caregivers' (1) unmet social and caregiving needs by querying need for 14 resource types and (2) HRSRs using the Center for Medicare &amp; Medicaid Services (CMS) Accountable Health Communities (AHC) screening tool. Using unmet social needs as the reference, we examined the sensitivity of the AHC tool to detect food, housing, and transportation needs. Analyses were stratified by gender.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Most caregivers were women (78%), non-Hispanic (96%), Black (81%), partnered (58%) and had an annual household income ≥$50K (64%). Unmet social and caregiving needs were similarly prevalent among women and men caregivers (87% had ≥1 need, 43% had ≥5 needs). HRSRs were also prevalent. The most common HRSR was lack of social support (45%). Housing instability, difficulty with utilities and having any HRSRs were significantly more prevalent among women (all <i>p</i> &lt; 0.05). The AHC screener had low sensitivity for detecting unmet food (39%, 95% confidence interval [CI]: 27%–53%), housing (42%, 95% CI: 31%–53%), and transportation (22%, 95% CI: 14%–31%) needs. Sensitivity did not differ by gender for food (41% for women and 30% for men, <i>p</i> = 0.72) or housing (44% for women and 29% for men, <i>p</i> = 0.37) needs. For transportation needs, sensitivity was 27% for women versus 0% for men (<i>p</i> = 0.01).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Men and women caregivers have high rates of unmet social needs that are often missed by the CMS-recommended risk-based screening method. Findings indicate a role for need-based screening in implementing social care.</p>\u0000 </section>\u0000 </div>","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"73 1","pages":"63-73"},"PeriodicalIF":4.3,"publicationDate":"2024-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11734105/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142309529","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"VSED bridge to MAID: Spotlighting better end-of-life options","authors":"Thaddeus M. Pope JD, PhD,&nbsp;Lisa Brodoff JD","doi":"10.1111/jgs.19197","DOIUrl":"10.1111/jgs.19197","url":null,"abstract":"&lt;p&gt;We thank Jaggard and Sams for their thoughtful comments on our article and on increasing patient access to person-centered palliative and hospice care.&lt;span&gt;&lt;sup&gt;1, 2&lt;/sup&gt;&lt;/span&gt; Here, we respond to their critiques of Medical Aid in Dying (MAID) and we expand our analysis of when voluntarily stopping eating and drinking (VSED) could be used as a bridge to MAID.&lt;/p&gt;&lt;p&gt;In our article, we explained that patients with dementia are not eligible for MAID based solely on their dementia diagnosis.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; Because of their dementia, these patients would no longer have decision-making capacity by the time they were determined to have a terminal illness, defined as six months from death. Yet, because many of these patients want access to MAID, we defended a path to eligibility by bridging VSED to speed the diagnosis to a less-than-six-month terminal condition.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; Jaggard and Sams oppose not only this combination but also other expansions of MAID and even MAID itself. We now address all three of their opposition points.&lt;/p&gt;&lt;p&gt;Jaggard and Sams are correct that access to MAID has been expanding. MAID states have: (1) shortened or permitted waiver of waiting periods, (2) authorized APRNs and PAs as prescribers, and (3) eliminated residency requirements.&lt;span&gt;&lt;sup&gt;3, 4&lt;/sup&gt;&lt;/span&gt; Jaggard and Sams describe these advances as “harmful expansions.”&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; But they cite no evidence, nor is any available, that any of these changes adversely impact patient safety. Instead, Jaggard and Sams commit the is/ought fallacy by abruptly moving from statements of fact to statements of value without explanation. The bare fact that MAID numbers are increasing cannot tell us whether those increases should be celebrated or avoided.&lt;/p&gt;&lt;p&gt;We celebrate expanded access to MAID because it promotes value-concordant care. Recent changes in most MAID states were carefully vetted through the state legislative process.&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; They were enacted in response both to robust evidence of impediments and to demand by constituents for broader availability. For example, because many patients do not explore MAID until late in their illness trajectory, they cannot survive the original 15-day waiting period. That led six MAID states to shorten or waive the waiting period.&lt;span&gt;&lt;sup&gt;3, 4&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;The basis of Jaggard and Sams's opposition to expanded access is not patient safety but value-based opposition to MAID itself. They argue we “should not legalize this practice in the first place” and “doctors should not prescribe death.”