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Background: Low nursing home staffing in the United States is a growing safety concern. Socioeconomic deprivation in the local areas surrounding a nursing home may be a barrier to improving staffing rates but has been poorly studied. Thus, the objective of this paper was to assess the relationship between neighborhood deprivation and nursing home staffing in the United States. Methods: This cross-sectional study used 2018 daily payroll-based staffing records and address data for 12,609 nursing homes in the United States linked with resident assessment data. Our primary exposure of interest was severe economic deprivation at the census block group (neighborhood) level, defined as an area deprivation index score ≥85/100. The primary outcome was hours worked per resident-day among nursing home employees providing direct resident care. Marginal linear regression models and generalized estimating equations with robust sandwich-type standard errors were used to estimate associations between severe neighborhood deprivation and staffing rates. Results: Compared to less deprived neighborhoods, unadjusted staffing rates in facilities located within severely deprived neighborhoods were 38% lower for physical and occupational therapists, 30% lower for registered nurses (RNs), and 5% lower for certified nursing assistants. No disparities in licensed practical nurse (LPN) staffing were observed. In models with state-level and rurality fixed effects and clustered on the county, a similar pattern of disparities was observed. Specifically, RN staffing per 100 resident-days was significantly lower in facilities located within severely deprived neighborhoods as compared to those in less deprived areas (mean difference: 5.6 fewer hours, 95% confidence interval [CI] 4.2–6.9). Disparities of lower magnitude were observed for other clinical disciplines except for LPNs. Conclusions: Significant staffing disparities were observed within facilities located in severely deprived neighborhoods. Targeted interventions, including workforce recruitment and retention efforts, may be needed to improve staffing levels for nursing homes in deprived neighborhoods. [ABSTRACT FROM AUTHOR]

Background: Retirement represents a crucial transitional period for many adults with possible consequences for cognitive aging. We examined trajectories of cognitive change before and after retirement in Black and White adults. Methods: Longitudinal examination of up to 10 years (mean = 7.1 ± 2.2 years) using data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study–a national, longitudinal study of Black and White adults ≥45 years of age. Data were from 2226 members of the REGARDS study who retired around the time when an occupational ancillary survey was administered. Cognitive function was an average of z‐scores for tests of verbal fluency, memory, and global function. Results: Cognitive functioning was stable before retirement (Estimate = 0.05, p = 0.322), followed by a significant decline after retirement (Estimate = −0.15, p < 0.001). The decline was particularly pronounced in White (Estimate = −0.19, p < 0.001) compared with Black (Estimate = −0.07, p = 0.077) participants, twice as large in men (Estimate = −0.20, p < 0.001) compared with women (Estimate = −0.11, p < 0.001), highest among White men (Estimate = −0.22, p < 0.001) and lowest in Black women (Estimate = −0.04, p = 0.457). Greater post‐retirement cognitive decline was also observed among participants who attended college (Estimate = −0.14, p = 0.016). While greater work complexity (Estimate = 0.92, p < 0.05) and higher income (Estimate = 1.03, p < 0.05) were related to better cognitive function at retirement, neither was significantly related to cognitive change after retirement. Conclusion: Cognitive functioning may decline at an accelerated rate immediately post‐retirement, more so in White adults and men than Black adults and women. Lifelong structural inequalities including occupational segregation and other social determinants of cognitive health may obscure the role of retirement in cognitive aging. [ABSTRACT FROM AUTHOR]

Background: Obesity and loss of muscle mass are emerging as risk factors for dementia, but the role of adiposity infiltrating skeletal muscles is less clear. Skeletal muscle adiposity increases with older age and especially among Black women, a segment of the US population who is also at higher risk for dementia. Methods: In 1634 adults (69–79 years, 48% women, 35% Black), we obtained thigh intermuscular adipose tissue (IMAT) via computerized tomography at Years 1 and 6, and mini‐mental state exam (3MS) at Years 1, 3, 5, 8 and 10. Linear mixed effects models tested the hypothesis that increased IMAT (Year 1–6) would be associated with 3MS decline (Year 5–10). Models were adjusted for traditional dementia risk factors at Year 1 (3MS, education, APOe4 allele, diabetes, hypertension, and physical activity), with interactions between IMAT change by race or sex. To assess the influence of other muscle and adiposity characteristics, models accounted for change in muscle strength, muscle area, body weight, abdominal subcutaneous and visceral adiposity, and total body fat mass (all measured in Years 1 and 6). Models were also adjusted for cytokines related to adiposity: leptin, adiponectin, and interleukin‐6. Results: Thigh IMAT increased by 4.85 cm2 (Year 1–6) and 3MS declined by 3.20 points (Year 6–10). The association of IMAT increase with 3MS decline was statistically significant: an IMAT increase of 4.85 cm2 corresponded to a 3MS decline of an additional 3.60 points (p < 0.0001), indicating a clinically important change. Interactions by race and sex were not significant. Conclusions: Clinicians should be aware that regional adiposity accumulating in the skeletal muscle may be an important, novel risk factor for cognitive decline in Black and White participants independent of changes to muscle strength, body composition and traditional dementia risk factors. [ABSTRACT FROM AUTHOR]

Background: Poor functional status is a key marker of morbidity, yet is not routinely captured in clinical encounters. We developed and evaluated the accuracy of a machine learning algorithm that leveraged electronic health record (EHR) data to provide a scalable process for identification of functional impairment. Methods: We identified a cohort of patients with an electronically captured screening measure of functional status (Older Americans Resources and Services ADL/IADL) between 2018 and 2020 (N = 6484). Patients were classified using unsupervised learning K means and t‐distributed Stochastic Neighbor Embedding into normal function (NF), mild to moderate functional impairment (MFI), and severe functional impairment (SFI) states. Using 11 EHR clinical variable domains (832 variable input features), we trained an Extreme Gradient Boosting supervised machine learning algorithm to distinguish functional status states, and measured prediction accuracies. Data were randomly split into training (80%) and test (20%) sets. The SHapley Additive Explanations (SHAP) feature importance analysis was used to list the EHR features in rank order of their contribution to the outcome. Results: Median age was 75.3 years, 62% female, 60% White. Patients were classified as 53% NF (n = 3453), 30% MFI (n = 1947), and 17% SFI (n = 1084). Summary of model performance for identifying functional status state (NF, MFI, SFI) was AUROC (area under the receiving operating characteristic curve) 0.92, 0.89, and 0.87, respectively. Age, falls, hospitalization, home health use, labs (e.g., albumin), comorbidities (e.g., dementia, heart failure, chronic kidney disease, chronic pain), and social determinants of health (e.g., alcohol use) were highly ranked features in predicting functional status states. Conclusion: A machine learning algorithm run on EHR clinical data has potential utility for differentiating functional status in the clinical setting. Through further validation and refinement, such algorithms can complement traditional screening methods and result in a population‐based strategy for identifying patients with poor functional status who need additional health resources. [ABSTRACT FROM AUTHOR]

