J Am Geriatr Soc
· 2026 Jun · PMID 42095697
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Securing a participant's voluntary, informed consent is widely acknowledged as a requirement of ethical research. Yet, challenges can arise, particularly when a researcher seeks to enroll older adults who may lack the ca...Securing a participant's voluntary, informed consent is widely acknowledged as a requirement of ethical research. Yet, challenges can arise, particularly when a researcher seeks to enroll older adults who may lack the capacity to consent to research participation due to cognitive impairment. To address this challenge, this article outlines a nine-step framework for designing consent processes: (1) identify the participants in the study and assess whether some or all might reasonably be expected to lack decisional capacity; (2) determine whether enrolling participants who lack decisional capacity is justifiable; (3) determine whether informed consent is needed for some or all research procedures; if consent is required, (4) prepare the information that will be provided to prospective participants; (5) make both the information and the consent process accessible; (6) specify how prospective participants' decisional capacity will be assessed; (7) specify how surrogates will be identified and contacted when prospective participants are determined to lack decisional capacity; (8) determine how to involve prospective participants who lack decisional capacity in the decision-making process, such as through assent or dissent; and as appropriate, (9) consider how capacity and consent might change across the duration of the study. This framework can help researchers anticipate and address common challenges and ensure they fulfill ethical and regulatory obligations. Applications of this framework include writing the human subjects portion of grant applications, preparing protocols for submission to an Institutional Review Board, and informing research practice.
Keller MS, Gotanda H, Mays AM
… +2 more, Hoang H, Rosen S
J Am Geriatr Soc
· 2026 May · PMID 42089560
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BACKGROUND: Falls are a leading cause of preventable injury and disability among older adults. Although fall risk screening is routine in the Medicare Annual Wellness Visit (AWV), timely follow-up after a positive screen...BACKGROUND: Falls are a leading cause of preventable injury and disability among older adults. Although fall risk screening is routine in the Medicare Annual Wellness Visit (AWV), timely follow-up after a positive screen is often lacking. We implemented a primary care-based quality improvement initiative to increase the rate of fall risk prevention interventions provided to older adults at elevated fall risk. METHODS: We conducted a retrospective study of patients aged ≥ 65 years who completed an AWV between September 2024 and October 2025 and screened positive for fall risk using a three-item screener and confirmed with an abnormal Timed Up and Go (TUG) test. On January 1, 2025, we implemented a package of two quality improvement strategies to improve the uptake of evidence-based fall prevention interventions. First, we implemented a SmartSet in the Electronic Health Record which guides clinicians to select a clinically appropriate follow-up after a positive fall risk screen, and second, the geriatrics clinic proactively reached out to eligible patients to schedule comprehensive fall and bone health assessments. We evaluated follow-up rates over time. Outcomes measured 120 days post-screening during the AWV included: (1) the proportion of patients ≥ 65 with any documented follow-up action post-screening (physical therapy referral, case management visit, geriatrics referral, or geriatrics clinic visit), (2) any geriatrics referral, (3) any geriatrics visit, (4) any physical therapy referral, and (5) any case management referral. RESULTS: Three hundred thirty-five patients aged ≥ 65 years completed an AWV, screened as positive for fall risk, and had an abnormal TUG. Any follow-up increased from 53.8% to 67.8%. Follow-up geriatrics clinic visits increased from 7.5% to 40.4%. Primary care referral rates to geriatrics, physical therapy referrals and case management referrals remained stable. CONCLUSION: A proactive package of implementation strategies embedded in primary care significantly improved follow-up rates after positive fall risk screening.
