Journal of the American Geriatrics Society

BackgroundMobility loss is common in hospitalized older adults, and resources to prevent mobility loss are finite. Our goal was to develop a rapid, universal screening tool that identifies individuals at risk of losing the ability to walk during hospitalization on the first hospital day. Second, we determined if the model could inform the use of mobility-preserving interventions. MethodsWe included patients admitted to a general medical service, aged [&ge;]65 years, who could walk on admission (Braden Scale Activity subset >=3). Patients were considered to have a new mobility impairment if the activity score was <3 on discharge. We used predictors available on the first hospital day to develop (2017-18) and validate (2019) a prediction model. We determined the association between predicted risk and therapy use in the validation cohort to highlight the models clinical utility. Results5542 patients were included (median age 76yrs, 48% women); 7.6% were discharged unable to walk. The model included six predictors: age, marital status, medication administrations, Glasgow Coma Scale verbal score, serum albumin, and urinary catheter presence. In the validation cohort, the model discriminated well (c-statistic 0.75) and was strongly associated with hospital-acquired mobility loss (lowest decile 1%, highest decile 24%). In the validation cohort, therapy consultation ordering increased linearly with predicted risk; however, observed mobility loss increased exponentially. ConclusionThe Day-1 Mobility Loss model predicts the risk of mobility loss in hospitalized older adults on the first hospital day. Further, it identifies at-risk older adults who may benefit from mobility interventions.

BackgroundLimitations in activities of daily living have widespread implications for the well-being of older adults. However, the relation between performance-based physical function and self-reported functional impairment is inconsistent. MethodsThe cohort included 6,282 White women and 310 Black women aged 65 and older participating in the Study of Osteoporotic Fractures (SOF) from 1986 to 2010 who reported no limitations in any Instrumental Activities of Daily Living (IADL) at baseline. Approximately every two to six years, participants self-reported their physical limitations and trained interviewers assessed common measures of physical performance (i.e., usual gait speed, grip strength, and chair stand time). We used Cox proportional hazards models using age as the time scale to calculate hazard ratios between individual and summary measures of physical performance and incident IADL limitations. ResultsOver follow-up, 4,193 White women and 118 Black women developed IADL impairment (IR = 451.34 and 361.52 per 10,000 person-years, respectfully). Usual gait speed was associated with IADL limitations in both race cohorts (slowest gait vs. fastest gait HR: 3.83, 95% CI: 3.41 - 4.31; HR: 2.59, 95% CI: 1.42 - 4.73). For every one-point increase in summary performance score, rate of IADL limitations was lower for both White women and Black women (HR: 0.79, 95% CI: 0.78-0.80; HR: 0.87, 95% CI: 0.81 - 0.94). ConclusionIn this longitudinal study, women with poorer performance in individual and summary measures of physical function had an increased rate of incident IADL limitations over follow-up compared to women with the best performance. These findings confirm previous research using cross-sectional data.

ObjectiveIdentify subgroups of postoperative older adults using electronic health record data. Summary of Background DataPostoperative older adults represent a vulnerable population who may benefit from tailored postoperative care pathways. Identifying clinical subgroups can inform the development of these pathways. MethodsRetrospective cohort study of postoperative adults >65 years (N=2,036) from a single healthcare system. Latent class analysis was used to identify patient subgroups based on measures of frailty, mobility, activities of daily living, and general health status. Hospital outcomes were described among each subgroup, including extended lengths of stay (LOS) (>0.5 SD beyond mean LOS by surgical category), discharge disposition (i.e., home versus non-home discharge), and utilization (weekly visit frequency) of physical therapy (PT) and occupational therapy (OT). ResultsWe identified 3 subgroups that we labeled Low Frailty-High Mobility (LF-HM), High Frailty-Low Mobility (HF-LM), and Low Frailty-Low Mobility (LF-LM), representing 15.3%, 27.6%, and 57.1% of the cohort, respectively. Discharge to home was highest among the LF-HM group (99%), followed by LF-LM (96%), and HF-LM (77%). Extended LOS was most common among the HF-LM group (27%), followed by LF-LM (18%), and LF-HM (6%). PT and OT visit frequencies were highest in the HF-LM group followed by the LF-LM and LF-HM groups. ConclusionsThis study identified 3 subgroups of postoperative older adults using routinely collected patient data. These groups may help to identify patients with increased odds of non-home discharge, extended LOS, and higher utilization of PT and OT and may inform the development of tailored postoperative care pathways for older adults.

