The Journal of Antibiotics, Published online: 31 July 2019; doi:10.1038/s41429-019-0212-x
Heterologous production of coryneazolicin in Escherichia coli
Cardiac troponin T, measured using a high‐sensitive assay (hs‐cTnT), and N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) are associated with increased stroke risk and perhaps with cognitive decline. However, few well‐designed prospective studies with extended follow‐up have been conducted. We aimed to estimate the association of hs‐cTnT and NT‐proBNP with 15‐year cognitive change in the Atherosclerosis Risk in Communities (ARIC) study.
Prospective cohort study.
Four US communities.
A total of 9114 and 9108 participants from the Atherosclerosis Risk in Communities study for analyses of hs‐cTnT and NT‐proBNP, respectively.
We examined association of hs‐cTnT and NT‐proBNP with 15‐year change (1996‐1998 to 2011‐2013) in three cognitive tests of executive function (Digit Symbol Substitution Test), verbal learning memory (Delayed Word Recall Test), and semantic fluency (Word Fluency Test), and an overall score combining the three tests using multivariable linear mixed effect models. We conducted several sensitivity analyses including multiple imputations to address bias due to missing data and attrition, and we compared associations within groups combining hs‐cTnT and NT‐proBNP into a three‐level categorical variable.
At baseline (1996‐1998), mean age was 63.4 (standard deviation [SD] = 5.7) years; 56.4% were women, and 17.5% were black. The hs‐cTnT at baseline was not associated with cognitive change in any measure. Some evidence indicated accelerated decline in verbal learning and memory when comparing those in the highest with the lowest NT‐proBNP quintiles; however, this association was not replicated when considering clinically relevant cutoffs or deciles of exposure in survivors. Sensitivity analyses were consistent with our primary analyses. There was little evidence to support effect modification by any considered factors. People with highest levels of both biomarkers had excessive decline in global z scores vs people with lowest levels (−.34; 95% confidence interval = −.63 to −.04).
Markers of myocardial injury and stretch were not associated with cognitive decline following 15 years among survivors, but when combined together they were suggestive in post hoc analysis. Whether this represents targets of intervention should be examined in the future.
To examine the association between the quality of care delivered to nursing home residents with and without a serious mental illness (SMI) and the proportion of nursing home residents with SMI.
Instrumental variable study. Relative distance to the nearest nursing home with a high proportion of SMI residents was used to account for potential selection of patients between high‐ and low‐SMI facilities. Data were obtained from the 2006‐2010 Minimum Data Set assessments linked with Medicare claims and nursing home information from the Online Survey, Certification, and Reporting database.
Nursing homes with high (defined as at least 10% of a facility's population having an SMI diagnosis) and low proportions of SMI residents.
A total of 58 571 Medicare nursing residents with an SMI diagnosis (ie, schizophrenia or bipolar disorder) and 558 699 individuals without an SMI diagnosis who were admitted to the same nursing homes.
Outcomes were nursing home quality measures: (1) use of physical restraints, (2) any hospitalization in the last 3 months, (3) use of an indwelling catheter, (4) use of a feeding tube, and (5) presence of pressure ulcer(s).
For individuals with SMI, admission to a high‐SMI facility was associated with a 3.7 percentage point (95% confidence interval [CI] = 1.4‐6.0) increase in the probability of feeding tube use relative to individuals admitted to a low‐SMI facility. Among individuals without SMI, admission to a high‐SMI facility was associated with a 1.7 percentage point increase in the probability of catheter use (95 CI = .03‐3.47), a 3.8 percentage point increase in the probability of being hospitalized (95% CI = 2.16‐5.44), and a 2.1 percentage point increase in the probability of having a feeding tube (95% CI = .43‐3.74).
Admission to nursing homes with high concentrations of residents with SMI is associated with worse outcomes for both residents with and without SMI.
Recognition of delirium in the emergency department (ED) is poor. Our objectives were to assess: (1) the diagnostic accuracy of the Predicting Emergency department Delirium with an Interactive Computer Tablet (PrEDICT) “serious game” to identify older ED patients with delirium compared to clinical recognition and (2) the feasibility of the PrEDICT application compared to existing tests of attention.
Prospective observational study.
ED of a Canadian tertiary care center.
We included ED patients, aged 70 years and older, with a minimum 4‐hour stay. We excluded anyone with critical illness, communication barriers, and visual impairment or those unable to use a computer tablet. None had prevalent delirium by ED clinicians' routine clinical assessment.
Participants were asked to tap targets on a tablet at four difficulty levels. Time and accuracy were automatically recorded. Other measures included the Confusion Assessment Method, the Delirium Severity Index, the Digit Vigilance Test (DVT), and the Choice Reaction Test (CRT).
We enrolled 203 patients. Their average age was 80.6 years, 49.8% were female, and their average ED length of stay was 15.9 hours. Sixteen subjects had clinically unrecognized delirium, and 14 of them completed the PrEDICT game (87.5%). We developed a threshold score with 100% sensitivity (95% confidence interval [CI] = 76.8%‐100.0%) and 59.7% specificity (95% CI = 52.3%‐66.6%) to identify patients with clinically unrecognized delirium. The area under the curve was 0.86 (95% CI = 0.77‐0.94). Completion rates were 196/203 (96.6%) for the PrEDICT serious game compared to 128/203 (63.1%) for the CRT and 51/203 (25.1%) for the DVT.
Older ED patients were able to use our serious game, including 87.5% of those with clinically unrecognized delirium. The PrEDICT application has potential to act as a sensitive screening tool to identify older ED patients with clinically unrecognized delirium.
Persons with Alzheimer disease and related dementias (ADRDs) require comprehensive care that spans health systems and community‐based organizations. This study examined the clinical outcomes of a comprehensive dementia care program and identified subgroups who were more likely to benefit.
Observational, baseline and 1 year after intervention.
Urban, academic medical center.
A total of 554 persons with dementia and their caregivers who had 1‐year follow‐up evaluations and data on clinical outcomes.
Health system‐based comprehensive dementia care management program using nurse practitioner dementia care managers.
Patient measures included the Mini‐Mental State Examination (MMSE), the Functional Activities Questionnaire, Basic and Instrumental Activities of Daily Living scales, the Cornell Scale for Depression in Dementia, and the Neuropsychiatric Inventory Questionnaire (NPI‐Q) Severity. Caregiver measures included the Modified Caregiver Strain Index, the Patient Health Questionnaire‐9, NPI‐Q Distress, and the Dementia Burden Scale‐Caregiver). We used established minimal clinically important differences and lowest tertiles of baseline symptoms to define improving symptoms and maintaining low symptoms as clinical benefit for patients and caregivers.
At year 1, persons with ADRD improved on all scales, except MMSE and functional status measures; caregivers improved on all scales. Using validated instruments, 314/543 (58%) of patients, 282/447 (63%) of caregivers, and 376/501 (75%) of patients or caregivers demonstrated clinical benefit. In adjusted multivariate models, at year 1, more behavioral symptoms and fewer depression symptoms at baseline were associated with patient improvement; and fewer baseline depression symptoms were associated with maintaining low behavioral symptoms. Male caregiver sex, higher baseline caregiver burden, and caring for patients with fewer baseline depression symptoms were associated with caregiver improvement. Male caregiver sex and patients with fewer depression symptoms, fewer behavioral symptoms, and more functional impairment at baseline were associated with caregivers maintaining low burden at 1 year.
Health system‐based comprehensive dementia care management is a promising approach to improving clinical outcomes, with benefits for both patients and caregivers.
The Journal of Antibiotics, Published online: 29 July 2019; doi:10.1038/s41429-019-0211-y
2-Pyrazol-1-yl-thiazole derivatives as novel highly potent antibacterials
To review the evidence evaluating the effectiveness of informal caregiver interventions to facilitate the recovery of older people discharged from the hospital.
Systematic review and meta‐analysis.
Hospital and community.
Published and unpublished randomized and nonrandomized controlled trials assessing the effectiveness of informal caregiver interventions to support the recovery of older people discharged from the hospital were identified (to March 2019). The primary outcome was patient health‐related quality of life (HRQOL). Secondary outcomes included patient function, caregiver burden, caregiver HRQOL, psychological distress, adverse events, and health resource use. Studies were critically appraised and meta‐analyzed.
