搜索结果：Journal of the American Geriatrics Society

Generative artificial intelligence (GenAI), particularly large language models (LLMs), is being integrated into healthcare documentation, decision support, patient education, administrative workflows, and emerging agentic systems capable of initiating clinical and operational actions. While GenAI may reduce clinician burden and support person-centered care, it also introduces risks such as misinformation, algorithmic bias, privacy harms, errors of omission, and automation over-reliance. These risks may be amplified for older adults because core geriatrics care tasks, such as goals-of-care discussions, capacity-sensitive consent, polypharmacy and deprescribing, and functional and cognitive assessment in the setting of multimorbidity, may be underrepresented in training data and are high-stakes in practice. The American Geriatrics Society (AGS) convened an interdisciplinary working and writing group, reviewed relevant literature and reports, incorporated input from multiple AGS committees, and completed review and approval through AGS committee processes in March 2026. This AGS position statement translates core geriatrics principles, person-centered care, equity, shared decision-making, and promoting independence into actionable recommendations for clinicians, health systems, developers, policymakers, older adults, and care partners. Recommendations address ethical use, clinical integration and oversight, transparency and documentation, privacy protections, governance across the AI lifecycle, including pre, during, and post-deployment monitoring and accountability, and priority geriatrics use cases. GenAI should augment, not replace, clinical judgment and relational care. Responsible use in geriatrics requires transparency, clinician-in-the-loop oversight, validation in older adult populations using age-relevant outcomes, and governance safeguards to protect dignity, safety, and equity.

EQUIPPED (Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department) is a program developed within the Veterans Affairs (VA) health system that aims to reduce the prescription of potentially inappropriate medications (PIMs) for people aged 65 and over. A recent trial evaluated implementation of EQUIPPED via (1) academic detailing, which involves one-on-one provider guidance and coaching, or (2) dashboards that monitor providers' PIM prescribing rates. Evidence suggests better implementation among academic detailing sites, but qualitative evidence is lacking. Our objective is to identify individual and organizational factors that affect EQUIPPED implementation and to compare these factors across the program's two audit and feedback arms. Four academic detailing sites and three dashboard sites (comprising a total of 28 interviewees) were included in this qualitative analysis between May 2019 and June 2022; each site submitted regular site adaptation reports and participated in a series of interviews (1) at baseline, (2) after 6-8 months of implementation, and (3) a year after the first interview. Thematic analysis was done using constructs from the Organizational Theory of Implementation Effectiveness; reports from participating sites were also compared and analyzed using a categorization matrix. Respondents from both arms underlined the importance of change valence, innovation-values fit, and situational factors, such as ongoing accreditation, in fostering a favorable implementation climate for EQUIPPED. A unique challenge for academic detailing sites was the lack of resources and time to implement the mentoring intervention; dashboard sites encountered difficulties in sustaining momentum and motivation among providers. Common challenges included the prompt development and approval of medication order sets. Results suggest the importance of implementation climate, alignment with shared individual and organizational values, and seamless integration of EQUIPPED implementation within existing workflows. ClinicalTrials.gov identifier: NCT04004936.

Family caregivers experience conflicts in caring for people with Alzheimer's dementia (PWD; e.g., siblings disagreeing, advocating with providers, PWD refusing assistance). Subsequently, family caregivers experience frustration, burden, and stress. Furthermore, these caregivers rarely receive formal conflict resolution training to ameliorate these concerns. We developed NegotiAge-an artificial intelligence (AI)-based negotiation training intervention that teaches caregivers how to resolve conflicts and provides the opportunity to practice negotiating with online avatars in real-world conflicts. We sought to optimize the potency and test the early effect of NegotiAge on family caregivers following the multiphase optimization strategy (MOST). National randomized factorial trial of NegotiAge with family caregivers of PWD (>&#x2009;65&#x2009;years). Caregivers were randomized to one of eight conditions and variables/outcomes assessed at baseline and 1&#x2009;month following NegotiAge. The mixed methods project used dependent sample t-tests (quantitative) and constant comparative analysis (qualitative). Across 23 states, 125 family caregivers (mean-age 54&#x2009;years, 77% female) completed the study. Participants experienced significantly less caregiver burden (-3.24, p&#x2009;<&#x2009;0.002) and negative affect (-2.1, p&#x2009;<&#x2009;0.0001) between baseline and 1&#x2009;month following. Those receiving two or more exercises experienced further significant burden reduction (-5.28, p&#x2009;<&#x2009;0.04). Qualitative analyses supported these findings: "There was a time when my mother was crying. Because of the training I was able to calm her."; "When we have a conflict, I focus on the interest of both of us-helped tremendously." In the month following, 54% (n&#x2009;=&#x2009;67) of participants experienced conflicts and 74% (n&#x2009;=&#x2009;93) applied skills learned. Among utilizers, there was a significant decrease in forcing behaviors (-1.24, p&#x2009;<&#x2009;0.0001). NegotiAge, an AI-based negotiation training intervention, significantly reduced burden and improved negative affect among family caregivers. Engaging in more negotiation exercises further reduced burden. NegotiAge has the potential to improve the lives of caregivers and PWD. Further testing is needed to determine the direct impact on older adults and long-term effects. ClinicalTrials.gov identifier: NCT04837937.