Objectives: To estimate hyperlipidemia medication order prevalence and associated variables in U.S. skilled nursing facility (SNF) residents. Design: Retrospective, observational study. Setting and Participants: Electronic Health Record data from 447,080 SNF residents with a hyperlipidemia diagnosis identified in PointClickCare's Life Sciences clinical database (January-April 2025) were reviewed. Methods: The presence and absence of medication orders for hyperlipidemia treatments recommended by the American Heart Association were assessed. Descriptive analyses summarized demographic and clinical characteristics, and a modified Poisson regression model was used to estimate risk ratios for having a medication order, adjusting for demographic, clinical, and facility characteristics. Results: Overall, 83.3% of residents diagnosed with hyperlipidemia had at least one hyperlipidemia medication order. Statins were ordered by 96.2% of active order residents, while other medication classes i.e., omega-3 fatty acids, cholesterol absorption inhibitors, fibrates were less common (<8%). Risk ratios (RRs) for medication orders ranged from 0.87-1.16. Factors most strongly associated with having an order included hypertension medication orders (RR=1.16), unspecified hyperlipidemia diagnosis (RR=1.10), and active diabetes medication orders (RR=1.09); female sex (RR=0.95) and private (0.94) or other (0.87) payer types were associated with a lower likelihood of having an order. Conclusions and Implications: Most residents with a hyperlipidemia diagnosis had an active relevant medication order, but use of non-statin therapies was rare. Differences in treatment patterns by sex and payer type, along with limited uptake of newer agents, warrant further investigation into prescribing practices and access within SNFs.

BackgroundMore 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, experienced fewer FRIs as compared to age-similar individuals who did not register. MethodsThis 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 months before and after Nymbl registration (or a randomly assigned index date). Logistic regression models 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 effects of Nymbl usage and whether the effect of Nymbl was additive to participation in other exercise programs. ResultsWe identified 3,735 individuals who registered for Nymbl and 114,219 age-eligible non-registrants. Among individuals with a prior FRI, Nymbl registration was associated with a 4.24 percentage point reduction in acute FRIs, however no significant effect 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 effects were limited to those not already participating in other exercise programs. ConclusionFindings 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.

Burn trauma disproportionately impacts older adults, yet existing burn severity models emphasize age, total body surface area (TBSA), and inhalation injury without accounting for geriatric-specific vulnerabilities such as frailty. We conducted a retrospective cohort study of 326 geriatric patients admitted with burn injuries between 2020 and 2024 to evaluate how TBSA, burn location, inhalation injury, renal insufficiency, comorbidities, and functional dependence in activities of daily living (ADLs) and instrumental activities of daily living (IADLs) affect in- hospital mortality and discharge disposition. Based on multivariable logistic regression and chi- square analyses, TBSA, as expected, emerged as the strongest predictor across models. Each 1% increase in TBSA was associated with a 7% increase in the odds of in-hospital mortality (p=0.006) and a 12 to 19% increase in odds of post-acute care placement (p<0.001). Inhalation injury and renal insufficiency were also independently associated with increased odds of both mortality and post-acute care disposition, whereas respiratory comorbidity predicted mortality alone. Functional status demonstrated outcome-specific prognostic value: ADL dependence predicted mortality, while IADL dependence predicted discharge disposition. Patients with some ADL dependence had five-fold higher odds of in-hospital mortality (p=0.011), while some (OR=2.48, p= 0.039) and full IADL dependence (OR=2.61, p=0.025) were associated with higher odds of post-acute care placement. Integrating structured functional assessments that distinguish basic from instrumental limitations alongside established burn severity metrics may enhance prognostication and guide individualized care planning for older adults with burn injuries.