&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; While we respect that minority position, we note that all MAID laws permit both individual clinicians and entities to opt out of participation.&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; Most religiously affiliated facilities have declined to offer MAID.&lt;/p&gt;&lt;p&gt;Jaggard and Sams confuse matters when they state that “there are alternatives” to MAID and that patients “need” hospice. Th","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"73 1","pages":"314-315"},"PeriodicalIF":4.3,"publicationDate":"2024-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.19197","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142335365","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"End-of-life emergency department use and healthcare expenditures among older adults: A nationally representative study","authors":"Cameron J. Gettel MD, MHS,&nbsp;Courtney Kitchen BA,&nbsp;Craig Rothenberg MPH,&nbsp;Yuxiao Song MS,&nbsp;Susan N. Hastings MD, MHSc,&nbsp;Maura Kennedy MD, MPH,&nbsp;Kei Ouchi MD, MPH,&nbsp;Adrian D. Haimovich MD, PhD,&nbsp;Ula Hwang MD, MPH,&nbsp;Arjun K. Venkatesh MD, MBA, MHS","doi":"10.1111/jgs.19199","DOIUrl":"10.1111/jgs.19199","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Emergency department (ED) visits at end-of-life may cause financial strain and serve as a marker of inadequate access to community services and health care. We sought to examine end-of-life ED use, total healthcare spending, and out-of-pocket spending in a nationally representative sample.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Using Medicare Current Beneficiary Survey data, we conducted a pooled cross-sectional analysis of Medicare beneficiaries aged 65+ years with a date of death between July 1, 2015 and December 31, 2021. Our primary outcomes were ED visits, total healthcare spending, and out-of-pocket spending in the 7, 30, 90, and 180 days preceding death. We estimated a series of zero-inflated negative binomial models identifying patient characteristics associated with the primary outcomes.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Among 3812 older adult decedents, 610 (16%), 1207 (31.7%), 1582 (41.5%), and 1787 (46.9%) Medicare beneficiaries had ED visits in the final 7, 30, 90, and 180 days, respectively, of life. For Medicare beneficiaries with at least one ED visit in the final 30 days of life, the median total and out-of-pocket costs were, respectively, $12,500 and $308, compared, respectively, with $278 and $94 for those without any ED visits (<i>p</i> &lt; 0.001 for both comparisons). Having a diagnosis of dementia (odds ratio [OR] 0.71; 95% confidence interval [CI] 0.51–0.99; <i>p</i> = 0.04) and being on hospice status during the year of death (OR 0.56; 95% CI 0.48–0.66; <i>p</i> = &lt;0.001) were associated with a decreased likelihood of having an ED visit. Having dementia was associated with a decreased likelihood of having any healthcare spending (OR 0.50; 95% CI 0.36–0.71; <i>p</i> = 0.001) and any out-of-pocket spending (OR 0.51; 95% CI 0.36–0.72; <i>p</i> = &lt;0.001).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>One in three older adults visit the ED in the last month of life, and approximately one in two utilize ED services in the last half-year of life, with evidence of associated considerable total and out-of-pocket spending.</p>\u0000 </section>\u0000 </div>","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"73 1","pages":"101-111"},"PeriodicalIF":4.3,"publicationDate":"2024-09-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142305005","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Identifying and quantifying potentially problematic prescribing cascades in clinical practice: A mixed-methods study","authors":"Atiya K. Mohammad MSc,&nbsp;Jacqueline G. Hugtenburg PharmD, PhD,&nbsp;Joost W. Vanhommerig PhD,&nbsp;Patricia M. L. A. van den Bemt PharmD, PhD,&nbsp;Petra Denig PharmD, PhD,&nbsp;Fatma Karapinar-Carkıt PharmD, PhD","doi":"10.1111/jgs.19191","DOIUrl":"10.1111/jgs.19191","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>A prescribing cascade occurs when medication causes an adverse drug reaction (ADR) that leads to the prescription of additional medication. Prescribing cascades can cause excess medication burden, which is of particular concern in older adults. This study aims to identify and quantify potentially problematic prescribing cascades relevant for clinical practice.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>A mixed-methods study was conducted. First, prescribing cascades were identified through literature search. An expert panel (<i>n</i> = 16) of pharmacists and physicians assessed whether these prescribing cascades were potentially problematic. Next, a cohort study quantified potentially problematic prescribing cascades in adults using Dutch community pharmacy data for the period 2015–2020. Additionally, the influence of multiple medications potentially causing the same ADR was evaluated. Prescription sequence symmetry analysis was used to calculate adjusted sequence ratios (aSRs), adjusting for temporal prescribing trends. An aSR &gt;1.0 indicates the occurrence of a prescribing cascade. In a subgroup analysis, aSRs were calculated for older adults.