Search

Presents several abstracts clinical investigation in the 2001 edition of the American Geriatrics Society. 'Tolterodine: A Safe and Effective Treatment for Older Patients with Overactive Bladder,' by J.G. Malone-Lee, J.B. Walsh, M-F. Maugourd, et al.

Presents developments related to clinical trials of various diseases and their treatment. Role of delirium in the mortality rate of hospitalized older adults.

Background: The presence of treatment limitations in patients with frailty at intensive care unit (ICU) admission is unknown. We aimed to evaluate the presence and predictors of treatment limitations in patients with and without COVID‐19 pneumonitis in those admitted to Australian and New Zealand ICUs. Methods: This registry‐based multicenter, retrospective cohort study included all frail adults (≥16 years) with documented clinical frailty scale (CFS) scores, admitted to ICUs with admission diagnostic codes for viral pneumonia or acute respiratory distress syndrome (ARDS) over 2 years between January 01, 2020 and December 31, 2021. Frail patients (CFS ≥5) coded as having viral pneumonitis or ARDS due to COVID‐19 were compared to those with other causes of viral pneumonitis or ARDS for documented treatment limitations. Results: 884 frail patients were included in the final analysis from 129 public and private ICUs. 369 patients (41.7%) had confirmed COVID‐19. There were more male patients in COVID‐19 (55.3% vs 47.0%; p = 0.015). There were no differences in age or APACHE‐III scores between the two groups. Overall, 36.0% (318/884) had treatment limitations, but similar between the two groups (35.8% [132/369] vs 36.1% [186/515]; p = 0.92). After adjusting for confounders, increasing frailty (OR = 1.72; 95%‐CI 1.39–2.14), age (OR = 1.05; 95%‐CI 1.04–1.06), and presence of chronic respiratory condition (OR = 1.58; 95%‐CI 1.10–2.27) increased the likelihood of instituting treatment limitations. However, the presence of COVID‐19 by itself did not influence treatment limitations (odds ratio [OR] = 1.39; 95%‐CI 0.98–1.96). Conclusions: The proportion of treatment limitations was similar in patients with frailty with or without COVID‐19 pneumonitis at ICU admission. [ABSTRACT FROM AUTHOR]

Background: In managing older adults with atrial fibrillation (AF), their symptomatology impacts their well‐being and may inform treatment decision‐making. We examined AF symptom perception, its impact on quality of life (QoL), and its relation to treatment strategies in older adults with AF. Methods: Data were obtained from older adults with AF enrolled in a multicenter study conducted at clinic sites in Massachusetts and Georgia between 2016 and 2018. Participants were stratified into three age groups: 65–74 (youngest–old), 75–84 (middle–old), and ≥85 (oldest). Perception of AF symptoms was assessed by participant self‐report during their clinic visit and at study enrollment by the Atrial Fibrillation Effect on Quality‐of‐Life Questionnaire which assessed cardiac‐specific and non‐specific, non‐cardiac AF symptoms and their impact on QoL. Treatment strategies (rate or rhythm control) utilized were ascertained from electronic medical records. Results: Among the 1184 participants (mean age 75 years, 48% women, 86% Non‐Hispanic White), 51% were aged 65–74 years, 36% were 75–84 years, and 13% were ≥ 85 years. The most commonly reported AF symptoms were non‐specific, non‐cardiac symptoms (fatigue, dyspnea, lightheadedness) with similar prevalence and impact on QoL in all age groups. Cardiac‐specific AF symptoms (palpitations, irregular heartbeat, pause in heart activity) were less prevalent, but most commonly reported by the youngest participants (65–74 years), who endorsed considerable impact of these symptoms on their QoL. Overall, those who reported experiencing any AF symptoms during their clinic visit were more likely to have received rhythm compared with rate control (OR: 1.56; 95% CI: 1.18–2.04) with similar findings for all age groups except those aged ≥85 years. Conclusions: Our findings suggest a high prevalence of non‐specific, non‐cardiac symptoms among older adults with AF and that cardiac‐specific AF symptoms may exert considerable impact on their QoL. The presence of any AF symptoms may drive more rhythm control in a majority of older adults. See related Editorial by Blachman et al. in this issue. [ABSTRACT FROM AUTHOR]

This editorial comments on the articles by Zingmond et al. and Jennings et al. in this issue. [ABSTRACT FROM AUTHOR]

Background: Physician Orders for Life‐Sustaining Treatment (POLST) facilitates documentation and transition of patients' life‐sustaining treatment orders across care settings. Little is known about patient and facility factors related to care preferences within POLST across a large, diverse nursing home population. We describe the orders within POLST among all nursing home (NH) residents in California from 2011 to 2016. Methods: California requires NHs to document in the Minimum Data Set whether residents complete a POLST and orders within POLST. Using a serial cross‐sectional design for each year, we describe POLST completion and orders for all California NH residents from 2011 to 2016 (N = 1,112,668). We used logistic mixed‐effects regression models to estimate POLST completion and resuscitation orders to understand the relationship with resident and facility characteristics, including Centers for Medicare and Medicaid Services (CMS) Nursing Home Compare overall five‐star quality rating. Results: POLST completion significantly increased from 2011 to 2016 with most residents having a POLST in 2016 (short‐stay:68%; long‐stay:81%). Among those with a POLST in 2016, 54% of long‐stay and 41% of short‐stay residents had a DNR order. Among residents with DNR, >90% had orders for limited medical interventions or comfort measures. Few residents (<6%) had a POLST with contradictory orders. In regression analyses, POLST completion was greater among residents with more functional dependence, but was lower among those with more cognitive impairment. Greater functional and cognitive impairment were associated with DNR orders. Racial and ethnic minorities indicated more aggressive care preferences. Higher CMS five‐star facility quality rating was associated with greater POLST completion. Conclusions: Six years after a state mandate to document POLST completion in NHs, most California NH residents have a POLST, and about half of long‐stay residents have orders to limit life‐sustaining treatment. Future work should focus on determining the quality of care preference decisions documented in POLST. This article comments on the editorial by Lam et al. and the letter by Zingmond et al. in this issue. [ABSTRACT FROM AUTHOR]

