Journal of the American Medical Directors Association

BackgroundFalls among older adults are a leading cause of fractures, loss of independence, and need for long-term care. Community salons in Japan promote social participation and health activities among older adults. Hydrogen-rich water is widely used as a health product, but evidence in community settings remains limited. MethodsWe conducted a prospective observational study among 48 community-dwelling older adults attending community salons in Hiroshima City, Japan. Hydrogen-rich water was offered by the salon operators as part of routine activities; the research team did not assign participants to consume it. Participants were categorized at baseline according to their usual hydrogen-rich water consumption at the salons (consumers vs non-consumers) and followed for six months. The primary outcome was the 30-second chair stand test (CS-30). Secondary outcomes included the Timed Up and Go test (TUG), usual gait speed, one-leg stance time, and grip strength. Within-group changes and between-group differences in change scores were compared. ResultsAll 48 participants completed follow-up, and no serious adverse events were reported during the study period. The consumers group showed a greater improvement in CS-30 over six months (baseline 12.96 (SD 3.21) to follow-up 14.52 (SD 3.59); change 1.57 (SD 2.41)) compared with the non-consumers group (12.52 (SD 3.00) to 12.22 (SD 3.54); change -0.30 (SD 1.55)), with a significant between-group difference in change scores (p=0.003). The consumers group also showed a greater increase in usual gait speed (0.91 (SD 0.24) to 0.98 (SD 0.26); change 0.07 (SD 0.08)) than the non-consumers group (0.94 (SD 0.24) to 0.97 (SD 0.22); change 0.03 (SD 0.05); p=0.008). No significant between-group differences were observed for TUG (p=0.57), one-leg stance time (p=0.13), or grip strength (p=0.10). ConclusionIn community-dwelling older adults participating in community salons, routine hydrogen-rich water consumption was associated with improved lower extremity function as measured by CS-30 and gait speed. Because exposure was not randomized, residual confounding cannot be excluded, and causal inference is limited. Larger studies with stronger designs are warranted.

Background Older adults' walking has so far been evaluated using standardised assessments of walking capacity within a clinical setting. By taking the evaluation out of the laboratory into the real world, this study provides first evidence of the ability of Digital Mobility Outcomes (DMOs) to detect changes over time and the Minimal Important Difference (MID) in patients after proximal femoral fracture (PFF). This will guide the implementation of DMOs in research and clinical care. Methods For this multicenter prospective cohort study, 381 community-dwelling older adults were included within one year after sustaining a PFF and assessed at two time points, separated by six months. Walking activity and gait DMOs were measured using a single wearable device worn on the lower back for up to seven days. A global impression of change question and three mobility-related outcome measures (Late-Life Function and Disability Instrument; Short Physical Performance Battery; 4m gait speed) were used as anchor variables. To assess each DMOs ability to detect changes, we calculated the standardized mean change as effect size. For estimating MIDs, both distribution-based and anchor-based methods were applied, followed by triangulation by experts if at least three anchor-based estimates were available per DMO, resulting in single-point estimates. Results All three anchor variables demonstrated substantial changes. Overall, 10 out of 24 available DMOs showed large and 7 DMOs moderate positive effects in the expected direction of the respective anchors. Seven DMOs showed no or only small effects. For 12 DMOs, at least three anchor-based estimates were available, enabling MID triangulation. MIDs for walking activity DMOs per day were: a walking duration of 10 minutes, a step count of 1,000 steps, 50 walking bouts (WB), and 15 WBs in WBs over 10 seconds. For gait DMOs, depending on the walking bout length, MIDs for walking speed were between 0.04 m/s and 0.08 m/s, and MIDs for cadence between 4 and 6 steps/minute. Almost all DMOs showed a strong ability to detect improvement in mobility, but rarely in detecting decline. Conclusions For the first time, MIDs are presented for real-world DMOs in PFF patients. These MIDs inform sample size requirements and interpretation of intervention effects for clinical trials, thereby providing guidance and reassurance for clinicians and regulatory bodies.