Adults who had been admitted to the hospital.
A total of 23 studies were eligible (4695 participants). The indication for hospital admission was stroke in 21 trials (91%). Interventions consisted of training and/or skills‐based programs, with or without home visits/telephone follow‐up. Caregiver interventions for patients following stroke may provide no benefit for patient HRQOL at 12 months (standardized mean difference = .29; 95% confidence interval = ‐.12 to .69; low‐quality evidence). Caregiver interventions demonstrated benefit for caregiver burden and both patient and caregiver anxiety at 12 months. No consistent effect was found on functional outcomes, depression, HRQOL, adverse events, or health resource use measures.
Informal caregivers who receive training to facilitate the recovery of older people discharged from the hospital following stroke may have a lower burden and reduced anxiety at 12 months compared with those who do not. However, the evidence was moderate to low quality. Further study is warranted to explore whether caregiver interventions can be modified for nonstroke populations such as those with hip fracture.
To describe the structural characteristics and challenges associated with home telehealth (HT) use in the US Department of Veterans Affairs (VA) Home‐Based Primary Care (HBPC) program.
We designed a national survey to collect information about HBPC program structural characteristics. The survey included eight organizational and service domains, one of which was HT. HBPC program directors were surveyed online using REDCap.
We received 232 surveys from 394 HBPC sites (59% response rate).
HBPC structural domains were compared between sites using and not using HT technology. Open‐ended responses were analyzed using content analysis.
A total of 127 sites (76%) used HT, which was more likely when HBPC sites were aligned organizationally with the VA's Geriatrics and Extended Care Services division, when there were more disciplines on the HBPC team, and when primary care providers made home visits. Program directors overwhelmingly viewed HT as contributing to managing veterans' complex chronic conditions (81%), yet HT data were not readily integrated into care planning (24%). Challenges to HT use included veterans' acceptance and adherence, device issues, and collaboration between HBPC teams and HT staff.
Corresponding to HBPC's complexity, HT use is primarily a self‐organizing process that shapes the patterns of integration at each site. Although HT technology is compatible with core structures of the HBPC model, usability varies, and overall is low. To optimize HT use in HBPC, there are opportunities to redesign systems to mitigate challenges to adoption. As the Centers for Medicare and Medicaid Services' strives to increase access to both HBPC and telehealth benefits, evidenced by the continuation of its successful Independence at Home demonstration and the final changes in the proposed rule in April 2019 incorporating additional telehealth benefits for beneficiaries, this information will be relevant to VA and non‐VA alike.
Prior studies of mortality following traumatic brain injury (TBI) have not focused specifically on older adults compared with a non‐TBI trauma cohort or included specific causes of death. The objectives of this study were, among adults aged 65 years and older, to (1) generate standardized mortality ratios (SMRs) by cause of death for TBI and a non‐TBI trauma cohort compared with a general population, and (2) assess risk of mortality associated with TBI compared with a non‐TBI trauma cohort.
Retrospective cohort study of adults aged 65 years and older who were treated at an urban trauma center from 1997 to 2008.
Data from the trauma registry were linked to the National Death Index through 2008 to obtain date and cause of death. We identified individuals with TBI and non‐TBI trauma and calculated age‐ and sex‐adjusted SMRs by comparing with the state general population. We next compared time to mortality between individuals with TBI (n = 852) and non‐TBI trauma (n = 1050), adjusting for potential confounders.
Compared with the age‐ and sex‐adjusted state general population, older adults with TBI (SMR = 8.1; 95% confidence interval [CI] = 7.4‐9.0) and non‐TBI trauma (SMR = 6.7; 95% CI = 6.1‐7.4) were at a greatly increased risk of mortality. Highest SMRs in both cohorts were observed for accidents. In adjusted Cox regression models, TBI was not associated with increased risk of all‐cause mortality (hazard ratio = 1.03; 95% CI = .87‐1.23) compared with non‐TBI trauma.
This study provides evidence that, over a 4‐year follow‐up of older adults, any moderate to severe injury is associated with increased mortality risk. Specifically, older injured adults are at high risk of death from accidental and therefore preventable causes, suggesting that intervention could reduce mortality.
Barriers to treatment for depression and anxiety are prevalent among older adults and caregivers living in the community. We designed and implemented an evidence‐based psychotherapy program to reduce obstacles to care.
A practice improvement initiative providing no‐fee evidence‐based mental health care at home in clients' primary languages.
Independence at Home, a community service of SCAN Health Plan in Southern California.
Diverse older adults and adult caregivers of older people with age‐related disability (mainly dementia).
Redesign of an existing supportive counseling program to improve access to validated models of psychotherapy for depression and anxiety.
We describe program content, phases of development, equity in participation from referral to program completion, clinical outcomes, and estimated direct program delivery costs.
Insights successfully served demographically diverse clients experiencing a broad range of barriers to mental health care. A total of 211 clients completed therapy using one of three evidence‐based approaches in the first 33 months of operation (2015‐2018). Clinical efficacy was high and equivalent across demographic groups and therapy models. Depression, anxiety, quality of life, self‐rated disability, and patient activation all improved significantly. We supported therapists' transition to the new model, modified workflows, and used clinical outcome data and therapist focus groups to improve referral, selection, and enrollment processes and simplify treatment assignment. With program maturation, treatment duration and direct costs both declined.
The Insights model could add value to healthcare organizations seeking to provide effective, equitable mental health services for older adults and caregivers who have difficulty accessing care for depression, anxiety, or difficult life challenges.
Prospectively collected data on postoperative delirium (POD) after transcatheter aortic valve implantation (TAVI) are scarce. The aim of this study was to report the incidence and risk factors of delirium after TAVI under general anesthesia and to assess the association of POD with clinical outcome and short‐ and long‐term survival.
Prospective cohort study.
Academic medical center.
A total of 703 subsequent patients undergoing TAVI under general anesthesia between 2008 and 2017.
Delirium was assessed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‐IV), criteria. Outcomes were postprocedural clinical outcome and short‐ and long‐term survival (30 days and 5 years, respectively).
POD was observed in 16.5% (116/703), was the strongest independent predictor of long‐term mortality (hazard ratio = 1.91; 95% confidence interval [CI] = 1.36‐2.70), and was associated with impaired 30‐day and 5‐year survival (92.2% vs 96.8% [P = .025] and 40.0% vs 50.0% [P = .007], respectively). Stroke and new onset of atrial fibrillation were more often observed in delirious patients (6.9% vs 1.9% and 12.1% vs 5.1%, respectively). Strongest independent predictors of POD were prior delirium (odds ratio [OR] = 2.56; 95% CI = 1.52‐4.31) and aortic valve area less than 0.75 cm2 (OR = 2.39; 95% CI = 1.53‐3.74).
One in six patients experienced POD after TAVI under general anesthesia. POD was the strongest predictor of long‐term mortality and was associated with impaired short‐ and long‐term survival. Prior delirium and a more calcified aortic valve were the strongest independent predictors of POD.
Management of atrial fibrillation (AF) with rate and/or rhythm control could lead to fall‐related injuries and syncope, especially in the older AF population. We aimed to determine the association of rate and/or rhythm control with fall‐related injuries and syncope in a real‐world older AF cohort.
A retrospective cohort study.
Danish nationwide administrative registries from 2000 to 2015.
A total of 100 935 patients with AF aged 65 years or older claiming prescription of rate‐lowering drugs (RLDs) and/or anti‐arrhythmic drugs (AADs) were included. We compared the use of rate‐lowering monotherapy with rate‐lowering dual therapy, AAD monotherapy, and AAD combined with rate‐lowering therapy.
Outcomes were fall‐related injuries and syncope as a composite end point (primary) or separate end point (secondary).
In this population, the median age was 78 years (interquartile range [IQR] = 72‐84 y), and 53 481 (53.0%) were women. During a median follow‐up of 2.1 years (IQR = 1.0‐5.1), 17 132 (17.0%) experienced a fall‐related injury, 5745 (5.7%) had a syncope, and 21 093 (20.9%) experienced either. Compared with rate‐lowering monotherapy, AADs were associated with a higher risk of fall‐related injuries and syncope. The incidence rate ratio (IRR) for the composite end point was 1.29 (95% confidence interval [CI]: 1.17‐1.43) for AAD monotherapy and 1.46 [95% CI = 1.34‐1.58] for AAD combined with rate‐lowering therapy. When stratifying by individual drugs, amiodarone significantly increased the risk of fall‐related injuries and syncope (IRR = 1.40 [1.26‐1.55]). Compared with more than 180 days of rate‐lowering monotherapy, a higher risk of all outcomes was seen in the first 90 days of any treatment; however, the greatest risk was in the first 14 days for those treated with AADs.