Background: The protective effects of allopurinol on physical function in older adults are not well understood, despite its potential to improve functional gains and reduce sarcopenia. This study aims to determine the association between allopurinol, persistent physical disability, and frailty in older gout patients. Methods: This analysis used data from a randomized trial in an older cohort, ASPirin in Reducing Events in the Elderly (ASPREE). ASPREE recruited 19,114 participants aged ≥65 years without prior cardiovascular events, dementia, or independence‐limiting physical disability at trial enrolment. This analysis examined the association of baseline and time‐varying allopurinol use with persistent physical disability and new‐onset frailty in participants with gout at baseline (self‐report or use of any anti‐gout medications). Frailty was measured using the Fried frailty phenotype (score ≥3/5) and a deficit accumulation frailty index (FI) (score >0.21/1.0). Multivariable Cox proportional‐hazards models were used for main analyses. Results: This analysis included 1155 gout participants, with 630 taking allopurinol at baseline and 525 not. During a median follow‐up of 5.7 years, 113 new allopurinol users were identified. Compared with nonusers, baseline allopurinol use was associated with a significant risk reduction of persistent physical disability (Adjusted HR 0.46, 95% CI 0.23–0.92, p = 0.03). The strength of the association was modestly attenuated in the time‐varying analysis (Adjusted HR 0.56, 0.29–1.08, p = 0.08). No significant associations with frailty measures were observed for either baseline allopurinol use (Fried frailty: Adjusted HR 0.83, 0.62–1.12; FI: Adjusted HR 0.96, 0.74–1.24) or time‐varying allopurinol use (Fried frailty: Adjusted HR 0.92, 0.69–1.24; FI: Adjusted HR 1.02, 0.78–1.33). Conclusions: Allopurinol use in older adults with gout is associated with a reduced risk of persistent physical disability but not associated with risk of frailty. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation is a common cause of stroke among older adults and is often first detected during hospitalization, given frequent use of cardiac telemetry. Methods: In a 20% national sample of Medicare fee‐for‐service beneficiaries, we identified patients aged 65‐or‐older newly diagnosed with atrial fibrillation while hospitalized in 2016. Our primary outcome was an oral anticoagulant claim within 7‐days of discharge. Multivariable logistic regression analyses assessed relationships between anticoagulation initiation and thromboembolic and bleeding risk scores while controlling for demographics, frailty, comorbidities, and hospitalization characteristics. Results: Among 38,379 older adults newly diagnosed with atrial fibrillation while hospitalized (mean age 78.2 [SD 8.4]; 51.8% female; 83.3% white), 36,633 (95.4%) had an indication for anticoagulation and 24.6% (9011) of those initiated an oral anticoagulant following discharge. Higher CHA2DS2‐VASc score was associated with a small increase in oral anticoagulant initiation (predicted probability 20.5% [95% CI, 18.7%–22.3%] for scores <2 and 24.9% [CI, 24.4%–25.4%] for ≥4). Elevated HAS‐BLED score was associated with a small decrease in probability of anticoagulant initiation (25.4% [CI, 24.4%–26.4%] for score <2 and 23.1% [CI, 22.5%–23.8%] for ≥3). Frailty was associated with decreased likelihood of oral anticoagulant initiation (24.7% [CI, 23.2%–26.2%] for non‐frail and 18.1% [CI, 16.6%–19.6%] for moderately‐severely frail). Anticoagulant initiation varied by primary reason for hospitalization, with predicted probability highest among patients with a primary diagnosis of atrial fibrillation (46.1% [CI, 45.0%–47.3%]) and lowest among those with non‐cardiovascular conditions (13.8% [CI, 13.3%–14.3%]) and bleeds (3.6% [CI, 2.4%–4.8%]). Conclusions: Oral anticoagulant initiation is uncommon among older adults newly diagnosed with atrial fibrillation during hospitalization, even among patients hospitalized primarily for atrial fibrillation and patients with high thromboembolic risk. Clinicians should discuss risks and benefits of oral anticoagulants with all inpatients found to have atrial fibrillation. [ABSTRACT FROM AUTHOR]

Background: The American Rescue Plan Act of 2021 awarded $500 million toward scaling "strike teams" to mitigate the impact of Coronavirus Disease 2019 (COVID‐19) within nursing homes. The Massachusetts Nursing Facility Accountability and Support Package (NFASP) piloted one such model during the first weeks of the pandemic, providing nursing homes financial, administrative, and educational support. For a subset of nursing homes deemed high‐risk, the state offered supplemental, in‐person technical infection control support. Methods: Using state death certificate data and federal nursing home occupancy data, we examined longitudinal all‐cause mortality per 100,000 residents and changes in occupancy across NFASP participants and subgroups that varied in their receipt of the supplemental intervention. Results: Nursing home mortality peaked in the weeks preceding the NFASP, with a steeper increase among those receiving the supplemental intervention. There were contemporaneous declines in weekly occupancy. The potential for temporal confounding and differential selection across NFASP subgroups precluded estimation of causal effects of the intervention on mortality. Conclusions: We offer policy and design suggestions for future strike team iterations that could inform the allocation of state and federal funding. We recommend expanded data collection infrastructure and, ideally, randomized assignment to intervention subgroups to support causal inference as strike team models are scaled under the direction of state and federal agencies. See related Commentary by Berry et al. in this issue. [ABSTRACT FROM AUTHOR]

