Kaplan-Meier analysis of time to first all-cause readmission over 12 months among older adults with ischemic heart disease randomized to 3 months of mobile health cardiac rehabilitation (mHealth-CR) or usual care. There was no significant difference in time to first readmission between groups (log-rank P = 0.26).
BACKGROUND:Best Case/Worst Case (BC/WC) is a communication tool to support nephrologists and older adults with advanced chronic kidney disease with decisions about dialysis. We compared the effectiveness of training nephrologists to use BC/WC versus usual care on receipt of palliative care, quality of life (QOL), quality of communication, dialysis initiation, and death. PARTICIPANTS AND SETTING:From February 2021 to December 2023, we enrolled patients at 10 US sites who were ≥ 60 years, had an estimated glomerular filtration rate (eGFR) ≤ 24 mL/min/1.73m2, with estimated survival ≤ 18 months, and were considering dialysis initiation in the outpatient setting. We randomized nephrologists to intervention or usual care. METHODS:In this cluster randomized trial, we followed patients for up to 2 years using chart review and patient and caregiver surveys. The primary outcome was receipt of palliative care within 12 months of patient enrollment. RESULTS:We enrolled 68 nephrologists (36 intervention) and 268 patients (105 intervention). On intention-to-treat analysis, receipt of palliative care within 12 months did not significantly differ between groups (hazard ratio (HR) 0.94, 95% Confidence Interval (CI), 0.59-1.52; p = 0.812). Patients of intervention nephrologists were more likely to initiate dialysis (HR, 1.50, 95% CI, 1.00-2.25; p = 0.048) and report worse QOL throughout the study (FACIT-Pal effect estimate, -6.51; 95% CI, -12.20, -0.81; p = 0.025; FACT-G effect estimate, -4.78; 95% CI, -8.35, -1.22; p = 0.010). We found no significant differences in intensity of treatment at the end of life, quality of communication, or on-study death between groups. CONCLUSION:Training nephrologists to use the BC/WC communication tool does not significantly affect receipt of palliative care or other measurable clinical outcomes. TRIAL REGISTRATION:NCT04466865 (URL: clinicaltrials.gov/study/NCT04466865), registered 07/07/2020.
BACKGROUND:Neuropsychological assessment via remote videoconference and telephone administration in the home setting (i.e., direct-to-home tele-neuropsychological assessment) could increase service provision to older adults. However, current evidence has not yet been synthesized to guide use. OBJECTIVE:A systematic review was conducted to summarize and evaluate available data on (1) the feasibility and acceptability of direct-to-home tele-neuropsychological assessment in older adults; and (2) the reliability of neuropsychological tests compared to clinic standard. METHODS:Six databases were searched (PubMed, Web of Science, PsycINFO, CINAHL, Medline, and Scopus) capturing studies published from January 2014 to May 2025. Eligible studies described feasibility, acceptability, or test reliability with direct-to-home tele-neuropsychological assessment in older adults. The Mixed Methods Appraisal Tool was used for quality assessment. Feasibility and acceptability data were summarized descriptively. A pooled reliability value was calculated per neuropsychological test and compared to repeat in-person assessment as clinic standard. RESULTS:Forty-four studies were included. Feasibility was supported by high assessment completion rates and minimal disruptive faults during direct-to-home administration. Responses on acceptability questionnaire items mapped positively onto constructs from the Theoretical Framework for Acceptability of Healthcare Interventions. Ten of sixteen neuropsychological tests with available evidence had reliability comparable to clinic standard. These included: verbal fluency, Craft story 21, Rey Complex Figure, Judgment of Line Orientation, Boston Naming, Peabody Picture Vocabulary, Letter-Number Sequencing, Written Trail Making Part B, word list memory test recognition, and Montreal Cognitive Assessment. Written materials were provided to administer Rey Complex Figure, Written Trail Making Part B, and Montreal Cognitive Assessment. CONCLUSION:Consistent with the broader tele-neuropsychology literature, direct-to-home assessment is feasible and acceptable in older adults, with evidence indicating comparable test reliability to clinic standards. Embracing this practice model may promote greater support and access to neuropsychological assessment for older adults.
BACKGROUND:Oral care is a proven intervention for reducing non-ventilator-associated hospital-acquired pneumonia (NV-HAP) rates by 40%-60%. Comprehensive oral care education programs are not widely reported among hospital settings in the United States. We launched the nurse-driven Hospital Oral Care and Periodontal Disease Education (HOPE) program in July 2022 with an aim to establish evidence-based oral care protocols for hospitalized older adults to reduce NV-HAP. METHODS:This retrospective observational study evaluated the impact of the HOPE program, a quality improvement initiative, on oral care delivery, documentation rates, and the incidence of NV-HAP among hospitalized older adults over a 60-month period from January 2021 to December 2025. RESULTS:About 33,155 hospitalized older adults were analyzed. Oral care documentation rates demonstrated significant improvements from pre-implementation to post-implementation across all age groups. The 65-74 age group exhibited improvement in documentation from 30% to 57%. Patients aged 75-84 demonstrated comparable trends, with overall documentation increasing from 31% to 58%. The ≥ 85 age group showed documentation rates increased from 30% to 56%. Both genders had similar trends, with females from 32% to 58% and males from 29% to 57%. The rates of NV-HAP remained similar across the pre-implementation phase (2.1%), Pilot phase (2.3%), and post-implementation phase (2.4%). CONCLUSION:HOPE program improved oral care adherence and documentation, particularly for hospitalized older adults. The program's outcomes emphasize the importance of evidence-based standardized protocols, staff education, patient engagement, and a multidisciplinary approach to enhance patient safety across diverse patient populations.