ObjectivesTo characterize contemporary pharmacologic treatment patterns for Alzheimers disease and related dementias (ADRD) among U.S. long-term care residents and to examine facility- and resident-level factors associated with treatment. DesignRetrospective, observational study. Setting and ParticipantsElectronic health record data from 1,675,873 long-term care residents in the PointClickCare Life Sciences database included 359,801 with a documented ADRD diagnosis in skilled nursing facilities in the U.S. (January-April 2025). MethodsResidents were classified as treated/untreated based on receipt of guideline-directed ADRD therapy, consistent with Alzheimers Association guidelines. Analyses incorporated demographics, comorbidities, medication burden, and facility characteristics. Multivariate logistic regression estimated odds of receiving guideline-concordant therapy. ResultsOverall, 72.5% of residents with ADRD received [≥]1 pharmacologic treatment recommended for ADRD. Treatment was most common among residents with Lewy body dementia (83.9%) and early-onset Alzheimers disease (82.3%) and least frequent among residents aged [≥]90 years (65.1%), Black/African American residents (66.8%), and those with cerebral degeneration (66.8%). Treated residents exhibited higher medication burden (mean 4.4 vs 3.3). Diagnoses for other chronic conditions as well as specific ADRD subtypes strongly impacted probability of treatment; diabetes and hyperlipidemia were associated with lower odds of treatment, whereas ADRD subtypes strongly predicted treatment. Conclusions and ImplicationsMore than one-quarter of residents with ADRD remain untreated with guideline-recommended pharmacotherapy, and treatment varied significantly by non-clinical predictors. These findings underscore the need to investigate and understand possible treatment disparities, optimize polypharmacy management, and discover new ADRD treatments, as current options are often ineffective with many side effects. Brief SummaryThis study used real-world data from electronic health records (EHR) to understand treatment patterns of those with Alzheimers disease and related dementias (ADRD) in U.S. long-term care facilities. International Classification of Diseases Tenth Revision, Clinical Modification (ICD-10) codes were used to identify ADRD diagnoses and medication orders were used to identify treatment. From January to April 2025, there were 359,801 with a documented ADRD diagnosis in skilled nursing facilities. Over 25% of those with ADRD did not have a medication order for a guideline-recommended pharmacological treatment. Comorbidities of diabetes and hyperlipidemia were associated with lower odds of receiving ADRD treatment, suggesting concerns related to adverse drug reactions and competing clinical priorities. The use of cognitive and disease-modifying therapies was low compared to behavioral/psychiatric medications; this finding suggests a need for more effective and safe drugs that target the root causes of ADRD opposed to the behavioral and psychiatric complications. Taken together, the results of this study call for targeted interventions to address disparities in treatment, enhanced clinical decision-making support regarding polypharmacy, and improved pharmacological options for those with ADRD.

BackgroundSarcopenia is associated with increased fall risk, but its graded relationship with severity and age-specific patterns warrants further investigation in middle-aged and older adults. ObjectiveTo investigate the association between sarcopenia severity and fall risk among adults aged [≥]45 years and provide evidence for early intervention. MethodsUtilizing data from the China Health and Retirement Longitudinal Study (CHARLS) database (baseline 2011 to follow-up 2020), 9,608 participants without sarcopenia at baseline were included. Binary logistic regression analyses (univariate, multivariate, and interaction analyses) were employed to assess the association between sarcopenia severity and fall risk. The nonlinear effect of age was examined using restricted cubic splines (RCS curves). ResultsThe overall fall incidence rate among participants with sarcopenia was 18.88% (1,814/9,608). Fall incidence exhibited a graded increase with sarcopenia severity: non-sarcopenia group: 16.89% (1,108/6,560), possible sarcopenia group: 21.54% (439/2,038), confirmed sarcopenia group: 26.11% (217/831), and severe sarcopenia group: 27.93% (50/179). Multivariate logistic regression revealed a graded increase in fall risk with sarcopenia severity: possible sarcopenia (OR=1.28,CI[1.13-1.45]), confirmed sarcopenia (OR=1.36,CI[1.14-1.63]), and severe sarcopenia (OR=1.44,CI[1.02-2.03]). RCS curves identified a biphasic risk pattern: a modest rise between ages 45-60 and a steep increase after age 70, with 70 years as the inflection point. The subgroup analysis revealed that fall risk was significantly elevated in individuals with sarcopenia who were male, or who had a history of smoking, alcohol consumption, stroke, arthritis, or pain. Key interactions included a 2.96-fold risk in those aged 45-60 with severe sarcopenia (OR=2.96,[1.24-7.06]) and a 4.46-fold risk in those with confirmed sarcopenia and stroke (OR=4.46,[1.45-13.68]). ConclusionSarcopenia is an independent risk factor for falls, with risk increasing in a severity-dependent graded manner. Early identification of high-risk individuals and implementation of graded interventions are crucial.