Improper footwear has been identified as a modifiable risk factor for falls in older adults. Studies suggest that certain footwear characteristics can impair gait and balance, thereby increasing the risk of falls. However, the impact of footwear on gait and balance control may vary across research protocols. A systematic review focusing on these relationships is currently unavailable to date. This study aims to investigate the impact of footwear on gait and balance control in older adults, as well as the research protocols employed and the study outcomes. A systematic review was conducted using PubMed, IEEE Xplore, Scopus, Web of Science, and Clinical Trials to identify relevant studies published between 2017 and 2024. Keywords were systematically searched, and data were manually extracted. Thirteen studies were included. The review synthesized findings on the influence of various footwear designs on gait and balance control in older adults. Footwear featuring a minimal outsole, a textured insole design, and a high collar design was generally associated with improved balance outcomes. The evidence for toe-beveled footwear designs was mixed. Studies incorporated both walking and balance assessments, with some including perception-based questionnaires. A combination of walking, balance, and perceptual assessments provides a more comprehensive understanding of how footwear affects balance in older adults. Among the included studies, featuring a minimal outsole, a textured insole design, and a high collar design showed consistency to benefit older adults that provides textured feedback while offering foot protection, which may enhance balance control. However, some studies also implied that certain designs may have potential negative effects, including toe-beveled, minimal outsole, less-fixation, and barefoot condition. The lack of comprehensive descriptions of experimental footwear affects scientific transparency and reproducibility.

Direct oral anticoagulants (DOACs) are prescribed using fixed dosing regimens, despite limited evidence on their pharmacokinetic behavior in nursing home residents. One hundred nursing home residents are receiving apixaban, rivaroxaban, dabigatran, or edoxaban in multiple long-term care facilities in the Netherlands. In this prospective observational study, DOAC peak levels were measured 2-4&#x2009;h post-dose during routine laboratory testing. Levels were classified as below, within, or above the expected on-therapy range. Logistic regression analyses identified factors associated with peak levels outside the expected on-therapy range. Overall, 40% of residents had DOAC peak levels outside the expected on-therapy range; 32% were above and 8% were below. In univariable analyses, above-range levels were associated with lower renal function, apixaban use, and history of myocardial infarction, but none remained independently associated after multivariable adjustment. Below-range levels were associated with preserved renal function and rivaroxaban use; analyses for below-range levels were limited to univariable analyses due to the small number of events. A substantial proportion of nursing home residents exhibited DOAC peak levels outside the expected on-therapy range despite guideline-concordant dosing. These findings highlight the complexity of anticoagulant management in frail older adults residing in long-term care and support the need for careful clinical reassessment of DOAC therapy in this population.