BackgroundPhysical performance tests are predictive of mortality and have been proposed for screening for certain health conditions (e.g., sarcopenia); however, the diagnostic screening and prognostic value of physical performance tests has primarily been studied in age-limited or disease-specific cohorts. In this study, we sought to identify the most salient characteristics associated with three lower quarter balance and strength tests in a deeply phenotyped cohort of community-dwelling adults. MethodsWe applied a stacked elastic net approach on detailed data on sociodemographic, health and health-related behaviors, and biomarker data from the first visit of the Project Baseline Health Study (N=2502) to determine which variables were most associated with three physical performance measures: single-legged balance test (SLBT), sitting-rising test (SRT), and 30-second chair-stand test (30CST). Analyses were stratified by age (<65 and [&ge;]65). ResultsFemale sex, Black or African American race, lower educational attainment, and health conditions such as non-alcoholic fatty liver disease and cardiovascular conditions (e.g., hypertension) were consistently associated with worse performance across all three tests. Several other health conditions were associated with either better or worse test performance, depending on age group and test. C-reactive protein was the only laboratory value associated with performance across age and test groups with some consistency. ConclusionsOur results highlighted previously identified and several novel salient factors associated with performance on the SLBT, SRT, and 30CST. Future research should discern and validate the value of these tests as affordable, noninvasive biomarkers of prevalent and/or future disease in the community.

BackgroundPre-injury frailty among older trauma patients is a predictor of increased morbidity and mortality. We sought to determine the relationship between frailty status and the care trajectories of older adult patients who underwent frailty screening in the emergency department (ED). MethodsUsing a retrospective cohort design of a single institutional trauma database, we pooled data on trauma patients, 65 years and older, who had frailty screening at ED presentation (N=987). The predictor variable was frailty status, measured as either robust, pre-frail, or frail. The outcome variables were measures of clinical care trajectory: inpatient admission, length of hospital stay, home discharge, and discharge to rehabilitation. We controlled for age, sex, race/ethnicity, body mass index, Charlson Comorbidity Index, injury type and severity, and Glasgow Coma Scale score. We performed multivariable logistic and quantile regressions to measure the influence of frailty on post-trauma care trajectories. ResultsThe mean (SD) age of the study population was 81 (9.0) years and the population was predominantly female (66%) and non-Hispanic White (64%). Compared to older adult trauma patients classified as robust, those categorized as frail had 2.8 (95% CI: 1.75 - 4.40), 0.4 (95% CI: 0.27 - 0.63), and 2.1 (95% CI: 1.38 - 3.27) times the adjusted odds of hospital admission, home discharge, and discharge to rehabilitation, respectively. Those classified as pre-frail (Adjusted MD: 1.0; 95% CI: 0.46 - 1.54) and frail (Adjusted MD: 2.0; 95% CI: 1.35 - 2.65) had longer lengths of hospital stay compared to those classified as robust. ConclusionPre-injury frailty is a predictor of care trajectories for older-adult trauma patients.