Background: People with dementia (PWD) take medications that may be unnecessary or harmful. This problem can be addressed through deprescribing, but it is unclear if PWD would be willing to engage in deprescribing with their providers. Our goal was to investigate attitudes toward deprescribing among PWD. Methods: This was a cross‐sectional study of 422 PWD aged ≥65 years who completed the medications attitudes module of the National Health and Aging Trends Study (NHATS) in 2016. Proxies provided responses when a participant was unable to respond due to health or cognitive problems. Attitudinal outcomes comprised responses to two statements from the patients' attitudes toward deprescribing questionnaire and its revised version (representing belief about the necessity of one's medications and willingness to deprescribe); another elicited the maximum number of pills that a respondent would be comfortable taking. Results: The weighted sample represented over 1.8 million PWD; 39% were 75 to 84 years old and 38% were 85 years or older, 60% were female, and 55% reported six or more regular medications. Proxies provided responses for 26% of PWD. Overall, 22% believed that they may be taking one or more medicines that they no longer needed, 87% were willing to stop one or more of their medications, and 50% were uncomfortable taking five or more medications. Attitudinal outcomes were similar across sociodemographic and clinical factors. PWD taking ≥6 medications were more likely to endorse a belief that at least one medication was no longer necessary compared to those taking <6 (adjusted probability 29% [95% confidence interval (CI), 22%–38%] vs. 13% [95% CI, 8%–20%]; p = 0.004); the same applied for willingness to deprescribe (92% [95% CI, 87%–95%] vs. 83% [95% CI, 76%–89%]; p = 0.04). Conclusions: A majority of PWD are willing to deprescribe, representing an opportunity to improve quality of life for this vulnerable population. [ABSTRACT FROM AUTHOR]

Objectives: To present a flexible protocol of vaginal pessaries for older women with significant pelvic organ prolapse (POP). Design A prospective cohort study of 140 consecutive older women (aged ≥65 years) with significant POP treated with individually fitted vaginal pessaries. After initial insertion, each patient was invited for a first evaluation after 1 month and subsequent follow‐ups at increasing intervals of 1 month. During each examination, the pessary was removed and the vagina was inspected for infection, bleeding, or erosions. All patients were advised to use a vaginal estrogen cream twice a week. Setting: The study was conducted during 2020 in the urogynecology clinic of a tertiary medical center. Participants: The study cohort included 140 consecutive older women with significant and symptomatic POP treated with vaginal pessaries. Main outcome: Primary outcomes included time intervals between follow‐up visits, pessary‐associated complications, need to change the pessary, need to remove the pessary temporarily, and whether the patients eventually underwent POP surgery. Results: The mean age of the patients at the time of pessary fitting was 76.7 ± 9.2 years (range 65–100 years). Mean interval between follow‐up examinations was 3.3 ± 1.1 months (range 1–6 months). Most patients (83.6%) used a ring pessary with support, but only a small number of patients were able to maintain the pessary by themselves. Of the 140 patients, five (3.6%) patients only eventually underwent POP surgery, and in 11 (7.9%) patients, the vaginal pessary had to be removed for 2–4 weeks because of significant vaginal discharge or superficial erosions. Additionally, 12 (8.6%) patients developed stress urinary incontinence following pessary insertion. Conclusions: Customized management with vaginal pessary for symptomatic POP in older women is effective and safe, and is a suitable therapeutic alternative for older women who are unable or unwilling to undergo reconstructive pelvic surgery. [ABSTRACT FROM AUTHOR]

This letter comments on the editorial by Lam et al. and the article by Jennings et al. in this issue. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Depressive Symptoms Increase the Risk of Mortality in Older Mexican Community-Dwelling Adults" by S. D. Piña-Escuerdo, A. P. Navarrete-Reyes and J. A. Ávila-Funes.

Swallowing problems, or dysphagia, are common as people age, and are associated with significant negative outcomes, including weight loss, pneumonia, dehydration, shortened life expectancy, reduced quality of life, and increased caregiver burden. In this article, we will discuss the complex process of swallowing in normal circumstances and with healthy aging, then review etiologies that contribute to dysphagia. We will discuss approaches to evaluating and treating dysphagia, providing relevant data where they are available. We highlight the desperate need for high‐quality research to guide best practices in treating dysphagia in older adults. J Am Geriatr Soc 67:2643–2649, 2019 [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which addresses the case of autopsy-proven exogenous lipoid pneumonia in a 100-year-old woman who underwent frequent sputum suction with catheters that were lubricated with oil-based nasal drops, and it mentions preventable illness in elderly adults.

An introduction is presented in which the editor discusses the theme of the issue, the workforce for seriously ill older adults in the community.

The lack of an adequately prepared workforce is a critical barrier to delivering high‐quality community‐based care for individuals living with serious illness. This article presents 16 consensus‐based recommendations to improve the capacity of the workforce in this area within the next 5 years, focusing on older adults. The recommendations were developed at a summit of 40 national leaders from practice, payment, labor, advocacy, and research arenas. The consensus‐based recommendations include specific steps for geriatrics leaders including curriculum reforms to increase skills in the care of older and seriously ill populations, expanding experiential learning opportunities for students to increase interest in careers in geriatric and palliative care, developing and improving curriculum in interprofessional and cultural competency skills, preparing clinicians to support incorporation of home care aides and family caregivers as healthcare team members, development of skills to support shared decision making with patients, and requiring specific skills related to serious illness care in licensing, accreditation, and continuing education regulations. Together, these recommendations put forward a charge to healthcare leaders to act to ensure a workforce that will optimize support for those with serious illness living in the community. J Am Geriatr Soc 67:S392–S399, 2019. [ABSTRACT FROM AUTHOR]

Family caregivers provide the vast majority of care for individuals with serious illness living in the community but are not often viewed as full members of the healthcare team. Family caregivers are increasingly expected to acquire a sophisticated understanding of the care recipient's condition and new skills to execute complex medical or nursing tasks, often without adequate preparation and support, and with little choice in taking on the role. This review draws on peer‐reviewed literature, government reports, and other publications to summarize the challenges faced by family caregivers of older adults in the context of serious illness and to identify opportunities to better integrate them into the healthcare workforce. We discuss promising approaches such as inclusion of family caregivers in consensus‐based practice guidelines; the "no wrong door" function, directing consumers to needed resources, regardless of where initial contact is made; and caregiver‐friendly workplace policies allowing flexible arrangements. We present specific recommendations focusing on research, clinical practice, and policy changes that promote family‐centered care and improve outcomes for caregivers as well as persons with serious illness. J Am Geriatr Soc 67:S451–S456, 2019. [ABSTRACT FROM AUTHOR]

