Levy CR, Magid KH, Kononowech J
… +2 more, Langner P, Sales A
J Am Geriatr Soc
· 2026 Jun · PMID 42319285
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BACKGROUND: The Veterans Health Administration (VHA) Life-Sustaining Treatment Decisions Initiative (LSTDI) aims to improve documentation of patient preferences for life-sustaining treatment (LST), particularly in high-r...BACKGROUND: The Veterans Health Administration (VHA) Life-Sustaining Treatment Decisions Initiative (LSTDI) aims to improve documentation of patient preferences for life-sustaining treatment (LST), particularly in high-risk populations such as those served by Home Based Primary Care (HBPC) programs. Despite this mandate, LST documentation in HBPC remains variable. Previous studies suggest audit and feedback may be insufficient when used alone. This study evaluated whether combining audit and feedback with tailored implementation facilitation can increase and sustain LST documentation rates in HBPC. METHODS: We evaluated the prospective implementation of a longitudinal intervention using retrospective data design with data from the VA Corporate Data Warehouse and HBPC Masterfile between October 2019 and December 2024. Eleven HBPC programs with historically low (< 50%) LST documentation rates participated in a phased intervention consisting of a 6-month pre-implementation phase, a 15-month implementation phase, and a 12-month sustainability phase. The intervention combined monthly audit and feedback reports with site-specific implementation facilitation. We used a difference-in-differences (DID) analysis to compare changes in monthly site-level LST documentation rates at intervention sites (Cohorts 1-3) versus non-intervention sites (Cohort 4). The primary site-level outcome was the percentage of Veterans with a completed LST template. RESULTS: The analysis included a total of 140 VA sites, with 11 intervention sites across six VA regions. Intervention sites demonstrated a significant and sustained increase in LST documentation during implementation. The overall average treatment effect was 0.21 (95% CI: 0.144-0.276), corresponding to an average increase over expected trends of 21 percentage points across all intervention cohorts. This effect was maintained throughout the 12-month sustainability period across all cohorts. CONCLUSIONS: Pairing audit and feedback with implementation facilitation produced a substantial and durable improvement in LST documentation in HBPC settings. These findings support the use of these two complementary, data-driven implementation strategies to achieve policy goals of goal-concordant care for seriously ill Veterans.
Ramirez-Zohfeld V, Murawski A, Jobin C
… +7 more, Olvera C, Mell J, Brett J, Gratch J, Tschoe M, Pfammatter AF, Lindquist LA
J Am Geriatr Soc
· 2026 Jun · PMID 42308028
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BACKGROUND: Family caregivers experience conflicts in caring for people with Alzheimer's dementia (PWD; e.g., siblings disagreeing, advocating with providers, PWD refusing assistance). Subsequently, family caregivers exp...BACKGROUND: Family caregivers experience conflicts in caring for people with Alzheimer's dementia (PWD; e.g., siblings disagreeing, advocating with providers, PWD refusing assistance). Subsequently, family caregivers experience frustration, burden, and stress. Furthermore, these caregivers rarely receive formal conflict resolution training to ameliorate these concerns. We developed NegotiAge-an artificial intelligence (AI)-based negotiation training intervention that teaches caregivers how to resolve conflicts and provides the opportunity to practice negotiating with online avatars in real-world conflicts. We sought to optimize the potency and test the early effect of NegotiAge on family caregivers following the multiphase optimization strategy (MOST). PARTICIPANTS, DESIGN, SETTING: National randomized factorial trial of NegotiAge with family caregivers of PWD (> 65 years). Caregivers were randomized to one of eight conditions and variables/outcomes assessed at baseline and 1 month following NegotiAge. The mixed methods project used dependent sample t-tests (quantitative) and constant comparative analysis (qualitative). RESULTS: Across 23 states, 125 family caregivers (mean-age 54 years, 77% female) completed the study. Participants experienced significantly less caregiver burden (-3.24, p < 0.002) and negative affect (-2.1, p < 0.0001) between baseline and 1 month following. Those receiving two or more exercises experienced further significant burden reduction (-5.28, p < 0.04). Qualitative analyses supported these findings: "There was a time when my mother was crying. Because of the training I was able to calm her."; "When we have a conflict, I focus on the interest of both of us-helped tremendously." In the month following, 54% (n = 67) of participants experienced conflicts and 74% (n = 93) applied skills learned. Among utilizers, there was a significant decrease in forcing behaviors (-1.24, p < 0.0001). CONCLUSIONS: NegotiAge, an AI-based negotiation training intervention, significantly reduced burden and improved negative affect among family caregivers. Engaging in more negotiation exercises further reduced burden. NegotiAge has the potential to improve the lives of caregivers and PWD. Further testing is needed to determine the direct impact on older adults and long-term effects. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04837937.