BackgroundFrailty is a geriatric syndrome characterized by an increased vulnerability to stressors and increased risk of adverse clinical outcomes. While older patients with acute stroke are routinely screened for prestroke disability using the modified Rankin Scale (mRS), because of its known association with stroke outcomes, prestroke frailty is still rarely assessed. The Clinical Frailty Scale (CFS) is a popoular tool for retrospective frailty assessment in the acute setting. The study hypothesis was that prestroke frailty measured with CFS was associated with stroke outcome of older patients independent of prestroke disability assessed with mRS. MethodsWe recruited 4086 individuals aged [&ge;]65 years consecutively admitted with acute stroke to an Italian hospital. Prestroke disability (mRS [&ge;]3) was assessed at admission. Prestroke CFS was retrospectively assessed using information from the medical records. Logistic models determined the association of CFS with poor functional outcome, prolonged discharge, unfavorable discharge setting, and poor rehabilitation potential. Cox models determined the association of CFS with 30-day and 1-month mortality. All models were adjusted for prestroke disability and other major confounders. ResultsParticipants were median age 81 years (25th-75th percentile, 75-87 years), 55.0% female, 82.6% with ischemic stroke, and 26.3% with prestroke disability. Overall prevalence of prestroke frailty (CFS [&ge;]4) was 41.6%. Multivariable-adjusted logistic models showed that CFS was associated with increasing risk of all outcomes except prologed discharge. In severe frailty (CFS 7-8), OR (95%CI) was 3.44 (2.33-5.07) for poor functional outcome, 0.53 (0.38-0.75) for prolonged discharge, 1.89 (0.36-263) for unfavourable discharge, and 6.24 (3.80-10.26) for poor rehabilitation potential (reference CFS 1-3). In multivariable adjusted-Cox models, CFS was unrelated to 30-day mortality but HR (95%CI) of 1-year mortality was significant for both CFS 4-6 (1.70, 1.36-2.11) and CFS 7-8 (1.69, 1.25-2.30). ConclusionsPrestroke frailty measured with CFS was associated with higher risk of several adverse outcomes even after adjustment for prestroke disability and other major confounders.

Objectives: To evaluate rates of pharmacological hypertension orders and identify resident- and facility-level predictors of pharmacologic care among skilled nursing facility (SNF) residents in the United States. Design: Retrospective, observational study. Setting and Participants: Electronic Health Record data from 1,285,062 long-term care residents in PointClickCare's Life Sciences database in facility on April 30, 2025 were reviewed, and 553,519 SNF residents with a documented hypertension diagnosis were identified. Methods: The presence and absence of medication orders for antihypertensive treatment recommended by the International Society of Hypertension was assessed. Descriptive analyses summarized demographic and clinical characteristics, and a modified Poisson regression model was used to estimate risk ratios (RRs) for having a medication order, adjusting for demographic, clinical, and facility characteristics. Results: Overall, 87.7% of residents diagnosed with hypertension had at least one antihypertensive medication order. Calcium channel blockers (44.3%) and beta blockers (43.5%) were the most frequently used classes. RRs ranged from 0.91 to 1.09. Higher likelihoods of antihypertensive orders were observed among residents prescribed hyperlipidemia and diabetes medication (RR = 1.09 and 1.05, respectively), while lower likelihoods of treatment were observed for other payer types (RR = 0.91), diabetes diagnoses (RR = 0.95), and hyperlipidemia diagnoses (RR = 0.98). Conclusions and Implications: Most residents with hypertension had orders for recommended pharmacologic therapy, although important gaps and disparities remain. The predominance of certain medication classes and persistent differences by comorbidity and facility type underscore the need for targeted strategies to improve equitable prescribing and access to evidence-based hypertension management in SNF settings.

BackgroundGrowth differentiation factor 15 (GDF-15) is a member of the TGF{beta} superfamily secreted by many cell types and found at higher blood concentrations as chronological age increases (1). Given the emergence of GDF-15 as a key protein associated with aging, it is important to understand the multitude of conditions with which circulating GDF-15 is associated. MethodsWe pooled data from 1,174 randomly selected Health ABC Study (Health ABC) participants and 1,503 Cardiovascular Health Study (CHS) participants to evaluate the risk of various conditions and age-related outcomes across levels of GDF-15. The primary outcomes were (1) risk of mobility disability and falls; (2) impaired cognitive function; (3) and increased risk of cardiovascular disease and total mortality. ResultsThe pooled study cohort had a mean age of 75.4 +/-4.4 years. Using a Bonferroni-corrected threshold, our analyses show that high levels of GDF-15 were associated with a higher risk of severe mobility disability (HR: 2.13 [1.64, 2.77]), coronary heart disease (HR: 1.47 [1.17, 1.83]), atherosclerotic cardiovascular disease (HR: 1.56 [1.22, 1.98]), heart failure (HR: 2.09 [1.66, 2.64]), and mortality (HR: 1.81 [1.53, 2.15]) when comparing the highest and lowest quartiles. For CHS participants, analysis of extreme quartiles in fully adjusted models revealed a 3.5-fold higher risk of dementia (HR: 3.50 [1.97, 6.22]). ConclusionsGDF-15 is associated with several age-related outcomes and diseases, including mobility disability, impaired physical and cognitive performance, dementia, cardiovascular disease, and mortality. Each of these findings demonstrates the importance of GDF-15 as a potential biomarker for many aging-related conditions.