Background: Sodium‐glucose cotransporter‐2 inhibitor (SGLT2I) use has increased among community‐dwelling populations, but little is known about how clinicians have prescribed them for US nursing home (NH) residents. We described the adoption of SGLT2Is by prescribers caring for long‐stay NH residents by clinician specialty and over time, compared with sulfonylureas, an older diabetes medication class. Methods: We conducted a retrospective cohort study of prescribers of SGLT2Is and sulfonylureas for all long‐stay US NH residents aged 65 years or older (2017–2019). Using 100% of Medicare Part D claims linked to prescriber characteristics data, we identified all dispensings of SGLT2Is and sulfonylureas for long‐stay NH residents and their associated prescribers. We described the distribution of prescriber specialties for each drug class over time as well as the number of NH residents prescribed SGLT2s versus sulfonylureas. We estimated the proportions of prescribers who prescribed both drug classes versus only sulfonylureas or only SGLT2Is. Results: We identified 36,427 unique prescribers (SGLT2I: N = 5811; sulfonylureas: N = 35,443) for 117,667 NH residents between 2017 and 2019. For both classes, family medicine and internal medicine physicians accounted for most prescriptions (75%–81%). Most clinicians (87%) prescribed only sulfonylureas, 2% prescribed SGLT2Is only, and 11% prescribed both. Geriatricians were least likely to prescribe only SGLT2Is. We observed an increase in the number of residents with SGLT2I use from n = 2344 in 2017 to n = 5748 in 2019. Conclusions: Among NH residents, most clinicians have not incorporated SGLT2Is into their prescribing for diabetes, but the extent of use is increasing. Family medicine and internal medicine physicians prescribed the majority of diabetes medications for NH residents, and geriatricians were the least likely to prescribe only SGLT2Is. Future research should explore provider concerns regarding SGLT2I prescribing, particularly adverse events. [ABSTRACT FROM AUTHOR]

Background: Dietary supplement and complementary and alternative medication (CAM) use can contribute to drug interactions, polypharmacy, nonadherence with prescription medications, and healthcare expenses, whereas evidence supporting benefits of using these products is sparse. There is a lack of current published literature describing the patterns or predictors of their use in community‐dwelling older adults. Materials and Methods: We performed a cross‐sectional analysis of community‐dwelling adults from Australia and the US, aged 70 years and older (65 years for US minorities), enrolled in the ASPirin in Reducing Events in the Elderly (ASPREE) study. At study enrollment, eligible participants were required to be without concurrent 5‐year life‐limiting illness and free of documented evidence of cardiovascular disease, dementia, or significant physical disability. During the final study visit, a questionnaire was administered to collect information about supplement/CAM use. Data from 15,729 participants who completed this questionnaire between January 2017 and January 2018 were analyzed. Descriptive statistics were used to report the prevalence and types of products used. Factors associated with use were determined using multivariate regression. Results: Mean age of respondents was 79.6 years; 56.4% were female, 88.8% were from Australia, 56.5% reported 12 years of education or less, and 98.7% were living at home. Two‐thirds (66.2%) of participants reported use of one or more supplement/CAM in the previous month. Products most commonly used included vitamin D (33.8% of participants), fish oil (22.7%), calcium (20.6%), glucosamine (14.8%), and multivitamin (12.9%). Female sex, US residency, higher education, polypharmacy (prescription medications), and frailty (in women) were significantly associated with higher use of supplements/CAMs. Conclusions: Dietary supplement and CAM use is common among community‐dwelling older adults in the United States and Australia. Given the high prevalence of use, collaboration between healthcare providers and older adult patients is important to insure safe and optimal use of these products. [ABSTRACT FROM AUTHOR]

Background: Nurse practitioners (NPs) are the largest group of providers delivering home‐based primary care (HBPC) in the U.S. We examined the association of scope‐of‐practice regulations and NP‐HBPC rates. Methods: Using the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use File for 2019, we conducted a state‐level analysis to examine the impact of scope‐of‐practice regulations on the utilization of NP‐HBPC. Healthcare Common Procedure Coding System codes were used to identify the HBPC visits in private residences (99341–99,345, 99,347–99,350) and domiciliary settings (99324–99,328, 99,334–99,337). We used linear regression to compare NP‐HBPC utilization rates between states of either restricted or reduced scope‐of‐practice laws to states with full scope‐of‐practice, adjusting for a number of NP‐HBPC providers, state ranking of total assisted living, the proportion of fee‐for‐service (FFS) Medicare beneficiaries and neighborhood‐level socio‐economic status and race and ethnicity. Results: Nearly half of NPs providing HBPC (46%; n = 7151) were in states with a restricted scope of practice regulations. Compared to states with full scope‐of‐practice, states with restricted or reduced scope‐of‐practice had higher adjusted rates of NP‐HBPC per 1000 FFS Medicare beneficiaries. The average level of the utilization rate of NP‐HBPC was 89.9, 63, and 49.1 visits, per 1000 FFS Medicare beneficiaries in states with restricted, reduced, and full‐ scope‐of‐practice laws, respectively. The rate of NP‐HBPC visits was higher in states with restricted (Beta coefficient = 0.92; 95%CI 0.13–1.72; p = 0.023) and reduced scope‐of‐practice laws (Beta coefficient = 0.91; 95%CI 0.03–1.79; p = 0.043) compared to states with full scope‐of‐practice laws. Conclusion: Restricted state NP scope‐of‐practice regulations were associated with higher rates of FFS Medicare NP‐HBPC care delivery compared with full or reduced scope‐of‐practice. Understanding underlying mechanisms of how scope‐of‐practice affects NP‐HBPC delivery could help to develop scope‐of‐practice regulations that improve access to HBPC for the underserved homebound population. [ABSTRACT FROM AUTHOR]