Hip fractures often lead to postoperative delirium in older adults, significantly impacting recovery, hospitalization, and nursing workload. While many delirium cases are preventable, implementation of non-pharmacological strategies remains inconsistent. Music has emerged as a safe, effective, and low-cost complementary strategy to prevent delirium by targeting its underlying mechanisms. However, evidence in hip fracture patients remains limited. This study evaluated whether a nurse-led recorded music intervention could reduce the prevalence and influence the course of postoperative delirium, while ensuring practical feasibility. Secondary outcomes included postoperative pain, opioid use, and length of stay (LOS). In this quasi-experimental study, usual care was compared with the addition of a music intervention comprising twice-daily, 30-min sessions of self-selected music over 5 postoperative days. Cognitively adequate patients aged 65 or older were assessed for postoperative delirium using the Delirium Observation Scale (DOS). Differences in postoperative pain, measured by the Numerical Rating Scale, were analyzed both between groups and within the intervention group. A total of 74 participants were included across control and intervention groups. Statistical power was achieved, and confounders were balanced between groups. Music adherence was 53.13%, with missed sessions approximately equally due to patient refusal and nurse non-administration. DOS scores decreased significantly, especially on postoperative Day 2. Although delirium prevalence was halved in the intervention group, this did not reach statistical significance. No significant differences were found in LOS, opioid use, or postoperative pain between groups, however, a significant decrease in pain was observed within the intervention group. Music influenced the course of postoperative delirium by reducing its intensity and lowered postoperative pain within the intervention group. Future research should build on these findings by implementing a 30-min, once-daily music intervention during the first 3 postoperative days.

Whether to continue breast cancer screening beyond age 74 is uncertain. Decision aids may improve understanding of health information and support informed screening decisions. The goal of this study was to develop a video-based decision aid for breast cancer screening among older women using patient-centered design. Following the Framework for Innovation, the research team first used formative focus groups to understand older women's perspectives on mammography. We developed a prototype video based on decision aid best practices and formative focus group findings. We then evaluated the content, clarity, and style of the decision aid in cognitive testing focus groups. We made iterative changes to the video in response to focus group feedback. Focus groups included women age&#x2009;&#x2265;&#x2009;70 without a personal history of breast cancer from Connecticut-area community and clinical settings. We coded and analyzed transcripts using both abductive and deductive approaches. We convened 6 formative focus groups and 7 cognitive testing groups with 31 participants (mean age 78 [range 70-93]); 39% Black, 58% White, and 3% Latina. In focus groups, participants perceived screening as largely beneficial and saw overdiagnosis as unfamiliar. Some participants valued quantitative information about risks and benefits of screening, while others relied on experience, perceptions of risk, and beliefs about the efficacy of mammography to make screening decisions. We incorporated these perspectives into the framing, language, and narrative arc of the decision aid. In cognitive testing focus groups, participants found the decision aid informative and engaging. Using a patient-centered approach, we developed a video-based decision aid for breast cancer screening for older women. Our design, which drew on the perspectives of older women, was perceived as easy to understand and informative. We will assess the impact of the decision aid on decision quality, decisional conflict, and intention to screen in future work.

Caregiver burden at the onset of acute Hospital-at-Home (HaH) episodes, particularly in programs where caregiver availability is required for admission, remains insufficiently characterized in real-world settings. Caregivers of patients admitted to an acute HaH program within Clalit Health Services, Northern District, Israel, between 2023 and 2024. We conducted a cross-sectional observational study of 125 caregivers assessed within the first 48&#x2009;h of the HaH episode. Caregiver burden was measured using the Caregiver Strain Index (CSI; range 0-13), with high burden defined as CSI &#x2265;&#x2009;7. Structured telephone interviews collected caregiver demographics, caregiving context, health-related quality of life (EQ-5D-5L; UK value set), resilience (CD-RISC-2), and perceived social support. Associations with high burden were examined using bivariate analyses and hierarchical logistic regression. High caregiver burden was present in 77 caregivers (61.6%) within the first 48&#x2009;h of the HaH episode. Prior caregiving experience was more prevalent among caregivers with high burden than among those with low burden (97.4% vs. 50.0%, p&#x2009;<&#x2009;0.001). High burden was also associated with anxiety/depression on the EQ-5D-5L (63.6% vs. 29.2%, p&#x2009;<&#x2009;0.001), lower resilience (52.0% vs. 79.2%, p&#x2009;=&#x2009;0.002), and lower perceived social support (59.7% vs. 83.3%, p&#x2009;=&#x2009;0.006). In multivariable analysis, perceived social support (OR 0.22, 95% CI 0.06-0.74) and high resilience (OR 0.33, 95% CI 0.11-0.95) were associated with lower odds of high burden, whereas paid caregiver assistance was associated with higher odds of high burden (OR 5.23, 95% CI 1.17-23.37). High caregiver burden is common at the onset of acute HaH care. These exploratory findings suggest that caregiver vulnerability at admission is related to pre-existing caregiving context and psychosocial resources, supporting systematic caregiver assessment early in the HaH episode to identify individuals who may benefit from targeted support.

