“Gluing” together integrated Geriatric Clinical Service lines (GCSL) within the US healthcare system is a significant challenge. Reasons encompass health professional workforce shortages, inconsistent requirements for geriatric educational competencies among the health professional disciplines, preconceived ageist attitudes about older adults with complex illnesses, and a US healthcare system infrastructure that is not aligned with longitudinal and interdisciplinary care needs for older adults. This review focuses on three major characteristics of the US healthcare system that have impeded widespread dissemination of GCSLs: 1) the US's historical fee for service (FFS) reimbursement system; 2) increasing reliance upon disease specific specialty care services for older patients that have resulted from advances in medicine; and 3) rising consolidation of US healthcare systems over the last 30 years. Three specific options are also provided that might help change the current and future trajectories of GCSLs: 1) local political advocacy to implement health policy legislation; 2) expand geriatric physician and health professional workforce by nontraditional means; and 3) reprioritize expansionist healthcare systems corporate behavior. Each of these interventions will be hard to achieve, but it is time to unite if GCSLs are to thrive as pathways to improve care outcomes for older adults with complex medical, cognitive and neuropsychiatric disorders.

Observational evidence suggests that higher physical activity is associated with slower kidney function decline; however, to our knowledge, no large trial has evaluated whether activity and exercise can ameliorate kidney function decline in older adults.To evaluate whether a moderate-intensity exercise intervention can affect the rate of estimated glomerular filtration rate per cystatin C (eGFRCysC) change in older adults.This ancillary analysis of the Lifestyle Interventions and Independence For Elders randomized clinical trial enrolled 1199 community-dwelling, sedentary adults aged 70 to 89 years with mobility limitations and available blood specimens. The original trial was conducted across 8 academic centers in the US from February 2010 through December 2013. Data for this study were analyzed from March 29, 2021, to February 28, 2022.Structured, 2-year, partially supervised, moderate-intensity physical activity and exercise (strength, flexibility) intervention compared with a health education control intervention with 2-year follow-up. Physical activity was measured by step count and minutes of moderate-intensity activity using accelerometers.The primary outcome was change in eGFRCysC. Rapid eGFRCysC decline was defined by the high tertile threshold of 6.7%/y.Among the 1199 participants in the analysis, the mean (SD) age was 78.9 (5.2) years, and 800 (66.7%) were women. At baseline, the 2 groups were well balanced by age, comorbidity, and baseline eGFRCysC. The physical activity and exercise intervention resulted in statistically significantly lower decline in eGFRCysC over 2 years compared with the health education arm (mean difference, 0.96 mL/min/1.73 m2; 95% CI, 0.02-1.91 mL/min/1.73 m2) and lower odds of rapid eGFRCysC decline (odds ratio, 0.79; 95% CI, 0.65-0.97).Results of this ancillary analysis of a randomized clinical trial showed that when compared with health education, a physical activity and exercise intervention slowed the rate of decline in eGFRCysC among community-dwelling sedentary older adults. Clinicians should consider targeted recommendation of physical activity and moderate-intensity exercise for older adults as a treatment to slow decline in eGFRCysC.ClinicalTrials.gov Identifier: NCT01072500.

The great health paradox is that the least expensive and most effective public health measures available for addressing the COVID-19 pandemic—and other society-wide health challenges—have long been ignored and rejected in the United States in favor of more expensive and personalized care. The U.S. medical system is being overwhelmed in part because of this paradox. The authors argue that the country has invested excessively in acute care medical technology while investing insufficiently in its public health infrastructure. In this Invited Commentary, the authors recommend 5 steps that academic medicine should take to increase emphasis on and understanding of public health interventions to address society’s health problems: (1) incorporate problem-based learning experiences in the medical school curriculum and community-based clinical rotations in public health departments, (2) better integrate schools of public health and schools of medicine, (3) encourage physicians to pursue public health careers, (4) educate the public about strategies for decreasing chronic illnesses, and (5) increase collaboration with colleagues around the world to identify and track outbreaks.