Sinha P, Chatterjee P, Kathiresan P
… +21 more, Raju KS, Panwar R, Mukherjee A, Kumar G, Cherian JJ, Velayuthan A, Chakrawarty A, Mondal S, Kalita M, Kamboj S, Sen S, Bhattacharjee M, Mondal M, Bhowmik K, Mukherjee S, Saha I, Dutta AK, Saha A, Chakrabarti A, Ghosh A, Das S
J Am Geriatr Soc
· 2026 Jun · PMID 42304935
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OBJECTIVE: To evaluate the efficacy of adjunct probiotic supplementation (Lactobacillus helveticus and Bifidobacterium longum) alongside standard care compared to placebo in older adults with moderate unipolar depression...OBJECTIVE: To evaluate the efficacy of adjunct probiotic supplementation (Lactobacillus helveticus and Bifidobacterium longum) alongside standard care compared to placebo in older adults with moderate unipolar depression. METHODS: A randomized, double-blind, placebo-controlled pilot trial was conducted at two tertiary centers. Fifty-eight participants (≥ 60 years) with moderate depression were randomized 1:1 to receive daily probiotics or a placebo for 12 weeks, alongside standard antidepressant care. They were followed up for another 12 weeks. The primary outcome was depression response (≥ 50% Montgomery-Åsberg Depression Rating Scale [MADRS] score reduction). Secondary outcomes included anxiety (General Anxiety Disorder 7-Item [GAD-7]), cognition, quality of life (WHOQOL-BREF), serum brain-derived neurotropic factor (BDNF), and gut microbiota profile. RESULTS: Mixed-effects models showed significant improvement over time in depressive symptoms (MADRS: F = 32.0, p < 0.001) and anxiety (GAD-7: F = 13.1, p < 0.001). Overall scores were lower in the probiotic group compared with the placebo group for both MADRS (F = 12.7, p = 0.001) and GAD-7 (F = 10.7, p = 0.002), although group × time interactions were not significant. Quality-of-life domains improved markedly (all F > 100, p < 0.001) without additional benefit from probiotics. Escitalopram-equivalent antidepressant dose and benzodiazepine use influenced selected outcomes. The probiotic group also had a significantly higher serum BDNF level and increased fecal abundance of supplemented strains vs. the placebo group. The attrition rate was > 50% over 24 weeks. CONCLUSION: In this pilot PRODG trial, adjunct probiotics produced modest overall advantages for depressive and anxiety symptoms compared with placebo but did not enhance quality-of-life beyond usual improvement - both groups improved substantially, and trajectories over 24 weeks were largely parallel across follow-up.