Residents with obesity in US nursing homes (NHs) present challenges for facilities, as these individuals often require specialized assistance and resources. However, recent trends, geographic variation, and NH characteristics related to the prevalence of obesity in NHs are understudied. We examined national trends in prevalence of Class 2-3 (moderate-to-severe) obesity in NHs over a 13-year period, geographic variation in trends, and facility characteristics associated with high prevalence. Prevalence of moderate-to-severe obesity in NHs was defined as the proportion of residents with body mass index (BMI) &#x2265;&#x2009;35&#x2009;kg/m2. Annual average prevalences were calculated across NHs between 2011 and 2023 and changes in state-level prevalence were analyzed over the study period. Lastly, resident and facility characteristics associated with NHs in the top quartile of prevalence in 2023 were examined. The sample included 16,886 NHs in 49 states. Mean prevalence increased from 26.5% in 2011 to 30.5% in 2023, a 15% relative increase, with substantial state variation. All states experienced increases in prevalence with Idaho exhibiting the largest increase of 34% (9.9 percentage points (pp); from 29.1% to 39.0%) and New York experiencing the smallest of 5.8% (1.4&#x2009;pp; from 24.0% to 25.4%). Compared to NHs in the lowest quartile of prevalence, those in the highest quartile had younger residents on average (75.2 vs. 78.3; p&#x2009;<&#x2009;0.001), lower proportions of non-White residents (18.1% vs. 30.6%; p&#x2009;<&#x2009;0.001), and higher shares covered by Medicaid (65.7% vs. 61.2%; p&#x2009;<&#x2009;0.001). NHs in the highest quartile also had lower occupancy rates (73.1% vs. 79.4%; p&#x2009;<&#x2009;0.001), and were more likely to be part of a multi-facility chain (64.6% vs. 52.8%; p&#x2009;<&#x2009;0.001) and in a rural area (39.2% vs. 13.8%: p&#x2009;<&#x2009;0.001). Our findings indicate continued increases in the prevalence of moderate-to-severe obesity in NHs with large variation across states and potential disparities associated with income and rurality.

Preoperative evaluation is essential for optimizing perioperative care. This study assessed the clinical utility of the Timed Get Up and Go Test (TUG) and the current practice of subjective functional capacity assessment in predicting loss of independence (LOI) in older adults undergoing noncardiac surgery. Elective surgical cases with TUG evaluated at the Johns Hopkins Center for Preoperative Optimization clinic (06/2018-01/2020) were retrospectively identified. Anesthesiologists evaluated subjective functional capacity using metabolic equivalents of tasks (METs&#x2009;<&#x2009;1, METs 1-4, METs&#x2009;>&#x2009;4). LOI was classified as discharge to a higher level of care, outside of the home, with new mobility deficit or functional dependence. We used adjusted logistic regression to characterize the relationship between METs and LOI. Kappa statistics were calculated to assess the agreement between METs and TUG. Cross validation was performed to assess how the sequential inclusion of METs then TUG affected prediction of LOI from a base model. Among 3302 eligible patients, 225 (6.8%) experienced LOI. In adjusted logistic regression with METs&#x2009;>&#x2009;4 as the reference category, METs 1-4 was associated with an approximately 3&#xd7; increase in odds of LOI (aOR&#x2009;=&#x2009;2.9; 95% CI&#x2009;=&#x2009;1.1-7.3; p&#x2009;=&#x2009;0.02) while <&#x2009;1 METs was associated with a 14X increase in odds of LOI (aOR&#x2009;=&#x2009;14; 95% CI&#x2009;=&#x2009;5.2-35; p&#x2009;<&#x2009;0.0001). METs minimally agreed with TUG. METs improved LOI prediction from a base model (AUC 0.74 to AUC 0.77). Adding TUG (Base model + METs+TUG) further improved LOI prediction (AUC 0.83) reclassifying patients in all METs levels (NRI&#x2009;=&#x2009;0.704; 95% CI&#x2009;=&#x2009;0.574-0.834; p&#x2009;<&#x2009;0.0001), particularly METs 1-4, an otherwise indeterminate-risk group that frequently undergoes additional preoperative testing. METs-based subjective functional capacity marginally improves LOI prediction and only showed partial agreement with TUG-based objective functional capacity assessment. TUG improved LOI prediction over current clinical care models that utilize METs for functional capacity assessment alone. TUG may offer additional utility to current clinical care models that evaluate functional capacity by METs alone.