BACKGROUND:People living with dementia (PLWD) are more likely to be hospitalized and have longer hospital stays compared with the general population. Prolonged hospitalizations are associated with inpatient complications, functional decline, and mortality. This study aimed to identify patient-level factors associated with prolonged hospitalizations for PLWD. METHODS:Secondary analysis of a stepped-wedge, cluster randomized trial that enrolled community-dwelling older adults hospitalized for at least 2 days at eight Veterans Health Administration hospitals between August 2017 and August 2019. A logistic regression model was used to identify patient-level factors associated with prolonged hospitalizations (≥ 21 days) for PLWD. RESULTS:2612 individuals with dementia were included in this cohort. PLWD had a median length of stay of 6.0 days (IQR: 4.0-9.0) and 138 (5.3%) were admitted to the hospital for at least 21 days. Social vulnerability (OR: 1.74, 95% CI: 1.16, 2.61), higher Nosos chronic disease burden (OR: 1.06, 95% CI: 1.01, 1.10), and presence of delirium at admission (OR: 1.55, 95% CI: 1.07, 2.26) were associated with higher odds of prolonged hospitalization. In contrast, greater clinical frailty was associated with lower odds of prolonged hospitalization (overall p = 0.006). CONCLUSIONS:Several patient-level factors present at time of admission are associated with prolonged hospitalizations for PLWD. These findings can inform early identification and tailored interventions for those at risk. Further research is needed to better characterize these relationships, particularly frailty. TRIAL REGISTRATION:NCT03300336.
In order to successfully meet the CMS Age-Friendly Hospital Measure (AFHM) requirements, hospitals will need to adapt clinical workflows to facilitate increased interdisciplinary collaboration. We present five key principles for hospitals to consider to meet the CMS AFHM requirements.
BACKGROUND:Excessive daytime sleepiness may reflect increased vulnerability to postoperative neurocognitive disorders given its association with neurodegenerative disease, cognitive decline, and dementia. However, the role of excessive daytime sleepiness in postoperative neurocognitive disorders is unknown. Here, we investigated whether preoperative moderate-severe excessive daytime sleepiness is associated with postoperative neurocognitive disorder severity. METHODS:This prospective observational cohort study included older non-cardiac surgery patients who completed preoperative Epworth sleepiness scale questionnaires, home sleep apnea testing, and pre- and postoperative delirium assessments and cognitive testing. Cognitive scores were combined with reflective factor analysis into a global cognitive index. Moderate-severe excessive daytime sleepiness was defined as an Epworth Sleepiness Scale score greater than 12. Postoperative neurocognitive disorder severity was assessed by the global cognitive index change from before to 6-weeks and 1-year after surgery. RESULTS:Of the 96 subjects who completed testing, 11 subjects exhibited moderate-severe excessive sleepiness. In a multivariable analysis adjusting for prespecified confounders and precision variables (age, sex, respiratory event index, baseline cognitive performance and surgery duration), moderate-severe EDS was significantly associated with 6-week postoperative change in global cognition (mean difference -0.24; 95% CI -0.48, -0.004; p = 0.046), but was not associated with peak postoperative delirium severity scores (OR 3.66; 95% CI, 0.96, 13.91; p = 0.057). CONCLUSIONS:Preoperative moderate-severe EDS is associated with decreased 6-week postoperative global cognitive performance after adjustment for relevant confounders and precision variables. These results suggest that pre-existing moderate-severe excessive daytime sleepiness is a risk factor for increased postoperative neurocognitive disorder severity. TRIAL REGISTRATION:clinicaltrials.gov: NCT03273335.
BACKGROUND:This study examined associations of body mass index (BMI) category and waist circumference (WC) independently and in tandem on all-cause mortality risk among US adults aged ≥ 65 years. METHODS:The present study utilized 14 years of longitudinal data (2011-2024) from 6905 participants in the National Health and Aging Trends Study. Cox proportional hazards models were used to estimate the hazard ratios (HRs), adjusted for baseline age, race, education, annual income, smoking status, and homebound status. RESULTS:Compared with normal weight, overweight males (HR, 0.54 [95% CI, 0.45-0.66]) and males with class I and II obesity (HR, 0.49 [95% CI, 0.37-0.65]) had lower mortality risk. High WC was associated with greater mortality risk in males (HR, 1.24 [95% CI, 1.07-1.44]). Similar patterns were observed in females. In joint BMI-WC analyses, overweight regardless of WC status and class I and II obesity with high WC were associated with lower mortality risk among males. Being underweight, regardless of WC status, and having normal weight with high WC were both associated with higher mortality risk in both sexes. CONCLUSIONS:These findings highlight the adverse association of central adiposity and the limitations of BMI-only classification for mortality risk stratification in older adults.
