Journal of the American Medical Directors Association

Introduction: End of life decision making poses unique challenges for individuals with dementia and their family caregivers as cognitive decline shifts decision making responsibility to surrogates. Methods: Using 2010 to 2022 Health and Retirement Study (HRS) exit interview data, we compared advance directive completion, decision making needs near death, involvement of others in decision making, and concordance between expressed preferences and care received among decedents with and without dementia. Analyses incorporated HRS exit interview sampling weights, primary sampling units, and strata to account for the complex multistage probability design of HRS and produce nationally representative estimates of U.S. older adult decedents (50 years or older). Weighted descriptive statistics and design adjusted Wald tests were used to compare groups. Results: Among 5,389 decedents, 1,010 (weighted 17.7%) had dementia prior to death. Decedents with dementia were more likely to have completed advance directives than those without dementia (81.3% vs. 69.1%, p<.001). However, they also had significantly higher decision making needs in the final days of life (54.3% vs. 47.2%, p<.001). Children or grandchildren were more frequently involved in care decisions for decedents with dementia (63.9% vs. 45.6%, p<.001). Despite differences in decision making processes, most decedents in both groups expressed preferences for comfort focused care, and preference care concordance exceeded 90% in both groups. Conclusions: Findings suggested that dementia reshaped the structure and intensity of the shared decision making process by increasing surrogate engagement and decisional demands, underscoring the importance of early advance care planning and structured support for family caregivers to sustain goal concordant care.

Background: Sleep problems are common in older people and have been associated with increased fall risk, but the mechanisms underlying this relationship remain unclear. Gait quality reflects balance control and neurological function and may provide insight into pathways linking sleep health and falls. Methods: Data from 758 community-dwelling older people ([&ge;]65 years; mean age 75.8 years, 69.3% women) were analysed. Sleep problems were assessed at baseline using a self-reported item (Patient Health Questionnaire-9, question 3). Daily-life gait quality and habitual walking speed were derived from one week of wearable sensor monitoring. Falls and injurious falls were prospectively recorded over 12 months. Associations between sleep problems, gait quality, and fall incidence were examined using regression models adjusted for demographic, pain and cognitive factors, and use of sleeping medication. Results: Sleep problems were reported by 43.9% of participants. Sleep problems were not associated with habitual walking speed, but were associated with lower gait quality in daily life (adjusted {beta} = -0.15, 95% CI -0.27 to -0.03). Participants reporting sleep problems had higher incidence rates of total falls (adjusted IRR = 1.42, 95% CI 1.07 to 1.90) and injurious falls (adjusted IRR = 1.50, 95% CI 1.07 to 2.10). Conclusions: Self-reported sleep problems were associated with impaired real-world gait quality and substantially higher rates of falls and injurious falls in older people. These findings suggest that sleep problems may increase fall risk by altering balance control rather than by reducing walking speed. Sleep should be considered when managing fall risk, and fall risk should be considered in older people with sleep complaints.

BackgroundOlder 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. MethodsFor 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. ResultsAll 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. ConclusionsFor 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.

Background: Advance care planning (ACP) documentation, including living wills and durable power of attorney (DPOA), is intended to support goal concordant end of life care. However, it is unknown if comprehensive documentation confers additional benefits, and how these associations vary across clinical contexts. Methods: We used 2010 to 2022 Health and Retirement Study exit interview data to examine associations between ACP documentation and end of life care among U.S. adults aged 50 years and older. Documentation was categorized as none, one document (living will or DPOA), or two documents (both). Outcomes included intensive care unit (ICU) use, life sustaining treatment, hospice enrollment, and out-of-hospital death. Modified Poisson regression models were used to estimate adjusted risk ratios (aRRs), and temporal trends in documentation were assessed using joinpoint regression. Results: Among 5,622 decedents representing 23.2 million individuals, 42.7% had two documents and 28.9% had none, documentation increased substantially around 2014. Compared with no documentation, having any documentation was associated with lower likelihood of life-sustaining treatment (aRR=0.85, 95% CI: 0.74 to 0.98) and higher likelihood of hospice enrollment (aRR=1.43, 95% CI: 1.28 to 1.60) and out-of-hospital death (aRR=1.11, 95% CI: 1.06 to 1.18), but not ICU use. Having two documents showed similar patterns, with modest differences compared with one document after adjustment. Associations were stronger among decedents with expected death and attenuated among those with unexpected death. Conclusions: Comprehensive ACP documentation is associated with less aggressive end of life care and greater hospice use, though the incremental benefits of two documents are modest. Findings highlight the importance of documentation within care planning processes and the clinical context.