The severe acute respiratory syndrome coronavirus 2 is a deadly threat, and although all individuals are susceptible, advanced age is one of the risk factors for its direst consequences in those who are infected. There are precious few times when individuals can come together to make clear a common cause for advocacy and health. We, the consortium of the editors of the nation's major geriatric and gerontology journals, offer this perspective as a way to raise awareness about ageism in association with the coronavirus disease 2019 (COVID-19) pandemic, and to acknowledge the extraordinary work that healthcare providers across all disciplines, including geriatrics, are doing at the frontlines of care. We also offer these thoughts as advocates for older patients, their families, their providers, and the broader community. COVID-19 transited the world with staggering speed, which speaks to the fact that the world is borderless when it comes to a virulent 50–200 nanometer mRNA virus. Initially, our nation's response to the pandemic was slow and poorly coordinated. Political and personal interests superseded evidence-based public health practices. Fortunately, steady and consistent efforts by teams of scientists and public health officials, and the visible impact of the illness in communities, have changed the narrative and nationwide response. To be sure, significant challenges with our healthcare and public health systems remain, and include supply-chain shortages, insufficient hospital bed capacity, poor public engagement with preventive measures, and lengthy treatment and vaccine development. We have been struck, however, by the emergence of an ageist bias towards older adults as part of the response and public discourse.1 For example, our colleague, Dr. Louise Aronson, in a sobering commentary in The Atlantic2 wrote about ageism making the pandemic worse, pointed out how differently we might be acting if COVID-19 put young people, as opposed to older people, at more risk. She pointed out ageist comments such as COVID-19 being "Boomer removers" and perceptions about older adults as being irresponsible, and contrasted these observations with the more empathic actions taken by responsible businesses such as grocery stores that offered reserved hours for older customers. Her most challenging reflection, however, was her medical center's initial lack of developing specific prevention and management protocols for older adults. We recognize the emerging thorny ethical and moral challenges that our frontline colleagues are beginning to face. One example is the need to decide who should or should not receive ventilator support when ventilators are in short supply. If medical resources were unlimited, the decisions of where, when and to whom they should be deployed is quite. simple—everyone gets what is needed. COVID-19 has revealed significant inadequacies in the nation's supply of ventilators necessary for respiratory support for patients in extreme respiratory distress. How, then, should decisions be made as to who should or should not be afforded access to them? Is the battlefield triage analogy applicable—meaning categorizing patients as healthy enough to survive without a ventilator; likely to die even with a respirator; high likely of survival if a ventilator is used? If this strategy is employed, an unavoidable question is the extent to which age of the patient should be considered in the decision. Such issues have already arisen in Italy, and all to easily age was advanced as the criterion for decision making rather than developing more nuanced approaches, as proposed by White and Lo.3 The need to make such decisions, should it arise, will create not only ethical conundrums, but also conditions for moral injury for providers who may already be experiencing burn-out and perhaps loss of their own family members.4, 5 Fortunately, many prognostic models in medicine demonstrate that age is but one of many factors in triage decisions such as this. Still, front line clinicians and families will face numerous care decisions that require multiple probabilistic judgments where guidelines may not be clear. These situations require the valued participation of interprofessional teams, in collaboration with the patient (if capable) and families, in order to bring about better decisions—tough though they may be. Experts in geriatric medicine and healthcare bring a critical informed voice to this decision-making. Society's diminished valuation of individuals as they age is a continuing thread within ageism. Tackling ageism in this pandemic requires evidence that contravenes these preconceived notions, and we offer two examples as evidence—the value of wisdom and personal resilience. First, leaders who are older are often deemed wise. A most notable example is the scientific leadership coordinating the nation's response to COVID-19. These leaders are in their 60's and the most respected voice—coming from Dr. Anthony Fauci of the National Institutes of Allergy and Immunology, is 79 years of age. During this national crisis the value of intergenerational wisdom should also not be discounted. For example, grandparents may have critical roles in nurturing and helping their grandchildren understand the many personal sacrifices that are being made to fight COVID-19. Conversely shared wisdom may encourage younger family members, because of their technology nativism, to assist older family members reduce social isolation through video streaming and help them interpret what they are viewing or reading. Intergenerational engagement is known to reduce ageism and bias. Resilience, the successful adaptation to adversity and to recover from crises with a sustained sense of purpose, has been an increasing focus of successful aging. Ageism is the implicit bias that older adults are less resilient and less capable to adapt to challenging events such as COVID-19. Older adults have shown remarkable agency in this crisis as witnessed by their willingness to engage in positive public health practices such as social isolation, shelter at home and basic hand washing. Older adults have engaged in meaningful social connection through email, social media, and other forms of electronic communication. And older retired healthcare workers have demonstrated great moral purpose by volunteering their skills to help frontline healthcare providers treat those afflicted with COVID-19. Last, we recognize that COVID-19 will require sustained efforts over an uncertain time frame. Specifically, we urge greater attention to four goals: (1) make clinical research more inclusive of all ages, such as emergent use of experimental therapies and diagnostic tools; (2) engage geriatricians and gerontologists in institutional decisions regarding care, including rationing; (3) inform policy and funding with cognizance of the needs of vulnerable populations (e.g., personal protective equipment for home care workers and better infection control in long term care facilities; and (4) emphasize the importance of personalized approaches to older adults that enact respect for autonomy, justice and beneficence. In appreciation for the contributions that older adults make to society, we as editors of the nation's leading journals in geriatrics and gerontology believe that drawing upon the experience and resources across the life span will build resilience against despair. Our obligations are to steadfastly tackle ageism in all of its forms, and to offer hope, compassion and empathy to those for whom we are responsible.

The coronavirus (COVID-19) pandemic is having profound effects on the lives and well-being of the world's population. All levels of the nation's public health and health care delivery systems are rapidly adjusting to secure the health infrastructure to manage the pandemic in the United States. As the nation's safety net health care systems, academic medical centers (AMCs) are vital clinical and academic resources in managing the pandemic. COVID-19 may also risk the financial underpinnings of AMCs because their cost structures are high, and they may have incurred large amounts of debt over the last decade as they expanded their clinical operations and facilities. This Invited Commentary reviews existing data on AMC debt levels; summarizes relief provided in the Coronavirus Aid, Relief, and Economic Security Act; and suggests policy options to help mitigate risk.