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Seventy-six prescribing cascades were identified in literature and three were provided by experts. Of these, 66 (83.5%) were considered potentially problematic. A significant positive aSR for the medication sequence was found for 41 (62.1%) of these prescribing cascades. The highest aSR was found for amiodarone potentially causing hypothyroidism treated with thyroid hormones (4.63 [95% confidence interval 4.40–4.85]), based on 565 incident users. The biggest population (<i>n</i> = 34,645) was found for angiotensin converting enzyme-inhibitors potentially causing urinary tract infections treated with antibiotics. Regarding four potential ADRs, the aSRs were higher for people using multiple medications that cause the same ADR as compared to people using only one of those medications. Among older adults the aSRs remained significant for 37 prescribing cascades.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>An overview was generated of potentially problematic prescribing cascades relevant for clinical practice. These results can support healthcare providers to intervene and reduce medication burden for older adults.</p>\u0000 </section>\u0000 </div>","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"72 12","pages":"3681-3694"},"PeriodicalIF":4.3,"publicationDate":"2024-09-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11637293/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142305006","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Antipsychotics for nursing home residents with dementia: Chemical restraints or essential therapeutic intervention?","authors":"Joseph G. Ouslander MD","doi":"10.1111/jgs.19198","DOIUrl":"10.1111/jgs.19198","url":null,"abstract":"&lt;p&gt;In this issue of the Journal of the American Geriatrics Society, Dr. Theresa Shireman and her colleagues from Brown University and the University of Michigan make the case that federal policies on antipsychotics were not responsible for the increased rates of exclusionary diagnoses in U.S. nursing homes (diagnoses for which antipsychotic use is appropriate, including schizophrenia, Tourette's syndrome, and Huntington's disease) during the period of 2009–2018.&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; Five years after this data collection period ended, in January of 2023, the Centers for Medicare and Medicaid Services (CMS) announced plans to conduct audits of schizophrenia coding and related antipsychotic prescription in nursing homes, and for facilities that fail the audit, adjust the overall quality measure component of their Five-Star rating for six months downward to a rating of one Star. This would have the net effect of dropping a nursing home's overall Five-Star rating by one star.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; Five-Star ratings are calculated based on quality measures, as well as health inspection (survey) results, nursing staffing levels, and nurse and administrator turnover. These ratings are meant to be used by consumers to select nursing homes, and a drop of one star could negatively affect a nursing home's census and revenue by influencing potential patient and family perceptions, and in some cases, make the facility ineligible for Medicare Advantage program waivers of the 3-day hospital stay requirement and the ability to directly admit people from home or the Emergency Department. These waivers generally require a minimum three-star rating.&lt;/p&gt;&lt;p&gt;The use of antipsychotics as “chemical restraints” in nursing home residents with dementia and related behavioral symptoms, such as verbal agitation and physical aggression, has been discussed in the medical literature and lay press for decades. Many studies document that these drugs are associated with an increase in all-cause mortality and the risk of stroke and myocardial infarction among older people, nursing home residents in general, and nursing home residents with dementia in particular.&lt;span&gt;&lt;sup&gt;3, 4&lt;/sup&gt;&lt;/span&gt; Antipsychotics may impair glucose tolerance and are associated with weight gain and obesity, can be sedating and cause hypotension, and can have significant extrapyramidal side effects, including tardive dyskinesia, gait disturbances, and bradykinesia. These side effects can in turn not only lead to metabolic and cardiovascular consequences but can increase the risk of conditions that cause mortality. For example, hypotension and effects on mentation and mobility can increase the risk of falls and related injuries, as well as death. Sedation and altered mental status can also interfere with quality of life by reducing the ability to participate in various activities, and exercise, as well as predispose to aspiration and complications including death. Not all studies demonstrate these