BackgroundDementia diagnoses are captured across multiple routine data sources, but discrepancies between these may affect care and research. This study determined the prevalence and overlap of recorded dementia across primary care, hospital, and community prescribing data sources in a UK regional cohort, and examined whether outcomes differed by the setting in which dementia was first recorded. MethodsRetrospective cohort study of adults [&ge;]65 years (n=133,407) in a large Scottish health board. Dementia diagnoses recorded from 01/04/2016 to 01/04/2020 were identified across linked primary care, hospital discharge, and prescribing records. Associations between source of first recorded dementia diagnosis and subsequent mortality and emergency hospitalisation were estimated using Cox proportional hazards and Fine-Gray competing risks models. ResultsAt baseline (01/04/2016), 7544/133407 individuals (5.7%) had recorded dementia: 95.1% in primary care, 73.3% in hospital, and 54.3% in prescribing records. Over four years, 7359 of the remaining 125,863 individuals (5.8%) had newly recorded dementia: 70.2% in primary care, 22.2% in hospital, and 7.6% in prescribing records. Only 35.9% of hospital-recorded diagnoses were coded in primary care records within a year. People first diagnosed in hospital were older, more frail, more socioeconomically deprived, and had higher mortality than those first diagnosed in primary care (<30days: adjusted Hazard Ratio (aHR) 8.96, 95%CI 6.94-13.52; >365days: aHR 1.29, 95%CI 1.19-1.41). ConclusionsDementia is variably recorded across routine datasets, and the setting in which dementia is first recorded identifies groups with markedly different prognosis. Improved data source integration and scrutiny of hospital-based diagnostic pathways are needed to ensure diagnoses are reliably transferred and people with dementia receive timely, equitable post-diagnostic care.

BackgroundAntidepressant use is common in people with dementia. Antidepressants may be started to manage symptoms of dementia, rather than depressive and anxiety disorders. We hypothesised people prescribed antidepressants around the time of dementia diagnosis may have different characteristics from those with longstanding prescriptions. MethodsWe used linked primary care (Lambeth DataNet) and specialist (Clinical Record Interactive Search) data for patients with dementia in south London, UK. Antidepressant prescription was ascertained, and a new start was within one year before or after dementia diagnosis. Coded fields, a rating scale for neuropsychiatric symptoms and natural language processing of full-text were used to describe depression and anxiety. ResultsOf 3,713 patients with dementia, 28% were prescribed antidepressants within the year of dementia diagnosis, and 42% of these were new start prescriptions. Compared to the no antidepressant group, the new start group were more likely to be female, have vascular dementia and neuropsychiatric symptoms. Compared to the long-standing group, new start had fewer comorbidities; people from non-White ethnicities were more likely to lack documentation of depression or anxiety. Deprescribing was equally unlikely in new and long-term prescriptions (6.3% vs 5.5% per year of follow-up). ConclusionsThe high incidence of new prescribing, as well as the lack of deprescribing, points to unmet needs and a role for more proactive medication review. Further studies should include the clinician and patient voices to further understand how to improve non-pharmacological support for people at the threshold of dementia.

This study challenges the assumption that undiagnosed cognitive impairment (CI) is driven primarily by patient-level barriers like poor awareness. In a population-weighted cohort of 1,856 older Singaporeans, CI prevalence was 24.7% (95%CI 18.8-31.8); yet the undiagnosed rate was high (81.4%, 95%CI 65.6-90.9), especially for mild CI (97.9%, 95%CI 94.1-99.3). This diagnostic gap persisted despite high symptom awareness (81.3%, 95%CI 63.6-91.5) and help-seeking intent (63.3%, 95%CI 47.5-76.7), with informants becoming key as CI worsened. Findings suggest successful public health campaigns have shifted the bottleneck from community awareness to healthcare system capacity, creating an opportunity for a policy shift to meet rising demand for diagnosis--by empowering primary care with efficient case-finding tools, formalizing integrated diagnostic pathways, and establishing channels for family informants involvement. From these findings, we conceptualized a paradox of success model, providing a framework for other health systems to adapt policy as public engagement grows.