In AF patients aged 65 years and older, AAD use was associated with a higher risk of fall‐related injuries and syncope, and the risk was highest within the first 14 days for those treated with AADs. Only amiodarone use was associated with a higher risk.
The Journal of Antibiotics, Published online: 24 July 2019; doi:10.1038/s41429-019-0213-9
Novel neuroprotective hydroquinones with a vinyl alkyne from the fungus, Pestalotiopsis microspora
Use of statins is considerable among older persons. We investigated factors associated with statin discontinuation in new statin users aged 70 years or older within the first 4 years of use.
Register‐based descriptive drug utilization study using data from 2008 to 2016.
All Danish persons, aged 70 years or older, initiating statin treatment.
Rates and predictors of statin discontinuation after 1 year (early), 2 years, and 4 years. Predictors of discontinuation were estimated using logistic regression.
We included 83 788 statin initiators. At 1 year, 13% had discontinued their treatment, while another 12% and 13% discontinued after 2 and 4 years, respectively. The overall discontinuation rate over 4 years was 32%. Increasing age was associated with discontinuation at all time points (adjusted odds ratio [OR] = 2.06 [95% confidence interval {CI} = 1.35‐3.16] at 1 year, adjusted OR = 3.94 [95% CI, 1.83‐8.49] at 4 years, comparing those aged >95 years to those aged 70‐74 years). Further, higher comorbidity scores and use of more than 10 medications were modestly associated with discontinuation. Use of statins for secondary prevention was associated with decreased odds of discontinuation compared to primary prevention at 1 year (adjusted OR = 0.74; 95% CI, 0.65‐0.83) and at 4 years (adjusted OR = 0.83; 95% CI, 0.72‐0.95), along with concomitant use of cardiovascular (CV) therapies. The annual proportion of early discontinuers ranged from 14% to 17% for primary prevention and from 9% to 12% for secondary prevention between 2008 and 2015.
Statin discontinuation within the first 4 years after initiation appeared to be influenced most strongly by age, and may also be influenced by comorbidity, polypharmacy, use for secondary prevention, and concomitant CV medication use. Future research should clarify reasons for, and discussions about, statin discontinuation and initiation among older persons, to provide additional insight on this topic.
Whether early medication reconciliation and integration can reduce polypharmacy and potentially inappropriate medication (PIM) in the emergency department (ED) remains unclear. Polypharmacy and PIM have been recognized as significant causes of adverse drug events in older adults. Therefore, this pilot study was conducted to delineate this issue.
An interventional study.
A medical center in Taiwan.
Older ED patients (aged ≥65 years) awaiting hospitalization between December 1, 2017, and October 31, 2018 were recruited in this study. A multidisciplinary team and a computer‐based and pharmacist‐assisted medication reconciliation and integration system were implemented.
The reduced proportions of major polypharmacy (≥10 medications) and PIM at hospital discharge were compared with those on admission to the ED between pre‐ and post‐intervention periods.
A total of 911 patients (pre‐intervention = 243 vs post‐intervention = 668) were recruited. The proportions of major polypharmacy and PIM were lower in the post‐intervention than in the pre‐intervention period (−79.4% vs −65.3%; P < .001, and − 67.5% vs −49.1%; P < .001, respectively). The number of medications was reduced from 12.5 ± 2.7 to 6.9 ± 3.0 in the post‐intervention period in patients with major polypharmacy (P < .001).
Early initiation of computer‐based and pharmacist‐assisted intervention in the ED for reducing major polypharmacy and PIM is a promising method for improving geriatric care and reducing medical expenditures.
To determine factors associated with older adults becoming edentulous (complete tooth loss).
Longitudinal study over a 6‐year period.
United States, 2006, 2012.
Nationally representative US sample of adults, aged 50 years and older (n = 9982), participating in the Health and Retirement Study in 2006 and 2012. At the outset, they were dentate and not institutionalized.
None.
Self‐report of being dentate or edentulous, demographic variables, dental utilization and other health behaviors, self‐rated general health, and incidence between 2006 and 2012 of comorbid medical conditions, functional limitations, and disabilities.
From 2006 to 2012, 563 individuals (5%) became edentulous and 9419 (95%) remained dentate. Adults who became edentulous by 2012 were more likely than those who remained dentate to be black/African American compared to white, to be less educated, were current smokers, had diabetes, and reported poorer self‐rated general health, more functional limitations and disabilities, and fewer dental visits (all P < .0001), among other factors. Of those with regular dental visits (at least once every 2 years during the 6‐year period), 2.3% became edentulous compared to 9.9% among those without regular dental visits. After adjusting for age and other potential confounders, there was a strong association with poor dental attendance and smoking. Nonregular dental attenders were more likely than regular attenders to become edentulous (odds ratio [OR] = 2.74; 95% confidence interval [CI] = 2.12‐3.53), and current smokers were more likely than never smokers to become edentulous (OR = 2.46; 95% CI = 1.74‐3.46).
Although more contemporaneous data are needed to determine causality, regular dental utilization and smoking are modifiable factors that could prevent edentulism, even when many other comorbid conditions are present. J Am Geriatr Soc, 1–7, 2019.
To examine the relationship between registered nurse (RN) burnout, job dissatisfaction, and missed care in nursing homes.
Cross‐sectional secondary analysis of linked data from the 2015 RN4CAST‐US nurse survey and LTCfocus.
A total of 540 Medicare‐ and Medicaid‐certified nursing homes in California, Florida, New Jersey, and Pennsylvania.
A total of 687 direct care RNs.
Emotional Exhaustion subscale of the Maslach Burnout Inventory, job dissatisfaction, and missed care.
Across all RNs, 30% exhibited high levels of burnout, 31% were dissatisfied with their job, and 72% reported missing one or more necessary care tasks on their last shift due to lack of time or resources. One in five RNs reported frequently being unable to complete necessary patient care. Controlling for RN and nursing home characteristics, RNs with burnout were five times more likely to leave necessary care undone (odds ratio [OR] = 4.97; 95% confidence interval [CI] = 2.56‐9.66) than RNs without burnout. RNs who were dissatisfied were 2.6 times more likely to leave necessary care undone (OR = 2.56; 95% CI = 1.68‐3.91) than RNs who were satisfied. Tasks most often left undone were comforting/talking with patients, providing adequate patient surveillance, patient/family teaching, and care planning.
Missed nursing care due to inadequate time or resources is common in nursing homes and is associated with RN burnout and job dissatisfaction. Improved work environments with sufficient staff hold promise for improving care and nurse retention.
To evaluate geriatric education programs for emergency department (ED) professionals based on: content and teaching methods and learning outcome effects and factors promoting or hindering program implementation.
Systematic review.
ED.
Physicians, nurses, and medical residents working in the ED.
Five major biomedical databases were searched for (quasi) experimental studies, published between 1990 and April 2018, evaluating geriatric education programs for ED professionals. Data were synthesized around study quality, learning participants, teaching content and methods, and Kirkpatrick learning outcomes.
Nine before‐after studies were included. Learners were mostly ED residents and, to a smaller extent, ED nurses and physicians. Study quality was moderate, with the lowest scores on sampling and instrument validity. Programs varied from a 1‐day workshop to a 2‐year curriculum, mostly combining didactic lectures with active and experiential learning formats. Topics commonly addressed included managing: geriatric syndromes, trauma and falls, medication, atypical presentations, and care transitions. Statistically significant improvements were mostly found in learners' knowledge acquisition (six studies). Significant improvements were also found in single studies on: self‐reported geriatric screening, documentation of geriatric care, and appropriate urinary catheter placement. Factors promoting program implementation included: solving competing educational demands and busy work schedules, embedding the program in preexisting curricula, and close collaboration between emergency and geriatric medicine faculties.