Background: Existing models to predict fall‐related injuries (FRI) in nursing homes (NH) focus on hip fractures, yet hip fractures comprise less than half of all FRIs. We developed and validated a series of models to predict the absolute risk of FRIs in NH residents. Methods: Retrospective cohort study of long‐stay US NH residents (≥100 days in the same facility) between January 1, 2016 and December 31, 2017 (n = 733,427) using Medicare claims and Minimum Data Set v3.0 clinical assessments. Predictors of FRIs were selected through LASSO logistic regression in a 2/3 random derivation sample and tested in a 1/3 validation sample. Sub‐distribution hazard ratios (HR) and 95% confidence intervals (95% CI) were estimated for 6‐month and 2‐year follow‐up. Discrimination was evaluated via C‐statistic, and calibration compared the predicted rate of FRI to the observed rate. To develop a parsimonious clinical tool, we calculated a score using the five strongest predictors in the Fine‐Gray model. Model performance was repeated in the validation sample. Results: Mean (Q1, Q3) age was 85.0 (77.5, 90.6) years and 69.6% were women. Within 2 years of follow‐up, 43,976 (6.0%) residents experienced ≥1 FRI. Seventy predictors were included in the model. The discrimination of the 2‐year prediction model was good (C‐index = 0.70), and the calibration was excellent. Calibration and discrimination of the 6‐month model were similar (C‐index = 0.71). In the clinical tool to predict 2‐year risk, the five characteristics included independence in activities of daily living (ADLs) (HR 2.27; 95% CI 2.14–2.41) and a history of non‐hip fracture (HR 2.02; 95% CI 1.94–2.12). Performance results were similar in the validation sample. Conclusions: We developed and validated a series of risk prediction models that can identify NH residents at greatest risk for FRI. In NH, these models should help target preventive strategies. [ABSTRACT FROM AUTHOR]

Objective: Participation of Hispanic/Latinx American older adults (HLAOA) in clinical trials is fundamental to health equity in aging research. However, information on strategies for the successful recruitment of this population in clinical trials is limited. Design: This scoping review aims to identify hindering and facilitating factors that impact the recruitment of HLAOA in clinical trials in the United States. Methods: Two databases (PubMed, EMBASE) were searched for original research articles from inception until March 2022 reporting on factors that engaged HLAoa (≥65) in clinical trials. One thousand and thirteen studies were scrutinized to identify 31 eligible articles. Results: Most articles were from cancer clinical trials (14 studies). Hindering factors that impacted the recruitment of HLAoa in clinical trials were related to (i) study design and logistics challenges, (ii) challenges imposed by social determinants of health, (iii) communication barriers, and (iv) patients' mistrust, and (v) family issues. Facilitating factors include (i) effective modes of outreach, (ii) strategic clinical trial design, (iii) incorporating culturally‐respectful approaches that are tailored to the participants' sociocultural background, and (iv) bridging language barriers. Conclusions: Successful recruitment of HLAOA into clinical trials requires identifying the study question, co‐designing the trial design, implementation, and evaluation in respectful collaboration with the Hispanic/Latinx community with careful attention to their needs and minimizing the study burden on this vulnerable population. Factors identified here may guide researchers to better understand the needs of HLAOA and successfully recruit them into clinical trials, leading to more equitable research that increases their representation in clinical research. [ABSTRACT FROM AUTHOR]

Background: Asian and Pacific Islander (Asian/PI) adults have lower hip fracture incidence than non‐Hispanic White (NHW) adults, but data regarding Asian/PI subgroups are limited. We compared hip fracture incidence among older US Asian/PI and NHW populations, including ethnic subgroup differences. Methods: Using observational data from a California healthcare system, we identified Asian/PI and NHW adults aged ≥50 years (2000–2019) and followed subjects to 2021 for hip fracture determined by principal/primary hospital diagnosis or by secondary hospital diagnosis with hip/femur procedure codes. Age‐adjusted hip fracture incidence was calculated with 95% confidence intervals (CIs). Log‐Poisson regression was used to determine fracture incidence rate ratios (IRRs, [CI]; NHW or Chinese as reference) adjusting for age and year. Results: Among 215,359 Asian/PI and 776,839 NHW women, hip fracture incidence was 1.34 (1.28–1.40) and 2.97 (2.94–3.01) per 1000 person‐years, respectively, with IRR 0.45 (0.43–0.47). Among 188,328 Asian/PI and 697,046 NHW men, hip fracture incidence was 0.62 (0.58–0.67) and 1.81 (1.78–1.84) per 1000 person‐years, respectively, with IRR 0.34 (0.32–0.37). For the four largest Asian/PI subgroups, Filipina women (IRR 0.85 [0.75–0.96]) had lower, and Japanese (IRR 1.36 [1.20–1.54]) and South Asian (IRR 1.36 [1.07–1.72]) women had higher hip fracture incidence compared to Chinese women. Hip fracture incidence was only higher among South Asian (IRR 1.61 [1.21–2.14]) compared to Chinese men. Conclusion: Hip fracture incidence among US Asian/PI adults was 55% (women) and 66% (men) lower than NHW adults, but incidence varied by Asian/PI subgroup. The heterogeneity among Asian/PI adults highlights the importance of examining fracture risk by ethnic subgroup. [ABSTRACT FROM AUTHOR]

Introduction: For most older adults with dementia, the short‐term harms and burdens of routine cancer screening likely outweigh the delayed benefits. We aimed to provide a more updated assessment of the extent that US older adults with dementia receive breast and prostate cancer screenings. Methods: Using the Health and Retirement Study (HRS) Wave 12 (2014–2015) linked to Medicare, we examine rates of breast and prostate cancer screenings in adults 65+ years by cognitive status. We used claims data to identify eligibility for screening and receipt of screening. We used a validated method using HRS data to define cognitive status. Results: The analytic sample included 2439 women in the breast cancer screening cohort and 1846 men in the prostate cancer screening cohort. Average ages were 76.8 years for women and 75.6 years for men, with 9.0% and 7.6% with dementia in each cohort, respectively. Among women with dementia, 12.3% were screened for breast cancer. When stratified by age, 10.6% of those 75+ and have dementia were screened for breast cancer. When stratified by predicted life expectancy, 10.4% of those with predicted life expectancy of <10 years and have dementia were screened for breast cancer. Among men with dementia, 33.9% were screened for prostate cancer. When stratified by age, 30.9% of those 75+ and have dementia were screened for prostate cancer. When stratified by predicted life expectancy, 34.4% of those with predicted life expectancy of <10 years and have dementia were screened for prostate cancer. Using multivariable logistic regression, dementia was associated with lower odds of receiving breast cancer screening (OR 0.36, 95% CI 0.23–0.57) and prostate cancer screening (OR 0.58, 95% CI 0.36–0.96). Discussion: Our results suggest potential over‐screening in older adults with dementia. Better supporting dementia patients and caregivers to make informed cancer screening decisions is critical. [ABSTRACT FROM AUTHOR]