The worldwide spread of COVID-19 is alarming to all of us and has created an enormous public health and clinical crisis. Emerging data indicate that COVID-19 is a particular risk for older persons, particularly those with multimorbidity. Recent reports of COVID-19 infections indicate that both community-dwelling older persons as well as those residing in nursing homes, assisted living facilities, and other congregate living settings are at high risk. The editors of the Journal of the American Geriatrics Society (JAGS) want to make sure our readers are aware of resources for clinicians and our patients1-6 that provide superb guidance. As this outbreak progresses, JAGS will monitor events and provide periodic updates focused on older persons as needed.

This editorial comments on the article by . in this issue.

Journal of the American Geriatrics SocietyVolume 68, Issue 10 p. 2205-2206 EditorialFree Access Feeding the Beast William B. Applegate MD, MPH, Corresponding Author William B. Applegate MD, MPH [email protected] President and Dean Emeritus, Wake Forest University Health Sciences, Winston-Salem, North Carolina, USASearch for more papers by this authorChristopher C. Colenda MD, MPH, Christopher C. Colenda MD, MPH President Emeritus, West Virginia University Health System, Morgantown, West Virginia, USA Dean Emeritus, College of Medicine, Texas A&M University Health Sciences, Bryan, Texas, USASearch for more papers by this authorDan G. Blazer MD, MPH, PhD, Dan G. Blazer MD, MPH, PhD J.P. Gibbons Professor Emeritus, Department of Psychiatry, Dean Emeritus of Medical Education, Duke University School of Medicine, Durham, North Carolina, USASearch for more papers by this authorBurton V. Reifler MD, MPH, Burton V. Reifler MD, MPH Professor and Chair Emeritus, Department of Psychiatry, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USASearch for more papers by this author William B. Applegate MD, MPH, Corresponding Author William B. Applegate MD, MPH [email protected] President and Dean Emeritus, Wake Forest University Health Sciences, Winston-Salem, North Carolina, USASearch for more papers by this authorChristopher C. Colenda MD, MPH, Christopher C. Colenda MD, MPH President Emeritus, West Virginia University Health System, Morgantown, West Virginia, USA Dean Emeritus, College of Medicine, Texas A&M University Health Sciences, Bryan, Texas, USASearch for more papers by this authorDan G. Blazer MD, MPH, PhD, Dan G. Blazer MD, MPH, PhD J.P. Gibbons Professor Emeritus, Department of Psychiatry, Dean Emeritus of Medical Education, Duke University School of Medicine, Durham, North Carolina, USASearch for more papers by this authorBurton V. Reifler MD, MPH, Burton V. Reifler MD, MPH Professor and Chair Emeritus, Department of Psychiatry, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USASearch for more papers by this author First published: 11 August 2020 https://doi.org/10.1111/jgs.16753Citations: 1AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Each of us has been gratified to have varying leadership roles as geriatricians or geriatric psychiatrists in our academic healthcare systems (AHCSs). Our AHCSs have provided excellent clinical care for persons with a broad range of medical maladies, trained tomorrow's healthcare professionals, and produced cutting edge clinical and basic science research. We remain optimistic about healthcare delivery in our country. However, in the last several years, we have been plagued by the sense that a dark cloud is hanging over our AHCSs. As the complexity of the healthcare enterprise has grown exponentially, we are concerned that our system and its leadership have lost perspective regarding the appropriate balance between the clinical enterprise and the education and research missions, and in so doing, have created a large clinical beast that is consuming all financial and human resources in its path. Also, we are now greatly concerned that one of the most common causes of bankruptcy in the United States, particularly for older persons, is inability to pay large medical bills.1-3 We ask, how did we get to this point? First, Medicare's original fee-for-service approach to reimbursement has become inflationary and allowed providers to incrementally create new services and charge more per service based on evolving provider trends. In addition, as the sophistication in and body of knowledge of each organ system expanded, healthcare professionals often limited their careers to one organ system or subsystem to ensure that they had the ability to manage the explosion of knowledge, neglecting overall patient function and whole person care. This has resulted in fragmentation of care, particularly in patients with disease in more than one organ system, which is usually the case with older persons. With dramatic growth in funding for the clinical enterprise, healthcare institutions grew exponentially, but care and care systems become more fragmented, without cohesive oversight or leadership. Growth for growth's sake became the predominant guiding principle. In many institutions, including our own, the governing and advisory boards were composed of prominent community business people whose entire careers had been focused on building larger and more profitable enterprises. Two of us spent much time with our boards. In retrospect, we all were infatuated with the dynamic of growth. After all, how could providing more health services, conducting more research, and educating more future health professionals ever be inappropriate? The driving engine for this growth came from clinical care revenue, which dwarfed funds for research