High quality dementia care is expected to address cognitive, functional, behavioral, social, and caregiving needs of patients and families, but such comprehensive care is challenging to provide. Medicare introduced the cognitive assessment and care plan (CACP) billing code in 2017 to reimburse comprehensive assessment and care planning for patients with dementia. We aimed to describe trends in the service and characterize potential drivers of low uptake. This study sampled repeated cross-sections of Medicare beneficiaries, providers, and services from 100% samples of Medicare fee-for-service claims and Medicare Advantage (MA) Encounters from 2017 to 2022. We examined rates of CACP receipt among Medicare beneficiaries aged &#x2265;&#x2009;65 with dementia in fee-for-service Medicare and MA (n&#x2009;=&#x2009;5,175,137 in 2022) and assessed CACP receipt across sociodemographic subgroups. We measured CACP claim-denial rates in fee-for-service Medicare and the types of MA plans associated with CACP receipt. We also examined the specialty of healthcare providers who billed for CACP during the study period (n&#x2009;=&#x2009;6635 providers and n&#x2009;=&#x2009;172,982 visits in 2022). Through 2022, 5% of fee-for-service beneficiaries with dementia received CACP compared to 3% of MA beneficiaries (p&#x2009;<&#x2009;0.001). We observed a high denial rate for CACP fee-for-service claims (7%). MA enrollees who received CACP were more likely to be enrolled in preferred provider organization plans (46% vs. 37%, p&#x2009;<&#x2009;0.001). In 2022, primary care physicians accounted for the plurality of CACP-adopting providers (49% of providers, 40% of visits). Neurologists accounted for a disproportionately high share of CACP visits in the same year (11% of total providers, 20% of total visits). CACP delivery remained low despite annual growth in CACP adoption during our study period. Payment incentives in MA, drivers of payment denial in fee-for-service, and dissemination and implementation strategies warrant further exploration.

More than one in four older adults experience a fall each year. While exercise programs are effective in reducing fall-related injuries (FRI), participation remains low due to access barriers. The primary aim of this study was to evaluate whether older adults who registered for Nymbl, a self-guided, asynchronous, balance application, were associated with fewer FRIs as compared to age-similar individuals non-registrants. This retrospective cohort study used data from Kaiser Permanente Colorado, linked to Nymbl registration and usage records based on patient name and demographic information between February 2018 and September 2024. The cohort included individuals aged 60 and older with continuous health plan enrollment for 12&#x2009;months before and after Nymbl registration (or a randomly assigned index date). Logistic regression models with inverse probability of treatment weighting estimated the association between Nymbl registration and FRIs during the 12-month follow-up, stratified by history of FRIs. Marginal effects reported the absolute risk difference associated with Nymbl registration. Secondary analyses examined dose-response associations of Nymbl usage and whether the association of Nymbl was additive to participation in other exercise programs. We identified 3735 individuals who registered for Nymbl and 114,219 age-eligible non-registrants. Among individuals with a prior FRI, Nymbl registration was associated with a 3.83 percentage point reduction in acute FRIs; however, no significant association was estimated for individuals without a baseline FRI. Secondary analysis indicated that at least five sessions were required to achieve a meaningful reduction in FRIs, and associations were limited to those not already participating in other exercise programs. Findings from this study suggest that asynchronous, self-guided balance applications may reduce FRIs among older adults with a history of falls who are not otherwise engaged in structured exercise programs. Remotely delivered fall prevention programs may help overcome access barriers and can be used to supplement in-person and guided exercise programs.