Background: Family caregivers offer essential support to persons living with dementia (PLWD). Providing care for more than one family member or close other across adulthood is becoming increasingly common, yet little is known about the ways that caregiving experiences shape caregiver preparedness. The current study presents a grounded theory of future caregiver preparedness in former caregivers of PLWD. Method: A coding team (five coders and two auditors) used Consensual Qualitative Research and grounded theory techniques to analyze transcripts from 32 semi‐structured interviews with midlife former caregivers of parents who died following advanced Alzheimer's disease and related dementias. Results: Qualitative analysis revealed two dimensions of future caregiver preparedness: caregiving confidence and caregiving insights. Narratives from caregiving experiences informed participants' descriptions of their future caregiver preparedness. Though some former caregivers described a positive (i.e., boosted or sustained) sense of caregiving confidence following care for their parents, others described a diminished (i.e., restricted or impeded) sense of confidence. Regardless of their confidence, all caregivers described specific caregiving insights related to one or more categories (i.e., caregiving self‐conduct, care systems and resources, and relating with a care partner). Conclusions: Preparedness for future caregiving following recent care for a PLWD varies: For some, past experiences appear to offer cumulative advantages in anticipating future care roles, whereas for others, past experiences may contribute to apprehension towards, or rejection of, future care roles. Entering new caregiving roles with diminished confidence may have negative consequences for caregivers' and care partners' wellbeing. Multidimensional assessment of future caregiver preparedness in former caregivers of PLWD may support development of resources for former caregivers entering new caregiving roles. [ABSTRACT FROM AUTHOR]

Background: Social isolation is a key public health concern and has been associated with numerous negative health consequences. Technology is increasingly thought of as a solution to address social isolation. This study examines the longitudinal association between the access and use of technology and social isolation in older adults 65 and older, living in the United States. Methods: This observational cohort study included community‐dwelling older adults (N = 6704) who participated in the National Health and Aging Trends Study. Regression analyses were conducted using data from 2015 to 2019. Information about technology access and use was ascertained using self‐reported questionnaires. The primary outcome was the risk of social isolation. Results: At baseline, the majority of older adults that were not socially isolated had a working cell phone (88%) or computer (71%) and used email or text messaging (56%). Older adults that had access to (cell phone‐ incidence rate ratio [IRR] 0.62 [95% CI 0.48–0.81]; computer‐ IRR 0.63 [95% CI 0.51–0.78]), and used technology (email or text messaging‐ IRR 0.64 [95% CI 0.51–0.80]) in the year prior had a lower risk of social isolation than older adults who reported they did not access or use technology. Additionally, over four years, older adults who reported that they had access to a computer had a lower risk (0.69 [0.57, 0.84]) for social isolation than their counterparts. Conclusion: In this cohort study, technology access was associated with a lower risk for social isolation among community‐dwelling older adults. These findings suggest that technology has an important role in approaches that seek to prevent social isolation among older adults. [ABSTRACT FROM AUTHOR]

Background: Despite possible major adverse cognitive, physical, social, and behavioral consequences, little is known about how persons living with dementia perceive satisfaction with life, a key component of well‐being. We sought to examine (i) whether persons living with dementia perceive a lower level of satisfaction compared to their peers without dementia and (ii) whether the associations between individual characteristics and life satisfaction are different between persons living with and without dementia. Methods: Using a nationally representative sample of community‐dwelling older adults aged ≥70 years in the U.S. from the Health and Retirement Study, we compared scores on the Satisfaction with Life Scale (SWLS), a self‐reported 5‐item scale ranging from 1 to 7 (more satisfaction), between persons with probable dementia (n = 341) and those without (n = 5530), adjusting for individual characteristics. We also tested whether the associations between the individual characteristics and SWLS differ by dementia status. Results: Scores on SWLS did not differ between persons with probable dementia and those without when adjusting for individual characteristics including limitations in activities of daily living (ADL) (adjusted difference, −0.09; 95% CI, −0.33 to +0.15; p‐value, 0.45). However, dementia status was associated with lower life satisfaction through the mediation of limitations in ADL (total effect, −0.29; bootstrapped 95% CI, −0.47 to −0.12). Most individual characteristics associated with lower life satisfaction were similar in the two groups, including younger age, more limitations in ADL, and depression. Less wealth was associated with lower satisfaction among persons without dementia but not among those with probable dementia. Conclusions: Dementia status was only modestly associated with lower life satisfaction through the mediation of limitations in ADL among participants who were able to provide response. Future research is warranted to determine whether life satisfaction can be used as a meaningful outcome when evaluating well‐being among persons living with dementia. [ABSTRACT FROM AUTHOR]

Background: The contemporary uptake of lipid‐lowering therapies (LLT), including more intensive treatment with high‐intensity statins and non‐statin LLT, among U.S. older adults (≥75 years old) with ASCVD is unknown. Methods: In this multicenter retrospective cohort study of a large geographically diverse sample of commercially insured U.S. older adults with ASCVD, we assessed treatment with LLT. Secondary measures included LDL‐C above target ≥70 mg/dl, persistence and adherence to therapy. Results: Treatment with statins, high‐intensity statins, ezetimibe, and PCSK9 inhibitors was assessed in 194,503 older adults (49.9% female) with known ASCVD on January 31st, 2019. 49.3% of older adults with ASCVD were on any statin, with 16.6% receiving a high‐intensity statin and 32.7% on low‐or moderate‐intensity statins. Treatment with ezetimibe (2.4%) or PCSK9 inhibitors (0.24%) was rare and 62.6% of the overall cohort had an LDL‐C above target at ≥70 mg/dl. Patients on high‐intensity statins were more frequently male, had a diagnosis of coronary artery disease, and were more frequently seen by a cardiologist compared with those on low‐or moderate‐intensity statins and untreated individuals (p < 0.0001). The majority of older adults on high‐intensity statins remained on therapy at 12 months (91.9%) and 85.7% had ≥75% adherence to treatment. Conclusions: Less than half of eligible older adults with ASCVD are on statins and only a minority of patients are receiving more intensive lipid‐lowering to improve outcomes. [ABSTRACT FROM AUTHOR]