advers","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"72 12","pages":"3634-3637"},"PeriodicalIF":4.3,"publicationDate":"2024-09-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.19198","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142305003","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Dexmedetomidine for agitation in dementia: Current data and future direction.","authors":"Kayla S Murphy,Julia C Golden,Rajesh R Tampi","doi":"10.1111/jgs.19196","DOIUrl":"https://doi.org/10.1111/jgs.19196","url":null,"abstract":"BACKGROUNDThe incidence and prevalence of dementia, and thus dementia-related behavioral and psychological symptoms, are increasing significantly. Currently, there are limited safe and efficacious options for treating these symptoms. Dexmedetomidine has been used for agitation related to delirium and showed significant benefit in prior studies. This raises the question whether dexmedetomidine could also provide a safe and effective treatment for BPSD, including agitation related to dementia.METHODSOur team searched PubMed, Cochrane Database, and Ovid with the terms dexmedetomidine and dementia. Only studies published in English language journals, or with official English language translations, and human studies were included. All reports of dexmedetomidine for dementia were included regardless of study type.RESULTSNo completed studies on dexmedetomidine for agitation in dementia were identified. The TRANQUILITY study is in progress, although results are yet to be published.CONCLUSIONDexmedetomidine has shown benefit for hospital delirium and for agitation in schizophrenia and bipolar disorder. However, there are no completed studies published on dexmedetomidine for agitation in dementia. Controlled studies with larger sample sizes are needed to assess the efficacy, safety, and the best route of administration for this drug in managing BPSD including agitation.","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"191 1","pages":""},"PeriodicalIF":6.3,"publicationDate":"2024-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142251927","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cardiovascular health, measured using Life's Essential 8, is associated with reduced dementia risk among older men and women","authors":"Xin Li MSPH,&nbsp;Yichen Jin MSPH,&nbsp;Stefania Bandinelli MD,&nbsp;Luigi Ferrucci MD, PhD,&nbsp;Toshiko Tanaka PhD,&nbsp;Sameera A. Talegawkar PhD","doi":"10.1111/jgs.19194","DOIUrl":"10.1111/jgs.19194","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Dementia poses considerable challenges to healthy aging. Prevention and management of dementia are essential given the lack of effective treatments for this condition.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>A secondary data analysis was conducted using data from 928 InCHIANTI study participants (55% female) aged 65 years and older without dementia at baseline. Cardiovascular health (CVH) was assessed by the “Life's Essential 8” (LE8) metric that included health behaviors (diet, physical activity, smoking status, sleep duration) and health factors (body mass index, blood lipid, blood glucose, blood pressure). This new LE8 metric scores from 0 to 100, with categorization including “low LE8” (0–49), indicating low CVH, “moderate LE8 (50-79)”, indicating moderate CVH, and “high LE8 (80-100)”, indicating high CVH. Dementia was ascertained by a combination of neuropsychological testing and clinical assessment at each follow-up visit. Cox proportional hazards models were used to examine associations between CVH at baseline and risk of incident dementia after a median follow-up of 14 years.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Better CVH (moderate/high LE8 vs. low LE8) was inversely associated with the risk of incident dementia (hazard ratio [HR]: 0.61, 95% confidence interval [CI]: 0.46–0.83, <i>p</i> = 0.001). Compared with health factors, higher scores of the health behaviors (per 1 standard deviation [SD]), specifically weekly moderate-to-vigorous physical activity time (per 1 SD), were significantly associated with a lower risk of incident dementia (health behaviors: HR:0.84, CI:0.73–0.96, <i>p</i> = 0.01; physical activity: HR: 0.62, CI: 0.53–0.72, <i>p</i> &lt; 0.001).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>While longitudinal studies with repeated measures of CVH are needed to confirm these findings, improving CVH, measured by the LE8 metric, may be a promising dementia prevention strategy.</p>\u0000 </section>\u0000 </div>","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"72 12","pages":"3695-3704"},"PeriodicalIF":4.3,"publicationDate":"2024-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142251625","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The quality of home-based primary care delivered by nurse practitioners: A national Medicare claims analysis","authors":"Jennifer Perloff PhD,&nbsp;Alex Hoyt PhD,&nbsp;Meera Srinivasan MS,&nbsp;Michelle Alvarez MSN,&nbsp;Sam Sobul MPA,&nbsp;Monica O'Reilly-Jacob PhD","doi":"10.1111/jgs.19182","DOIUrl":"10.1111/jgs.19182","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>As the US population ages, there is an increasing demand for home-based primary care (HBPC) by those with Alzheimer's/dementia, multiple chronic conditions, severe physical limitations, or those facing end-of life. Nurse practitioners (NPs) are increasingly providing HBPC, yet little is known about their quality of care in this unique setting.