Early recognition of cognitive impairment (CI) and timely diagnoses of mild CI (MCI) and Alzheimer's Disease and Related Dementias (ADRD) are key to optimal dementia care. No previous research has examined the extent to which healthcare interventions/services (specific blood tests, specialist referrals, and brain imaging) conducted after annual wellness visits (AWVs) contribute to subsequent MCI/ADRD diagnosis. We assessed the role of post-AWV healthcare services on the association of incident AWVs with the first ADRD or MCI diagnosis in Medicare enrollees. Propensity score matching of AWVs generated an active comparator cohort of Texas fee-for-service Medicare enrollees who received a Primary Care Provider visit, but without AWVs in 2018 (n&#x2009;=&#x2009;66,443 in each group). Healthcare services (laboratory testing for CI: vitamin B12, thyroid stimulating hormone; specialist referrals: neurology, psychiatry; and brain images: CT, MRI) occurring after AWV and before the first MCI/ADRD diagnosis were examined. Both groups had similar proportions of patients receiving specific blood tests, specialist referrals, and brain images in the 12&#x2009;months before AWV/index date. Among those with no previous specialist visits, 39.2% in the AWV group and 31.1% in the non-AWV group received laboratory testing in the follow-up period. Similarly, among those with no previous brain images, 12.4% in the AWV group and 13.1% in the non-AWV group received brain images in the follow-up period. AWV receipt was associated with a 28% increase in MCI diagnosis; mediation analyses indicated that 14% of this increase was explained through post-AWV laboratory testing. AWV receipt was not associated with an increase in ADRD diagnosis. Medicare AWV had a large direct effect on MCI diagnosis, but not on dementia diagnosis, suggesting that cognitive assessment and clinical evaluations during AWV directly contributed to the early recognition of MCI.

Long-term services and supports (LTSS) serve&#x2009;>&#x2009;9&#x2009;million adults in the United States. We examined prevalence and quality of life (QoL)-related outcomes of consumer-reported unmet LTSS needs in publicly-funded LTSS. We pooled cross-sectional data from the 2016-2017, 2017-2018, 2018-2019, 2021-2022, and 2022-2023 National Core Indicators-Aging and Disability Adult Consumer Surveys. We included 61,829 adults (34% with age&#x2009;<&#x2009;65&#x2009;years; 66% female; 27 states). Survey weights generated population-representative estimates. We ascertained unmet LTSS needs by response to: "Do the long-term care services you receive meet your current needs and goals?" (dichotomized- yes vs. no). We estimated weighted prevalence of unmet LTSS needs overall and across subpopulations, and examined associations with two self-reported QoL-related outcomes (dichotomized- yes/no): (1) being active in community; (2) satisfied with how one spends one's day. Prevalence ratios (PRs) were estimated using weighted Poisson regression with robust variance estimators, adjusting for demographics, health and functional status, multimorbidity, funding program, residence setting, state, and survey year. Among respondents, 18,004 (weighted-estimate, 29%) reported unmet LTSS needs. Prevalence of unmet needs varied across sociodemographic strata, care settings (higher in community-based than in residential-care settings), and funding programs (lower in PACE than in Medicaid programs). Individuals with unmet needs were significantly less likely to report being active in the community (PR, 0.65; 95% CI, 0.62-0.68) and satisfied with how they spend their day (PR, 0.62; 95% CI, 0.60-0.64). Post hoc analyses revealed potential dose-response associations between increasing degree of unmet LTSS needs and outcomes. Consumer-reported unmet LTSS needs are frequent, vary greatly across care settings and funding programs, and are associated with poorer QoL-related outcomes; highlighting substantial system-level gaps in the fragmented LTSS landscape and the need for coordinated investments and structural reforms to better meet the needs of individuals relying on these services.