IntroductionAlzheimers disease (AD) prevalence rises with societal ageing. In clinical care, behavioral and psychological symptoms of dementia (BPSD)--including depression, agitation/aggression, apathy, and sleep disturbance--worsen patients quality of life and substantially increase caregiver burden, more significantly than the cognitive symptoms. Standard BPSD assessments rely on caregiver-rated questionnaires that are cross-sectional and may be biased when caregivers are themselves older adults. Device-based measures (e.g., research-grade wrist actigraphy) can provide objective longitudinal data and novel features. In parallel, therapeutic wearables may improve sleep and mood in adults, and might improve BPSD if accepted by people living with dementia. This study aims to assess the feasibility and acceptability of two wearables (Geneactiv actigraphy and Re-Timer circadian regulator) among AD patients with significant BPSD and their caregivers in Taiwan. MethodsThis dyadic pilot study will recruit 20 participants (n=10 AD patients; n=10 caregivers) from outpatient services and affiliated day-care/dementia hubs in rural Taiwan. Participants will wear Geneactiv continuously for 8 weeks and Re-Timer [&ge;]30 min/day for 4 weeks. Device-based data will be processed with GGIR, a well validated R-package designed for processing accelerometer data. Questionnaire assessments include Pittsburgh Sleep Quality Index, PSQI (PSQI), Neuropsychiatry Inventory Questionnaire (NPI-Q), Caregiver Burden Inventory (CBI), and a semi-structured interview based on the Taiwanese version of Quebec User Evaluation of Satisfaction with Assistive Technology (T-QUEST) at prespecified timepoints. DiscussionWearable devices may facilitate the measurement and treatment of specific BPSD, as well as reduce caregiver burden. If proven feasible even in rural Taiwan where both digital and health literacy and resources are limited, this model will inform how device-based dementia care model can be considered and applied in the context of global ageing. Ethics & registrationThis protocol has been approved by the China Medical University and Hospital Research Ethics Committee (CMUH114-REC3-072), and pre-registered in ClinicalTrials.gov (NCT07249918).

BackgroundThere is growing consensus regarding the multidimensional nature of frailty and the need for comprehensive approaches to its assessment. However, existing assessment instruments have shown limited validity evidence or failed to adequately cover all the proposed theoretical dimensions of frailty. To address this gap, we recently developed the preliminary items of the Multidimensional Frailty Scale (MFS), a new instrument aimed to assess physical, cognitive, affective, social, and environmental frailty in older adults. This study sought to determine the final item set and to evaluate the psychometric properties of the final version. MethodsWe conducted a cross-sectional observational study with 283 individuals aged 65- 98 years. Participants completed the preliminary 51-item version of the MFS, the Tilburg Frailty Indicator (TFI), and a sociodemographic questionnaire. Item selection was guided by corrected item-dimension correlations, standardized factor loadings and content validity considerations. We examined dimensionality using confirmatory factor analysis comparing a unidimensional model and a five-factor second-order model, assessed internal consistency with Cronbachs alpha, and evaluated convergent validity through Spearman correlations between analogous dimensions of the MFS and the TFI. ResultsItem analysis yielded a final 29-item version of the MFS. The five-factor second-order model demonstrated excellent fit to the data, whereas the unidimensional model showed poor fit. Internal consistency was high for all dimensions and for the total scale. Convergent validity was supported by moderate-to-large correlations between corresponding MFS and TFI dimensions. ConclusionsThe MFS demonstrates robust psychometric properties and provides a brief yet comprehensive instrument to assess multidimensional frailty in older adults. Its hierarchical structure allows both global and domain-specific assessment, supporting more precise identification of frailty profiles. The ease of administration facilitates its use in research and clinical practice. Further validation in diverse linguistic and cultural contexts may enhance its applicability and support cross-national comparative research on multidimensional frailty.