Lindsay ME, Odole I, Mohamed S
… +4 more, King C, Schoenborn NL, Schonberg MA, Richman IB
J Am Geriatr Soc
· 2026 Jun · PMID 42302231
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BACKGROUND: Whether to continue breast cancer screening beyond age 74 is uncertain. Decision aids may improve understanding of health information and support informed screening decisions. The goal of this study was to de...BACKGROUND: Whether to continue breast cancer screening beyond age 74 is uncertain. Decision aids may improve understanding of health information and support informed screening decisions. The goal of this study was to develop a video-based decision aid for breast cancer screening among older women using patient-centered design. METHODS: Following the Framework for Innovation, the research team first used formative focus groups to understand older women's perspectives on mammography. We developed a prototype video based on decision aid best practices and formative focus group findings. We then evaluated the content, clarity, and style of the decision aid in cognitive testing focus groups. We made iterative changes to the video in response to focus group feedback. Focus groups included women age ≥ 70 without a personal history of breast cancer from Connecticut-area community and clinical settings. We coded and analyzed transcripts using both abductive and deductive approaches. RESULTS: We convened 6 formative focus groups and 7 cognitive testing groups with 31 participants (mean age 78 [range 70-93]); 39% Black, 58% White, and 3% Latina. In focus groups, participants perceived screening as largely beneficial and saw overdiagnosis as unfamiliar. Some participants valued quantitative information about risks and benefits of screening, while others relied on experience, perceptions of risk, and beliefs about the efficacy of mammography to make screening decisions. We incorporated these perspectives into the framing, language, and narrative arc of the decision aid. In cognitive testing focus groups, participants found the decision aid informative and engaging. DISCUSSION: Using a patient-centered approach, we developed a video-based decision aid for breast cancer screening for older women. Our design, which drew on the perspectives of older women, was perceived as easy to understand and informative. We will assess the impact of the decision aid on decision quality, decisional conflict, and intention to screen in future work.
Perone AK, Zhou L, Glusker A
… +14 more, Shin J, Xu C, Thairani P, Iriguchi Y, George J, Khov K, Abud A, Peng WS, Dua M, Wallrath AJ, Chicotel A, Walsh L, Chillemi M, King J
J Am Geriatr Soc
· 2026 Jun · PMID 42302162
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BACKGROUND: Older adults in the United States increasingly require residential long-term care, where staff must frequently navigate complex conflicts between residents' rights to safety and autonomy. Despite the prevalen...BACKGROUND: Older adults in the United States increasingly require residential long-term care, where staff must frequently navigate complex conflicts between residents' rights to safety and autonomy. Despite the prevalence of these ethical dilemmas and the potential for legal or professional harm, guidance for staff remains scarce. This scoping review identifies and synthesizes existing empirical strategies used to resolve these conflicts within U.S. residential long-term care. METHODS: Following the Arksey and O'Malley framework, a search was conducted across three academic databases (ProQuest Social Sciences, PubMed, and Scopus) for peer-reviewed, empirical studies published in English between 1987 and 2024. Two independent reviewers screened articles based on their focus on safety and autonomy conflicts and the inclusion of resolution strategies. Data were extracted from 14 final articles to categorize topics and solutions. RESULTS: The review identified 14 empirical studies covering topics such as fall prevention, dementia care, sexual expression, and daily routines. Strategies were synthesized into five categories: Innovation (new tools/policies), Compromise (balancing values), Advocacy (defending preferences), Reflection (team discussions), and Education (training, information). Innovation was the most frequently used strategy (8 of 14 studies), while education was the least utilized but most frequently suggested for future implementation. CONCLUSIONS: A significant research gap exists regarding evidence-based strategies for navigating safety-autonomy conflicts. These five categories provide guidance for clinical care and policymakers to understand the diversity of ways staff can address conflicting rights. More research is needed on how residential long-term care staff understand and address conflicting rights on the ground and how to best disseminate these strategies more broadly.