Various geriatric education programs improve the geriatric knowledge of ED professionals and seem to positively impact their clinical practice. However, more program evaluations with larger study samples, and use of valid and reliable outcome measures, are needed to provide robust evidence on the effectiveness of such programs. J Am Geriatr Soc, 1–8, 2019.
The Journal of Antibiotics, Published online: 24 July 2019; doi:10.1038/s41429-019-0210-z
Rescrutiny of the sansanmycin biosynthetic gene cluster leads to the discovery of a novel sansanmycin analogue with more potency against Mycobacterium tuberculosis
To describe patterns of antihypertensive medication treatment in hypertensive nursing home (NH) residents with and without dementia and determine the association between antihypertensive treatment and outcomes important to individuals with dementia.
Observational cohort study.
All US NHs.
Long‐term NH residents treated for hypertension in the second quarter of 2013, with and without moderate or severe cognitive impairment, as defined by the NH Minimum Data Set (MDS) Cognitive Function Scale.
The primary exposure was intensity of antihypertensive treatment, as defined as number of first‐line antihypertensive medications in Medicare Part D dispensing data. The outcome measures were hospitalization, hospitalization for cardiovascular diseases using Medicare Hierarchical Condition Categories, decline in physical function using the MDS Activities of Daily Living (ADLs) scale, and death during a 180‐day follow‐up period.
Of 255 670 NH residents treated for hypertension, 117 732 (46.0%) had moderate or severe cognitive impairment. At baseline, 54.4%, 34.3%, and 11.4% received one, two, and three or more antihypertensive medications, respectively. Moderate or severe cognitive impairment (odds ratio [OR] = 0.80 vs no or mild impairment; P < .0001), worse physical function (OR = 0.64 worst vs best tertile; P < .0001), and hospice or less than a 6‐month life expectancy (OR = 0.80; P < .0001) were associated with receipt of fewer antihypertensive medications. Increased intensity of antihypertensive treatment was associated with small increases in hospitalization (difference per additional medication = 0.24%; 95% confidence interval = 0.03%‐0.45%) and cardiovascular hospitalization (difference per additional medication = 0.30%; 95% confidence interval = 0.21%‐0.39%) and a small decrease in ADL decline (difference per additional medication = −0.46%; 95% confidence interval = −0.67% to −0.25%). There was no significant difference in mortality (difference per additional medication = −0.05%; 95% confidence interval = −0.23% to 0.13%).
Long‐term NH residents with hypertension do not experience significant benefits from more intensive antihypertensive treatment. Antihypertensive medications are reasonable targets for deintensification in residents in whom this is consistent with goals of care.
The Journal of Antibiotics, Published online: 23 July 2019; doi:10.1038/s41429-019-0214-8
Aspermicrones A-C, novel dibenzospiroketals from the seaweed-derived endophytic fungus Aspergillus micronesiensis
The Journal of Antibiotics, Published online: 22 July 2019; doi:10.1038/s41429-019-0208-6
Cipralphelin, a new anti-oxidative N-cinnamoyl tripeptide produced by the deep sea-derived fungal strain Penicillium brevicompactum FKJ-0123
The Journal of Antibiotics, Published online: 19 July 2019; doi:10.1038/s41429-019-0209-5
Antibacterial diketopiperazines from an endophytic fungus Bionectria sp. Y1085
To assess whether gait speed under complex conditions predicts long‐term risk for mobility disability as well as or better than usual‐pace gait speed.
Longitudinal cohort study.
Subsample of Health Aging and Body Composition study with follow‐up from 2002 to 2003 to 2010 to 2011, including 337 community‐dwelling adults (mean age = 78.5 years, 50.7% female, 26.1% black).
Associations of gait speed measured under usual‐pace, fast‐pace, dual‐task, and narrow‐path conditions with mobility disability, defined by any self‐reported difficulty walking ¼ mile assessed annually, were tested by Cox proportional hazard models adjusted for demographic and health characteristics. Models were fitted for each walking condition, and R 2 statistics were used to compare predictive value across models. Models were repeated for persistent mobility disability, defined as at least two consecutive years of mobility disability.
Mobility disability occurred in 204 (60.5%) participants over the 8‐year follow‐up. There was a lower hazard of developing mobility disability with faster gait speed under all conditions. Hazard ratios, confidence intervals, and R 2 of gait speed predicting mobility disability were similar across all four walking conditions (R 2 range = 0.22‐0.27), but were strongest for dual‐task gait speed (hazard ratio [95% confidence interval], R 2 of fully adjusted models = 0.81 [0.75‐0.88], 0.27). Results were comparable for persistent mobility disability (R 2 range = 0.26‐0.28).
Slower gait speed under both usual‐pace and complex conditions may be a clinical indicator of future risk of mobility disability. These results support the call for increased use of gait speed measures in routine geriatric care. J Am Geriatr Soc, 1–5, 2019.
Nursing home (NH) residents with complex care needs ask for attentive monitoring of changes and appropriate in‐house decision making. However, access to geriatric expertise is often limited with a lack of geriatricians, general practitioners, and/or nurses with advanced clinical skills, leading to potentially avoidable hospitalizations. This situation calls for the development, implementation, and evaluation of innovative, contextually adapted nurse‐led care models that support NHs in improving their quality of care and reducing hospitalizations by investing in effective clinical leadership, geriatric expertise, and care coordination.
An effectiveness‐implementation hybrid type 2 design to assess clinical outcomes of a nurse‐led care model and a mixed‐method approach to evaluate implementation outcomes will be applied. The model development, tailoring, and implementation are based on the Consolidated Framework for Implementation Research (CFIR).
NHs in the German‐speaking region of Switzerland.
Eleven NHs were recruited. The sample size was estimated assuming an average of .8 unplanned hospitalizations/1000 resident days and a reduction of 25% in NHs with the nurse‐led care model.
The multilevel complex context‐adapted intervention consists of six core elements (eg, specifically trained INTERCARE nurses or evidence‐based tools like Identify, Situation, Background, Assessment and Recommendation [ISBAR]). Multilevel implementation strategies include leadership and INTERCARE nurse training and support.
The primary outcomes are unplanned hospitalizations/1000 care days. Secondary outcomes include unplanned emergency department visits, quality indicators (eg, physical restraint use), and costs. Implementation outcomes included, for example, fidelity to the model's core elements.
The INTERCARE study will provide evidence about the effectiveness of a nurse‐led care model in the real‐world setting and accompanying implementation strategies.
Frailty places individuals at greater risk of adverse health outcomes. However, it is a dynamic condition and may not always lead to decline. Our objective was to determine the relationship between frailty status (at baseline and follow‐up) and mortality using both the frailty phenotype (FP) and frailty index (FI).
Population‐based cohort.
Community‐dwelling older adults.
A total of 909 individuals aged 65 years or older (55% female), mean age 74.4 (SD 6.2) years, had frailty measurement at baseline. Overall, 549 participants had frailty measurement at two time points.
Frailty was measured using the FP and FI, with a mean 4.5 years between baseline and follow‐up. Mortality was matched to official death records with a minimum of 10 years of follow‐up.
For both measures, baseline frailty was a significant predictor of mortality up to 10 years, with initially good predictive ability (area under the curve [AUC] = .8‐.9) decreasing over time. Repeated measurement at follow‐up resulted in good prediction compared with lower (AUC = .6‐.7) discrimination of equivalent baseline frailty status. In a multivariable model, frailty measurement at follow‐up was a stronger predictor of mortality compared with baseline. Frailty change for the Continuous FI was a significant predictor of decreased or increased mortality risk based on corresponding improvement or worsening of score (hazard ratio = 1.04; 95% confidence interval = 1.02‐1.07; P = .001).
Frailty measurement is a good predictor of mortality up to 10 years; however, recency of frailty measurement is important for improved prediction. A regular review of frailty status is required in older adults.
To determine if antibiotic prescribing in community nursing homes (NHs) can be reduced by a multicomponent antibiotic stewardship intervention implemented by medical providers and nursing staff and whether implementation is more effective if performed by a NH chain or a medical provider group.
Two‐year quality improvement pragmatic implementation trial with two arms (NH chain and medical provider group).
A total of 27 community NHs in North Carolina that are typical of NHs statewide, conducted before announcement of the US Centers for Medicare and Medicaid Services antibiotic stewardship mandate.