Racial disparities in end-of-life (EOL) care persist, yet the role of caregiver availability in shaping these inequities remains poorly understood. We examined whether caregiver availability modifies racial differences in perceived EOL care quality and tested the hypothesis that Black older adults without caregivers face compounded disadvantages in EOL care. We analyzed data from 2228 non-Hispanic White and Black decedents (weighted N&#x2009;=&#x2009;10.1&#x2009;million) from the 2017-2024 National Health and Aging Trends Study. Proxy respondents completed Last Month of Life interviews. Outcomes included overall care quality ratings and receipt of help managing pain, breathing difficulties, and anxiety/sadness. Survey-weighted logistic regression models assessed associations between caregiver availability and outcomes, adjusting for demographic, clinical, and functional characteristics. Interaction terms examined joint effects of race and caregiver availability. Black decedents were less likely than White decedents to receive excellent/very good care (64.9% vs. 77.8%; p&#x2009;<&#x2009;0.001) and help with anxiety (28.2% vs. 38.7%; p&#x2009;<&#x2009;0.001). A significant race-caregiver interaction suggested intersectional disadvantage: compared with White decedents with caregivers, Black decedents without caregivers had the lowest odds of excellent/very good care (OR&#x2009;=&#x2009;0.36; 95% CI, 0.19-0.67). Black decedents with caregivers also had reduced odds (OR&#x2009;=&#x2009;0.52; 95% CI, 0.36-0.76) despite receiving more caregiving hours (7.0 vs. 3.4&#x2009;h/week; p&#x2009;=&#x2009;0.005). Black older adults without caregivers had the worst observed EOL care quality. Caregiver presence was associated with narrower but persistent racial differences, suggesting structural factors that may attenuate the benefits of caregiving for Black older adults. Policy interventions designed to provide culturally responsive support to minority caregivers may help reduce racial disparities in EOL care quality.

To evaluate the efficacy of adjunct probiotic supplementation ( Lactobacillus helveticus and Bifidobacterium longum ) alongside standard care compared to placebo in older adults with moderate unipolar depression. A randomized, double-blind, placebo-controlled pilot trial was conducted at two tertiary centers. Fifty-eight participants (&#x2265;&#x2009;60&#x2009;years) with moderate depression were randomized 1:1 to receive daily probiotics or a placebo for 12&#x2009;weeks, alongside standard antidepressant care. They were followed up for another 12&#x2009;weeks. The primary outcome was depression response (&#x2265;&#x2009;50% Montgomery-&#xc5;sberg Depression Rating Scale [MADRS] score reduction). Secondary outcomes included anxiety (General Anxiety Disorder 7-Item [GAD-7]), cognition, quality of life (WHOQOL-BREF), serum brain-derived neurotropic factor (BDNF), and gut microbiota profile. Mixed-effects models showed significant improvement over time in depressive symptoms (MADRS: F&#x2009;=&#x2009;32.0, p&#x2009;<&#x2009;0.001) and anxiety (GAD-7: F&#x2009;=&#x2009;13.1, p&#x2009;<&#x2009;0.001). Overall scores were lower in the probiotic group compared with the placebo group for both MADRS (F&#x2009;=&#x2009;12.7, p&#x2009;=&#x2009;0.001) and GAD-7 (F&#x2009;=&#x2009;10.7, p&#x2009;=&#x2009;0.002), although group &#xd7; time interactions were not significant. Quality-of-life domains improved markedly (all F&#x2009;>&#x2009;100, p&#x2009;<&#x2009;0.001) without additional benefit from probiotics. Escitalopram-equivalent antidepressant dose and benzodiazepine use influenced selected outcomes. The probiotic group also had a significantly higher serum BDNF level and increased fecal abundance of supplemented strains vs. the placebo group. The attrition rate was >&#x2009;50% over 24&#x2009;weeks. In this pilot PRODG trial, adjunct probiotics produced modest overall advantages for depressive and anxiety symptoms compared with placebo but did not enhance quality-of-life beyond usual improvement -&#xa0;both groups improved substantially, and trajectories over 24&#x2009;weeks were largely parallel across follow-up.