BackgroundVestibular complaints are common in older adults and are linked to imbalance and falls. Some older adults show impaired vestibular perception despite preserved peripheral-reflex ("vestibular agnosia"). Yet it remains unclear if vestibular agnosia is independently linked to imbalance and falls in otherwise healthy older adults. We therefore investigated the prevalence of vestibular agnosia in community-dwelling older adults, and examined its association to balance and prospective falls. MethodsVestibular perceptual thresholds were measured during yaw-plane rotational chair testing. Postural sway and instrumented Timed-Up-and-Go were assessed using wearable sensors, and falls were recorded prospectively over six-month. Vestibular agnosia was identified using K-means clustering. Multivariable regressions examined associations between perceptual thresholds and balance outcomes; logistic and negative binomial regressions evaluated associations with prospective falls. ResultsAmong 166 participants (75.4 years; 81.9% female), 18.7% were classified as having vestibular agnosia. These individuals had worse cognition and somatosensation. Elevated (i.e. worse) vestibular perceptual thresholds were independently associated with greater sway velocity when standing on foam with eyes-open (adjusted {beta}=0.002, p=0.03). Associations with other balance outcomes were attenuated after adjustment. Vestibular perceptual thresholds were not associated with prospective falls (odds of [&ge;]1 fall: adjusted OR=0.99, p=0.65; fall counts: adjusted IRR=1.02, p=0.35). ConclusionsApproximately one-fifth of healthy older adults exhibit vestibular agnosia. While elevated perceptual thresholds are independently associated with poorer balance, they did not predict falls. Vestibular perceptual testing provides complementary insight into age-related balance impairment, although its utility in fall-risk prediction requires further investigation. Key PointsO_LIApproximately one-fifth of healthy older adults had vestibular agnosia (impaired vestibular perception despite intact peripheral function) C_LIO_LIOlder adults with vestibular agnosia have poorer cognition, reduced lower limb somatosensation, and higher anxiety. C_LIO_LIHigher (i.e. worse) vestibular perceptual thresholds were independently associated with greater sway velocity when standing on foam (eyes open). C_LIO_LIHigher vestibular perceptual thresholds were only associated with slower TUG performance and greater eyes-closed foam sway in unadjusted models. C_LIO_LIVestibular perceptual thresholds did not predict prospective falls over 6 months. C_LI

BackgroundThis study used qualitative methods to test and refine a framework for educating cognitively unimpaired individuals about their individual risk for Alzheimers disease and related dementias (ADRD) and intrapersonal health belief factors as part of the TEACH (Tailored Education for Aging and Cognitive Health) intervention. MethodWe assessed individuals ADRD risk factors and health belief concepts. Personalized data were presented individually, followed by a semi-structured phenomenographic interview. Applied thematic analysis was used to identify representative statements, trends, and differences. ResultsIn N=11 individual interviews with middle-aged and older participants (ages 49-69; 45% women), participants had generally positive experiences of learning their personal dementia risk; the information was perceived to be unsurprising and occasionally consoling. They demonstrated a good understanding of the health belief concepts, including identifying relationships between intrapersonal health beliefs and health behaviors. Participants provided feedback on the visual aids and methods of conveying health belief information. ConclusionsWe used qualitative data from individual interviews to refine an explanatory framework for educating individuals about their personalized risk for ADRD and intrapersonal health beliefs that may be barriers or facilitators of health behavior change. The refined TEACH intervention is designed to promote long-term maintenance of target health behaviors in middle-aged adults to mitigate ADRD risk.

INTRODUCTIONAgitation is a common and burdensome neuropsychiatric symptom in dementia that fluctuates from day to day, but objective tools for short-term risk stratification are limited. We examined whether nocturnal physiological signals from unobtrusive under-mattress sensors predict next-day daytime agitation and whether associations differ for agitation occurrence versus severity. METHODSWe extracted cardiorespiratory, movement, and sleep-proxy features from two long-term care cohorts (N=55; 333 nights) and one external home-monitoring cohort (N=18; 803 nights). A two-part mixed-effects framework was used to model next-day agitation episodes. RESULTSLower nocturnal respiratory rate and greater activity instability independently predicted higher odds of next-day agitation occurrence. Associations were stronger for motor than verbal agitation. Respiration-related predictors were validated externally. Conversely, no nocturnal features significantly predicted agitation severity. DISCUSSIONPassive sleep monitoring identified reproducible, physiologically interpretable markers of next-day agitation occurrence, supporting the potential of under-mattress sensing for short-term risk stratification and more proactive dementia care.