Home health, home care, and personal care aides provide most of the paid hands‐on care delivered to seriously ill, functionally impaired individuals in their homes, assisted living, and other noninstitutional settings. This workforce delivers personal care, assistance with activities of daily living, and emotional support to their patients. They are often the eyes and ears of the health system, observing subtle changes in condition that can provide important information for clinical decision making and therapeutic intervention. Despite this fact, the growing number of team‐based home care initiatives have failed to incorporate this workforce into their programs. Barriers to inclusion of aides into teams include a basic lack of value and understanding on the part of clinical team members and society in general of the complex tasks that these caregivers perform, inadequate investments in training and education of this workforce to develop their knowledge and competencies, and variation in state delegation laws that limit the scope of practice and consequently the ability of aides to work effectively in teams and to advance in their careers. Building on the few programs that have successfully included aides as key members of home care teams, federal and state policymakers, educators, and health systems and providers should standardize competency‐based training requirements, expand nurse delegation consistently across states, and support evaluation, dissemination, and replication of successful programs. J Am Geriatr Soc 67:S444–S448, 2019. [ABSTRACT FROM AUTHOR]

Osteoporosis is the most common bone disease in humans. Older persons are at higher risk of osteoporotic fractures that also result in poor quality of life, disability, loss of independence, institutionalization, and higher mortality. Osteoporosis shares a distinct pathophysiologic relationship with sarcopenia, an age‐related disease comprising declines in muscle mass, strength, or function. The combination of these two diseases is known as osteosarcopenia. Understanding the pathophysiology of osteosarcopenia, in addition to its diagnostic and therapeutic approaches, is key in providing older adults with the best falls and fractures prevention strategies. This review provides updated information on new discoveries on the combined pathophysiology of osteoporosis and sarcopenia that have led to the development of novel therapeutic approaches. New recommendations for the use of risk calculators and densitometry are also presented in this review as well as evidence on current and upcoming pharmacologic treatments to prevent falls and fractures in older persons. J Am Geriatr Soc 67:831–840, 2019. [ABSTRACT FROM AUTHOR]

Objectives: To review intervention programs that measure gait to investigate what features of the intervention may contribute to improving gait in older adults with cognitive impairment or dementia. Design: Systematic review using Medline, Cinahl, Scopus, PsychInfo, Amed, Embase, Web of Science, and PubMed for original research published in English between January 1, 2000, and July 23, 2018, to identify interventional controlled trials. Narrative synthesis was undertaken. Results: Of 6,379 citations, 36 articles met inclusion criteria. Interventions were categorized as medication or medical devices (8 studies), exercise (19 studies), and exercise plus cognitive training (9 studies). Antidementia medication may improve gait variability in people with Alzheimer's disease. Exercise programs focusing on strength and balance training, especially when combined with functional mobility training, improve gait in people with mild cognitive impairment or dementia. Exercise plus cognitive training programs combining strength and balance training, functional mobility training, and training on attention and executive function also improve gait. Conlusion: Physical and cognitive factors affect gait performance, and both should be addressed in intervention programs. Physical exercises including functional mobility training, especially walking, have better results than physical programs with only static, resistance, and flexibility training. Cognitive intervention should be concomitant with physical exercises rather than separate, with a focus on attention and executive function. Combining physical training with cognitive training in a functional context may assist older adults with cognitive impairment generalize from training to everyday activity. J Am Geriatr Soc 67:381–391, 2019. [ABSTRACT FROM AUTHOR]

Objectives: To assess the efficacy of haloperidol in reducing postoperative delirium in individuals undergoing thoracic surgery. Design: Randomized double‐blind placebo‐controlled trial. Setting: Surgical intensive care unit (ICU) of tertiary care center. Participants: Individuals undergoing thoracic surgery (N=135). Intervention: Low‐dose intravenous haloperidol (0.5 mg three times daily for a total of 11 doses) administered postoperatively. Measurements: The primary outcome was delirium incidence during hospitalization. Secondary outcomes were time to delirium, delirium duration, delirium severity, and ICU and hospital length of stay. Delirium was assessed using the Confusion Assessment Method for the ICU and delirium severity using the Delirium Rating Scale‐Revised. Results: Sixty‐eight participants were randomized to receive haloperidol and 67 placebo. No significant differences were observed between those receiving haloperidol and those receiving placebo in incident delirium (n=15 (22.1%) vs n=19 (28.4%); p =.43), time to delirium (p =.43), delirium duration (median 1 day, interquartile range (IQR) 1‐2 days vs median 1 day, IQR 1‐2 days; p =.71), delirium severity, ICU length of stay (median 2.2 days, IQR 1–3.3 days vs median 2.3 days, IQR 1‐4 days; p =.29), or hospital length of stay (median 10 days, IQR 8–11.5 days vs median 10 days, IQR 8‐12 days; p =.41). In the esophagectomy subgroup (n = 84), the haloperidol group was less likely to experience incident delirium (n=10 (23.8%) vs n=17 (40.5%); p =.16). There were no differences in time to delirium (p =.14), delirium duration (median 1 day, IQR 1‐2 days vs median 1 day, IQR 1‐2 days; p =.71), delirium severity, or hospital length of stay (median 11 days, IQR 10‐12 days vs median days 11, IQR 10‐15 days; p =.26). ICU length of stay was significantly shorter in the haloperidol group (median 2.8 days, IQR 1.1–3.8 days vs median 3.1 days, IQR 2.1–5.1 days; p =.03). Safety events were comparable between the groups. Conclusion: Low‐dose postoperative haloperidol did not reduce delirium in individuals undergoing thoracic surgery but may be efficacious in those undergoing esophagectomy. J Am Geriatr Soc 66:2289–2297, 2018. [ABSTRACT FROM AUTHOR]

Objectives: To determine the association between weight trajectory, health status, and mortality in older women. Design: Cohort study. Setting: Study of Osteoporotic Fractures. Participants: Older community‐dwelling women (age: baseline (1986–88), mean 68, range 65–81; Year 20 (2006–08), mean 88, range 83–102 (N = 1,323)). Measurements: Body weight measured repeatedly over 20 years (mean 8 times). Logistic and Cox proportional hazard models were used to evaluate whether 20‐year weight trajectory measures were associated with hip fracture, falls, physical performance, and mortality. Results: In models adjusted for age, clinic, calcium use, Year 20 weight, walking speed, comorbidity score, smoking, self‐reported health, and walking for exercise, women with moderate weight loss (>9.0 kg) over 20 years had a 74% greater risk of death (hazard ratio (HR) = 1.74, 95% confidence interval (CI) = 1.37–2.20) in the 5 years after the Year 20 visit than those with no weight loss and more than twice the risk of hip fracture (HR = 2.56, 95% CI = 1.39–4.70). They were 3.6 times (odds ratio (OR) = 3.60, 95% CI = 1.86–6.95) as likely to have poor physical function at the Year 20 visit as women with no weight loss but no greater risk of 2 or more falls in the 1.5 years after the Year 20 visit. Weight variability and abrupt weight decline were not associated with adverse health oucomes (falls, fractures, mortality), but those in the highest quartile of variability were 2.3 times (OR = 2.26, 95% CI = 1.34–3.80) as likely to have poor physical function scores. Conclusion: In women surviving past 80 years of age, moderate weight loss over 20 years was associated with greater risk of hip fracture, poor physical function, and mortality but not of falls. Future work should separate voluntary from involuntary weight loss. [ABSTRACT FROM AUTHOR]