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

Context: In the UK, and in other countries, people living with a terminal illness are eligible for financial support to help with the costs of serious illness and to support their dignity and independence. This study investigates the take-up of benefits in the last year of life and identifies sociodemographic, clinical, and geographical factors associated with underclaiming. Methods: Retrospective cohort study using linked mortality, Census and benefits data for all people who died aged 16+ from chronic illnesses in England and Wales between 1 May 2018 and 30 April 2021. Outcome was receipt of non-means tested disability benefits in the last 12 months of life. We describe geographical variation in take up, and association with sociodemographic, clinical and geographical exposures using Poisson models. Findings: Our population included 1,049,493 eligible decedents, with an overall take-up rate of 65.9%. After adjusting for sociodemographic factors, variation in take-up by cause of death was wide: liver disease 44% (95% CI 43, 45%), heart failure 52% (51, 52%), cancer 62% (61, 62%), dementia 75% (74, 75%), and neurodegenerative diseases 90% (88, 91%). Across Local Authorities, the age-and-sex-standardised take-up varied from 53% to 78%; rates were generally higher in more deprived areas, but not uniformly. Conclusions: In England and Wales, 1 in 3 people who die from expected causes (120,000 each year) do not receive the benefits for which they are eligible. Our analysis uses novel data linkages and highlights clinical and sociodemographic groups and geographical areas that could be targeted with proactive take-up initiatives.

BackgroundEarly recognition of dementia-related changes is critical for timely intervention. The AD8 Dementia Screening Interview (AD8) detects subtle cognitive and functional changes, yet its broader associations with health and wellbeing among Chinese-speaking older adults remain underexplored. MethodsA cross-sectional study was conducted with 144 community-dwelling Chinese older adults (mean age 73.1 years; 81.3% female). Participants completed sociodemographic, health, functional, and psychosocial measures, including the AD8 and the Geriatric Depression Scale (GDS-15). Exploratory Factor Analysis (EFA) assessed the dimensionality of the AD8, and binary logistic regression examined associations between AD8 items and demographic, health, functional, and psychosocial outcomes. ResultsChronic disease was prevalent (68.1 percent), and 13.2 percent reported a mental health disorder. EFA identified three domains: memory impairment, executive and interest decline, and functional recall difficulties, explaining 61.7 percent of the variance. Logistic regression showed predictive roles for judgment problems (AD8_1), repetition (AD8_3), financial difficulties (AD8_6), tool-use difficulties (AD8_4), and daily memory problems (AD8_8). Financial and executive difficulties were associated with age and mobility challenges, while repetition predicted psychological disorders and hopelessness. Judgment problems were linked to lower life satisfaction and happiness but greater helplessness. Worthlessness was predicted by financial, tool-use, and memory difficulties, whereas intact temporal recall (AD8_5) was protective. Several outcomes including boredom, low energy, and staying home were not significant. ConclusionDistinct AD8 items predicted vulnerabilities across physical, psychological, and social domains. Findings highlight the multidimensional value of the AD8 as a culturally relevant screening and risk stratification tool for community-based assessments of Chinese older adults. Summary Statement Implications for PracticeO_ST_ABSWhat does this research add to existing knowledge in gerontology?C_ST_ABSThis study shows that specific AD8 items identify early multidimensional vulnerability among community-dwelling Chinese-speaking older adults. Difficulties with judgment, repetition, financial management, tool use, and daily memory were associated with functional limitations and psychosocial distress, extending the AD8 beyond dementia screening alone. The identification of three AD8 domains supports a broader understanding of early cognitive change as involving cognitive, functional, and emotional processes. The findings contribute culturally specific evidence from an under-researched population in gerontological research. What are the implications of this new knowledge for nursing care with older people?For nursing practice, the AD8 provides a brief, feasible tool to support holistic assessment in community and aged care settings. Key AD8 indicators can guide nurses in identifying older people at risk of functional decline and emotional vulnerability, enabling earlier, person-centred interventions. The findings highlight the importance of culturally and linguistically appropriate assessment when caring for diverse ageing populations. How could the findings be used to influence policy or practice or research or education?The results support integrating brief cognitive screening into routine nursing assessments and community-based aged care services to promote early identification and ageing in place. Nursing education should emphasise interpreting cognitive screening within psychosocial and cultural contexts. Longitudinal research is needed to assess intervention effectiveness. Key Points[tpltrtarr] Early cognitive changes matter for older Chinese-speaking adults, because difficulties with judgment, repetition, financial management, and tool use (AD8 domains) were consistently linked to poorer functional and psychosocial outcomes. [tpltrtarr]Beyond dementia screening, the AD8 proved useful for detecting vulnerabilities in wellbeing and daily functioning, extending its role beyond diagnostic sensitivity. [tpltrtarr]A cultural focus is vital, as this study is among the first to examine AD8 associations in older Chinese-speaking adults, underscoring the need for culturally tailored screening. [tpltrtarr]The psychosocial impact of cognitive changes was evident, with strong associations to helplessness, worthlessness, and reduced life satisfaction, reinforcing the overlap between cognitive and emotional health. [tpltrtarr]In practice, integrating AD8 screening into community and primary care could help identify at-risk individuals early and support targeted interventions in culturally and linguistically diverse populations.