ObjectivesTo develop a simple risk prediction model for cognitive decline in a Chinese older adult cohort, and to evaluate its performance and transportability through temporal validation and external validation in a Japanese older adult cohort. MethodsThe prediction model was developed using a derivation cohort of 5,985 cognitively normal older adults from the China Health and Retirement Longitudinal Study (CHARLS, 2011-2015). A comparison of seven machine learning algorithms was conducted, and the standard Cox Proportional Hazards (CoxPH) model was selected based on its optimal balance of performance and parsimony. The final model was then validated on a temporal cohort (CHARLS 2015-2018, n=1,333) and an external cohort (Japanese Study of Aging and Retirement [JSTAR] 2007-2009, n=2,798). A comprehensive preprocessing pipeline, including Iterative Imputation for high-missingness predictor variables and One-Hot Encoding for categorical variables, was developed on the training data and applied to all cohorts. Model performance was assessed via discrimination, calibration, risk stratification and clinical utility. ResultsIn temporal validation, the model demonstrated strong performance with an AUC of 0.72 and reliable calibration (Slope = 1.02). In the external JSTAR cohort, the model maintained high discriminative power (AUC = 0.68), which was even superior to the development set (AUC = 0.62). However, a notable calibration shift was observed (Slope = 1.54), indicating a systematic underestimation of absolute risk in the low-prevalence Japanese population. While decision curve analysis (DCA) showed substantial net benefit in the temporal cohort, its utility in the external cohort was most effective within a narrow threshold range near the population prevalence. Sensitivity analyses confirmed that the models risk-ranking ability remained robust across 2-year and 4-year horizons. ConclusionOur 6-predictor model shows robust risk-ranking consistency across cohorts, but absolute risk estimates are sensitive to population and temporal differences. While effective for identifying high-risk individuals, local recalibration is essential for accurate clinical prognosis in new settings.

ObjectivesCurrent methods of health expenditure reporting make spending on palliative care services difficult to quantify. This paper (1) examines trends in the components of government (public) spending on health-related long-term care reported in the UK Health Accounts for the period of 2013 to 2022 to establish the wider context of palliative care expenditure, and (2) relates these trends to existing knowledge of expenditure on specialist palliative care services in the UK. MethodsWe conducted a descriptive secondary analysis of annually reported government expenditure on health-related long-term care between 2013 and 2022 from the UK Health Accounts dataset. We contrasted this with UK governmental and non-governmental spending on specialist palliative care services using annual expenditure figures reported by Hospice UK. ResultsReal-terms UK government spending on health-related long-term care grew by {pound}6.4 billion (22.9%) between 2013 and 2022, from {pound}27.9 to {pound}34.3 billion. Real-terms spending on specialist palliative care grew by {pound}110 million (10.7%) over the same period, from {pound}1,027 to {pound}1,137 million. In 2022, spending on inpatient care comprised the majority of government health-related long-term care expenditure ({pound}22.6 billion; 65.9%). Home-based care comprised one-third ({pound}11.8 billion; 33.4%). Outpatient care accounted for 0.7% ({pound}260.2 million). Equivalent data was not available for analysis of specialist palliative care expenditure. ConclusionsLow granularity of UK national health expenditure accounts limits national and international comparisons of spending on palliative care. However, it is clear that UK expenditure on specialist palliative care services has not kept pace with growth in expenditure on health-related long-term care. What is already known on this topicO_LIGlobal demand for palliative care is increasing as rates of serious life-limiting illness, dementia, cancer and multiple long-term conditions rise internationally. C_LIO_LIIncreasing complexity of illness and population ageing are two factors implicated in both rising healthcare expenditure and growing demand for palliative care internationally. C_LIO_LIThe UK has previously been ranked as providing the highest quality of palliative care amongst international competitors - however, concerns about the longevity of funding sources for specialist palliative care services has led to calls for further investment. C_LI What this study addsO_LIReal terms UK government spending on health-related long-term care - which includes, but is not limited to, palliative care services - increased by 22.9% between 2013 and 2022. C_LIO_LIOver the same period, UK spending on specialist palliative care services as reported by Hospice UK grew by only 10.7%. C_LIO_LIOur results take into account health-related social care spending, which forms a key part of care for people living with illness, including those receiving palliative care services. C_LI How this study might affect research, practice or policyO_LIThe future of funding for specialist palliative care in the UK is uncertain, and current funding frameworks are complex. This paper adds to ongoing policy discussions surrounding this issue, highlighting the discrepancy between growth in public sector spending on health-related long-term care and overall spending on specialist palliative care services (from governmental and non-governmental sources). C_LI