and education. It now seems that our fee-for-service clinical care focuses on doing the most tests and interventions that are conceivable (and profitable) rather than that which is most likely to improve future patient health and function. The recent COVID-19 crisis has shown the danger of driving profitable reimbursement rather than population or cohort risk adjusted reimbursement. Our strong clinical income streams have enabled growth of programs and infrastructure through issuance of debt underwritten by investment banks and other private investment entities. This strategy now puts AHCSs in great financial danger. Public and private health insurance currently are attempting to control the financial demands created by healthcare systems by charging those with insurance coverage higher and higher copays for care received. Ironically, with inflation and growth of healthcare costs, health insurance copays are potentially as burdensome to individuals now as the total healthcare bill was decades ago. Over time, we have become increasingly alarmed by the rate of patient financial hardship caused by medical bills.4 Previously, when patients could not or would not pay their bills, we usually blamed both insurance companies and patients. We now understand that we may have been pointing our collective fingers in the wrong direction. We have come to realize that there were three particular groups of colleagues most responsible for the exorbitant proliferation of medical charges and bills: subspecialty trained physicians who performed remunerative procedures and always advocated for higher reimbursement, the business persons on our boards, and the leaders, like us, of our institutions. Now that we have retired from institutional leadership, we are most concerned by the high cost system we helped create. We once had the mistaken illusion that seriously ill persons could usually find adequate care in the United States, at least with "safety net" providers. Unfortunately, the growth in healthcare complexity plus cost inflation make this infeasible. A recent editorial in this journal has pointed out that as many as half of our older patients (including those with some insurance coverage) will no longer be able to afford health care, including both acute and long-term care.5 To address these issues, AHCSs will need to rebalance the funding of their three missions based on changing financial models. The most likely precipitant of change will be budgeted universal coverage of all patients through a combination of private and public insurance options that will be structured as value-based payment models where shared risk between payers and providers rewards care coordination and treatments that are evidence based. The beast must be put on a diet.6 Additionally, we propose the following: Reimbursement must be redesigned based on risk-adjusted cohorts or populations, and all healthcare providers must be held to negotiated budgets. Geriatric models designed to care for older adults can serve as important examples for value-based care and can be translated to other AHCS service lines. Experience shows that for complex patients, care coordination requires dynamic interprofessional teamwork involving patients and their families, with a focus on maximizing functional outcomes that improve quality of life. Value-based reimbursement models, as opposed to fee-for-service models, incentivize this form of care delivery. Such reimbursement should be based on per capita rate models and risk adjusted.6 Quality standards combined with reimbursement strategies should create incentives for providing only appropriate levels of care while disincentivizing unnecessary tests, procedures, and polypharmacy. AHCS boards should choose membership to enable a balance between business and academics, with greater emphasis on education and research. We hope that our colleagues will share their views on the opinions we have expressed. At stake is the viability of the overall medicine enterprise for older adults and, importantly, the financial security of our most vulnerable patients. Academic health centers should be the models for such changes. Through the application of our collective knowledge and experience, we can successfully respond to the changes that are underway. ACKNOWLEDGMENTS Conflict of Interest The authors have no conflicts of interest to report. Author Contributions All four authors participated equally in concept development, writing, revising, and citing and verifying sources. Sponsor's Role None. REFERENCES 1Colenda CC, Applegate WB, Reifler BV, Blazer DG. COVID-19: financial stress test for academic medical centers. Acad Med. 2020; 95: 1143- 1145. 2Johnson PT, Alvin MD, Zeigelstein RC, et al. Transitioning to a high value health care model; academic accountability. Acad Med. 2018; 93: 850- 855. 3Gormich ME, Warren JL, Eggers PW, et al. Thirty years of Medicare: impact on the covered population. Health Care Financ Rev. 1996; 18(2): 179- 237. 4Kirzinger A, Munana C, Wu B, Brodie M. Data Note: Americans' Challenges with Health Care Costs. June 2019. https://www.kff.org/health-costs/issue-brief/data-note-americans-challenges-health-care-costs/. Accessed March 28, 2020. 5Lynn J. The fierce urgency of now: geriatrics professional speaking up for eldercare in the US. J Am Geriatr Soc. 2019; 67: 2001- 2003. 6Halvorson SAC, Tanski M, Milligan L, Yackel T. Transitioning from volume to value: lessons learned from the dissolution of a population health partnership. Acad Med. 2019; 94(9): 1305- 1309. Citing Literature Volume68, Issue10October 2020Pages 2205-2206 ReferencesRelatedInformation