Background: Racial inequality in functional trajectories has been well documented in the U.S. civilian population but has not been explored among Veterans. Our objectives were to: (1) assess how functional trajectories differed for Black and White Veterans aged ≥50 and (2) explore how socioeconomic, psychosocial, and health‐related factors altered the relationship between race and function. Methods: We conducted a prospective, longitudinal analysis using the 2006–2016 Health and Retirement Study. The study cohort included 3700 Veterans who self‐identified as Black or White, responded to baseline psychosocial questionnaires, and were community‐dwelling on first observation. We used stepwise and stratified linear mixed effects models of biannually assessed functional limitations. The outcome measure was as a count of functional limitations. Race was measured as respondent self‐identification as Black or White. Demographic measures included gender and age. Socioeconomic resources included partnership status, education, income, and wealth. Psychosocial stressors included exposure to day‐to‐day and major discrimination, traumatic life events, stressful life events, and financial strain. Health measures included chronic and mental health diagnoses, smoking, rurality, and use of Veterans Affairs services. Results: Black Veterans developed functional limitations at earlier ages and experienced faster functional decline than White Veterans between the ages of 50 and 70, with convergence occurring at age 85. Once we accounted for economic resources and psychosocial stressors in multivariable analyses, the association between race and the number of functional limitations was no longer statistically significant. Lower wealth, greater financial strain, and traumatic life events were significantly associated with functional decline. Conclusions: Health systems should consider how to track Veterans' function earlier in the life course to ensure that Black Veterans are able to get timely access to services that may slow premature functional decline. Providers may benefit from training about the role of economic resources and psychosocial stressors in physical health outcomes. [ABSTRACT FROM AUTHOR]

Background: The comparative safety of sulfonylureas (SUs) in nursing home (NH) residents remains understudied despite widespread use. We compared the effects of three SU medications and initial SU doses on adverse glycemic and cardiovascular events among NH residents. Methods: This national retrospective cohort study linked Medicare claims with Minimum Data Set 2.0 assessments for long‐stay NH residents aged ≥65 years between January 2008 and September 2010. Exposures were the SU medication initiated (glimepiride, glipizide, or glyburide) and doses (standard or reduced). One‐year outcomes were hospitalizations or emergency department visits for severe hypoglycemia, heart failure (HF), stroke, and acute myocardial infarction (AMI). After the inverse probability of treatment and inverse probability of censoring by death weighting, we estimated hazard ratios (HR) using Cox regression models with robust 95% confidence intervals (CI). Results: The cohort (N = 6821) included 3698 new glipizide, 1754 glimepiride, and 1369 glyburide users. Overall, the mean (standard deviation) age was 81.4 (8.2) years, 4816 (70.6%) were female, and 5164 (75.7%) were White non‐Hispanic residents. The rates of severe hypoglycemia were 30.3 (95% CI 22.3–40.1), 49.0 (95% CI 34.5–67.5), and 35.9 (95% CI 22.2–54.9) events per 1000 person‐years among new glipizide, glimepiride, and glyburide users, respectively (glimepiride versus glipizide HR 1.6, 95% CI 1.0–2.4, p = 0.04; glyburide versus glipizide HR 1.2, 95% CI 0.7–1.9, p = 0.59). The rates of severe hypoglycemia were 27.1 (95% CI 18.6–38.0) and 42.8 (95% CI 33.6–53.8) events per 1000 person‐years among new users of reduced and standard SU doses, respectively (HR 2.2, 95% CI 1.4–3.5, p < 0.01). Rates of HF, stroke, and AMI were similar between medications and doses. Conclusions: Among long‐stay NH residents, new use of glimepiride and standard SU doses resulted in higher rates of severe hypoglycemic events. Cardiovascular outcomes may not be affected by the choice of SU medication or dose. [ABSTRACT FROM AUTHOR]

The article presents a study which examined the association between social isolation and incident dementia over nine years in large and nationally representative sample of Medicare beneficiaries in the U.S. Topics include criteria for participants to be classified as having probable dementia, distribution of baseline participant characteristics, and characteristics of baseline participants for the total sample and by social isolation status.

Background: Many U.S. caregivers provide care to the generation above and below simultaneously, described as “sandwich” generation caregivers. We seek to provide the first national estimates characterizing sandwich generation caregivers and the older adults for whom they care. Methods: We used the 2015 National Study of Caregiving (NSOC) and National Health and Aging Trends Study (NHATS) to compare individual (demographic, socio-economic, health, and caregiving characteristics) and caregiving-related experience (financial and emotional difficulties, caregiver role overload and gains, supportive services, employment and participation restrictions) between sandwich and non-sandwich generation caregivers. The analysis included adult child caregivers with or without any minor child under 18 years (n = 194 and 912 NSOC respondents, respectively) providing care to n = 436 and 1217 older adult NHATS respondents. Results: Of all adult child caregivers, 24.3% also cared for a minor child (i.e., sandwich generation caregivers), representing 2.5 million individuals. Sandwich generation caregivers provided similar care hours to older care recipients as non-sandwich caregivers (77.4 vs. 71.6 h a month, p = 0.60), though more of them worked for pay (69.4% vs. 53.9%, p = 0.002). Both sandwich generation caregivers (21.0% vs. 11.1%, p = 0.005) and their care recipients (30.1% vs. 20.9%, p = 0.006) were more likely to be Medicaid enrollees than their non-sandwich caregiving counterparts. More sandwich generation caregivers reported substantial financial (23.5% vs. 12.2%, p < 0.001) and emotional difficulties (44.1% vs. 32.2%, p = 0.02) than non-sandwich caregivers; they also reported higher caregiver role overload (score: 2.9 vs. 2.4, p = 0.04). Their supportive services use was similarly low as non-sandwich caregivers except for seeking financial help (24.8% vs. 14.7%, p = 0.008). Conclusions: Besides caring for minor child(ren), sandwich generation caregivers provided similarly intense care to care recipients as nonsandwich caregivers and had higher labor force participation; they experienced more caregiving-related financial and emotional difficulties and role overload. Policymakers may consider supportive services that address their unique needs and roles. [ABSTRACT FROM AUTHOR]