As the number of Americans living with dementia increases, healthcare delivery systems face increasing pressure to provide dementia-care services to improve patient and family outcomes. The primary care nurse practitioner (NP) workforce is critical to dementia care; however, many NPs practice in environments that lack organizational attributes needed to maximize their contributions. We examined the associations between the NP practice environment and key indicators of workforce sustainability-burnout, job satisfaction, and intent to leave. We conducted a national cross-sectional survey of NPs providing care to patients with dementia in 2021-2023. A total of 968 NPs across 847 practices completed the survey. On average, NPs were 47.5&#x2009;years old, female (84.2%), and White (83.6%). The NP practice environment was measured using four subscales of the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ). Multivariable regression models assessed the relationship between practice environment and NP workforce outcomes. Overall, 92.0% of NPs were satisfied with their jobs, 35.8% experienced burnout, and 21.3% reported intent to leave their job in the coming year. Higher NP-PCOCQ subscale scores were associated with better NP outcomes. For example, one standard deviation (SD) increase in Professional Visibility score was associated with 28% lower prevalence of burnout (Prevalence Ratio [PR]&#x2009;=&#x2009;0.72, p&#x2009;<&#x2009;0.001); one SD increase in the NP-Administration Relations and NP-Physician Relations scores was associated with 9% and 7% higher prevalence of job satisfaction (PR&#x2009;=&#x2009;1.09, p&#x2009;<&#x2009;0.001; PR&#x2009;=&#x2009;1.07, p&#x2009;<&#x2009;0.001), and one SD increase in the Independent Practice and Support score was associated with 29% lower prevalence of intent to leave (PR&#x2009;=&#x2009;0.71; p&#x2009;<&#x2009;0.001). Enhancements to the practice environment that promote NP role visibility, independent practice, and collegial relationships could increase job satisfaction, reduce burnout, and expand primary care capacity to care for patients with dementia.

Homebound older adults represent a high-risk, high-needs population characterized by significant clinical and sociodemographic heterogeneity. Little is known about how such heterogeneity shapes care needs and utilization patterns. We characterized utilization patterns among distinct subgroups of homebound older adults and examined associations between levels of outpatient care and emergency department (ED) utilization. We used nationally representative data from the National Health and Aging Trends Study (NHATS) linked to Medicare Fee-For-Service (FFS) claims from 2011 to 2019 and 2021-2023 to examine trends among homebound older adults ages 70 or older. In this retrospective observational study, we characterized utilization patterns among distinct subgroups of homebound older adults identified using latent class analysis (LCA). We then used multivariable regression to examine associations between level of outpatient utilization and probability of both any ED visit and any potentially avoidable ED visit identified using Ambulatory Care Sensitive Conditions (ACSC). We adjusted for other indicators of ED use and access to care (i.e., self-reported health, rurality, and disease burden). There was a total of 2202 person-year observations across 1343 unique homebound individuals. The LCA identified four subgroups of homebound older adults: functional independence; dementia; multimorbidity; and dementia plus multimorbidity. There were significant differences in levels of ambulatory and acute care utilization between subgroups. Regression analyses did not show evidence to support the conventional wisdom that inability to access ambulatory care leads to more avoidable ED visits among the homebound older adult population. Heterogeneity among the homebound older adult population shapes care needs that in turn influence utilization patterns. Understanding these dynamics is crucial to targeting interventions like home-based primary care to the highest risk groups while tailoring care to individual needs.

Family caregivers provide essential support to older adults, yet those caring for individuals who face language discordance may experience added challenges affecting their psychological well-being. To synthesize the existing literature on the psychological impact of caregiving in contexts of language discordance, focusing on stress, anxiety, depression, burnout, and coping strategies. A scoping review was conducted across six electronic databases from 2000 to 2025 to identify studies examining caregivers of culturally and linguistically diverse individuals in healthcare and community settings. Quantitative and qualitative study characteristics were summarized via frequencies, and qualitative studies were additionally analyzed using content analysis. Preliminary results were reviewed with patient and family partners to inform discussion, interpretation, and implications for optimizing caregiver supports. A total of 7590 citations were retrieved, with 53 full text reviews. Ten studies were included, primarily composed of qualitative studies. Key themes include the emotional and cognitive burden of acting as interpreters, advocates, and system navigators; filial obligations, gendered expectations, and stigma on caregiving experiences; and the protective role of language-concordant or ethno-specific services. Language-discordant caregiving was closely tied to cultural norms. Fragmented and unilingual healthcare systems, unmet service needs, and system-level barriers increased caregiver distress, whereas culturally tailored supports and coping strategies provided mitigation. Caregivers supporting individuals who face language barriers experience significant psychological strain. Routine screening for caregiver burden, integration of professional interpreters, and expanded access to multilingual and culturally appropriate supports are recommended. Future research should employ quantitative and mixed-method designs to quantify psychological impact, investigate the intersection of language, gender, and other aspects of identity, and evaluate interventions that reduce caregiver burden. Addressing both linguistic and cultural dimensions is essential for improving caregiver well-being and promoting equitable healthcare delivery.