This letter comments on the letter by Bonnie Lashewicz.

BACKGROUNDPhysical activity (PA) preserves mobility, but few practices screen older adults for mobility impairment or counsel on PA.DESIGN“Promoting Active Aging” (PAA) was a mixed‐methods randomized‐controlled pilot, to test the feasibility and acceptability of a video‐based PA counseling tool and implementation into practice of two mobility assessment tools.SETTINGThree primary care practices affiliated with Wake Forest Baptist Health.PARTICIPANTSAdults aged 65 years and older who presented for primary care follow‐up and were willing and able to answer self‐report questions and walk 4 meters (n = 59).INTERVENTIONVideo‐based PA counseling intervention versus control video, “Healthy Eating.”MEASUREMENTSPotential participants completed mobility assessments: self‐report (Mobility Assessment Tool‐short form (MAT‐sf)) and performance based (4‐meter walk test). We assessed PAAʼs implementation—feasibility, acceptability, and value—via interviews and surveys. Effectiveness was measured via participant attendance at a PA information session.RESULTSOf 92 patients approached, 89 (96.7%) agreed to mobility assessment. Eighty‐nine completed MAT‐sf, and 97.8% (87/89) completed 4‐meter walk test. Sixty‐seven (75%) met eligibility criteria, and 59 (88%) consented to be randomized either to the PA counseling intervention (Video‐PA) or to active control (Video‐C). Most participants viewed the walk test positively (51/59; 86.4%). Staff reported that completion of patient surveys, MAT‐sf, and videos required significant staff time and support (median = 26 minutes for all), resulting in low acceptability of MAT‐sf and the videos. Attendance at a PA information session did not differ by randomization group (Video‐PA = 11/29 (37.9%); Video‐C = 12/30 (40%); 95% confidence interval for difference in proportion = −0.29 to 0.25).CONCLUSIONSMobility assessment, particularly a 4‐meter walk test, was feasible in primary care. Tablet‐based assessment (MAT‐sf) and video counseling tools, selected to reduce staff effort, instead required significant time to implement. Future work to promote PA should identify effective ways to facilitate adoption of PA in sedentary older adults that do not burden staff.