Background: End-stage renal disease (ESRD) is closely associated with frailty, but the relationship between earlier stages of kidney dysfunction and frailty in the broader older population remains unclear. This study investigates the association between kidney function and frailty in community-dwelling older adults in Northeast Germany, using cross-sectional data from the population-based SHIP-TREND study. Methods: Data of 1,456 community-dwelling participants aged [&ge;]60 years of the SHIP-TREND cohort were analyzed. Frailty was classified using modified Fried phenotype criteria. Kidney function was assessed using various estimated glomerular filtration rate (eGFR) formulas (MDRD, CKD-EPI and EKFC, based on creatinine or cystatin C). Associations between eGFR, and albuminuria and frailty were examined using multivariable linear and logistic regression models adjusted for age, sex, comorbidities, and body composition. Results: Frailty prevalence was 2.3%, and frail individuals had significantly lower eGFR, particularly when calculated using cystatin C-based formulas. CKD-EPI and EKFC equations using cystatin C showed the strongest associations with frailty (e.g. CKD-EPICysC: OR = 31.3, 95 % CI 5.04 - 194.93, p < 0.001 for eGFR <30 vs. [&ge;]60 mL/min/1.73 m{superscript 2}). Creatinine-based equations demonstrated weaker associations, likely due to confounding by muscle mass. Albuminuria was not significantly associated with frailty. Frail participants exhibited higher BMI but lower muscle mass, pointing to sarcopenic obesity as a potential contributor to the pathophysiology linking reduced kidney function and frailty. Conclusion: This study shows that lower kidney function, especially when estimated using cystatin C-based equations, is significantly associated with frailty in older adults. The strength of our study lies in the large, well-defined population and standardized assessments. In clinical practice, incorporating cystatin C into GFR estimation alongside muscle mass assessments may provide a more reliable framework for identifying CKD in older adults, and may also improve the prediction of frailty. Key pointsO_LILower kidney function, especially via cystatin C-based eGFR, is strongly linked to frailty in older adults. C_LIO_LISarcopenic obesity may drive this link, with frail individuals showing high BMI but low muscle mass. C_LIO_LICombining cystatin C-based eGFR with muscle mass assessment may improve CKD detection and frailty prediction in clinical practice. C_LI

Background Delirium is common among hospitalized older adults on many clinical services and associated with poor outcomes. Given delirium's fluctuations, wearable devices are promising continuous monitors. While recruiting for a wearable electroencephalography (EEG) delirium study, we initially experienced low enrollment rates among older adults and patients on non-neurologic services. Our aim was to understand patient and community perspectives on inpatient, wearable research to adapt recruitment protocols and increase enrollment. Methods We approached patients admitted to an academic medical center to participate in an observational, wearable EEG delirium study and recorded reasons for enrolling or declining. To gain insight into recruitment protocols, we held a community panel with patients, family members, and caregivers. Recruitment protocols were refined in two phases: 1) personalizing the recruitment approach to emphasize symptoms that were personally relevant to individual patients and 2) sharing educational materials about the study in addition to delirium. We compared enrollment rates before and after these protocol adaptations. Results Initially, 18.5% of approached patients enrolled (68/367). Despite antecedent concerns that wearable devices would be the primary deterrent to participation, only a small proportion of people who did not participate did so because of wearable EEG (8.8%, 26/299). Community panel members (n=7) suggested that personal relevance and understanding of the clinical conditions being studied, such as delirium, would have a greater impact on decisions to participate than study procedures. Adapting recruitment protocols to highlight personally relevant delirium-related symptoms, such as sleep disturbance, significantly increased enrollment rates (30.1%, 58/188, p<0.001), including for patients over 65 years old (p<0.001) and patients on non-neurologic services (p<0.001). The addition of educational materials focused on clinical delirium did not further impact enrollment (p=0.61). Conclusions Recruitment of older, hospitalized patients for inpatient research can be challenging, but can be significantly improved by highlighting familiar symptoms of personal relevance.