Objectives: To use restricted mean survival time, which summarizes treatment effects in terms of event‐free time over a fixed time period, to evaluate the benefit of pravastatin therapy for primary prevention of cardiovascular disease in older adults. Design: Secondary analysis of the Antihypertensive and Lipid‐Lowering Treatment to Prevent Heart Attack Trial‐Lipid‐Lowering Trial (ALLHAT‐LLT). Setting: Ambulatory setting. Participants: Individuals aged 65 and older (mean aged 71, 49% female) free of cardiovascular disease (N=2,867). Intervention: Pravastatin 40 mg/d (n=1,467) versus usual care (n=1,400). Measurements: We estimated the difference in RMST for total and coronary heart disease (CHD)‐free survival between the pravastatin and usual care groups over the 6‐year trial period and used parametric survival models to estimate RMST differences projected over 10 years. Results: Over 6 years, individuals treated with pravastatin lived (RMST 2,008.1 days), on average, 33.7 fewer days than those receiving usual care (RMST 2,041.8 days) (difference –33.7 days, 95% confidence interval (CI)=–67.0 to –0.5 days, p=.047). Pravastatin‐treated individuals lived RMST 2,088.1 days), on average, 18.7 more days free of CHD over 6 years than those receiving usual care (RMST 2,069.4 days), but this difference was not statistically significant (difference 18.7 days, 95% CI=–10.4–47.8 days, p=.21). The 10‐year projection showed that pravastatin‐treated individuals would live 108.1 fewer days (95% CI=–204.5 to –14.1, p=.03) than those receiving usual care, although treated individuals would gain 77.9 days (95% CI=3.8–159.6, p=.046) of CHD‐free survival. Conclusion: RMST provides an intuitive and explicit way to express the effect of pravastatin therapy on CHD‐free and overall survival in older adults free of cardiovascular disease. This measure allows a more personalized interpretation than hazard ratios of the benefits and risks of a medical intervention for decision‐making. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether antidepressant use is associated with dementia risk. DESIGN: Prospective cohort study. SETTING: Kaiser Permanente Washington (KPWA), an integrated healthcare delivery system. PARTICIPANTS: Community‐dwelling individuals aged 65 and older without dementia and with 10 years or more of KPWA enrollment at baseline (N=3,059). MEASUREMENTS: Primary exposures were selective serotonin reuptake inhibitors (paroxetine vs other), tricyclic antidepressants, and serotonin antagonist and reuptake inhibitors. Using health plan pharmacy data, we calculated cumulative medication exposure, defined as total standardized daily doses (TSDDs), over rolling 10‐year windows. Exposure in the most recent year was excluded to avoid use related to prodromal symptoms. The Cognitive Abilities Screening Instrument was administered every 2 years; low scores triggered clinical evaluation and consensus diagnosis procedures. Dementia risk was estimated according to medication use using Cox proportional hazards models. RESULTS: During a mean follow‐up of 7.7 years, 775 participants (25%) developed dementia; 659 (22%) developed possible or probable Alzheimer's disease. Individual antidepressant classes were not associated with differences in dementia risk, although paroxetine use was associated with higher risk of dementia for all TSDD categories than no use (0–90 TSDDs: hazard ratio (HR)=1.69, 95% confidence interval (CI)=1.18–2.42; 91–365 TSDDs: HR=1.40, 95% CI=0.88–2.23; 366–1095 TSDDs: HR=2.13, 95% CI=1.32–3.43; ≥1095 TSDDs: HR=1.42, 95% CI=0.82–2.46). CONCLUSION: Most commonly prescribed nonanticholinergic depression medications used in late life do not appear to be associated with dementia risk. Paroxetine and other anticholinergic antidepressants may be exceptions in older individuals. Future studies are warranted to improve scientific understanding of potential associations in other settings and populations. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the prevalence, characteristics, and management of pain in older hospitalized medical patients. Design: Medical record aggregate review. Setting: Tertiary care hospital. Participants: Individuals aged 65 and older admitted to the medicine service between November 28, 2014, and May 28, 2015. Measurements: Demographic characteristics, comorbidity burden, pain characteristics, and analgesics during index hospitalization were assessed in individuals with moderate to severe pain (≥4 on 0–10 Numeric Pain Rating Scale). Results: Of 1,267 patients admitted to the medicine service, 248 (20%) had moderate to severe pain on admission (mean age 75 ± 8, 57% female, 50% white). During hospitalization, most participants received opioids (80%) and acetaminophen (74%), and few received nonsteroidal antiinflammatory drugs (9%). Participants with chronic pain had less reduction in pain intensity score from admission to discharge than those without a history of chronic pain (mean change score 3.7 vs 4.9, p=.002) and were more likely to receive opioids, adjuvant analgesics, and other analgesics (all p<.05). Conclusion: Twenty percent of older adults admitted to a general medicine service had moderate to severe pain. Further research about optimal pain management in hospitalized older adults, particularly those with chronic pain, is necessary to improve care in this population. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the cardiovascular (CV) effects of acetylcholinesterase inhibitors (AChEIs) in individuals with dementia Design: Systematic review and meta‐analysis. Setting: Two authors independently searched major electronic databases from inception until June 17, 2017, for longitudinal (without a control group) and cohort (with a control group) studies reporting CV outcomes in relation to AChEIs. Randomized controlled trials were excluded because they included relatively healthy subjects. Participants: Individuals with dementia and controls. Measurements: Changes in CV parameters were summarized using standardized mean differences (SMDs) with 95% confidence intervals (CIs). Event rates were used to assess incidence of hypertension and bradycardia. Incidence of CV events in demented patients versus in healthy controls were compared using hazard ratios (HRs). Results: Of 4,588 initial hits, 31 studies including 258,540 individuals with dementia and 2,246,592 controls were analyzed. In longitudinal and open‐label studies, AChEIs were associated with a significantly greater incidence of hypertension (n=1,573, 4%, 95% CI=2–8%, I2=47%) and bradycardia (n=13,703, 2%, 95% CI=1–6%, I2=98%). AChEIs were associated with a decrease in heart rate (SMD=–1.77, 95% CI=–3.58–0.03, I2=78%) and an increase in PR interval (SMD=0.10, 95% CI=0.008–0.19, I2=3%) from baseline. During a median follow‐up of 116 weeks, AChEIs were associated with a significantly lower risk of CV events (stroke, acute coronary syndrome, CV mortality; HR=0.63, 95% CI=0.45–0.88, I2=18%), without a significantly greater risk of bradycardic events (HR=1.40, 95% CI=0.76–2.59, I2=98%). Conclusion: AChEI therapy may be associated with negative chronotropic and hypertensive effects but also with lower risk of CV events. [ABSTRACT FROM AUTHOR]