Journal of the American Geriatrics SocietyVolume 68, Issue 6 p. 1177-1177 Special Article In Memory of Rosalie Kane, PhD Joseph G. Ouslander MD, Corresponding Author Joseph G. Ouslander MD jousland@health.fau.edu Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USAAddress correspondence to Joseph G. Ouslander, MD, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL. E-mail: jousland@health.fau.eduSearch for more papers by this authorWilliam B. Applegate MD, MPH, William B. Applegate MD, MPH Sticht Center on Aging, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USASearch for more papers by this author Joseph G. Ouslander MD, Corresponding Author Joseph G. Ouslander MD jousland@health.fau.edu Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USAAddress correspondence to Joseph G. Ouslander, MD, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL. E-mail: jousland@health.fau.eduSearch for more papers by this authorWilliam B. Applegate MD, MPH, William B. Applegate MD, MPH Sticht Center on Aging, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USASearch for more papers by this author First published: 14 June 2020 https://doi.org/10.1111/jgs.16564Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume68, Issue6June 2020Pages 1177-1177 RelatedInformation

Since January 2017, the science and healthcare communities have witnessed policy and regulatory decisions by the current administration that have defied conventional wisdom and we believe have grave implications for older Americans. The undersigned are four older geriatricians who are at the end of their careers and who are grateful for the privilege to expand the research, educational, and clinical knowledge base of our chosen profession. We viscerally feel that the current political climate is blind to the consequential increases in the number of older Americans who need our field's expertise in the United States and around the world. We fret about the decline in civil debate and language that emanates from our national leaders. We seriously wonder whether any of our national leaders (in either party) have the courage to face the stark truth: that decisions made today will have unintended outcomes for older Americans and the future of our specialty. Thus, we believe there are battles worth fighting. Our comments will focus on 3 themes with examples that are worthy of consideration by our field as we advocate for older Americans. Politicization of science and healthcare is nothing new and has occurred in Republican and Democratic administrations.1, 2 Nevertheless, the speed and breadth by which recent attacks on science have occurred have unsettled many. Whether it is climate or energy policy, dismantling the President's Advisory Council on HIV/AIDS,3 or the failure to appoint a director of the White House Office of Science and Technology Policy,4 the evidence is clear that the last 40 years of scientific and healthcare progress is at risk. When sound scientific evidence is attacked using partisan ideology and language that demeans rather than inspires, we believe the health of real people is at risk. We acknowledge that science is only part of the base from which public policy is conceived, but public policy, especially as it relates to public health, should not be based on an ideology or wish. Scientific method provides objective evidence along with unflinching acknowledgment of the limitations of its findings. Science is an iterative process, an ever-expanding foundation of evidence that eventually leads to a conclusion. To subject science and its methods to politicization, whether from the right or the left, is not only ill advised, but is also dangerous. We offer the recent “word” kerfuffle at the Centers for Disease Control and Prevention (CDC) as an example. In December 2017, news reports said that 7 words had been banned from 2019 budget documents for the CDC:5, 6 transgender, fetus, vulnerable, diversity, entitlement, science-based, and evidence-based. The CDC director refuted the reports that the words were banned. Follow-on reports suggested that the incident was more complicated than originally outlined. Officials asserted that “word” guidelines were an attempt to improve the chances for program budget support, and if these words would cause “someone to jump to a conclusion, then use a substitute…if there is no substitute, then go ahead and use the word.”6 We firmly believe that there are no substitutes for “vulnerable” in the study and care of older adults. Even though the CDC apparently provides guidance for word choice in annual budget documents,6 the selection of these 7 words for exclusion was either a conscious attempt by officials to avoid politically charged terms that would decrease programmatic funding, or conversely, they represented political pressure that telegraphed the administration's indifferent attitudes toward vulnerable populations, including older adults. We choose to believe the official CDC's position because of the integrity of the CDC workforce but fear the latter based upon the current administration's actions toward other healthcare policy initiatives. The current political climate also questions the value of applying rigorous, evidence-based standards to healthcare policy and regulatory decisions. Secondary to the CDC incident, the leadership of the national academies of science, engineering, and medicine expressed that they were “stunned” that “evidence-based” and “science-based” were reportedly banned words.7 Evidence-based therapeutics has greatly benefited the discipline of geriatrics. We offer Ginkgo biloba as an example of the above principle. As geriatricians, we wish that the field had a magic bullet for Alzheimer's disease (AD). In the mid-2000s, there was considerable public interest in whether the botanical Ginkgo biloba could prevent AD. Several small clinical studies and the popular press suggested a benefit. The botanical was vigorously marketed to the public as an important supplement to combat the disease. The results of the National Institutes of Health large multisite clinical trial found that Ginkgo biloba did not prevent dementia or slow decline in cognitive impairment.8 Many individuals with AD and their families may have had an a priori wish that Gingko biloba would be a magic bullet. Should geriatricians hold similar views? No. We must be bound by our professional responsibility and code of ethics that demands our thinking and clinical decision-making be grounded by rigorous scientific evidence, and we should insist that our country's political establishment be under the same obligation when making decisions that affect the health of all Americans, regardless of age. The Tax Cut and Jobs Act of 2017 dramatically cut corporate tax rates and personal tax rates for wealthy individuals, modified a variety of personal tax deductions, undermined the Affordable Care Act by striking the tax penalty for individuals who failed to secure insurance, and is expected to increase the projected deficit by $1.5 trillion over 10 years. Immediately after the President signed the bill, Republican congressional leadership announced their intent to “reform” federal entitlement programs such as Medicare, Medicaid, and Social Security to address the increasing federal deficit, part of which is a result of the tax bill.9 The bill's passage is also projected to raise premium rates for private co-insurance for many older persons. Those of us who have spent our careers in geriatrics see these efforts as a violation of the covenant (a word we prefer to entitlement) our government made with our patients. We will use Medicaid funding for long-term care services for older Americans as an example. Approximately 35 million children and 7 million older adults received Medicaid benefits in fiscal year 2014.10 Although Medicaid served more children than older Americans, Medicaid spent about $13,000 per older enrollee and $2,500 per child enrollee.11 Furthermore, of the $554 billion in Medicaid spending in FY2016, 21% ($119 billion) was spent on fee-for-service long-term care services and supports, which makes Medicaid the largest public payer for long-term care services for older adults.12 As state and federal budgets experience increase financial pressures on Medicaid and Medicare, what ethical, moral, and evidence-based values will our political leaders use when they face “Sophie's Choice” decisions about funding long-term care for older Americans? Please understand that, as geriatricians, we encourage healthcare innovations that improve quality, access, and accountability of healthcare for older adults and that reduce overall Medicare and Medicaid expenditures, but in our current political environment, will words such as “vulnerable” and “entitlement reform” be used to justify degradation of the healthcare safety net for older Americans? Healthcare works best when it is evidence based and focused on interventions that are compassionate and evidence based (the art and science of medicine). As older geriatricians with no further career aspirations, we are free to say what we think, but we are passing the baton to you who will carry the light of truth, and the battles will be yours. As you take up the gauntlet, trust that you will succeed because truth ultimately wins. A final thought to embrace is Edward Albee's thoughtful advice. “In a democracy you cannot stop public access to that art that will most misinform the people. You cannot stop people from being misinformed. But what you can do is to educate the people to the point that they will throw the rascals out.”13 The opinions in this article are only those of the authors and not the Editorial board of the Journal of the American Geriatrics Society or the American Geriatrics Society Board of Directors.