An understated disruption to health services brought about by the Covid-19 pandemic was the increase in deaths occurring outside a hospital. Since quality of end-of-life care is typically monitored through place of death and hospital activity, a new approach focused on care in community settings is needed. In this study, we aimed to test whether patient-centric measures of quality at the end of life can be derived from primary care electronic records. With the approval of NHS England, analysis was undertaken in OpenSAFELY-TPP using electronic health care records of over 970,000 patients who died between March 2019 and August 2023, covering periods before, during and after the pandemic. We developed two new measures of end-of-life care quality--specialist palliative care team contacts and advance care planning, and tracked the proportion of patients with these records, categorized by place and cause of death, along with an existing measure indicating palliative care needs. The proportion of people with a GP record of specialist palliative care was 4-5% on average, higher for those who died of cancer or died in a hospice. Advance care planning records increased from 19% to 27% (barring a decrease following the onset of the Covid-19 pandemic) driven in large part by increases for patients who died in care homes. Advance care planning and recording of palliative care needs were plausible measures to track changes in care, unlike the specialist palliative care measure where recorded use was sparse. Improved coding in primary care records would improve reliability of measures. Key messagesO_LIQuality of end-of-life care is traditionally measured by how patients use health services (for example emergency department attendances) C_LIO_LIWe used routine GP health records to track aspects of end-of-life care quality which matter to patients and discuss the impact of the covid-19 pandemic on these quality measures C_LIO_LIA new measure of advance care planning and the existing palliative care needs measure could be used to track end of life care delivered in the community C_LIO_LIThe measure of specialist palliative care was sparsely coded and unlikely to be useful unless coding and data linkage between GP and other systems improves C_LI

Background and ObjectivesPhysical activity and sleep are potential modifiable risk factors for the development of Alzheimers disease and related disorders (ADRD), but few studies have objectively measured both domains in participants across the cognitive continuum. Research Design and MethodsStandard clinical assessment, accelerometry, and at-home EEG sleep data were obtained from older controls (n=9) and adults who met consensus diagnostic criteria for mild cognitive impairment (MCI; n=7), Alzheimers disease (AD; n=10), and dementia with Lewy bodies (DLB; n=11). Given these sample sizes, descriptive statistics are presented rather than formal statistical testing. ResultsThe MCI group had the most surprising findings--although they were cognitively similar to the control group, they were less physically active than the AD group and had the worst sleep efficiency. The DLB group had the most severe motor and neuropsychiatric symptoms, were the least physically active, spent the least amount of time in rapid eye movement (REM) sleep, and spent the highest amount of time in non-REM sleep with hypotonia (NRH). The AD group had physical activity counts that fell between the DLB and control groups; REM sleep and NRH levels that were similar to the control and MCI groups; and autonomic activation index (AAI) and sleep spindle durations that were higher than the MCI and DLB groups. Discussion and ImplicationsThese findings highlight interesting physical activity and sleep patterns between groups, but larger samples are needed to investigate how objectively measured physical activity and sleep might serve as disease-specific digital biomarkers of neurodegenerative disorders. Translational SignificanceThis study uses wearable technologies to measure physical activity and sleep in adults with and without cognitive impairment. The study found that adults with mild cognitive impairment had physical activity and sleep patterns that resembled people with dementia despite having cognitive scores that were closer to cognitively healthy controls. Sleep and activity patterns were distinct when comparing participants with Alzheimers and dementia with Lewy bodies. Larger studies are needed to validate these findings, but mobile health devices may be an accessible way to detect early cognitive decline and help differentiate dementia subtypes, resulting in earlier, targeted clinical care.

BackgroundThe one-year SINEMA trial demonstrated improved blood pressure (BP) control and reduced mortality up to 72 months after the intervention. This article aims to assess between-arm differences in mean annual cumulative BP and to explore whether the associations between cumulative BP and biofunctional outcomes differed by trial arm. MethodsPost-hoc secondary analysis of the SINEMA cluster-randomized trial, which recruited 1299 adults with stroke from 50 rural villages in Hebei, China, between 2017 and 2018. The 12-month intervention was followed by observational assessments at 72 and 84 months post-baseline. BP was measured during each face-to-face follow-up, assessed by blinded assessors at baseline, 12, 72, and 84 months. Mean annual cumulative systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), and pulse pressure (PP) were calculated. Biofunctional outcomes included health-related quality of life, modified Rankin Scale, activities of daily living, physical function, and cognition function. ResultsAmong 897 participants (mean age 62.7 years; 40.8% female) with complete data across all assessment, the intervention arm demonstrated significantly lower mean annual cumulative SBP (-2.2 mm Hg; 95% CI, -3.9 to -0.6), DBP (-1.6 mm Hg; 95% CI, -2.4 to -0.7), and MAP (-1.8 mm Hg; 95% CI, -2.8 to -0.8), not PP, compared with usual care. Significant associations between cumulative BP and biofunctional outcomes were observed in the control arm while not in the intervention arm. Interaction effects between trial arm and cumulative BP were significant for multiple outcomes, most prominently for cumulative SBP. ConclusionsThe one-year SINEMA intervention was associated with lower cumulative BP burden over 72-84 months but did not improve overall biofunctional outcomes. Secondary analyses revealed that the association between cumulative BP burden and biofunctional decline differed by intervention arm, suggesting cumulative BP exposure may be an important long-term risk indicator and the intervention may modify BP-outcome relationships through mechanisms requiring further investigation.