Burton CH, van Zuilen MH, Wong CN
… +11 more, Primbas A, Danielewicz M, Farrell TW, Aggarwal R, Streed CG, Josyula AV, Karani R, Torke AM, Keefe B, Shega J, Javier NM
J Am Geriatr Soc
· 2026 Jun · PMID 42299479
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In the decade since the American Geriatrics Society (AGS) released a position statement on Care of Lesbian, Gay, Bisexual, and Transgender Older Adults, we have seen significant progress toward achieving equal health and...In the decade since the American Geriatrics Society (AGS) released a position statement on Care of Lesbian, Gay, Bisexual, and Transgender Older Adults, we have seen significant progress toward achieving equal health and civil rights for lesbian, gay, bisexual, transgender, queer, intersex, and more (LGBTQI+) individuals. Advances have included increased visibility, legalization of same-sex marriage, and legal protections against discrimination. Even so, for LGBTQI+ older adults, substantial gaps, fears of discrimination, and legal uncertainty persist. Older LGBTQI+ adults experience the intersection of ageism with structural discrimination associated with their sexual and gender minority status-homophobia and transphobia. These experiences occur in many sectors of society, including health care, exacerbating disparities, impacting social determinants of health, and leading to accumulated discrimination across time. The potential for setbacks to progress remains as lawsuits are filed and policymakers consider legislation that would roll back rights at the state and federal levels. Recognizing this evolving landscape, AGS established a writing group to update the 2015 position statement with the goals of supporting progress on eliminating discrimination against LGBTQI+ older adults in healthcare and supporting integration of evidence-based approaches to caring for these older adults across care settings. By providing recommendations on inclusive education, policy reform, and focused research, AGS aims to promote the health, independence, quality of life, and dignity of LGBTQI+ older adults. Within education, we recommend standardized training for all healthcare staff, with specialized instruction for clinicians caring for LGBTQI+ older adults. On the policy front, we emphasize maintaining nondiscriminatory measures, supporting chosen families in caregiving, promoting completion of advance directives, and collecting and ensuring privacy of sexual orientation and gender identity (SOGI) information. Research priorities include continuing to advance SOGI data collection, understanding mechanisms driving disparities, developing health promotion interventions, and furthering research into long-term services and supports.
Montoya AT, Park P, Benloucif S
… +2 more, Davis MA, Bynum JPW
J Am Geriatr Soc
· 2026 Jun · PMID 42298330
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BACKGROUND: Transfer trauma, defined as the negative consequences of moving from one environment to another, can affect some long-term nursing home (NH) residents who are relocated between facilities. However, it remains...BACKGROUND: Transfer trauma, defined as the negative consequences of moving from one environment to another, can affect some long-term nursing home (NH) residents who are relocated between facilities. However, it remains unclear whether such transfers are associated with serious acute health risks, such as hospitalization or death, and whether these outcomes should be considered indicators of transfer trauma. METHODS: We conducted a retrospective cohort study to determine whether long-term NH residents who experience a transfer are at greater risk for hospitalization or death compared to residents who remain in the same facility. We used a 20% national Medicare sample linked to minimum data set (MDS) assessments. Long-term NH residents who underwent a NH-to-NH transfer in 2019 were matched 1:1 with residents from the same facility in the same calendar month who did not transfer. Outcomes were hospitalization and death within 90 days following the transfer. We used conditional logistic regression models, adjusted for demographic variables, dual enrollment status, activities of daily living, cognitive function, and comorbidity scores to assess the association of transfer with outcomes. RESULTS: A total of 1375 matched resident pairs (n = 2750) were analyzed. The number of hospitalizations did not differ between the transfer and non-transfer groups (173 vs. 160, respectively; p = 0.45). Ninety-day mortality also did not differ between the two groups; however, exact death counts are not reported in accordance with CMS small cell suppression rules. In adjusted analysis, transfer status was not associated with higher odds of 90-day hospitalization (OR = 1.18 [95% CI: 0.91, 1.53]) or death (OR = 1.58 [95% CI: 0.27, 9.40]). CONCLUSION: Among long-term NH residents, transfer to another NH was not associated with a higher risk of hospitalization or mortality within 90 days post-transfer. These findings suggest that NH-to-NH transfers, when necessary, may not inherently increase severe acute health risks for this population.