Liang S, Lapane KL, Ott BR
… +4 more, Tjia J, Baek J, Yuan Y, Alcusky M
J Am Geriatr Soc
· 2026 May · PMID 42089534
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BACKGROUND: In 2024, 6.9 million Americans lived with Alzheimer's disease and related dementias (ADRD), with nursing homes serving as a major site of care. Antidepressants are the most prescribed psychotropic medications...BACKGROUND: In 2024, 6.9 million Americans lived with Alzheimer's disease and related dementias (ADRD), with nursing homes serving as a major site of care. Antidepressants are the most prescribed psychotropic medications among nursing home residents with ADRD, yet detailed information on prescribing patterns, potential indications, and associated resident and facility characteristics remain limited. METHODS: Using 2018 minimum data set 3.0 assessments linked to Medicare claims, we conducted a cross-sectional study of long-stay nursing home residents aged ≥ 65 years with ADRD who were continuously enrolled in Medicare fee-for-service for 120 days before their annual assessment. We described usage by drug class and type and compared characteristics of users versus non-users overall and by potential indications: depression, anxiety, pain, and insomnia. RESULTS: Among 232,543 residents with ADRD, 51.6% used antidepressants. Fewer than 5% had moderate or severe depressive symptoms (PHQ-9 ≥ 10). Use was highest among residents with depression or anxiety (69.5%), pain (61.9%), and insomnia (60.0%). Among those without these conditions, 14.1% were prescribed antidepressants. SSRIs were the most prescribed class (60.7%) overall. Citalopram, mirtazapine, sertraline, and trazodone were the most common medications. Residents with any current level of depression severity were more likely to use antidepressants compared to those without symptoms, whereas all levels of cognitive impairment were associated with lower use compared with cognitively intact residents with ADRD. Polypharmacy was strongly associated with increased use, while diabetes, heart failure, and stroke were associated with reduced use. CONCLUSIONS: Antidepressants were frequently prescribed to residents with ADRD despite limited documentation of active depressive symptoms. Limitations in accurately capturing depressive symptoms in nursing home records, including underreporting by residents due to cognitive impairment and reliance on staff observation rather than self-report, may contribute to apparent discordance between symptoms and prescribing. Further research should evaluate treatment appropriateness, deprescribing opportunities, and risk-benefit balance of chronic treatment in this population.
Umoh ME, Garcia Morales EE, Zhang W
… +3 more, Brown CH, Oh ES, Reed NS
J Am Geriatr Soc
· 2026 Jun · PMID 42068258
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IMPORTANCE: Delirium is common among hospitalized adults, prevalence estimates ranging from 33% to 50% of hospitalized patients over age 65. Yet, little is known about the association between social determinants of healt...IMPORTANCE: Delirium is common among hospitalized adults, prevalence estimates ranging from 33% to 50% of hospitalized patients over age 65. Yet, little is known about the association between social determinants of health (SDOH) and delirium. OBJECTIVE: To describe neighborhood-level risk factors for hospitalization with delirium. We examined the association between hospitalization with delirium and neighborhood disadvantage, measured by the Area Deprivation Index (ADI)-a tool that measures SDOH by assessing socioeconomic conditions and disadvantages within a geographic area. METHODS: The Atherosclerosis Risk in Communities (ARIC) study is a community-based prospective cohort of adults recruited from four US communities. This analysis included ARIC participants that attended visit 5 (2011-2013) and had at least one hospitalization before visit 7 (2018-2019). Delirium was identified and quantified using hospital claim records. The association between ADI quartiles and incidence and number of delirium events was estimated with offset Poisson regression models for the time participants were observed. Associations were also examined by cognitive status. RESULTS: In this analytic cohort of 4130 participants, 486 (11.8%) experienced at least one hospitalization with delirium. Unadjusted regression analyses showed a higher incidence of delirium (proportion ratio, PR = 1.32; and 95% CI = 1.03, 1.69) and number of delirium events (incidence rate ratio, IRR = 1.30; 95% CI = 1.05, 1.63) among participants from the highest ADI quartile compared to the lowest quartile. In fully adjusted models, this association was attenuated. Among participants with mild cognitive impairment (MCI) and dementia, those from the most disadvantaged neighborhoods experienced a higher incidence and number of delirium events. CONCLUSION: In this cohort of hospitalized older adults, participants from more disadvantaged neighborhoods had a higher incidence of delirium; this association was attenuated in adjusted analyses. This suggests that neighborhood-level social disadvantage may be meaningful in studies on prevention and management of delirium, though overlapping demographic and clinical characteristics likely confound this relationship.