BackgroundHip fracture remains a leading cause of morbidity and mortality among older adults in the United States. The aim of this systematic and meta-analytical review is to synthesize available evidence on predictors of one-year mortality following hip fracture among older adults, guided by a socio-ecological framework. MethodsWe searched PubMed, Embase, Web of Science, CINAHL, and Scopus for U.S.-based studies published between 2010 and 2025 reporting one-year mortality after hip fracture. Studies were included if they evaluated predictors of mortality across pre-injury, perioperative, or post-discharge phases. Data were extracted on study design, population characteristics, mortality outcomes, and risk factors. Predictors examined in [&ge;]3 studies were pooled using random-effects meta-analysis, and narrative synthesis was conducted for predictors with limited data. Methodological quality was assessed using the Joanna Briggs Institute checklist. ResultsTwenty-eight studies (n = 835,226) met inclusion criteria. Pooled one-year mortality was 21.8%, ranging from 7.1% to 54.4%. Advancing age and male sex were consistent non-modifiable risk factors. Comorbidity burden, including congestive heart failure, chronic kidney disease, myocardial infarction, and dementia, and measures of frailty and functional impairment were among the strongest predictors, often doubling mortality odds. Perioperative factors such as higher injury severity and delayed surgery, and post-discharge factors including hospital readmission, missed follow-up visits, and postoperative complications, were also associated with increased mortality. ConclusionOne-year hip fracture-related mortality remains high and stems from multifactorial causes. A multi-level, systems-oriented approach may be necessary to meaningfully reduce long-term mortality in this growing and vulnerable population.

AimThis research aims to evaluate the effectiveness, cultural appropriateness, and feasibility of the Cook Islands palliative care model te vaerua k[o]p[u] tangata ora within palliative care practice. BackgroundAccess to palliative and end of life care is a recognised human right, yet significant disparities persist for Pacific peoples in Aotearoa, New Zealand. While the understanding of different cultural perspectives has grown, in Aotearoa, there remain gaps in the delivery of culturally appropriate palliative care. MethodologyThis study will use a Cook Islands T[i]vaevae research methodology to guide semi-structured interviews with 25-35 Cook Islands community members and 10 palliative care clinicians. This approach will support a rich, relational, and culturally grounded exploration of how a Cook Islands M[a]ori palliative care model can be integrated into clinical practice. DiscussionRecommendations to improve culturally responsive palliative care will be formulated in collaboration with community members and clinicians. The study will contribute to the limited body of knowledge on Pacific cultural understandings of palliative care and provide practical insights into applying an indigenous Pacific model within the palliative care system.

Structured AbstractO_ST_ABSBACKGROUNDC_ST_ABSPatient reports are the standard when examining subjective cognitive decline (SCD). Recent research suggests that informant and clinician reports may also be associated with cognition. This study examined differences between patient, informant, and clinician definitions of SCD and their relationship to cognition. METHODSData from 4290 older adults (n=1690 normal controls, NC; n=840 mild cognitive impairment, MCI; n=1760 Alzheimers disease, AD) were examined from the National Alzheimers Coordinating Center. Linear models examined the relationships between SCD status using the three definitions and cognition at baseline and over time. RESULTSIn NC, informant and clinician SCD were associated with worse cognition at baseline, with patient and clinician SCD associated with worse cognition over time. All definitions were associated with worse cognition at baseline and over time in MCI and AD. DISCUSSIONOur findings suggest the importance of examining different SCD definitions, especially the inclusion of clinician SCD.