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This observational study uses Medicare claims data from 2018 to assess the quality of care for high-intensity HBPC users (5 or more visits/year) based on provider type (NP-only, physician (MD)-only, or both NP and MDs). We employ 12 quality measures from 3 care domains: access and prevention, acute care utilization, and end-of-life. Analysis includes bivariate comparisons and logistic regression models that adjust for demographic, clinical, and geographic characteristics.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Among the 574,567 beneficiaries with 5 or more HBPC visits, 37% saw an NP, 37% saw a MD, and 27% saw both NPs and MDs. In multivariate models, those receiving HBPC from an NP or both NP-MD are significantly more likely to receive a flu shot than the MD-only group, but less likely to access preventive care. NP-only care is associated with more acute care hospitalizations, avoidable ED visits, and fall-related injuries, but significantly fewer avoidable admissions. For end-of-life care, those with NP-only or both NP-MD care are significantly more likely to have an advanced directive, be in hospice in the last 3 days of life, and more likely to die in hospice. The NP group is also more likely to die in the next year.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>HBPC patients are complex, with both palliative and curative needs. NPs provide almost half of HBPC in the Medicare program, to patients who are possibly sicker than those treated by physicians, with similar quality to MDs.</p>\u0000 </section>\u0000 </div>","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"72 12","pages":"3763-3772"},"PeriodicalIF":4.3,"publicationDate":"2024-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.19182","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142251626","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical momentum in the care of older adults with advanced dementia: What evidence is there in the medical record?","authors":"Lily N. Stalter MS,&nbsp;Bret M. Hanlon PhD,&nbsp;Kyle J. Bushaw MA,&nbsp;Taylor Bradley BS,&nbsp;Anne Buffington MPH,&nbsp;Karlie Zychowski MD,&nbsp;Alex Dudek RN, BSN,&nbsp;Sarah I. Zaza MD,&nbsp;Melanie Fritz MD,&nbsp;Kristine Kwekkeboom PhD, RN, FAAN,&nbsp;Margaret L. Schwarze MD, MPP","doi":"10.1111/jgs.19192","DOIUrl":"10.1111/jgs.19192","url":null,"abstract":"&lt;p&gt;Overtreatment at the end of life contributes to poor quality of life, is often discordant with patient preferences, and strains healthcare systems.&lt;span&gt;&lt;sup&gt;1, 2&lt;/sup&gt;&lt;/span&gt; “Clinical momentum” is a conceptual model to describe the latent, systems-level forces that create an inevitable trajectory toward intervention near the end of life.&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; Feeding tube placement in patients with advanced dementia is a clear example of overtreatment at the end of life, given the associated harms and limited benefits.&lt;span&gt;&lt;sup&gt;4&lt;/sup&gt;&lt;/span&gt; This study builds on qualitative work describing the contribution of clinical momentum to feeding tube placement and aims to identify previously characterized markers of clinical momentum in the medical record.&lt;span&gt;&lt;sup&gt;5&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;We conducted a retrospective, single-center, matched case-control study. We used an Electronic Health Record (EHR) search to identify all hospitalized older adults (age ≥65) with a dementia diagnosis and activated healthcare agent during an unplanned admission of ≥3 days between January 2015 and December 2022. We confirmed patients' dementia diagnosis via chart review. The case group included patients who received a permanent feeding tube (i.e., Gastrostomy, Gastrojejunostomy, or Jejunostomy tube). We 1-1 matched controls, patients who did not receive a permanent feeding tube, with cases based on age, sex, and admitting diagnosis. We excluded patients with a preexisting feeding tube. The University of Wisconsin institutional review board deemed this study exempt.&lt;/p&gt;&lt;p&gt;We abstracted data from one admission per patient, capturing controls' last encounter, using a standardized manual chart abstraction form, including hospital events (e.g., aspiration, consultations) identified in previous qualitative work.&lt;span&gt;&lt;sup&gt;5&lt;/sup&gt;&lt;/span&gt; We used Fisher's exact tests and &lt;i&gt;t&lt;/i&gt;-tests to compare groups' baseline characteristics. We cataloged hospital trajectories and the frequency of event combinations leading to permanent feeding tube placement in the case group and death or discharge for the control group, displayed via UpSet Plot.