This pilot work examined associations of brain grey matter volumes (GMV) with perceived fatigability in older adults to elucidate disablement mechanisms. A subsample (n = 29; age = 77.2 +/- 5.5; 86% female) of participants from the Lifestyle Interventions and Independence for Elders (LIFE) Study was utilized to quantify GMV for regions of interest in the basal ganglia and limbic system normalized to intracranial volume. The Pittsburgh Fatigability Scale measured physical and mental fatigability (score 0-50; higher physical fatigability >= 15; higher mental fatigability >= 13). We used an exploratory alpha level of p < 0.1. Nineteen (66%) participants had higher physical fatigability, 19 (66%) had higher mental fatigability, of these, 17 (57%) had both. Right hippocampal volumes/ICV were smaller in participants with higher verses lower physical fatigability (0.261 +/- 0.039 vs. 0.273 +/- 0.022, p = 0.07); associations were similar for right putamen and bilateral thalamus. Higher mental fatigability was associated with smaller right hippocampus, thalamus, and posterior cingulum and bilateral amygdala. Higher fatigability in older adults may be associated with smaller volumes of the basal ganglia and limbic system, indicating mechanisms for further exploration.

This editorial comments on the article by Blaum et al and Naik et al

With recent articles and an editorial, the Journal of the American Geriatrics Society has taken the initiative to propose a revision in the way medical care is provided to older adults with multimorbidity to provide an increased focus on patient-centered care (PCC). We encourage further submissions on this topic, particularly clinical investigation studies. In this article, we assert that the complexity of our current menu-driven care for older persons with multimorbidity can undermine PCC and must be revised. We state that we must shift from our current reimbursementdriven system with an exclusive focus on physician management of specific disease to a system driven more by patient preferences with a comprehensive view of the totality of care. This is especially important in hospital care. In recent decades, enormous progress has been made in the care of older persons, including those with multimorbidity. Patients with major acute and chronic medical disorders, who might not have lived previously, now routinely survive. Medical science and subspecialty medicine now drive care that enables most medically complex older patients to live longer than would have been expected a few decades ago, but this progress has created questions about the process of care. Our view is that care of older persons has become too menu driven, based on lists of medical problems, with insufficient attention to patient goals regarding function and quality of life and the inherent tradeoffs in complex care. The current piecemeal approach to care of complex multimorbidity can result in iatrogenic complications, excessive testing, and high-technology interventions, plus patient and family confusion. Although improvements have been made in tracking clinical detail and in linking medical records across sites of care, our current arcane computerized medical records exacerbate work complexity and take time and focus away from detailed interactions with patients. Our rapid growth in sophistication has been accompanied by ever-greater subspecialization and fragmentation, particularly in complex older patients. To feel competent to master the ballooning detail in each subspecialty, we tend to split areas of clinical focus into ever-smaller fields of endeavor. As inpatient attending physicians today, we frequently wonder who is looking at the overall big picture. In years past, this was the responsibility of the patient’s primary physician and the hospital ward team. These days, all care is compressed in time and space, which drives the internal medicine team to become scribes and servants for subspecialty experts who themselves have an increasingly narrow focus. The speed of this fragmented care is driven by our anachronistic reimbursement system, which rewards technology and interventions over personal care and a focus on functional status. With this growing fragmentation and narrowing of focus, we are now reminded of an activity from our youth: “paint by numbers.” As children, paint by numbers allowed us to follow a simplistic coloring format and create an image of the subject desired. The goal was to provide a template for potential artists to create a recognizable image. However, these images were lifeless and flat, and they failed to evoke any larger understanding or insight on the part of the viewer. On today’s hospital internal medicine wards, the combination of time pressures and volume incentives forces most of us to rely on simple menus and specialty recommendations as the primary drivers of our clinical decisions. We see vanishingly little evidence that guidelines and subspecialty opinions are applied after thoughtful deliberation of the complexities and tradeoffs of caring for older persons with multiple chronic disorders. Deliberation regarding care delivery for the individual patient has been replaced by a paint by numbers approach. We often see younger consultants relying primarily on their mobile telephones to get the right “recipe” of recommendations for a given older patient. Often, such consultants have much of the note written based on the chart and a report template before they ever see the individual patient. In times past, attending rounds would be the time when perspective and thoughtful deliberation could be applied, important for nuanced care and for role modeling how the seasoned attending artist can go beyond an initial paint by numbers approach. Now, we usually see regurgitation by both learners and faculty of a menu of standard recommendations focused only on a specific organ system. Little time is allowed for reflection and consideration of individual patient preferences or differences. We believe that this system of care has perverse effects on the training of new physicians and nurses. Our current paint by numbers system does not provide learners with a perspective on comprehensive or well-integrated care. In most hospitals today, physicians spend surprisingly little time examining and talking with patients or their families. House staff spend most of their time in computer rooms, in part to draft notes to facilitate faculty third-party billing. For expediency, rounds are frequently conducted in these same computer rooms and notes may be typed during these “rounds.” It is often not clear who has examined and discussed goals with the patient. In these settings, care plans are usually devised without patient or family input. At most, the house staff tend to report back to the patient and (occasionally) family what the care plan will be, with little input or discussion of goals and preferences. These rounds then take on a “flat dimension” devoid of humanity. DOI: 10.1111/jgs.15693

This editorial comments on the article by Cushman et al .

This issue of the Journal of the American Geriatrics Society (JAGS) contains a selection of peer-reviewed articles specifically focused on cardiovascular disease (CVD) as our first “mini-focus issue.” Guest editors Drs. Michael Rich and Dalane Kitzman previously published a request for submissions on CVD in older persons that would be peer reviewed and selected for this special mini-focus issue of JAGS.1 The articles presented here were either submitted in response to this open request or identified by the editors as topically relevant for this special focus; a couple articles were specifically requested from pre-identified authors. There is a compelling need to publish a mini-focus issue on CVD given the enormous effect it has on the lives and health of older persons. Epidemiological data have indicated for years that CVD risk factors and disorders predict and account for the greatest causes of mortality and loss of function in persons aged 65 and older.2 “In terms of morbidity, an estimated 80 million Americans have at least one form of CVD, and just over one-half of these are aged ≥60 years,2, 3 reflecting a marked increase in the incidence and prevalence of CVD with advancing age. The prevalence of CVD, including hypertension, CHD, HF, and stroke, increases from about 40% in men and women 40–59 years of age, to 70–75% in persons 60–79 years of age, and to 79–86% among those aged 80 years or older.3 Similarly, the incidence of CVD, including coronary heart disease, heart failure, and stroke or intracerebral hemorrhage, increases from 4–10 per 1,000 person-years in adults aged 45–54 years to 65–75 per 1,000 person-years in adults aged 85–94 years.2-4” Drs. Rich and Kitzman and others screened all submissions for quality and focus, and appropriate articles were reviewed through the usual JAGS peer review processes. The goal was not to fill an entire issue of JAGS with articles on CVD; the goal was to publish ALL submitted articles that met an acceptable standard through the peer review process. We are deeply appreciative of the thoughtful, high-quality work these editors have dedicated to this issue. Only experienced medical editors can really appreciate the amount of work and thought and the number of difficult decisions that such a focused set of peer-reviewed articles require. The original idea for this special focus edition came from Dr. Rich. The product that he and his colleagues have birthed has led our editorial team to decide that we will solicit articles for other special mini-focus issues in the future. Therefore, we are announcing our intent to create other special focus issues in the future and solicit your comments on topics. We plan to publish one or two yearly calls for papers for other special mini-focus issues, and our early efforts will be directed at recognized subspecialties of medicine. It is our thought that there is a dynamic and constructive tension between the breadth of science and praxis of the discipline called geriatrics (a “metadiscipline”) and other focused areas of specialty in internal medicine. We believe that geriatric medicine requires a broad clinical background juxtaposed with focused knowledge and experience applying this background to older adults. We are also discussing mini-focus issues on cancer, arthritis, infectious diseases, and palliative medicine. We have not yet chosen “special editors” to coordinate these issues; rather, we are encouraging self-nomination for topics and potential editors (2–4 editors per issue). Although we are unlikely to have capacity to produce more than two mini-focus issues per year, we encourage all of those with ideas and interest to contact us.