Nursing staff and medical care providers in the participating NHs.
Standardized antibiotic stewardship quality improvement program, including training modules for nurses and medical providers, posters, algorithms, communication guidelines, quarterly information briefs, an annual quality improvement report, an informational brochure for residents and families, and free continuing education credit.
Antibiotic prescribing rates per 1000 resident days overall and by infection type; rate of urine test ordering; and incidence of Clostridium difficile and methicillin‐resistant Staphylococcus aureus (MRSA) infections.
Systemic antibiotic prescription rates decreased from baseline by 18% at 12 months (incident rate ratio [IRR] = 0.82; 95% confidence interval [CI] = 0.69‐0.98) and 23% at 24 months (IRR = 0.77; 95% CI = 0.65‐0.90). A 10% increase in the proportion of residents with the medical director as primary physician was associated with a 4% reduction in prescribing (IRR = 0.96; 95% CI = 0.92‐0.99). Incidence of C. difficile and MRSA infections, hospitalizations, and hospital readmissions did not change significantly. No adverse events from antibiotic nonprescription were reported. Estimated 2‐year implementation costs per NH, exclusive of medical provider time, ranged from $354 to $3653.
Antibiotic stewardship programs can be successfully disseminated in community NHs through either NH administration or medical provider groups and can achieve significant reductions in antibiotic use for at least 2 years. Medical director involvement is an important element of program success.
Care coordination programs can improve patient outcomes and decrease healthcare expenditures; however, implementation costs are poorly understood. We evaluate the direct costs of implementing a collaborative dementia care program.
We applied a micro‐costing analysis to calculate operational costs per‐participant‐month between March 2015 and May 2017.
The University of California, San Francisco (UCSF) and the University of Nebraska Medical Center (UNMC).
Participants diagnosed with dementia, enrolled in Medicare or Medicaid, 45 years of age or older, residents of California, Nebraska or Iowa, and having a caregiver. The sample was 272 (UCSF) and 192 (UNMC) participants.
A collaborative dementia care program provided by care team navigators (CTNs), advanced practice nurses, a social worker, and a pharmacist, focusing on caregiver support and education, medications, advance care planning, and behavior symptom management.
We measured costs (personnel, supplies, equipment, and training costs) during three program periods, Start‐up, Early Operations, and Continuing Operations, and estimated the effects of caseload variation on costs.
Start‐up and Early Operations costs were, respectively, $581 and $328 (California), and $501 and $219 (Nebraska) per‐participant‐month. Average costs decreased across phases to $241 (California) and $142 (Nebraska) per‐participant‐month during Continuing Operations. We estimated that costs would range between $75 (UNMC) and $92 (UCSF) per‐participant‐month with the highest projected caseloads (90).
We found that CTN caseload is an important driver of service cost. We provide strategies for maximizing caseload without sacrificing quality of care. We also discuss current barriers to broad implementation that can inform new reimbursement policies.
To examine loss of community‐dwelling status 9 months after hospitalization for high‐acuity emergency general surgery (HA‐EGS) disease among older Americans.
Retrospective analysis of claims data.
US communities with Medicare beneficiaries.
Medicare beneficiaries age 65 years or older hospitalized urgently/emergently between January 1, 2015, and March 31, 2015, with a principal diagnosis representing potential life or organ threat (necrotizing soft tissue infections, hernias with gangrene, ischemic enteritis, perforated viscus, toxic colitis or gastroenteritis, peritonitis, intra‐abdominal hemorrhage) and an operation of interest on hospital days 1 or 2 (N = 3319).
Demographic characteristics (age, race, and sex), comorbidities, principal diagnosis, complications, and index hospitalization disposition (died; discharged to skilled nursing facility [SNF], long‐term acute care [LTAC], rehabilitation, hospice, home (with or without services), or acute care hospital; other) were measured. Survivors of index hospitalization were followed until December 31, 2015, on mortality and community‐dwelling status (SNF/LTAC vs not). Descriptive statistics, Kaplan‐Meier plots, and χ2 tests were used to describe and compare the cohort based on disposition. A multivariable logistic regression model, adjusted for age, sex, comorbidities, complications, and discharge disposition, determined independent predictors of loss of community‐dwelling status at 9 months.
A total of 2922 (88%) survived index hospitalization. Likelihood of discharge to home decreased with increasing age, baseline comorbidities, and in‐hospital complications. Overall, 418 (14.3%) HA‐EGS survivors died during the follow‐up period. Among those alive at 9 months, 10.3% were no longer community dwelling. Initial discharge disposition to any location other than home and three or more surgical complications during index hospitalization were independent predictors of residing in a SNF/LTAC 9 months after surviving HA‐EGS.
Older Americans, known to prioritize living in the community, will experience substantial loss of independence due to HA‐EGS. Long‐term expectations after surviving HA‐EGS must be framed from the perspective of the outcomes that older patients value the most. Further research is needed to examine the quality‐of‐life burden of EGS survivorship prospectively.
Most people with Alzheimer disease and related dementias will experience agitated and/or aggressive behaviors during the later stages of the disease. These behaviors cause significant stress for people living with dementia and their caregivers, including nursing home (NH) staff. Addressing these behaviors without the use of chemical restraints is a growing focus of policy makers and professional organizations. Unfortunately, evidence for nonpharmacological strategies for addressing dementia‐related behaviors is lacking.
Six‐month, preintervention‐postintervention pilot study.
US NHs (n = 4).
Residents with advanced dementia (n = 45).
Music & Memory, an individualized music program in which the music a resident preferred when she/he was young is delivered at early signs of agitation, using a personal music player.
Dementia‐related behaviors for the same residents were measured three ways: (1) observationally using the Agitation Behavior Mapping Instrument (ABMI); (2) staff report using the Cohen‐Mansfield Agitation Inventory (CMAI); and (3) administratively using the Minimum Data Set–Aggressive Behavior Scale (MDS‐ABS).
ABMI score was 4.1 (SD = 3.0) preintervention while not listening to the music, 4.4 (SD = 2.3) postintervention while not listening to the music, and 1.6 (SD = 1.5) postintervention while listening to music (P < .01). CMAI score was 61.2 (SD = 16.3) preintervention and 51.2 (SD = 16.1) postintervention (P < .01). MDS‐ABS score was 0.8 (SD = 1.6) preintervention and 0.7 (SD = 1.4) postintervention (P = .59).
Direct observations were most likely to capture behavioral responses, followed by staff interviews. Nursing‐home based, pragmatic trials that rely solely on available administrative data may fail to detect effects of nonpharmaceutical interventions on behaviors. Findings are relevant to evaluations of nonpharmaceutical strategies for addressing behaviors in NHs, and will inform a large, National Institute on Aging–funded pragmatic trial beginning spring 2019.
Concerns have repeatedly been raised about end‐of‐life decision making when a patient with diminished capacity is represented by a professional guardian, a paid official appointed by a judge. Such guardians are said to choose high‐intensity treatment even when it is unlikely to be beneficial or to leave pivotal decisions to the court. End‐of‐life decision making by professional guardians has not been examined systematically, however.
Retrospective cohort study.
Inpatient and outpatient facilities in the Department of Veterans Affairs (VA) Connecticut Healthcare System.
Decedent patients represented by professional guardians who received care at Connecticut VA facilities from 2003 to 2013 and whose care in the last month of life was documented in the VA record.
Through chart reviews, we collected data about the guardianship appointment, the patient's preferences, the guardian's decision‐making process, and treatment outcomes.
There were 33 patients with professional guardians who died and had documentation of their end‐of‐life care. The guardian sought judicial review for 33%, and there were delays in decision making for 42%. In the last month of life, 29% of patients were admitted to the intensive care unit, intubated, or underwent cardiopulmonary resuscitation; 45% received hospice care. Judicial review and high‐intensity treatment were less common when information about the patient's preferences was available.
Rates of high‐intensity treatment and hospice care were similar to older adults overall. Because high‐intensity treatment was less likely when the guardian had information about a patient's preferences, future work should focus on advance care planning for individuals without an appropriate surrogate.