Objectives: To describe the psychometric properties of the Picture‐based Memory Impairment Screen (PMIS) in a multidisciplinary memory disorder center serving an ethnically and educationally diverse community. Design: Cross‐sectional cohort study. Setting: Montefiore Center for Aging Brain (CAB) Participants: Individuals with cognitive complaints (N=405; average age 76±10, 66% female). Measurements: A geriatrician or neurologist administered the PMIS, and a neuropsychologist administered the Blessed Information, Memory, and Concentration (BIMC) test and determined whether participants had dementia, mild cognitive impairment (MCI), or subjective cognitive complaints (SCC). Results: Mean PMIS scores were 4.0±2.6 in participants with dementia (n=194), 6.8±1.5 in those with MCI (n= 155), and 7.0±1.8 in those with SCC (n= 56) (p<.001). PMIS scores showed similar significant linear trends when analyzed according to ethnicity, education, sex, and language. The PMIS was negatively correlated with BIMC score (p<.001). The PMIS had positive predictive value of 77%, negative predictive value of 73%, sensitivity of 68%, and specificity of 81% to detect all‐cause dementia in this population of individuals with cognitive complaints. Conclusion: The PMIS is a quick, valid screening tool to identify cognitive impairment in individuals with cognitive complaints that accounts for cultural and educational differences. [ABSTRACT FROM AUTHOR]

Objectives: To examine automobile crash risk associated with cognition in older drivers without dementia. Design: Retrospective secondary analysis of longitudinal cohort study. Setting: Our study used data from the Adult Changes in Thought (ACT) Study merged with Washington State crash reports and licensure records. Data were available from 2002 to 2015. Participants: Group Health enrollees from Washington State aged 65 and older with active driver's licenses (N=2,615). Measurements: Cognitive function was assessed using the Cognitive Abilities Screening Instrument scored using item response theory (CASI‐IRT). The study outcome was police‐reported motor vehicle crash. We used a negative binomial mixed‐effects model with robust standard errors clustered on the individual and considered associations between crash risk, level of cognition, and amount of decline since the previous study visit. Covariates included age, sex, education, alcohol, depression, medical comorbidities, eyesight, hearing, and physical function. Individuals were censored at dementia diagnosis, death, or failure to renew their license. Results: Over an average of 7 years of follow‐up, 350 (13%) people had at least one crash. A 1‐unit lower CASI‐IRT score was associated with a higher adjusted incidence rate ratio of crash of 1.26 (95% confidence interval=1.08–1.51). Beyond level of cognition, amount of cognitive decline between study visits was not associated with crash risk. Conclusion: This study suggests that, in older drivers, poorer performance on the CASI‐IRT may be a risk factor for motor vehicle crashes, even in individuals without diagnosed dementia. Further research is needed to understand driving behavior and inform driving decisions for older adults with poor cognitive function. [ABSTRACT FROM AUTHOR]

Objectives: To review the literature and summarize the evidence of temporomandibualar joint (TMJ) disorders (TMDs) in older adults, focusing on clinical manifestations of TMDs in older adults, highlighting the incidence and sexual dimorphism of TMJ degeneration and the role of sex hormones in this process, and providing potential treatment options for TMD in older adults. Design: Two review authors performed the literature search, study inclusion, and data extraction. PubMed, Embase, and Google scholar were searched for literature until August 2017 (Figure ). We adopted a combination of Medical Subject Headings with related free text words for the search in PubMed and optimized the search in other search engines. Results: Traditionally, it was believed that TMDs predominantly affected women of childbearing age, but recent large studies in Europe and the United States have shown that the prevalence of TMD peaks after childbearing age (45–64) and then gradually decreases with age, although not much is known about the disease in older adults. Conclusion: Most older adults have TMJ degeneration, which affects women more than men. In most older adults, the symptoms of TMD are mild and self‐limiting and can usually be treated with self management. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to research on implantable loop recorders in elderly adults.

The authors offer a reply to a letter to the editor by Paula T. Einhorn, Paul K. Whelton, Barry R. Davis, Jackson T. Wright Jr., William C. Cushman, and Susan J. Zieman in the current issue responding to their article "Risk of Thiazide-induced Metabolic Adverse Events in Older Adults," which appeared in the publication in 2014.

The article presents a case study involving a 78-year-old woman suffering from a lack of appetite and an upper respiratory tract infection. Her tongue also had a black coating consistent with black hairy tongue disease (BHT). She was prescribed oral antibiotics, and after two days the black coating was gone, as was the respiratory infection after four days.

Major depression in older adults, or late‐life depression (LLD), is a common and debilitating psychiatric disorder that increases the risk of morbidity and mortality. Although the effects of LLD make it important to achieve a diagnosis and start treatment quickly, individuals with LLD are often inadequately or unsuccessfully treated. The latest treatment developments suggest that interventions targeting executive dysfunction and neuroticism, constructs associated with poor response to antidepressants in older adults, are successful in treating LLD. Specific behavioral interventions (computerized cognitive training, mindfulness meditation, aerobic exercise) appear to decrease depressive symptoms and ameliorate executive dysfunction and neuroticism, but we do not fully understand the mechanisms by which these treatments work. We review recent research on neural network changes underlying executive dysfunction and neuroticism in LLD and their association with clinical outcomes (e.g., treatment response, cognitive functioning). [ABSTRACT FROM AUTHOR]

A response is provided to the article "State of Science of Neural Systems in Late Life Depression [LLD]-Impact on Clinical Presentation and Treatment Outcome," by K. Manning and D. Steffens, which appeared in the issue. It discusses the treatment of older people with mental depression, including through meditation, computerized cognitive training and mindfulness.