Gettel CJ, Rothenberg C, Kitchen C
… +6 more, Song Y, Hastings SN, Hwang U, Fischer MA, Shenvi CL, Venkatesh AK
J Am Geriatr Soc
· 2026 Jun · PMID 42287122
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STUDY OBJECTIVE: Emergency department (ED) visits among older adults represent critical transition points in health care, often resulting in substantial downstream utilization. We aimed to quantify health care contact da...STUDY OBJECTIVE: Emergency department (ED) visits among older adults represent critical transition points in health care, often resulting in substantial downstream utilization. We aimed to quantify health care contact days in the 30 days following a treat-and-release ED visit among older adults and examine associations with demographic and clinical characteristics. METHODS: We conducted a pooled cross-sectional analysis of 2016-2021 Medicare Current Beneficiary Survey data. The sample included treat-and-release ED visits among beneficiaries ≥ 65 years. Health care contact days were categorized as institutional (ED, hospital, skilled nursing facility, hospice) and ambulatory (outpatient visits, labs, imaging, procedures, or treatments). We applied zero-inflated Poisson regression to estimate the likelihood and intensity of health care contact. RESULTS: The analytic sample comprised 10,964 treat-and-release ED visits. Within 30 days, 22.5% of visits resulted in institutional contact and 84.4% in ambulatory contact. On average, each ED visit was followed by 4.3 total contact days (3.0 ambulatory, 1.3 institutional) within 30 days. Having ≥ 2 chronic conditions was associated with greater odds of both institutional (OR: 1.46, 95% CI: 1.28-1.66) and ambulatory contact (OR: 1.44, 95% CI: 1.25-1.66). Dementia was associated with reduced odds of ambulatory contact (OR: 0.51, 95% CI: 0.37-0.72). CONCLUSIONS: Older adults experience frequent and sustained health care contact following treat-and-release ED visits, with particularly high intensity among those with multi-morbidity. Reduced ambulatory follow-up among patients with dementia highlights a potential gap in care coordination after ED discharge.
Gray SL, Piccorelli AV, Hart LA
… +4 more, Cook AJ, Williamson BD, Balderson BH, Phelan EA
J Am Geriatr Soc
· 2026 Jun · PMID 42281185
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BACKGROUND: Little is known about substitution of alternative medications in the context of deprescribing. The objectives were to: (1) determine the frequency of medication substitutions among those who discontinued a ce...BACKGROUND: Little is known about substitution of alternative medications in the context of deprescribing. The objectives were to: (1) determine the frequency of medication substitutions among those who discontinued a central nervous system (CNS)-active medication, and (2) characterize substitutions as potentially inappropriate (as per the 2023 Beers Criteria) versus not. METHODS: We conducted a secondary analysis that combined data from the intervention and usual care arms from the STOP-FALLS deprescribing trial that tested a health-system-embedded intervention designed to reduce prescription of CNS-active medications. This analysis focused on participants followed for 360 days following baseline with chronic use of opioids, benzodiazepines, tricyclic antidepressants, skeletal muscle relaxants, or Z-drugs. Discontinuation was defined as the first date when there was no evidence of a prescription fill for 90 days, thus only participants with a discontinuation that occurred in the first 270 days were included. A list of likely alternative treatments was developed for each target medication. A substitution was operationalized as a new alternative medication prescribed during the 30 days prior to or 60 days after discontinuation of a target medication. RESULTS: The study sample included 2182 individuals (average age 70.5 years, 63.1% female). At baseline, a total of 2415 target medications were prescribed, of which 442 (18.3%) were discontinued. Discontinuation rates varied from 122 (8.0%) for users of opioids to 86 (49.7%) for users of skeletal muscle relaxants. Substitutions were made for 42 (9.5%) drug discontinuations. Of these substitutions, 11 of 42 (26.2%) were to a potentially inappropriate medication: tricyclic antidepressants (n = 5), benzodiazepines (n = 3) and hydroxyzine (n = 3). Other common substitutions included gabapentin, selective serotonin norepinephrine reuptake inhibitors, and trazodone. DISCUSSION: Of medication discontinuations with a substitution, one-quarter were to at least one potentially inappropriate medication. This finding highlights the need for additional guidance for prescribers to ensure safe deprescribing of CNS-active medications.