Background/ObjectivesCoronavirus disease 2019 (COVID-19) is associated with a hypercoagulable state and increased thrombotic risk in infected individuals. Several complex and varied coagulation abnormalities were proposed for this association1. Acetylsalicylic acid(ASA, aspirin) is known to have inflammatory, antithrombotic properties and its use was reported as having potency to reduce RNA synthesis and replication of some types of coronaviruses including human coronavirus-299E (CoV-229E) and Middle East Respiratory Syndrome (MERS)-CoV 2,3. We hypothesized that chronic low dose aspirin use may decrease COVID-19 mortality relative to ASA non-users. MethodsThis is a retrospective, observational cohort analysis of residents residing at Veterans Affairs Community Living Centers from December 13, 2020, to September 18, 2021, with a positive SARS-CoV-2 PCR test. Low dose aspirin users had low dose (81mg) therapy (10 of 14 days) prior to the positive COVID date and were compared to aspirin non-users (no ASA in prior 14 days). The primary outcome was mortality at 30 and 56 days post positive test and hospitalization. ResultsWe identified 1.823 residents who had SARS-CoV-2 infection and 1,687 residents were eligible for the study. Aspirin use was independently associated with a reduced risk of 30 days of mortality (adjusted HR, 0.60, 95% CI, 0.40-0.90) and 56 days of mortality (adjusted HR, 0.67, 95% CI, 0.47-0.95) ConclusionChronic low dose aspirin use for primary or secondary prevention of cardiovascular events is associated with lower COVID-19 mortality. Although additional randomized controlled trials are required to understand these associations and the potential implications more fully for improving care, aspirin remains a medication with known side effects and clinical practice should not change based on these findings.

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: 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.

AimThe Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) is an injury risk-triage tool. This study aims to validate the STTGMAs accuracy in predicting fall-related mortality among geriatric trauma patients. MethodsUsing a retrospective cohort design, we selected 5,791 geriatric trauma patients (aged 55 years and older) from a single institutional trauma database (2017-2021). The outcome variable was fatal fall injury, measured as a binary variable. The predictor variable was the STTGMA score, measured as a continuous variable and a four-level categorical variable. We report the predictive accuracy (95% confidence interval (CI)) of the STTGMA. We further assessed the relationship between the STTGMA risk categories and hospital length of stay and time-to-death by performing multivariable quantile regression and time-varying Cox proportional hazard analyses, respectively. ResultsA total of 122 patients (2.1%) died during admission and the median hospital length of stay was 2 days. STTGMA exhibited 84% (95% CI: 75.6 - 92.0) accuracy in predicting in-hospital fall-related mortality. Compared to the minimal risk category, geriatric trauma patients classified as low, moderate, and high risks each had significantly longer hospital stays and adjusted mortality risks, in a dose-response pattern. ConclusionSTTGMA can accurately predict in-hospital mortality and risk-stratify the length of stay and the time to death among geriatric patients with fall injuries.