A response is provided to the article "State of the Science: Apathy As a Model for Investigating Behavioral and Psychological Symptoms [BPSDs] in Dementia," by L. Massimo, H.C. Kales and A. Kolanowski, which appeared within the issue. An overview of the treatment of the BPSDs of dementia, including caregivers' pharmacological, or drug, treatment of these symptoms, is provided.

The American Geriatrics Society, with support from the National Institute on Aging and other funders, held its ninth Bedside‐to‐Bench research conference, entitled “Urinary Incontinence in the Older Adult: A Translational Research Agenda for a Complex Geriatric Syndrome,” October 16 to 18, 2016, in Bethesda, Maryland. As part of a conference series addressing three common geriatric syndromes—delirium, sleep and circadian rhythm disturbance, and urinary incontinence—the series highlighted relationships and pertinent clinical and pathophysiological commonalities between these conditions. The conference provided a forum for discussing current epidemiology, basic science, and clinical and translational research on urinary incontinence in older adults; for identifying gaps in knowledge; and for developing a research agenda to inform future investigative efforts. The conference also promoted networking involving emerging researchers and thought leaders in the field of incontinence, aging, and other fields of research, as well as National Institutes of Health program personnel. [ABSTRACT FROM AUTHOR]

Objectives: To examine the effects of exercise training on cognitive function in individuals at risk of or diagnosed with Alzheimer's disease (AD). Design: Meta‐analysis. Setting: PubMed, Scopus, ClinicalTrials.gov, and ProQuest were searched from inception until August 1, 2017. Participants: Nineteen studies with 23 interventions including 1,145 subjects with a mean age of 77.0 ± 7.5 were included. Most subjects were at risk of AD because they had mild cognitive impairment (64%) or a parent diagnosed with AD (1%), and 35% presented with AD. Intervention: Controlled studies that included an exercise‐only intervention and a nondiet, nonexercise control group and reported pre‐ and post‐intervention cognitive function measurements. Measurements: Cognitive function before and after the intervention and features of the exercise intervention. Results: Exercise interventions were performed 3.4 ± 1.4 days per week at moderate intensity (3.7 ± 0.6 metabolic equivalents) for 45.2 ± 17.0 minutes per session for 18.6 ± 10.0 weeks and consisted primarily of aerobic exercise (65%). Overall, there was a modest favorable effect of exercise on cognitive function (d+ = 0.47, 95% confidence interval (CI) = 0.26–0.68). Within‐group analyses revealed that exercise improved cognitive function (d+w = 0.20, 95% CI = 0.11–0.28), whereas cognitive function declined in the control group (d+w = −0.18, 95% CI = −0.36 to 0.00). Aerobic exercise had a moderate favorable effect on cognitive function (d+w = 0.65, 95% CI = 0.35–0.95), but other exercise types did not (d+w = 0.19, 95% CI = −0.06–0.43). Conclusion: Our findings suggest that exercise training may delay the decline in cognitive function that occurs in individuals who are at risk of or have AD, with aerobic exercise possibly having the most favorable effect. Additional randomized controlled clinical trials that include objective measurements of cognitive function are needed to confirm our findings. [ABSTRACT FROM AUTHOR]

Background/Objectives: To examine the comparative effectiveness and safety of cognitive enhancers for Alzheimer's disease (AD). Design: Systematic review and Bayesian network metaanalysis (NMA). Setting: MEDLINE, EMBASE, Cochrane Library, CINAHL, Ageline (inception–March 2016). Participants: Individuals with AD in randomized controlled trials (RCTs), quasi‐RCTs, and nonrandomized studies. Intervention: Any combination of donepezil, rivastigmine, galantamine, or memantine. Measurements: Two reviewers independently screened titles, abstracts, and full‐texts; abstracted data; and appraised risk of bias. Results: Twenty thousand three hundred forty‐three citations were screened, and 142 studies were included (110 RCTs, 21 non‐RCTs, 11 cohort studies). NMA found that donepezil (Mini‐Mental State Examination: mean difference (MD) = 1.39, 95% credible interval (CrI) = 0.53–2.24), donepezil+memantine (2.59, 95% CrI = 0.12–4.98), and transdermal rivastigmine (2.02, 95% CrI = 0.02–4.08) improved cognition more than placebo. NMA found that donepezil (Alzheimer's Disease Assessment Scale–cognitive: MD = −3.29, 95% CrI = −4.57 to −1.99) and galantamine (MD = −2.13, 95% CrI = −3.91 to −0.27) improved cognition more than placebo. NMA found that donepezil+memantine (MD = −5.23, 95% CrI = −8.72 to −1.56) improved behavior more than placebo. NMA found that donepezil (MD = −0.32, 95% CrI = −0.46 to −0.19), donepezil+memantine (MD = −0.57, 95% CrI = −0.95 to −0.21), oral rivastigmine (MD = −0.38, 95% CrI = −0.56 to −0.17), and galantamine (MD = −3.79, 95% CrI = −6.98 to −0.59) improved global status more than placebo. NMA found that galantamine decreased the odds of mortality (odds ratio = 0.56, 95% CrI = 0.36–0.87). No agent increased risk of serious adverse events, falls, or bradycardia. Some increased risk of headache (oral rivastigmine), diarrhea (oral rivastigmine, donepezil), nausea (oral rivastigmine, donepezil, galantamine), and vomiting (oral rivastigmine, donepezil, galantamine). Conclusion: An exhaustive review of the literature involving 142 studies demonstrated that cognitive enhancers in general have minimal effects on cognition according to minimal clinically important difference and global ratings. The drugs appear safe, but this must be interpreted cautiously because trial participants may have less comorbidity and fewer adverse effects than those treated with these drugs in clinical practice. [ABSTRACT FROM AUTHOR]