J Am Geriatr Soc
· 2026 Jun · PMID 42269086
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BACKGROUND: Home and community-based services (HCBS) are home-based services that enable people to remain in their own environment despite challenges related to disease, disability, or age. In rural areas, service availa...BACKGROUND: Home and community-based services (HCBS) are home-based services that enable people to remain in their own environment despite challenges related to disease, disability, or age. In rural areas, service availability may be lower. The purpose of this analysis was to examine rural-urban differences in HCBS use among Veterans enrolled in the Veterans Health Administration (VHA) and identify facility-level variation. METHODS: This cross-sectional study used data from fiscal year 2022 (10/1/21-9/30/22). We incorporated rurality for Veterans (dichotomized as rural/urban based on Rural-Urban Area Commuting Codes) and facilities (proportion of rural Veterans served). VHA payment files identified HCBS use. Regression analyses sequentially adjusted for demographics, comorbidity, Area Deprivation Index (ADI), and facility fixed effects to produce a risk ratio (RR) of HCBS use among rural Veterans (RR > 1.0 indicates higher HCBS use among rural vs. urban Veterans). RESULTS: Of over 6 million enrolled Veterans, 34.1% (n = 2,055,746) were identified as rural. Compared to urban Veterans, rural Veterans were more likely to be older (64.1 ± 16.1 vs. 61.0 ± 17.4 years, p < 0.001), male (92.0% vs. 88.8%, p < 0.001), and white (80.5% vs. 63.7%, p < 0.001). HCBS were used by 5.04% (n = 103,605) of rural Veterans and 5.21% (n = 206,608) of urban Veterans. The unadjusted rural HCBS RR was 0.97 (95% confidence interval (CI) = 0.96-0.97). After adjusting for demographics, comorbidity, ADI, and facility fixed effects, the adjusted RR of HCBS for rural Veterans was 0.92 (95% CI = 0.91-0.93). There was substantial variability across facilities, with rural Veterans ranging from 60% less likely to 167% more likely to use HCBS than urban Veterans (RRs: 0.40-2.67). CONCLUSION: While rural Veterans were less likely to use HCBS overall, there was substantial variability across facilities. These findings demonstrate that some VAMCs counteract the overall trend by ensuring rural Veterans receive HCBS at rates comparable to urban Veterans.
Casey CM, Lesko AC, On H
… +8 more, Marginean H, Anderson W, Leigh S, Haddad YK, Naumann RB, Caulley J, McConnachie J, Hodges MO
J Am Geriatr Soc
· 2026 Jun · PMID 42241717
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BACKGROUND: Universal fall risk screening as a first step to address falls has been endorsed in primary care but remains challenging due to competing clinical priorities and insufficient training. We studied the impact o...BACKGROUND: Universal fall risk screening as a first step to address falls has been endorsed in primary care but remains challenging due to competing clinical priorities and insufficient training. We studied the impact of our geriatric continuing medical education program, the Geriatric Mini-Fellowship (GMF), on the uptake of fall risk screening in primary care over a 5-year period. We hypothesized that primary care providers (PCP) with exposure to the GMF program would be more likely to implement fall risk screening than PCPs without direct or indirect program exposure. POPULATION AND SETTING: We identified 133,068 patients ≥ 65 years of age who received care at primary care clinics in a large health system. METHODS: Each year, we retrospectively assigned patients to one of three groups based on their provider's exposure to the GMF program. Groups included patients seen by: GMF providers who completed GMF training. GMF-influenced providers who practiced at a clinic with at least one GMF provider. Usual care providers who neither completed GMF training nor worked at a clinic with a GMF provider. We described fall risk screening rates and patterns using multivariate models to estimate the predicted probability and odds of being screened each year based on a provider's training exposure. RESULTS: GMF providers were associated with a greater predicted probability of screening patients for fall risk compared to usual care providers each year. Differences in predicted probabilities between GMF providers and usual care with bootstrapped confidence intervals favored GMF providers. Further, this screening advantage increased over time (2019: 5.8%, 2023: 12%). CONCLUSIONS: Our data supports intensive fall risk education on screening through a geriatrics training program to implement sustained fall risk screening in primary care. Screening is the first step in identifying high-risk patients, which can enable assessment of modifiable risk factors and lead to targeted interventions.
Minami CA, Heiling HM, Tayob N
… +17 more, Hughes ME, Snow C, Ryan S, Elfman S, Lima RF, Cunniff E, Kline D, Lo S, Fenton MA, Sinclair S, Smith-Graziani D, Faggen M, Constantine M, Walsh J, Sinclair N, McAllister SS, Freedman RA
J Am Geriatr Soc
· 2026 Jun · PMID 42233444
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