BACKGROUNDFall injuries in older adults are devastating and often caused by impaired reactive balance to unexpected trips and slips, which conventional exercise programs do not target. This study examined whether a low-dose perturbation balance training (PBT) program among older adults can improve balance recovery following trips and slips and reduce falls and fall injuries. METHODS111 older adults (65+ years) were randomised into an intervention or control group. The intervention group undertook one weekly PBT session for three weeks on the Trip and Slip Walkway, followed by three-monthly PBT booster sessions over one year, for a total of six sessions. The control group received an educational booklet. Blinded staff assessed laboratory-falls induced by a trip and slip with a safety harness at baseline and one year. Number of falls and fall injuries in daily life were collected weekly for one year. RESULTSCompared to the control group, the intervention group experienced a 26% reduction in laboratory falls at 12 months (RR = 0.74; 95% CI: 0.54, 0.99; P = .040) but not different in number of falls, trip-and slip-encounters in daily life. However, fall-related injuries were reduced by 57% (rate ratio = 0.43; 95% CI: 0.19, 0.94, P = .024) over one year. A reduction in falls occurred within the first three months, with greater benefit among participants who completed at least three training sessions. CONCLUSIONSA low-dose PBT program can improve reactive balance over 12 months and reduced injurious falls by 57%, with benefits likely due to enhanced reactive balance rather than proactive gait strategies. Older adults may require at least three sessions to achieve meaningful fall reduction, with periodic booster sessions to sustain benefits. Incorporating PBT into exercise programs may enhance their efficacy in preventing falls and fall injuries in daily life. Key PointsA low-dose perturbation-based training program (six sessions over 12 months) improved reactive balance at 12 months and reduced injurious falls by 57%. Benefits are likely due to task-specific improvements in reactive balance against trips and slips rather than proactive gait strategies or other risk factors. Incorporating PBT into exercise programs may improve their efficacy in preventing falls and fall injuries in daily life. Why does this paper matter?Falls are the leading cause of injury-related hospitalization and loss of independence in older adults. By targeting reactive balance--an ability neglected by conventional exercise programs--it offers a novel, evidence-based approach to enhance fall prevention and reduce injuries.

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.

ObjectiveTo examine whether menopausal women who initiate systemic menopausal hormone therapy (MHT) around menopause (45-60 years old) have a different risk of developing dementia than those not taking MHT. DesignSystematic review and meta-analysis of randomised controlled trials and longitudinal observational studies. Risk of bias was assessed using ROB-2 and ROBINS I-V2. Data sourcesMEDLINE, Web of Science, EMBASE, and Cochrane Library to 27 March 2026. Eligibility criteria for selecting studiesStudies which measured dementia or cognitive decline in women who initiated systemic MHT between ages 45-60 or within 5 years of menopause, compared with placebo or no MHT. Authors contacted for additional details if needed. Main outcome measuresDementia, Alzheimers disease (AD), cognitive decline. Results10 studies totalling 213,678 participants (189,525 in studies with the primary population). There was no significant increased risk in women with a uterus for all cause dementia (pooled hazard ratio (HR): 1.12; 95% CI 0.91-1.31, N=78,613, I2 = 96.9%), but increased AD risk (HR: 1.14; 95% CI 1.02, 1.29, N=134,865, I2 = 35.6%). Results were similar in sensitivity analyses including women with or without a uterus. Results for cognitive decline were variable. ConclusionsMHT initiated around the age of menopause should not be prescribed for cognition or dementia prevention. It is not protective against dementia and may increase risk slightly. The magnitude of risk was similar in AD and dementia, but the latter with larger confidence intervals. Studies which followed up individuals rather than on health records lost people to follow up. This may account for difference in cognitive decline outcomes between studies, as people with cognitive impairment and dementia are more likely not to attend. MHT prescribing should balance benefits against risks, including evidence of a small increased dementia risk. There are few high-quality studies, so further research would inform recommendations. Systematic review registration Prospero CRD420251010663 What is already known on this topic?O_LIMenopausal hormone therapy (MHT) is effective for alleviating vasomotor symptoms. Contemporary guidelines recommend treatment should be initiated for such symptoms under age 60 and or within 10 years of menopause onset. C_LIO_LIA large randomised trial on the topic found increased risk of dementia in women initiating MHT after the age of 65. C_LIO_LIIt is unknown whether initiating MHT around the age of menopause impacts the risk of dementia or cognitive decline. C_LI What this study addsO_LIThere was no evidence that taking MHT around the time of menopause decreases the risk of dementia or cognitive impairment. C_LIO_LIThey should not be prescribed for these indications. C_LIO_LIWe were able to find more studies which examine this question by contacting authors for additional data. C_LIO_LIInitiating MHT in women with a uterus around the age of menopause increased the risk of Alzheimers disease slightly, by over 10%, and there is a similar but not significant effect in the fewer studies of all cause dementia. Women with or without a uterus show similar results. C_LIO_LIWe found no significant difference shown in cognitive decline, possibly due to loss to follow up. This may be because most studies of cognitive decline follow up C_LI