Background: Heart failure (HF) is the leading cause of hospitalization among older adults in the United States and results in high rates of post-acute care (PAC) utilization. Federal policies have focused on shifting PAC to less intensive settings and reducing length of stay to lower spending. This study evaluates the impact of policy changes on PAC use among Medicare beneficiaries hospitalized with HF between 2008 and 2015 by (1) characterizing trends in PAC use and cost and (2) evaluating changes in readmission, mortality, and days in the community, overall and by frailty. Methods: Annual cross-section prospective cohorts of all HF admissions between 1/1/2008 and 9/30/2015 among a 20% random sample of all Medicare Fee-for-Service beneficiaries (n = 718,737). The Claims-based Frailty Index (CFI) was used to classify frailty status. Multivariable regression models were used to evaluate trends in first discharge location, readmissions, mortality, days alive in the community, and costs; overall and by frailty status. Results: Frailty was prevalent among HF patients: 54.1% were prefrail, 37.0% mildly frail, and 6.9% moderate to severely frail. Between 2008 and 2015, almost 4% more HF beneficiaries received PAC, with most of the increase concentrated in skilled nursing facilities (SNF) (+2.3%) and home health agencies (HHA) (+1.1%), and PAC cost increased by $123 (3.5%). Over the 180-days follow-up after hospitalization, hospital readmissions decreased significantly (-3.4% at 30-day; -6.3% at 180-day), days alive in the community increased (+1.5), and 180-day Medicare costs declined $2948 (-18.7%) without negative impact in mortality (except a minor increase in the pre-frail group). Gains were greatest among the frailest patients. Conclusions: Medicare beneficiaries hospitalized with HF spent more time in the community and experienced lower rehospitalization rates at lower cost without significant increases in mortality. However, important opportunities remain to optimize care for frail older adults hospitalized with HF. [ABSTRACT FROM AUTHOR]

Background: Assessing activity limitations is central to aging research. However, assessments of activity limitations vary, and this may have implications for the populations identified. We aim to compare measures of activities of daily living (ADLs) and their resulting prevalence and mortality across three nationally-representative cohort studies: the National Health and Aging Trends Study (NHATS), the Health and Retirement Survey (HRS), and the Medicare Current Beneficiary Survey (MCBS). Methods: We compared the phrasing and context of questions around help and difficulty with six self-care activities: eating, bathing, toileting, dressing, walking inside, and transferring. We then compared the prevalence and 1-year mortality for difficulty and help with eating and dressing. Results: NHATS, HRS, and MCBS varied widely in phrasing and framing of questions around activity limitations, impacting the proportion of the population found to experience difficulty or receive help. For example, in NHATS 12.4% [95% confidence interval (CI) 11.5%–13.4%] of the cohort received help with dressing, while in HRS this figure was 6.4% [95% CI 5.7%–7.2%] and MCBS 5.3% [95% CI 4.7%–5.8%]. When combined with variation in sampling frame and survey approach of each survey, such differences resulted in large variation in estimates of the older population of older adults with ADL disability. Conclusions: In order to take late-life activity limitations seriously, we must clearly define the measures we use. Further, researchers and clinicians seeking to understand the experience of older adults with activity limitations should be careful to interpret findings in light of the framing of the question asked. [ABSTRACT FROM AUTHOR]

Introduction: Medication reconciliation, a technique that assists in aligning a care team's understanding of an individual's true medication regimen, is vital to optimize medication use and prevent medication errors. Historically, most medication reconciliation research has focused on institutional settings and transitional care, with comparatively little attention given to medication reconciliation in community settings. To optimize medication reconciliation for community‐dwelling older adults, healthcare professionals and older adults must be engaged in co‐designing processes that create sustainable approaches. Methods: Academic researchers, older adults, and community‐ and health system‐based healthcare professionals engaged in a participatory process to better understand medication reconciliation barriers and co‐design solutions. The initiative consisted of two participatory research approaches: (1) Sparks Innovation Studios, which synthesized professional expertise and opinions, and (2) a Community Consultation Studio with older adults. Input from both groups informed a list of possible solutions and these were ranked based on evaluative criteria of feasibility, person‐centeredness, equity, and sustainability. Results: Sparks Innovation Studios identified a lack of ownership, fragmented healthcare systems, and time constraints as the leading barriers to medication reconciliation. The Community Consultation Studio revealed that older adults often feel dismissed in medical encounters and perceive poor communication with and among providers. The Community Consultation Studio and Sparks Innovation Studios resulted in four highly‐ranked solutions to improve medication reconciliation: (1) support for older adults to improve health literacy and ownership; (2) ensuring medication indications are included on prescription labels; (3) trainings and incentives for front‐line staff in clinic settings to become champions for medication reconciliation; and (4) electronic health record improvements that simplify active medication lists. Conclusion: Engaging community representatives with academic partners in the research process enhanced understanding of community priorities and provided a practical roadmap for innovations that have the potential to improve the well‐being of community‐dwelling older adults. [ABSTRACT FROM AUTHOR]

Background: Injuries are a leading cause of emergency department (ED) visits among older adults, and individuals with Alzheimer's disease and related dementias (ADRD) may be at particular risk. We compared injury‐related ED use among assisted living (AL) residents with and without ADRD and assessed differences in the risk of injury‐related ED visits among individuals with ADRD residing in ALs with memory care designation versus general AL. Methods: Using Medicare claims, we identified a cohort of fee‐for‐service beneficiaries who lived in AL in 2018 and resided in one of 20 states with site‐specific information on memory care designation (n = 116,754). Outcomes included all injury‐related ED visits and injury‐related ED visits resulting in hospitalization in the calendar year 2018. We fit multilevel models of the association between ADRD and outcomes, adjusting for resident demographic characteristics and chronic conditions, license type characteristics, and AL characteristics, with random intercepts at the AL and license type levels. Among residents with ADRD, we examined whether memory care licensure was associated with injury‐related ED visits. Results: The adjusted risk of injury‐related ED use during the year was 20.1% (95% CI: 19.6%, 20.6%) for residents with ADRD compared to 16.1% for residents without ADRD (95% CI: 15.7%, 16.5%; p < 0.001). The adjusted risk of injury‐related ED use ending in hospitalization was 4.9% (95% CI: 4.6%, 5.1%) for AL residents with ADRD and 3.9% for residents without ADRD (95% CI: 3.8%, 4.1%; p < 0.001). There were no significant differences in injury‐related ED visits between residents with ADRD in ALs with memory care designation and residents in general AL. Conclusions: Injury‐related ED visits are common among AL residents with ADRD and residents in memory care, but residents in memory care AL experienced similar risks of injury as those in general AL. Further research should identify modifiable factors that can prevent injury among AL residents with ADRD. [ABSTRACT FROM AUTHOR]

The article discusses the improvement of equitable implementation of evidence-based innovations to promote successful Aging In Place in the U.S. as of 2023. Topics covered include identifying implementation determinants, selecting equitable implementation strategies, identifying hypothesized mechanisms of change, and evaluating outcomes. Also noted is the guidance provided by the equitable implementation logic model in developing empirical studies and a broad application of Aging-in-Place.