The Journal of Antibiotics, Published online: 12 July 2019; doi:10.1038/s41429-019-0204-x
Azithromycin, a 15-membered macrolide antibiotic, inhibits influenza A(H1N1)pdm09 virus infection by interfering with virus internalization process
The Journal of Antibiotics, Published online: 12 July 2019; doi:10.1038/s41429-019-0199-3
Novel adenosine-derived inhibitors of Cryptosporidium parvum inosine 5′-monophosphate dehydrogenase
Falls are frequent and often devastating events among older adults. Cardiovascular disease (CVD) is associated with greater fall risk; however, it is unknown if pathways that contribute to CVD, such as subclinical myocardial damage or wall strain, are related to future falls. We hypothesized that elevations in high‐sensitivity cardiac troponin T (hs‐cTnT) and N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP), measured in older adults, would be associated with greater fall risk.
Prospective cohort study.
Atherosclerosis Risk in Communities Study participants without known coronary heart disease, heart failure, or stroke.
We measured hs‐cTnT or NT‐proBNP in 2011 to 2013. Falls were identified from hospital discharge International Classification of Diseases, Ninth Revision (ICD‐9), codes or Centers for Medicare and Medicaid Services claims. We used Poisson models adjusted for age, sex, and race/study center to quantify fall rates across approximate quartiles of hs‐cTnT (less than 8, 8‐10, 11‐16, and 17 or greater ng/L) and NT‐proBNP (less than 75, 75‐124, 125‐274, and 275 or greater pg/mL). We used Cox models to determine the association of cardiac markers with fall risk, adjusted for age, sex, race/center, and multiple fall risk factors.
Among 3973 participants (mean age = 76 ± 5 years, 62% women, 22% black), 457 had a subsequent fall during a median follow‐up of 4.5 years. Incidence rates across quartiles of hs‐cTnT and NT‐proBNP were 17.1, 20.0, 26.2, and 36.4 per 1000 person‐years and 12.8, 22.2, 28.7, and 48.4 per 1000 person‐years, respectively. Comparing highest vs lowest quartiles of either hs‐cTnT or NT‐proBNP demonstrated a greater than two‐fold higher fall risk, with hazard ratios of 2.17 (95% confidence interval {CI} = 1.60‐2.95) and 2.34 (95% CI = 1.73‐3.16), respectively. In a joint model, the relationships of hs‐cTnT and NT‐proBNP with falls were significant and independent.
Subclinical elevations of cardiac damage and wall strain were each associated with a higher fall risk in older adults. Further research is needed to determine whether interventions that lower hs‐cTnT or NT‐proBNP also lower fall risk.
The Journal of Antibiotics, Published online: 11 July 2019; doi:10.1038/s41429-019-0205-9
Strategies in anti-Mycobacterium tuberculosis drug discovery based on phenotypic screening
Telephone‐based cognitive screens, such as the Telephone Interview for Cognitive Status (TICS), can potentially reduce the barriers and costs of assessing older adults. However, validation of clinically relevant psychometric properties is lacking in a large and comprehensively assessed sample of older adults. Furthermore, published normative data may lack sensitivity as they have not used regression‐based demographic corrections or accounted for cases with subsequent dementia. We address these gaps using the modified TICS (TICS‐M; a modified, 13‐item, 39‐point version) and provide an online norms calculator for clinicians and researchers.
Prospective longitudinal study.
Sydney, Australia.
A total of 617 community‐living older adults, aged from 71 to 91 years.
The measures used included the TICS‐M, the Mini‐Mental State Examination (MMSE), Addenbrooke's Cognitive Examination‐Revised (ACE‐R), and a comprehensive neuropsychological test battery. Descriptive statistics, correlations, area under the curve, and regression analyses were used to determine the validity and normative properties of the TICS‐M.
TICS‐M total scores (mean = 24.20; SD = 3.76) correlated well with the MMSE (0.70) and ACE‐R (0.80) and moderately with neuropsychological tests tested noncontemporaneously. A cutoff score of 21 or lower reliably distinguished between those with and without incident dementia after 1 year (sensitivity = 77%; specificity = 88%) but was less reliable at distinguishing mild cognitive impairment from normal cognition. TICS‐M scores decreased with age and increased with higher education levels. The robust normative sample, which excluded incident dementia cases, scored higher on the TICS‐M and with less variability than the whole sample. An online calculator is provided to compute regression‐based norms and reliable change statistics.
In a large sample of community‐dwelling older adults, the TICS‐M performed well in terms of construct validity against typical screening tools and neuropsychological measures and diagnostic validity for incident dementia. The comprehensive, regression‐based, and robust normative data provided will help improve the sensitivity, accessibility, and cost‐effectiveness of cognitive testing with older adults.
As life expectancy continues to rise, the burden of cardiovascular disease among older people is expected to increase, making cardiovascular prevention in older people an issue of growing interest and public health importance. We aimed to explore the long‐term effects of adherence to statins on mortality and cardiovascular morbidity among older adults.
A historical population‐based cohort study using routinely collected data.
Clalit Health Services Northern District.
We followed members of Clalit Health Services aged 65 years or older who were eligible for primary cardiovascular prevention for a period of 10 years.
We fitted Cox regression models to assess the association between the adherence to statin therapy and all‐cause mortality and cardiovascular morbidity, adjusting for cardiovascular risk factors and associated morbidity as time‐updated variables.
The analysis included 19 518 older adults followed during 10 years (median = 9.7 y). All‐cause mortality rates were 34% lower among those who had adhered to statin treatment, compared with those who had not (hazard ratio [HR] = .66; 95% confidence interval [CI] = .56‐.79). Adherence to statins was also associated with fewer atherosclerotic cardiovascular disease events (HR = .80; 95% CI = .71‐.81). The benefit of statin use did not diminish among beyond age 75 and was evident for both women and men.
Adherence to statins may be associated with reduced mortality and cardiovascular morbidity among older adults, regardless of age and sex.
The Clock Drawing Test (CDT) is a widely used measure, which has been included as a recommended cognitive screen for driving evaluations. This study aimed to develop an optimized scoring method—the West Haven–Yale CDT (WHY‐CDT)—based on the scoring methods of Freund and Royall's CLOX, the latter of which is significantly associated with executive control functions.
Retrospective cohort study.
Greater New Haven, Connecticut, area.
A total of 237 adults, aged 70 years and older, who had a current driver's license and drove at least once a month.
Clock drawings were independently scored using both scoring systems, as well as a qualitative‐based 5‐point gestalt score. Interrater reliability was calculated using Light's κ for dichotomous variables and intraclass correlations for continuous variables. A categorical principal component analysis was conducted to determine which items from the Freund and Royall scoring systems should be retained in the modified system, with the Kuder‐Richardson test used to assess internal consistency (reliability).
The majority of the quantitative scoring items had moderate to almost perfect interrater reliability, with excellent interrater reliability for the qualitative gestalt score. The final scoring method retained seven items from the Freund and Royall versions, of which over 85% were from the latter. Internal consistency was fair to acceptable for the WHY‐CDT's two dichotomously scored subscales, but poor for both the Freund and Royall scoring methods.
The WHY‐CDT is a simple scoring method that combines elements of the Freund and Royall methods, as well as an overall gestalt score, and has strong interrater reliability. Future directions for use of this modified system are discussed.
Advances in understanding fundamental processes of aging have led to a variety of investigational therapies to delay or prevent age‐related diseases and conditions. These geroscience therapeutics hold the promise of revolutionizing medical care of older adults by treating the complex syndromes of aging and preserving health and independence. A crucial bottleneck is the study of geroscience therapeutics in early‐stage, first‐in‐human, or proof‐of‐concept clinical trials. There is a limited pool of clinical investigators with the combination of knowledge and skills at the interface of clinical research, care of older adults, and aging biology needed to successfully design, fund, and implement geroscience trials. Current training pipelines are insufficient to meet the need. The sixth retreat of the National Institute on Aging R24 Geroscience Network brought together basic scientists, gerontologists, clinicians, and clinical researchers from the United States and Europe to discuss how to identify, recruit, and train investigators who can perform early‐stage clinical trials in geroscience. We present herein the group's consensus on necessary subject domains and competencies, identification of candidate learners, credentialing learners, and the efficient and rapid implementation of training programs. Foundations and funding agencies have crucial roles to play in catalyzing the development of these programs. Geriatrician investigators are indispensable but cannot meet the need alone. Translational geroscience training programs can create a cadre of groundbreaking investigators from a variety of backgrounds and foster institutional cultures supportive of multidisciplinary translational aging research to turn innovative ideas into transformative therapeutics that can improve the health and independence of older adults.