Background: Evidence regarding dementia prevention strategies has been accumulating. However, disseminating research findings to the public is often difficult, and addressing the evidence-practice gap presents an important challenge. This study examined potential strategies to support sustained engagement in dementia prevention activities. Participants and Setting: Members of senior citizens' clubs in Tottori Prefecture, Japan. Methods: This questionnaire survey collected data on basic demographics, frailty, and subjective cognitive decline (SCD). It also included questions on awareness of the Tottori Method Dementia Prevention Program, interest in experiencing the program if an instructor was dispatched, and the feasibility of engaging in the program through internet-based delivery or printed materials. Results: A total of 9,506 respondents were included in the analysis. Awareness of the dementia prevention program was 11.9%. Overall, 50.4% of the respondents registered a desire to try the program if an instructor was dispatched. The highest proportion of respondents (50.5%) reported willingness to engage in the program if materials summarizing activities that could be completed in approximately 10 min were provided. However, both frailty and SCD were associated with a lower interest in these dementia prevention activities (adjusted odd ratio [95% confidence interval] = 0.77 [0.67-0.89] and 0.86 [0.79-0.95], respectively). Conclusions: To promote sustained engagement in dementia prevention activities, opportunities to experience the program and activities that can be completed in a short time should be availed. However, disseminating research findings to the public remains challenging, and individuals at a higher risk of health problems may be less interested in dementia prevention. Proactive outreach strategies targeting high-risk individuals may be necessary to effectively disseminate the information.

We evaluated 2024/25 KP.2 vaccine effectiveness (VE) against COVID-19 hospitalization among adults >60 years old eligible for publicly-funded vaccination during fall and/or spring campaigns in the province of Quebec, Canada. We included Quebec residents tested for COVID-19-compatible symptoms in an acute-care hospital between October 13, 2024 (epi-week 2024-42) and August 23, 2025 (2025-34), linking vaccine, hospital, chronic diseases and laboratory administrative records to assess VE through test-negative design. We compared the odds of being COVID-19 test-positive versus test-negative among vaccinated versus non-vaccinated participants, adjusting for sex, age, comorbidities, place of residence, and epidemiological week. Overall, 49,949 (43%) participants were vaccinated. Over an analysis period spanning up to ten months, including median time since vaccination of 16 weeks (interquartile range 9-24 weeks), VE was 34% overall, declining from 43% <8 weeks to negligible by the 32nd week post-vaccination. Findings confirm meaningful but short-lived COVID-19 vaccine protection against hospitalization in older adults.