BackgroundGuidelines recommend vascular specialist evaluation and revascularization consideration before major amputation in chronic limb-threatening ischemia (CLTI). Whether patients consistently receive pre-amputation vascular workup is poorly characterized nationally. MethodsWe conducted a retrospective cohort study of Medicare fee-for-service beneficiaries [&ge;]66 years with CLTI undergoing incident major lower-extremity amputation (2021-2022) with [&ge;]12 months continuous enrollment. Using claims in the 180 days preceding hospitalization for amputation, we classified patients into mutually exclusive pathway phenotypes: (A) no specialist, no imaging, no revascularization attempt; (B) specialist only, no revascularization attempt; (C) imaging, no revascularization attempt; or (D) revascularization attempted. Mixed-effects multinomial regression with hospital random intercepts identified predictors of phenotype membership. Post-amputation outcomes were compared across phenotypes. ResultsAmong 10,666 patients (mean age 76.6 years; 35% female; 70% White, 21% Black), phenotype distribution was: A, 9.4%; B, 7.1%; C, 50.7%; D, 32.7%. Thus, 16.6% had no vascular imaging before amputation. Dementia (OR 2.0; 95% CI, 1.61-2.52), paralysis (OR 4.1; 2.62-6.34), and dual eligibility (OR 1.2; 1.01-1.42) were independently associated with phenotype A. Higher comorbidity burden was inversely associated with A (OR 0.49 for >6 vs 0-3 Elixhauser comorbidities). Phenotype A patients had lower 1-year mortality (40% vs 51% for D), fewer readmissions (90-day OR 0.54; 0.47-0.64), and lower costs (adjusted 50% lower at 180 days). Results were robust to acuity adjustment, exclusion of early deaths, and propensity-score matching (n=824 pairs). Phenotype A prevalence varied widely across hospital referral regions, ranging from 3% (Boston, Atlanta) to 16% (Little Rock) among regions with >100 patients. ConclusionsOne in six CLTI amputees had no vascular imaging before amputation. Patients without evaluation were characterized by cognitive impairment, functional limitation, lower healthcare engagement, and socioeconomic disadvantage rather than extreme medical complexity. Hospital-level variation suggests system-level interventions could address these gaps. WHAT IS KNOWNO_LIPrior studies have shown that 50-63% of Medicare patients with chronic limb-threatening ischemia undergo major amputation without receiving revascularization, with substantial racial and geographic disparities in pre-amputation vascular care. C_LI WHAT THE STUDY ADDSO_LIThis study documents the extent to which CLTI patients proceed with amputation without first being evaluated by a vascular specialist, which suggests lack of guideline-recommended care. C_LIO_LIAbout 1 in 10 Medicare CLTI amputees had no vascular specialist contact and no vascular imaging in the 6 months before amputation. C_LIO_LIPatients reaching amputation without evaluation were characterized not by extreme medical complexity but by dementia, paralysis, depression, and dual eligibility--suggesting populations unable to self-advocate within the healthcare system. C_LIO_LISubstantial hospital-level and geographic variation (3-16% phenotype A prevalence across large hospital referral regions) indicates that system-level factors, not just patient characteristics, drive these gaps. C_LI