Background: Traumatic brain injury (TBI) is a leading cause of death and disability in older adults. The aim of this study was to characterize the burden of TBI in older adults by describing demographics, care location, diagnoses, outcomes, and payments in this high‐risk group. Methods: Using 2016–2019 Centers for Medicare & Medicaid Services (CMS) Inpatient Standard Analytical Files (IPSAF), patients >65 years with TBI (>1 injury ICD‐10 starting with "S06") were selected. Trauma center levels were linked to the IPSAF file via American Hospital Association Hospital Provider ID and fuzzy‐string matching. Patient variables were compared across trauma center levels. Results: Three hundred forty‐eight thousand eight hundred inpatients (50.4% female; 87.1% white) from 2963 US hospitals were included. Level I/II trauma centers treated 66.9% of patients; non‐trauma centers treated 21.5%. Overall inter‐facility transfer rate was 19.2%; in Level I/II trauma centers transfers‐in represented 23.3% of admissions. Significant TBI (Head AIS ≥3) was present in 70.0%. Most frequent diagnoses were subdural hemorrhage (56.6%) and subarachnoid hemorrhage (30.6%). Neurosurgical operations were performed in 10.9% of patients and operative rates were similar regardless of center level. Total unadjusted mortality for the sample was 13.9%, with a mortality of 8.1% for those who expired in‐hospital, and an additional 5.8% for those discharged to hospice. Medicare payments totaled $4.91B, with the majority (73.4%) going to Level I/II trauma centers. Conclusions: This study fills a gap in TBI research by demonstrating that although the majority of older adult TBI patients in the United States receive care at Level I/II trauma centers, a substantial percentage are managed at other facilities, despite 1 in 10 requiring neurosurgical operation regardless of level of trauma center. This analysis provides preliminary data on the function of regionalized trauma care for older adult TBI care. Future studies assessing the efficacy of early care guidelines in this population are warranted. [ABSTRACT FROM AUTHOR]

Background: The use of a new medication (e.g., potassium supplementation) for managing a drug‐induced adverse event (e.g., loop diuretic‐induced hypokalemia) constitutes a prescribing cascade. However, loop diuretics are often stopped while potassium may be unnecessarily continued (i.e., relic). We aimed to quantify the occurrence of relics using older adults previously experiencing a loop diuretic‐potassium prescribing cascade as an example. Methods: We conducted a prescription sequence symmetry analysis using the population‐based Medicare Fee‐For‐Service data (2011–2018) and partitioned the 150 days following potassium initiation by day to assess the daily treatment scenarios (i.e., loop diuretics alone, potassium alone, combination of loop diuretics and potassium, or neither). We calculated the proportion of patients developing the relic, proportion of person‐days under potassium alone, the daily probability of the relic, and the proportion of patients filling potassium after loop diuretic discontinuation. We also identified the risk factors of the relic. Results: We identified 284,369 loop diuretic initiators who were 8 times more likely to receive potassium supplementation simultaneously or after (i.e., the prescribing cascade), rather than before, loop diuretic initiation (aSR 8.0, 95% CI 7.9–8.2). Among the 66,451 loop diuretic initiators who subsequently (≤30 days) initiated potassium, 20,445 (30.8%) patients remained on potassium after loop diuretic discontinuation, and 9365 (14.1%) patients subsequently filled another potassium supplementation. Following loop diuretic initiation, 4.0% of person‐days were for potassium alone, and daily probability of the relic was the highest after day 90 of loop diuretic initiation (5.6%). Older age, female sex, higher diuretic daily dose, and greater baseline comorbidities were risk factors for the relic, while patients having the same prescriber or pharmacy involved in the use of both medications were less likely to experience the relic. Conclusions: Our findings suggest the need for clinicians to be aware of the potential of relic to avoid unnecessary drug use. [ABSTRACT FROM AUTHOR]

The article discusses a study on the impact of the coronavirus disease 2019 (COVID-19) pandemic on influenza and infection control practices in U.S. nursing homes. Topics covered include the pandemic's enhancement of infection control practices which may be continued, and of the value of masking, and the improvement of healthcare workers' vaccination via a vaccine champion. Also noted are general infection control knowledge and practices.

Background: Antiepileptics are commonly prescribed to nursing home residents with Alzheimer's disease and related dementias (ADRD) but there is little scientific support for their use in this population. It is unclear whether different antiepileptics are targeting different indications. Methods: Using the Minimum Data Set and Medicare data, including Part D pharmacy claims, we constructed annual cohorts of residents with ADRD with long‐term stays in nursing homes from 2015 to 2019. For each year, we measured the proportion of residents with ADRD in nursing homes nationwide with at least one antiepileptic prescription. We also measured trends in valproic acid, gabapentin, antipsychotic, and opioid prescribing. Finally, we examined how prescribing rates differed based on whether residents with ADRD had disruptive behaviors or reported pain. Results: Our study sample includes 973,074 persons living with ADRD who had a long‐term stay in a nursing home, which was defined as at least 3 months. The proportion of residents with ADRD with at least one antiepileptic prescription increased from 29.5% in 2015 to 31.3% in 2019, which was driven by increases in the rate of valproic acid and gabapentin prescribing. Conversely, antipsychotic prescribing rates declined from 32.1% to 27.9% and opioid prescribing rates declined from 39.8% to 31.7%. The risk of valproic acid prescribing was 10.9 percentage points higher among residents with ADRD with disruptive behaviors, while the risk of being prescribed gabapentin was 13.9 percentage points higher among residents with ADRD reporting pain. Conclusions: Antiepileptic prescribing among nursing home residents with ADRD is increasing, while antipsychotic and opioid prescribing is declining. Examining antiepileptic prescribing to residents with ADRD who had disruptive behaviors and/or reported pain suggests that two of the most common antiepileptics, valproic acid and gabapentin, are being used in clinically distinct ways. Antiepileptic prescribing of questionable risk–benefit for dementia care warrants further scrutiny. See related editorial by Carnahan et al. in this issue. [ABSTRACT FROM AUTHOR]