ObjectiveDemographic corrections (e.g., sex, education, race, ethnicity) are often applied when assessing cognition in adults; however, these corrections have significant limitations (e.g., using years of education does not capture the quality of, or access to, education). It is therefore critical to develop novel assessment options that are less susceptible to demographic factors. This study compared demographic effects on a verbal memory test and a performance-based test of cognition and daily functioning in older adults. Based on prior work, we hypothesized the performance-based tests would be less susceptible to demographic factors than paired associates learning. MethodData from 1326 participants (mean{+/-}SD age=61.9{+/-}10.9 yrs; Female = 1066, 80%) were collected through the MindCrowd electronic cohort, with 79 (6%) non-White, 109 (8.2%) identifying as Hispanic/Latino ethnicity, and 327 (25%) reporting education as less than a college degree. Paired associates learning is a well-established measure of medial temporal lobe-dependent learning and memory through recall of word-pairs, scored as the number of correct word pairs entered out of 36 possible. The performance-based test involved functional upper-extremity movement, specifically transporting beans to target cups in a repeating sequence (a task also shown to be dependent on the medial temporal lobe), scored as the intraindividual variability (standard deviation) in trial time across four consecutive trials. ResultsAs hypothesized, linear regression analysis showed that PAL was significantly affected by sex, education, race (particularly Black/African American), and ethnicity, whereas the performance-based test was affected only by sex and with a much smaller effect size than that of PAL. ConclusionsPerformance-based assessments may be an equitable approach to evaluating cognition without requiring score corrections, particularly for diverse populations.

Nighttime agitation (NA) is a prevalent and challenging phenomenon affecting people with dementia (PwD), often resulting in premature institutionalization. Yet, informal caregivers' perspectives on this phenomenon remain underexplored. We conducted 15 in-depth interviews with informal caregivers to gain insight into their experiences and reactions to NA. Thematic analysis identified seven sub-themes related to carers' experience and eight sub-themes concerning their reactions. These themes emerged across three levels, namely, PwD, informal caregiver and the environment. Most phenomena occurred at a dyadic level between PwD and informal caregiver, highlighting the potential of interventions targeting dyadic coping. Informal caregivers feel insufficiently supported when sleep disturbances co-occur with NA. They primarily rely on self-initiated strategies and learn by experience. Caregivers mention the need for more advanced knowledge and skills in reacting to co-occurrence of sleep disturbances with NA or systemic support in terms of dealing with emergencies. Caregivers also reflect extensively on the impact of challenging behaviors during the night on their mental and physical well-being. Notably, no non-pharmacological interventions for NA adequately address the themes identified in this study, highlighting the urgent need for integrative approaches and recognition of caregiver wellbeing as a core outcome, not a secondary consideration in interventions.

BackgroundAdvance care planning in older persons with palliative care needs is often not (timely) initiated. Certified nursing assistants are closely involved in the (daily) care for older persons and have important insights regarding their clients care preferences and quality of life. However, their role in advance care planning is currently overlooked. AimTo examine the perspectives of nursing assistants on their role in advance care planning for older persons. DesignA qualitative descriptive study design using semi-structured interviews. Setting/participantsFifteen nursing assistants working in community care and nursing homes in the Netherlands were interviewed between March and December 2023. A combined inductive and deductive thematic analysis was performed using the Capability, Opportunity, Motivation Behavioral model. ResultsMost nursing assistants were not structurally involved in advance care planning and were in need of additional knowledge and skills (capability). The team culture affected nursing assistants opportunities and motivation to participate in advance care planning both positively and negatively. The opportunity was further shaped by nursing assistants relationship with clients and relatives and time management, while motivation also depended on personal circumstances. ConclusionThis study found several barriers and facilitators affecting nursing assistants role in advance care planning for older persons. Structurally involving nursing assistants in advance care planning, supporting their work environment, and empowering them can foster equal collaboration with other healthcare professionals. This might contribute to the timely initiation of advance care planning and palliative care for older persons. Key statementsi) What is already known about the topic?O_LIAdvance care planning enables patients, relatives, and involved healthcare professionals to define and discuss goals and preferences for current and future medical treatment and care. C_LIO_LICertified nursing assistants are often closely involved in the (daily) care for older persons and their relatives, providing important insights into their preferences and quality of life. C_LIO_LINursing assistants are currently not structurally involved in the interprofessional collaboration regarding advance care planning. C_LI ii) What this paper addsO_LIVariation was observed in nursing assistants roles in advance care planning across care teams and settings, with most indicating a need for additional knowledge and skills (capability). C_LIO_LIThe team culture affected nursing assistants opportunities and motivation to participate in advance care planning both positively and negatively. C_LIO_LIThe opportunity was further shaped by nursing assistants relationship with clients and relatives and time management, while motivation was also depended on personal circumstances. C_LI iii) Implications for practiceO_LIStructural involvement of certified nursing assistants in advance care planning can contribute to timely initiation of advance care planning and palliative care for older persons. C_LIO_LIA supportive work environment that enables nursing assistants to develop their skills and grow professionally can facilitate an advance care planning process involving the expertise of all healthcare professionals. C_LIO_LIThe empowerment of nursing assistants could help them to become a more equal partner in advance care planning in collaboration with other involved professionals. 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