Background/Objectives Off-label use of antipsychotics is common in hospitals, most often for delirium management. Antipsychotics have been associated with aspiration pneumonia in community and nursing home settings, but the association in hospitalized individuals is unexplored. We aimed to investigate the association between antipsychotic exposure and aspiration pneumonia during hospitalization. Design Retrospective cohort study. Setting Large academic medical center. Participants All adult hospitalizations between January 2007 and July 2013. We excluded outside hospital transfers, hospitalizations shorter than 48 hours, and psychiatric hospitalizations. Measurements Antipsychotic use defined as any pharmacy charge for an antipsychotic medication. Aspiration pneumonia was defined according to a discharge diagnosis code for aspiration pneumonia not present on admission and validated using chart review. A generalized estimating equation was used to control for 43 potential confounders. Results Our cohort included 146,552 hospitalizations (median age 56; 39% male). Antipsychotics were used in 10,377 (7.1%) hospitalizations (80% atypical, 35% typical, 15% both). Aspiration pneumonia occurred in 557 (0.4%) hospitalizations. The incidence of aspiration pneumonia was 0.3% in unexposed individuals and 1.2% in those with antipsychotic exposure (odds ratio ( OR) = 3.9, 95% confidence interval ( CI) = 3.2-4.8). After adjustment, antipsychotic exposure was significantly associated with aspiration pneumonia (adjusted OR = ( aOR) = 1.5, 95% CI = 1.2-1.9). Similar results were demonstrated in a propensity-matched analysis and in an analysis restricted to those with delirium or dementia. The magnitude of the association was similar for typical ( aOR = 1.4, 95% CI = 0.94-2.2) and atypical ( aOR = 1.5, 95% CI = 1.1-2.0) antipsychotics. Conclusion Antipsychotics were associated with greater odds of aspiration pneumonia after extensive adjustment for participant characteristics. This risk should be considered when prescribing antipsychotics in the hospital. [ABSTRACT FROM AUTHOR]

Objectives To determine whether potentially inappropriate medications ( PIMs) or potentially inappropriate associations ( PIAs) prescribed knowingly are associated with patient monitoring. Design Prospective observational study. Setting Geriatric units (n = 56) in 28 hospitals. Participants Inpatients aged 75 and older (N = 1,327). Measurements Potentially inappropriate prescriptions ( PIP) were defined as a PIM or a PIA selected by an expert board from lists of explicit criteria (Beers, Priscus, Laroche, French Health Agency) using a Delphi process. They were considered to be prescribed knowingly if they were maintained after reassessment by the geriatrician and the clinical pharmacist. Primary outcome was the rate of PIPs maintained (prescribed knowingly) and for which a geriatrician declared that specific monitoring was performed. Secondary outcomes were the parameters monitored and the rate of participants receiving knowingly a PIP. Results One thousand sixty-three PIPs were detected in 607 participants (46%). After reassessment, 826 (78%) PIPs were maintained in 490 participants (37%), the main reasons being participant's regular treatment and lack of alternative. Psychotropic (36%), cardiovascular (including antithrombotics) (29%), and laxative or antiemetic drugs (16%) were the most-frequent classes prescribed knowingly. The geriatricians declared to perform clinical or biological monitoring for 69% (n = 570) of PIMs or PIAs prescribed knowingly. Three types of specific monitoring were identified: clinical, biological, and follow-up with a specialist. Conclusion Approximately three-quarters of PIMs or PIAs were prescribed knowingly, of which 69% were monitored, with wide variations in occurrence and in quality according to drug classes. This underlines the need for accurate guidelines on PIP monitoring. [ABSTRACT FROM AUTHOR]

Objectives Epidemiologic data suggest older adults receiving serotonergic antidepressants may have accelerated bone loss. We examined bone turnover marker changes and patient-level variables associated with these changes in older adults receiving protocolized antidepressant treatment. Design Open-label, protocolized treatment study. Setting Medical centers in Pittsburgh, St Louis, and Toronto. Participants Older adults with major depression (N = 168). Measurements Serum levels of the bone resorption marker C-terminal cross-linking telopeptide of type 1 collagen ( CTX) and the bone formation marker procollagen type 1 N propeptide (P1 NP) were assayed before and after 12 weeks of treatment with venlafaxine. Whether CTX and P1 NP changes were associated with depression remission and duration of depression and genetic polymorphisms in the serotonin transporter (5 HTTLPR) and 1B receptor ( HTR1B) were also examined. Results CTX increased and P1 NP decreased during venlafaxine treatment, a profile consistent with accelerated bone loss. Two individual-level clinical variables were correlated with bone turnover; participants whose depression did not go into remission had higher CTX levels, and those with chronic depression had lower P1 NP levels. HTR1B genotype predicted P1 NP change, whereas 5 HTTLPR genotype was unrelated to either biomarker. Conclusion Bone turnover markers change with antidepressant treatment in a pattern that suggests accelerated bone loss, although the clinical significance of these changes is unclear. These data are preliminary and argue for a larger, controlled study to confirm whether antidepressants are harmful to bone metabolism and whether certain individuals might be at increased risk. [ABSTRACT FROM AUTHOR]

Prescribing medications, recognizing and managing medication side effects and drug interactions, and avoiding polypharmacy are all essential skills in the care of older adults in primary care. Important side effects of medications commonly prescribed in older adults (statins, proton pump inhibitors, trimethoprim-sulfamethoxazole and fluoroquinolone antibiotics, zolpidem, nonsteroidal antiinflammatory drugs, selective serotonin reuptake inhibitors, dipeptidyl peptidase 4 inhibitors) were reviewed. Important drug interactions with four agents or classes (statins, warfarin, factor Xa inhibitors, and calcium channel blockers) are discussed. [ABSTRACT FROM AUTHOR]

See the Reply by Zheng et al. [ABSTRACT FROM AUTHOR]

This letter comments on the letter by Xin Tian [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which is concerned with research which investigated an intervention to prevent falls in elderly adults living in a residential home.

This letter comments on the letter by Gwen Thomas et al. in this issue. [ABSTRACT FROM AUTHOR]