The Editors of Age and Ageing of the British Geriatrics Society and the Journal of the American Geriatrics Society have agreed to publish periodic joint editorials or commentaries on clinical or policy issues of interest to our readers. Initially we will focus on recently released clinical guidelines or policy issues of importance to the care of older persons. The intent is to discuss these topics from our respective viewpoints, hoping to broaden the dialogue around the issues discussed. These articles will be written by our editors or solicited from experts on a given topic. In this set of initial companion editorials, we discuss our reactions to the recent National Institute for Health and Care Excellence (NICE) guideline “Multimorbidity: clinical assessment and management.” The management of the older patient with two or more co-morbidities is one of the most complex and challenging problems in healthcare. It is certainly a core component of geriatric medicine, but also a core component of the care provided by most health care systems in the United States (US). Unfortunately, most current clinical guidelines for management of chronic diseases focus on one specific disease or organ system. Such uni-focused clinical guidelines can unwittingly drive polypharmacy and iatrogenic complications plus compliance burden in older persons. For example, the care of an older woman with hypertension, coronary artery disease, chronic kidney disease, and osteoarthritis is a case study in complexity and therapeutic tradeoffs. In the US, such persons often see multiple specialists who focus on each individual disease component. In nearly all such cases, polypharmacy is created. Medications to treat one disorder may cause problems with another. Many of the prescribed medications, particularly in combination, can sap the energy and vitality of the older person and increase the risk for falls. Such patients and their families spend inordinate amounts of their time in doctors’ offices and health care facilities. In many cases, doctors complain about poor patient compliance with medications and doctor visits while, in the same cases, the patients and families say they are literally spending too much of their lives juggling various doctor visits and therapeutic regimens. From the US perspective, the NICE guideline statement is both comprehensive and compelling. It is comprehensive in that it is truly patient centered, focuses on a broad array of health domains including medical, sensory, functional, and psychosocial, including quality of life. It is compelling because it clearly articulates a balanced, thoughtful approach to care that transcends the limited algorithmic organ system approach to care that is so often applied to older patients in the US. Most of the substance of the report is already appreciated and practiced by geriatricians in the US, but less often by the wider health care delivery system here. At its core, the NICE guidelines provide very clear advice on how to elicit patient goals and preferences and weave these into a care management plan that anticipates future clinical and social problems for each individual and provides guidance for future decisions. The plan clearly articulates the need for advance care planning for crucial medical decisions such as resuscitation orders and willingness to be transferred to a hospital. It also elicits patient and family preferences around goals of care with regard to degree of future medical diagnostic and therapeutic aggressiveness, the burden of multiple doctor and hospital visits, and the degree of therapeutic complexity and polypharmacy that patients/families are willing to tolerate. It overtly asks older persons to address their values and goals regarding how strongly they desire increasing treatment to extend their lifespan. Its primary focus is on the patient’s quality of life and not on any disease-specific endpoint. This approach is an effective antidote to the US paymentfor-volume system and the iatrogenesis it can create in caring for older persons. The report provides clear advice for clinical management of patients with multiple chronic diseases. When evaluating treatment strategies for older persons with multimorbidity, the primary focus should be on individual function and quality of life. This basic approach includes maximizing benefits of current treatment, stopping treatments that may be of marginal benefit, increasing emphasis on non-pharmacologic therapies, and the provision of alternative arrangements to help with the burden of multiple doctor and hospital visits. Importantly, the NICE guideline specifically advises that the person(s) responsible for coordination of care be formally designated as part of each person’s care plan. Clinicians need to think beyond single disease guidelines and work to balance the benefit and burden of potential adverse events from the polypharmacy that can result. The report advises thinking carefully about a given person’s potential longevity or prognosis when instituting preventive medications like lipid lowering drugs or bisphosphonates. Physicians need to be aware of the absolute potential outcome benefit for a given drug and condition, the duration of treatment necessary to reach benefit, and the timeframe of current data showing benefit, as in the case of bisphosphonates. Physicians are urged to consider competing morbidity and mortality when estimating benefits of a single disease therapeutic DOI: 10.1111/jgs.14803

This Editorial comments on the article by Philip Donald St John .