Zhang P, Hanna V, Thai GH
… +4 more, Green CM, Cagle J, Wolff JL, Saylor MA
J Am Geriatr Soc
· 2026 May · PMID 42068255
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BACKGROUND: Supporting involvement and engaging care partners in advance care planning (ACP) conversations is a best practice principle that is especially important in the context of cognitive impairment. This study appl...BACKGROUND: Supporting involvement and engaging care partners in advance care planning (ACP) conversations is a best practice principle that is especially important in the context of cognitive impairment. This study applied an existing decision-making framework (1) autonomous, (2) shared, (3) delegated, and (4) surrogate to describe types of patient and care partner involvement in ACP. METHODS: Deductive content analysis of transcripts from ACP conversations involving 88 older adults with mild (n = 15), moderate (n = 13), and severe (n = 60) cognitive impairment and care partners. RESULTS: Patient involvement in ACP decision-making was highly related to patient level of cognitive impairment. Many older adults with mild cognitive impairment (60%) were able to state clear preferences for end-of-life treatments. With higher severity of cognitive impairment, patients were more reliant on care partners and required a greater level of support. Among older adults with severe impairment, surrogate decision-making with known preferences was most common (48.3%). Delegated decision-making was rare (n = 2) and driven by patient preference rather than cognitive limitation. Care partners shared a common role in supporting patient involvement in each decision-making type, but the required level of support increased with the severity of cognitive impairment. CONCLUSIONS: The findings underscore the vital and evolving role of care partners in ACP for older adults with cognitive impairment. Supporting and intentionally involving care partners early-while respecting patients' preferences for autonomy-may help reduce decisional burden and promote person-centered ACP as cognitive impairment progresses. These insights can inform clinical guidelines on dyad-centered approaches to ACP.
English to Spanish language communication pictogram tool for hospitalized patients.English to Spanish language communication pictogram tool for hospitalized patients.
BACKGROUND: The Alzheimer's Association partnered with health systems in Illinois, Greater Missouri, and Washington to implement and evaluate the Knight Family dementia care coordination (DCC) program, a novel telephone-...BACKGROUND: The Alzheimer's Association partnered with health systems in Illinois, Greater Missouri, and Washington to implement and evaluate the Knight Family dementia care coordination (DCC) program, a novel telephone-based care coordination service that bridged the gap between clinical care and community support. Healthcare providers were trained to systematically identify dementia caregivers and refer them to Alzheimer's Association care consultants who provided personalized education, resources, and support. This innovative model addressed critical care coordination gaps in dementia care delivery. METHODS: A mixed-methods process evaluation assessed DCC implementation and caregiver outcomes. Caregivers completed validated surveys at baseline and follow-up, including the PROMIS Self-Efficacy for Managing Emotions scale and the general self-efficacy scale (GSE). Surveys also captured action plan uptake, resource utilization, and barriers to implementation. Health system employees completed surveys and structured interviews about program satisfaction and workflow integration. The Consolidated Framework for Implementation Research (CFIR) and the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance) guided identification of barriers, facilitators, and implementation outcomes. RESULTS: Caregiver self-efficacy scores were mixed: approximately 44%-45% improved on the self-efficacy scales at follow-up, while a nearly equal proportion (42%-44%) worsened. Mean PROMIS scores showed no significant change (all p > 0.4), and mean GSE scores declined slightly but significantly at 3 months. Although improvements in self-efficacy were not consistently observed, caregivers demonstrated high program engagement: 70% completed action steps, 80% utilized community resources, and 90% demonstrated comprehension of their individualized action plans. Health system employees reported high program satisfaction, though clinician engagement remained a barrier. CONCLUSIONS: This multi-state evaluation demonstrates the feasibility of implementing a telephone-based dementia care coordination program across diverse health systems and highlighted strong caregiver engagement with program resources. However, self-efficacy outcomes did not show consistent improvement. Controlled trials are needed to determine which caregivers benefit most and whether more intensive or targeted interventions are required.