&lt;span&gt;&lt;sup&gt;6&lt;/sup&gt;&lt;/span&gt; Analyses were performed in SAS software (version 9.4, SAS Institute Inc., Cary, North Carolina).&lt;/p&gt;&lt;p&gt;We identified 34 cases and 34 matched controls. The mean age (SD) was 80.2 (8.7), and 34 (50%) were male. Demographic characteristics were similar between groups (Table 1). Although not statistically significant, case patients had a lower mean Charlson comorbidity score (8.8 (3.6) vs. 10.3 (3.2), &lt;i&gt;p&lt;/i&gt; = 0.082).&lt;/p&gt;&lt;p&gt;The median (interquartile range (IQR)) length of stay was 21.5 (15–43) days among cases and 5 (4–9) days among controls. At the median, feeding tubes were placed on day 15 (IQR 7–18) of admission. One case patient and three control patients died in the hospital. On average, patients in the case group experienced 9.0 (2.2) unique hospital events before feeding tube placement, while control patients e","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"73 1","pages":"297-301"},"PeriodicalIF":4.3,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11734092/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142305004","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Home alone and high risk: Supporting medication management in older adults living alone with cognitive impairment","authors":"Peter M. Hoang MD,&nbsp;Nathan M. Stall MD, PhD,&nbsp;Paula A. Rochon MD, MPH","doi":"10.1111/jgs.19186","DOIUrl":"10.1111/jgs.19186","url":null,"abstract":"&lt;p&gt;Older adults living with cognitive impairment are at increased risk of medication nonadherence and administration errors, which can result in an increased risk of hospitalization and death.&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; Currently, one quarter of older adults living with cognitive impairment reside at home alone.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; These individuals are mostly women who often have no support or oversight for medication management, placing them at risk for adverse drug events. In this issue of the &lt;i&gt;Journal of the American Geriatrics Society&lt;/i&gt;, Growdon et al.&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; describe and compare high-risk medication use among older adults living with cognitive impairment who were either residing with others or living alone.&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;The cross-sectional study used data from the National Health and Aging Trends Study (NHATS), a nationally representative longitudinal cohort of Medicare beneficiaries, aged 65 years and older.&lt;span&gt;&lt;sup&gt;4&lt;/sup&gt;&lt;/span&gt; Individuals were included if they had cognitive impairment identified by a validated algorithm, were aged 66 years or older, enrolled in Medicare part D for a year or more, had at least one prescription claim in the last 6 months, and resided in a community setting. Individuals self-reported whether they lived alone, if they received support with medication administration, and if they had any difficulty with medication use. The primary outcome was being on one or more high-risk medication, defined as (1) highly sedating and/or anticholinergic medications or medications on the 2023 American Geriatrics Society Beers Criteria,&lt;span&gt;&lt;sup&gt;5&lt;/sup&gt;&lt;/span&gt; (2) anticoagulants, (3) sulfonylureas, (4) insulin, and/or (5) opioid medications.&lt;/p&gt;&lt;p&gt;Among 1569 older adults living with cognitive impairment, about a third resided alone. Individuals living alone were more likely to be older, be female, have a diagnosis of mild cognitive impairment as compared with dementia, and have fewer comorbidities. Seventy-nine percent of those living alone did not receive any help with medication administration, whereas 54% of those living with others received help. Eighteen percent of those living alone required total support with medications, and 14% had some difficulty with medication administration. The median number of prescribed medications was similar among those living alone versus with others. Forty-six percent of those living alone were on at least one high-risk medication, compared with 52% of those living with others (&lt;i&gt;p&lt;/i&gt; = 0.06, unadjusted analyses). As such, although living alone was not associated with an increased risk of being prescribed one or more high-risk medication, living alone was associated with being prescribed one or more high-risk medication and not receiving help with medication management (34% of those living alone vs. 23% of those living with others, &lt;i&gt;p&lt;/i&gt; = 0.003).&lt;/p&gt;&lt;p&gt;Limitations of the study included the inability to evaluate the use of over-the-counter","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"72 12","pages":"3631-3633"},"PeriodicalIF":4.3,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.19186","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142252188","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}