The global nursing workforce is aging, yet limited research has explored the lived experiences of never married nurses entering midlife and later adulthood. Existing studies have primarily focused on burnout and retention, with less attention to the social and existential dimensions of aging without a spouse or children. This study aimed to explore the experiences of never married clinical nurses aged 40 years and older, focusing on perceptions of aging, professional identity, social support, and future security. A qualitative descriptive design was employed. Twenty-five never married nurses aged 44-62 years were recruited through purposive sampling from intensive care, emergency, medical, surgical, oncology, outpatient, and community departments across four government hospitals. Semi-structured interviews were conducted and analyzed using reflexive thematic analysis. Trustworthiness was ensured through member checking, peer debriefing, and maintenance of an audit trail. Four themes were identified: Nursing as a Life Anchor, where professional identity provided meaning and structure; Independence Coexisting with Loneliness, reflecting autonomy alongside episodic loneliness; The Invisible but Available Workforce, describing expectations of greater work availability due to single status; and Anticipating an Uncertain Future, capturing concerns about retirement, declining health, and limited advocacy in later life. Never married aging nurses experience a complex balance of professional fulfillment, autonomy, vulnerability, and uncertainty. Healthcare organizations should recognize this subgroup and consider equitable workload policies, tailored retirement planning, and psychosocial support to promote well-being and workforce sustainability.

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.

Objectives: Cardiovascular disease (CVD) is a leading cause of mortality and disability in older populations. This study aimed to identify CVD risk factors in community-dwelling older adults and to examine whether frailty-related factors (sarcopenia and nutritional status) interact with chronic kidney disease (CKD). Methods: This cross-sectional study included 307 community-dwelling Japanese adults aged [&ge;]65 years between September 2024 and March 2025. CVD history was assessed based on self-reported physician diagnoses obtained through a structured questionnaire. Lifestyle-related factors included hypertension, diabetes, dyslipidemia, and body mass index (BMI). Frailty-related factors included sarcopenia (Asian Working Group for Sarcopenia 2019 criteria), nutritional status (Mini Nutritional Assessment-Short Form), and physical activity (International Physical Activity Questionnaire-Short Form). CKD was defined using the estimated glomerular filtration rate (eGFR): non-CKD ([&ge;]60 mL/min/1.73 m2) and CKD (<60 mL/min/1.73 m2). Multivariable logistic regression identified independent correlates of CVD, and interactions between CKD and frailty-related factors were tested. Results: The prevalence of CVD was 17.9%. Independent correlates included CKD (aOR 5.0), hypertension (aOR 4.0), male sex (aOR 3.1), undernutrition (aOR 2.7), sarcopenia (aOR 2.7), and low physical activity (aOR 2.5). No significant interactions were observed between CKD and sarcopenia (p = 0.70) or nutritional status (p = 0.40). Conclusions: CKD, sarcopenia, undernutrition, and low physical activity were independently associated with CVD, with no interaction between CKD and frailty factors. These findings suggest that integrated management addressing both renal function and frailty-related factors may be important for CVD prevention in older adults.

Background and ObjectivesMultifactorial interventions have been reported to be effective in improving cognitive function; however, their long-term effectiveness in community settings remains to be sufficiently examined. This study aimed to investigate the effects of a socially implemented multifactorial intervention program on dementia onset, long-term care insurance certification, and post-intervention cognitive and physical functions. MethodsThis retrospective observational study collected data from three municipalities. The study population comprised individuals suspected of having mild cognitive decline based on cognitive function screening tests conducted by March 31, 2024, and who had been invited to participate in a dementia prevention class, but had not applied for long-term care insurance at the time of the invitation. Participants were classified into class participation and non-participation groups for analysis. Most participants attended the class only once (intervention duration: 4 or 6 months). ResultsData from 104, 218, and 256 individuals were collected from the three municipalities, respectively. No significant association was found between class participation and suppression of dementia onset or long-term care insurance certification in any of the municipalities. Regarding pre-post comparisons among class participants, significant improvements in cognitive function and some physical functions were observed in all the three municipalities. ConclusionsThe multifactorial interventions implemented in community settings showed no effect on dementia onset or health outcomes. However, class participation was associated with improvements in cognitive function and some physical functions. These findings suggest that implementing programs based on evidence can achieve effects similar to those observed in studies conducted under ideal conditions.