BACKGROUND:Chronic Kidney Disease (CKD) impacts ~40% of US adults aged ≥ 60 years. Palliative care, which can improve symptoms of serious illness, is underutilized in CKD despite it's association with a high symptom burden. We conducted a scoping review of palliative care interventions in CKD, with particular attention to older adults. METHODS:We searched PubMed, CINAHL, EMBASE, Cochrane Central, PsycInfo, ClinicalTrials.gov, and Web of Science for: (1) kidney disease; (2) palliative care; and (3) study design. Palliative care interventions were defined as medical strategies that address ≥ 1 domain of the Clinical Practice Guideline for Quality Palliative Care. We characterized studies, quantified palliative care domains assessed, summarized symptom and quality of life outcomes, and identified studies limited to older adults. RESULTS:Of 2046 studies screened, 25 (1%) met inclusion criteria. Ten studies (40%) were randomized controlled designs. The most common quality domains addressed were physical aspects of care (21, 84%) and structure and processes of care (16, 64%). Twenty-four (96%) studies measured symptoms, 12 (48%) measured quality of life, and 11 (44%) measured both. Twenty-one different instruments were used to measure symptoms or quality of life. Six (24%) studies were limited to older adults. CONCLUSIONS:In our sample of studies evaluating CKD palliative care interventions, limited quality domains were addressed, a variety of measurement tools were used, and less than a quarter of studies were conducted only in older adults. Future research should address the holistic nature of palliative care, apply standardized instruments, and increase inclusion of older adults.
BACKGROUND:Aging populations require physicians skilled in competencies essential for the care of older adults. The extent to which such geriatric competencies are included in non-geriatric postgraduate medical training programs is not known. Therefore this study examined the inclusion of 13 geriatric competencies in postgraduate training programs in Australia and New Zealand, the United Kingdom, and the United States. METHODS:Thirteen core geriatric competencies were identified and defined: aging physiology; health equity and sociodemography in aging; geriatric assessment and management; individualized care and decision-making; multidisciplinary team collaboration; effective communication; cognition and mental health; common geriatric syndromes and presentations; medication prescribing and pharmacology; ethical and legal issues; coordination of care; end-of-life care and advance care planning; and older adults in research. Curricula of programs accredited by the Australian Medical Council, General Medical Council, and Accreditation Council for Graduate Medical Education were reviewed for inclusion of these competencies. Subspecialty programs pursued after initial training, and specialties without direct clinical care of older adults were excluded. RESULTS:Twenty-four of 52 programs (46%) included no core geriatric competencies. Among curricula that did include them, coverage ranged from 1 to 12 competencies. The most frequently included were ethical and legal issues (18 programs [35%]), cognition and mental health (15 programs [29%]), and geriatric syndromes (14 programs [27%]). CONCLUSIONS:Significant gaps exist in the integration of geriatric competencies across postgraduate medical training programs. Coordinated efforts are needed to integrate and assess these competencies to prepare physicians to care for aging populations.
The integration of artificial intelligence and robotics into clinical medicine is no longer a question of whether but of how, and physicians currently caring for older adults with complex multimorbidity need practical guidance for the transformation ahead. This commentary offers a framework organized around three fundamental domains of clinical care-information collection, data analysis, and treatment delivery-and describes how the physician's role within each is shifting rather than disappearing. In information collection, the clinician moves from direct performer to supervisor, deciding which data streams and alerts warrant attention and eliciting the contextual, values-based history no algorithm can capture. In data analysis, where AI will prove most transformative, the physician becomes a critical appraiser and ethical arbiter of machine-generated options, a role demanding vigilance against documented hazards: training-data bias, digital ageism, large language model confabulation, and automation bias. In treatment delivery, the physician becomes an orchestrator, matching the level of intervention to the patient's goals across a spectrum from robotic nursing support to autonomous self-management. Throughout, the organizing principle is augmented intelligence-AI as an amplifier of expert physician judgment rather than a replacement for it-operationalized as an architectural safeguard in which AI outputs remain interrogable, sourced, and subordinate to the responsible clinician. A specialty-endorsed certification of clinical AI tools, modeled on the American Geriatrics Society Beers Criteria, is proposed. Geriatric medicine's emphasis on multimorbidity, goals-of-care conversations, and interdisciplinary coordination, exemplified by the PACE model, positions geriatricians to lead this transition and to prepare, beginning today.