BACKGROUNDCardiorespiratory fitness (CRF) measured by peak oxygen consumption (VO2peak) declines with aging and correlates with mortality and morbidity. Cardiopulmonary Exercise Testing (CPET) has long been the criterion method to assess CRF, but its feasibility, efficacy and reliability in older adults is unclear. The large, multicenter Study of Muscle, Mobility and Aging (SOMMA) employed CPET to evaluate the mechanisms underlying declines in mobility with aging among community-dwelling older adults. Our primary objective was to design and implement a CPET protocol in older adults that was dependable, safe, scientifically valuable, and methodologically reliable. METHODSCPET was performed using treadmill exercise in 875 adults [&ge;]70 years. A composite protocol included a symptom-limited peak exercise phase and two submaximal phases to assess cardiopulmonary ventilatory indices during 1) participants preferred walking speed and 2) at slow walking speed of 1.5 mph (0.67 m/s). An adjudication process was in place to review tests for validity if they met any prespecified criteria (VO2peak <12.0 ml/kg/min; maximum heart rate (HR) <100 bpm; respiratory exchange ratio (RER) <1.05 and a rating of perceived exertion <15). A repeat test was performed in a subset (N=30) to assess reproducibility. RESULTSCPET was safe and well tolerated, with 95.8% of participants able to complete the VO2peak phase of the protocol. Only 56 (6.4%) participants had a risk alert during any phase of testing and only two adverse events occurred during the peak phase: a fall and atrial fibrillation. The average {+/-} standard deviation for VO2peak was 20.2 {+/-} 4.8 mL/kg/min, peak HR 142 {+/-} 18 bpm, and peak RER 1.14 {+/-} 0.09. VO2peak and RER were slightly higher in men than women. Adjudication was indicated in 47 participants; 20 were evaluated as valid, 27 as invalid (18 had a data collection error, 9 did not reach VO2peak). Reproducibility of VO2peak was high (intraclass correlation coefficient=0.97). CONCLUSIONSCPET was feasible, effective and safe for community-dwelling older adults, many of whom had multimorbidity and frailty. These data support a broader implementation of CPET to provide important insight into the role of CRF and its underlying determinants in aging and age-related conditions and diseases. Clinical PerspectiveO_ST_ABSWhat Is New?C_ST_ABSPerforming cardiopulmonary exercise testing in a community dwelling older adult with multimorbidities or frailty is feasible and exceptionally safe under highly trained exercise physiologists and physician supervision. Reproducibility of VO2peak among community-dwelling older adults with significant clinical complexity was high (intraclass correlation coefficient=0.97). The VO2peak observed was comparable to established normative data for older adults, and adds merit to the limited data collected on VO2peak norms in older adults. What Are the Clinical Implications?Ventilatory gas collection during clinical cardiac stress testing may be valuable to plan of care in routine management of older adults due to the important role of aerobic fitness on morbidity and mortality. Cardiopulmonary exercise testing can provide insight into the role of cardiorespiratory fitness and its underlying determinants in aging and age-related conditions and diseases.

AimsThis study aimed to quantify the prevalence of frailty, and investigate the impact of frailty on adverse outcomes, in older patients with cancer in Vietnam. MethodsA prospective, observational study was conducted in adults aged 65 or above with cancer who attended the outpatient clinics of two urban hospitals in Vietnam from September 2023 to May 2024. Frailty was defined by the Carolina Frailty Index (CFI) and participants with a CFI >0.35 were identified as frail. All participants were followed up for 3 months after discharge, recording falls, all-cause hospitalization, and all-cause mortality. ResultsThere were 379 participants (mean age 72.3 years, 48.5% female). The prevalence of frailty was 26.6% (95%CI 22.2% - 31.0%), highest in participants with stomach cancer (35.7%) and lung cancer (33.9%). Participants with advanced stages of cancer had a significantly higher prevalence of frailty: 39.3% in stage 4, 21.7% in stage 3, compared to 18.1% in stage 2 and 13.0% in stage 1. During the follow up, 19.0% of the participants had a fall (44.4% in the frail vs. 9.7% in the non-frail, p<0.001), 33.4% were admitted to hospitals (42.2% in the frail vs. 30.1% in the non-frail, p=0.026). The mortality rate was 1.9% (5.1% in the frail vs. 0.7% in the non-frail, p=0.017). Odds ratios were 7.48 (95%CI 4.24 - 13.40, p<0.001) for falls, 1.71 (95%CI 1.06 - 2.75, p=0.027) for all-cause hospitalization, and 7.10 (95%CI 1.36 - 37.22, p=0.020) for all-cause mortality. ConclusionFrailty was observed in over a quarter of the participants, with the highest prevalence among those with stomach and lung cancer. Frailty significantly increased the odds of falls, hospitalization, and mortality in three months post-discharge. Further research is needed to gain a better understanding of the impact of frailty on adverse outcomes, and the quality of life for older adults with cancer in Vietnam.