As key team members caring for people with advanced illness, nurses teach patients and families about managing their illnesses and help them to understand their options. Our objective was to determine if nurses' personal healthcare experience with serious illness and end‐of‐life (EOL) care differs from the general population as was shown for physicians.
Observational propensity‐matched cohort study.
Fee‐for‐service Medicare.
Nurses' Health Study (NHS) and a random 20% national sample of Medicare beneficiaries aged 66 years or older with Alzheimer's disease and related dementias (ADRD) or congestive heart failure (CHF) diagnosed in the hospital.
Characteristics of care during the first year after diagnosis and the last 6 months of life (EOL).
Among 57 660 NHS participants, 7380 had ADRD and 5375 had CHF; 3227 ADRD patients and 2899 CHF patients subsequently died. Care patterns in the first year were similar for NHS participants and the matched national sample: hospitalization rates, emergency visits, and preventable hospitalizations were no different in either disease. Ambulatory visits were slightly higher for NHS participants than the national sample with ADRD (13.1 vs 12.5 visits; P < .01) and with CHF (13.7 vs 12.5; P < .001). Decedents in the NHS and national sample had similar acute care use (hospitalization and emergency visits) in both diseases, but those with ADRD were less likely to use life‐prolonging treatments such as mechanical ventilation (10.9% vs 13.5%; P = .001), less likely to die in a hospital with a stay in the intensive care unit (10.4% vs 12.1%; P = .03), and more likely to use hospice (58.9% vs 54.8%; P < .001). CHF at the EOL results were similar.
Nurses with newly identified serious illness experience similar care as the general Medicare population. However, at EOL, nurses are more likely to choose less aggressive treatments than the patients for whom they care. J Am Geriatr Soc 00:1–8, 2019.
The Journal of Antibiotics, Published online: 09 July 2019; doi:10.1038/s41429-019-0207-7
Coumamarin: a first coumarinyl calcium complex isolated from nature
In nursing homes across the world, and particularly in Spain, there are concerns that psychotropic medications are being overused. For older Spanish nursing home residents who had dementia, we sought to evaluate the association between applying interventions designed to reduce inappropriate psychotropic medication use and subsequent psychotropic use.
Retrospective, propensity score–matched, controlled, patient‐level observational analysis.
A total of 45 nursing homes in Spain.
A total of 1653 nursing home residents, aged 70 to 99 years, who had dementia and were prescribed an antipsychotic, anxiolytic, or antidepressant medication, 606 of whom received an intervention; the remainder served as propensity score–matched controls.
Team Rounds, Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert Doctors to Right Treatment (START) criteria, or a Patient Decision Aid.
At 2 and 4 weeks following intervention: change from baseline drug class–specific milligram‐equivalent daily dose (MEDD); at 2 weeks: patient falls and restraint use.
Within each intervention/drug‐class cohort, intervention patients and matched controls had similar baseline demographic characteristics, Charlson scores, lengths of admission, and drug class–specific MEDDs. Compared to controls, patients exposed to Team Rounds experienced a 23.3% (95% confidence interval [CI] = 13.9%‐32.8%) reduction in antipsychotic and a 23.1% (95% CI = 18.3%‐28.0%) reduction in anxiolytic MEDDs; those exposed to Patient Decision Aids had a 24.8% (95% CI = 15.6%‐33.9%) reduction in antipsychotic and a 31.8% (95% CI = 25.5%‐38.2%) reduction in anxiolytic MEDDs; and those exposed to STOPP/START application had a 27.7% (95% CI = 22.4%‐33.0%) reduction in antipsychotic and a 39.5% (95% CI = 35.5%‐43.5%) reduction in anxiolytic MEDDs. Intervention‐associated antidepressant MEDD reductions were statistically significant but less dramatic. Interventions were associated with higher rates of medication discontinuation, but not higher rates of deaths, patient falls, or physical restraints.
We found strong evidence that the interventions we studied were associated with reduced psychotropic use without commensurate harms, suggesting that such interventions should be incorporated into Spanish nursing home care models. Public reporting of psychotropic medication use in Spanish care homes may encourage care homes to regularly monitor psychotropic medication use and implement such instruments. J Am Geriatr Soc, 2019.
To determine predictors of new activities of daily living (ADLs) disability and worsened mobility disability and secondarily increased daily care hours received, in previously independent hip fracture patients.
Retrospective cohort study.
Academic hospital with ambulatory follow‐up.
Community‐dwelling adults 65 years or older independent in ADLs undergoing hip fracture surgery in 2015 (n = 184).
Baseline, 3‐ and 6‐month ADLs, mobility, and daily care hours received were ascertained by telephone survey and chart review. Comorbidities, medications, and characteristics of hospitalization were extracted from patient charts. Models for each outcome used logistic regression with a backward elimination strategy, adjusting a priori for age, sex, and race.
Predictors of new ADL disability at 3 months were dementia (odds ratio [OR] = 11.81; P = .001) and in‐hospital delirium (OR = 4.20; P = .002), and at 6 months were age (OR = 1.04; P = .014), dementia (OR = 9.91; P = .001), in‐hospital delirium (OR = 3.00; P = .031) and preadmission opiates (OR = 7.72; P = .003). Predictors of worsened mobility at 3 months were in‐hospital delirium (OR = 4.48; P = .001) and number of medications (OR = 1.13; P = .003), and at 6 months were age (OR = 1.06; P = .001), preadmission opiates (OR = 7.23; P = .005), in‐hospital delirium (OR = 3.10; P = .019), and number of medications (OR = 1.13; P = .013). Predictors of increased daily care hours received at 3 and 6 months were age (3 months: OR = 1.07; P = .014; 6 months: OR = 1.06; P = .017) and number of medications (3 months: OR = 1.13; P = .004; 6 months: OR = 1.22; P = .013). The proportion of patients with ADL disability and care hours received did not change from 3 to 6 months, yet there were significant improvements in mobility.
Age, dementia, in‐hospital delirium, number of medications, and preadmission opiate use were predictors of poor outcomes in independent older adults following hip fracture. Further investigation is needed to identify factors associated with improved mobility measures from 3 to 6 months to ultimately optimize recovery.
To examine the effect of subjective and objective sleep quality on subsequent recurrence of peptic ulcer disease (PUD) among older patients after Helicobacter pylori eradication.
Eight grade A hospitals in China.
Of 1689 older Chinese with H. pylori–infected PUD recruited between January 2011 and October 2014, H. pylori were eradicated and PUD was cleared in 1538 patients by the end of 2014; 1420 of these patients were followed up for up to 36 months.
Using multiple measures at 6‐month intervals, PUD recurrence was determined with esophagogastroduodenoscopy. Subjective sleep quality was measured using the Pittsburgh Sleep Quality Index. Objective sleep quality domains were measured using an accelerometer, including sleep onset latency, sleep efficiency, total sleep time, and number of awakenings.
This study documented a 36‐month cumulative PUD recurrence of 8.3% (annual rate = 2.8%). Multivariate analyses showed that participants who reported poorer sleep quality were more likely to experience PUD recurrence during the 36‐month follow‐up period (hazard ratio [HR] = 1.895; 95% confidence interval [CI] = 1.008‐3.327). Regarding objective sleep quality domains, longer sleep onset latency (HR = 1.558; 95% CI = 1.156‐2.278) and more nighttime awakenings (HR = 1.697; 95% CI = 1.168‐2.665) increased the risk of PUD recurrence. However, a longer total sleeping time protected against PUD recurrence (HR = 0.768; 95% CI = 0.699‐0.885).
Poor sleep quality predicts a greater risk of PUD recurrence. Accurate diagnosis and effective treatments should, therefore, be provided for older adults afflicted with poor sleep, particularly for those who previously had PUD. It is equally important to include sleep assessment as an integral part while dealing with these patients.
To examine the use of electronic medical record (EMR) data to ascertain falls and develop a fall risk prediction model in an older population.