Objectives Renal insufficiency is common among older patients and, accordingly, renally excreted drugs may require an adjustment in dosage for them. Rates of non-adherence to renal dosing guidelines range from 19% to 70% across all settings, with the highest rate occurring in outpatient care. However, there is a paucity of research in this field. The main objective of this systematic review is to assess how often drugs are inappropriately prescribed in non-hospitalized patients with renal insufficiency. Design A systematic literature search was performed. Data were identified from three electronic databases: PubMed, CINAHL, and Scopus. Studies were included if they reported quantitative data on inappropriate drug use with respect to renal function in non-hospitalized patients. Results Our search strategy resulted in 2,403 hits, of which 18 articles satisfied the criteria for inclusion. Mean estimated glomerular filtration rate ranged from 36.0 to 60.4 mL/min. Prevalence of renally inappropriate drug use ranged from 1% to 37% in outpatient settings other than nursing homes, and from 6% to 43% in nursing homes. Eight of the studies we included identified predictors for use of drugs inappropriate for kidney function. Most frequently determined risk factors were increasing age and a high number of prescribed drugs. Conclusion Lack of dose adjustment for renal impairment seems to be a common problem, even in outpatients. However, the differences in methodologies used in these studies hampered any direct comparison. Accepted and comparable standards regarding the drugs included in the studies as well as estimation of renal function would be beneficial. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the efficacy of treatment options to reduce osteoporotic fracture risk in men. Design Systematic review and meta-analysis. Setting Randomized clinical trials that evaluated the efficacy of a treatment for osteoporosis or low bone mineral density for adult men and reported fracture outcomes. Participants Men. Measurements PubMed, Embase, and the Cochrane Library databases were searched for relevant studies. Information was extracted from included studies on participant sociodemographic characteristics, number of male participants, treatment evaluated, comparator for evaluated treatment, study duration, and fracture outcomes. Risk of bias of individual studies was assessed using measures recommended by the Cochrane Collaboration. Results Twenty-four articles reporting results for 22 studies (including 4,868 male participants) met strict inclusion criteria. Fixed-effects meta-analyses using the Mantel-Haenszel method demonstrated significantly lower risk of vertebral fractures with alendronate (relative risk ( RR) = 0.328, 95% confidence interval ( CI) = 0.155-0.692) and risedronate ( RR = 0.428, 95% CI = 0.245-0.746) but not with calcitonin ( RR = 0.272, 95% CI = 0.046-1.608) or denosumab ( RR = 0.256, 95% CI = 0.029-2.238) than in controls. For bisphosphonates as a treatment category, meta-analyses demonstrated significantly lower risk of vertebral fractures ( RR = 0.368, 95% CI = 0.252-0.537) and nonvertebral fractures ( RR = 0.604, 95% CI = 0.404-0.904) than in controls. The meta-analysis finding that bisphosphonates significantly reduce nonvertebral fracture risk was not robust to sensitivity analysis. Conclusion Bisphosphonates reduce the risk of vertebral and possibly nonvertebral fractures for men with osteoporosis. Further studies are needed to evaluate the efficacy of bisphosphonates for reducing nonvertebral fracture risk and the efficacy of nonbisphosphonates for reducing vertebral and nonvertebral fracture risk in men with osteoporosis. [ABSTRACT FROM AUTHOR]

The control of bacterial dental plaque through daily oral hygiene is essential to prevent oral diseases such as caries or periodontal disease, especially in at-risk populations, including the elderly with mild cognitive impairment and dementia. The aim of this study was to determine the association between different levels of cognitive impairment and dementia in an elderly population and their capacity to maintain adequate oral hygiene. A case-control study (elderly with versus without mild cognitive impairment or dementia) was performed in Granada, Spain. Outcome variables were tooth/prosthesis-brushing frequency/day, bacterial plaque index, and gingival bleeding index. Statistical models were adjusted by age, sex, educational level, and tobacco and alcohol habits. The study included 240 cases and 324 controls. The final model, adjusted by age, sex, educational level, and tobacco and alcohol consumption, showed a significant association between degree of cognitive impairment and daily oral hygiene, accumulation of bacterial plaque, and gingival bleeding. In summary, deficient daily oral hygiene, evidenced by greater bacterial dental plaque accumulation and gingival inflammation, is independently associated with cognitive impairment, even at its earliest stage. [ABSTRACT FROM AUTHOR]

Objective To examine the use of antimuscarinics for treating urinary incontinence (UI) in older adults with varying levels of cognition. Design Cross-sectional. Setting National Alzheimer's Coordinating Center from 2005 through 2015. Participants Community-dwelling men and women aged 65 and older (N = 24,106). Measurements Clinicians and staff evaluated each participant's dementia status during annual in-person assessments. Participants or their informants reported all medications taken in the 2 weeks before each study visit. Results Overall, 5.2% (95% confidence interval (CI) = 4.9-5.5%) of the cohort took a bladder antimuscarinic. Participants with impaired cognition were more likely to be taking an antimuscarinic than those with normal cognition. Rates of bladder antimuscarinic use were 4.0% (95% CI = 3.6-4.4%) for participants with normal cognition, 5.6% (95% CI = 4.9-6.3%) for those with mild cognitive impairment, and 6.0% (95% CI = 5.5-6.4%) for those with dementia (p < .001). Of 624 participants with dementia who took antimuscarinics, 16% (95% CI = 13-19%) were simultaneously taking other medicines with anticholinergic properties. Conclusion Use of bladder antimuscarinics was more common in older adults with impaired cognition than in those with normal cognition. This use is despite guidelines advising clinicians to avoid prescribing antimuscarinics in individuals with dementia because of their vulnerability to anticholinergic-induced adverse cognitive and functional effects. A substantial proportion of cognitively impaired individuals who took antimuscarinics were simultaneously taking other anticholinergic medications. These findings suggest a need to improve the treatment of UI in individuals with impaired cognition. [ABSTRACT FROM AUTHOR]

Objectives To identify which individual- and context-related factors influence the translation into clinical practice of interventions based on physical exercise (PE) as an adjunct to antidepressants (AD) for the treatment of late-life major depression (LLMD). Design Secondary analysis of a randomized controlled trial. Setting Primary care with psychiatric consultation-liaison programs (PCLPs)-organizational protocols that regulate the clinical management of individuals with psychiatric disorders. Participants Individuals aged 65 and older with major depression according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (N = 121). Intervention Participants with LLMD were randomized to AD (sertraline) or AD plus PE (AD + PE). Measurements Participant characteristics that were associated with greater effectiveness of AD + PE (moderators) were identified, and effect sizes were calculated from success rate differences. Whether the characteristics of the study setting influenced participant flow and attendance at exercise sessions was then explored, and primary care physicians (PCPs) were surveyed regarding their opinions on PE as a treatment for LLMD. Results The following participant characteristics were associated with greater likelihood of achieving remission from depression with AD + PE than with AD alone: aged 75 and older (effect size 0.32), polypharmacy (0.35), greater aerobic capacity (0.48), displaying psychomotor slowing (0.49), and less-severe anxiety (0.30). The longer the PCLP had been established at a particular center, the more individuals were recruited at that center. After participating in the study, PCPs expressed positive views on AD + PE as a treatment for LLMD and were more likely to use this as a therapeutic strategy. Conclusions The combination of PE and sertraline could improve the management of LLMD, especially when customized for individuals with specific clinical features. Liaison programs might influence the implementation of similar interventions in primary care, and PCPs viewed them positively. [ABSTRACT FROM AUTHOR]