Retrospective longitudinal study using 10 years of EMR data (2004‐2014). A series of 3‐year cohorts included members continuously enrolled for a minimum of 3 years, requiring 2 years pre‐fall (no previous record of a fall) and a 1‐year fall risk period.
Kaiser Permanente Hawaii, an ambulatory setting.
A total of 57 678 adults, age 60 years and older.
Initial EMR searches were guided by current literature and geriatricians to understand coding sources of falls as our outcome. Falls were captured by two coding sources: International Classification of Diseases, Ninth Revision (ICD‐9) codes (E880‐889) and/or a fall listed as a “primary reason for visit.” A comprehensive list of EMR predictors of falls were included into prediction models enabling statistical subset selection from many variables and modeling by logistic regression.
Although 72% of falls in the training data set were coded as “primary reason for visit,” 22% of falls were coded as ICD‐9 and 6% coded as both. About 80% were reported in face‐to‐face encounters (eg, emergency department). A total of 2164 individuals had a fall in the risk period. Using the 13 key predictors (age, comorbidities, female sex, other mental disorder, walking issues, Parkinson's disease, urinary incontinence, depression, polypharmacy, psychotropic and anticonvulsant medications, osteoarthritis, osteoporosis) identified through LASSO regression, the final model had a sensitivity of 67%, specificity of 69%, positive predictive value of 8%, negative predictive value of 98%, and area under the curve of .74.
This study demonstrated how the EMR can be used to ascertain falls and develop a fall risk prediction model with moderate sensitivity/specificity. Concurrent work with clinical providers to enhance fall documentation will improve the ability of the EMR to capture falls and consequently may improve the model to predict fall risk.
Given an aging human immunodeficiency virus (HIV) population, we aimed to determine the prevalence of HIV for long‐stay residents in US nursing homes (NHs) between 2001 and 2010 and to compare characteristics and diagnoses of HIV‐positive (HIV+) and negative (HIV‐) residents. Also, for residents with dementia diagnoses, we compared antipsychotic (APS) medication receipt by HIV status.
A cross‐sectional comparative study.
NHs in the 14 states accounting for 75% of persons living with HIV.
A total of 9 245 009 long‐stay NH residents.
Using Medicaid fee‐for‐service claims data in the years 2001 to 2010, together with Medicare resident assessment and Chronic Condition Warehouse data, we identified long‐stay (more than 89 days) NH residents by HIV status and dementia presence. We examined dementia presence by age groups and APS medication receipt by younger (aged younger than 65 years) vs older (aged 65 years or older) residents, using logistic regression.
Between 2001 and 2010, the prevalence of long‐stay residents with HIV in NHs increased from 0.7% to 1.2%, a 71% increase. Long‐stay residents with HIV were younger and less often female or white. For younger NH residents, rates of dementia were 20% and 16% for HIV+ and HIV‐ residents, respectively; they were 53% and 57%, respectively, for older residents. In adjusted analyses, younger HIV+ residents with dementia had greater odds of APS medication receipt than did HIV‐ residents (AOR = 1.3; 95% confidence interval [CI] = 1.2‐1.4), but older HIV residents had lower odds (AOR = 0.9; 95% CI = 0.8‐0.9).
The prevalence of long‐stay HIV+ NH residents has increased over time, and given the rapid aging of the HIV population, this increase is likely to have continued. This study raises concern about potential differential quality of care for (younger) residents with HIV in NHs, but not for those aged 65 years and older. These findings contribute to the evidence base needed to ensure high‐quality care for younger and older HIV+ residents in NHs.
Population‐based incidence estimates of dementia and Alzheimer disease (AD) provide important information for public health policy and resource allocation. We conducted a meta‐analysis of published studies that reported age‐specific incidence rates of dementia and AD to determine whether dementia and AD incidence rates are changing over time.
PubMed and MEDLINE were searched for publications through June 30, 2017, using key words “dementia”, “Alzheimer”, and “incidence.” Inclusion criteria for the meta‐analysis are: (1) population‐based studies using personal interviews and direct examinations of the study subjects, (2) standardized clinical diagnosis criteria, (3) reporting age‐specific incidence rates, (4) published in English, and (5) sample size of 500 or greater and length of follow‐up of 2 years or greater. Mixed‐effects models were used to determine the association between birth year and incidence rates.
Age‐specific dementia/AD incidence rates and their standard errors reported in each study.
Thirty‐eight articles with 53 cohorts on dementia incidence and 31 articles with 35 cohorts on AD incidence met the inclusion criteria. There were significant associations between later birth years and decreased dementia incidence rates in all three age groups (65‐74, 75‐84, and 85 years and older). There were no significant associations between birth year and AD incident rates in any of the three age groups. In particular, AD incidence rates reported from Western countries stayed steady in all age groups, while studies in non‐Western countries showed significantly increased AD incidence rates for the 65 to 74 years age group (odds ratio = 2.78; P = .04), but a nonsignificant association for the 75 to 84 or 85 years and older groups.
Dementia incidence declined over the past four decades, but AD incidence did not decline. Further research, especially from non‐Western countries, is needed to elucidate the mechanism underlying the trends in dementia and AD incidence over time.
To determine the effect of home‐based primary care (HBPC) for frail older adults, operating under Independence at Home (IAH) incentive alignment on long‐term institutionalization (LTI).
Case‐cohort study using HBPC site, Medicare administrative data, and National Health and Aging Trends Study (NHATS) benchmarks.
Three IAH‐participating HBPC sites in Philadelphia, PA, Richmond, VA, and Washington, DC.
HBPC integrated with long‐term services and supports (LTSS) cases (n = 721) and concurrent comparison groups (HBPC not integrated with LTSS: n = 82; no HBPC: n = 573). Cases were eligible if enrolled at one of the three HBPC sites from 2012 to 2015. Independence at Home‐qualified (IAH‐Q) concurrent comparison groups were selected from Philadelphia, PA; Richmond, VA; and Washington, DC.
HBPC integrated with LTSS under IAH demonstration incentives.
Measurements include LTI rate and mortality rates, community survival, and LTSS costs.
The LTI rate in the three HBPC programs (8%) was less than that of both concurrent comparison groups (IAH‐Q beneficiaries not receiving HBPC, 16%; patients receiving HBPC but not in the IAH demonstration practices, 18%). LTI for patients at each HBPC site declined over the three study years (9.9%, 9.4%, and 4.9%, respectively). Costs of home‐ and community‐based services (HCBS) were nonsignificantly lower among integrated care patients ($2151/mo; observed‐to‐expected ratio = .88 [.68‐1.09]). LTI‐free survival in the IAH HBPC group was 85% at 36 months, extending average community residence by 12.8 months compared with IAH‐q participants in NHATS.
HBPC integrated with long‐term support services delays LTI in frail, medically complex Medicare beneficiaries without increasing HCBS costs.
To evaluate the relationship between self‐reported hearing loss and nonfatal fall‐related injury in a nationally representative sample of community‐dwelling adults living in the United States.
Cross‐sectional analysis of national survey data.
National Health Interview Survey (2016).
A total of 30 994 community‐dwelling adults in the United States, aged 18 years and older.
We evaluated the association between self‐reported hearing loss and nonfatal injury resulting from a fall in the previous 3 months. We used multivariate logistic regression to calculate adjusted odds ratios (ORs) and evaluated effect measure modification by age.
The odds of nonfatal fall‐related injury were 1.60 times higher among respondents with hearing loss compared to respondents without hearing loss (95% confidence interval [CI] = 1.20‐2.12; P = .0012). Results were unchanged when adjusting for demographics (OR = 1.59; 95% CI = 1.18‐2.15; P = .002). After adjustment for cardiovascular risk factors, cardiovascular disease, visual impairment, and limitation caused by nervous system/sensory organ conditions and depression, anxiety, or another emotional problem, the OR fell to 1.27 (95% CI = 0.92‐1.74; P = .14). In the fully adjusted model, including adjustment for vestibular vertigo, there was little support to link hearing loss and fall‐related injury (OR = 1.16; 95% CI = 0.84‐1.60; P = .36). Effect modification by age was not observed.
Self‐reported hearing loss may be a clinically useful indicator of increased fall risk, but treatment for hearing loss is unlikely to mitigate this risk, given that there is no independent association between self‐reported hearing loss and nonfatal falls after accounting for vestibular function and other potential confounders.
