Prevalent Atherosclerotic Cardiovascular Disease Among Veterans by Sexual Orientation.

Background: Seven million lesbian, gay, and bisexual (LGB) adults will be aged >50 years by 2030; assessing and addressing their risk for cardiovascular disease is critical.

Methods And Results: We analyzed a nationwide cohort using the Veterans Health Administration data. Sexual orientation (SO) was classified via a validated natural language processing algorithm.

Social Determinants of Health and Delivery of Rehabilitation to Older Adults During ICU Hospitalization.

Importance: Older adults with socioeconomic disadvantage develop a greater burden of disability after critical illness than those without socioeconomic disadvantage. The delivery of in-hospital rehabilitation that can mitigate functional decline may be influenced by social determinants of health (SDOH). Whether rehabilitation delivery differs by SDOH during critical illness hospitalization is not known.

High-Intensity Care for Nursing Home Residents with Severe Dementia Hospitalized at the End of Life: A Mixed Methods Study.

Objective: For nursing home residents with severe dementia, high-intensity medical treatment offers little possibility of benefit but has the potential to cause significant distress. Nevertheless, mechanical ventilation and intensive care unit (ICU) transfers have increased in this population. We sought to understand how and why such care is occurring.

Antimicrobial resistance in and urine isolates from a national sample of home-based primary care patients with dementia.

Annual prevalences of antimicrobial resistance among urine isolates (3,913 isolates and 1,736 isolates) from home-based primary care patients with dementia were high between 2014 and 2018 (ciprofloxacin, 18%-23% and 5%-7%, respectively; multidrug resistance, 9%-11% and 5%-6%, respectively). Multidrug resistance varied by region. Additional studies of antimicrobial resistance in home-care settings are needed.

Effect of Computer-Tailored Print Feedback, Motivational Interviewing, and Motivational Enhancement Therapy on Engagement in Advance Care Planning: A Randomized Clinical Trial.

Importance: There is a tension between clinician-led approaches to engagement in advance care planning (ACP), which are effective but resource-intensive, and self-administered tools, which are more easily disseminated but rely on ability and willingness to complete.

Objective: To examine the efficacy of computer-tailored print feedback (CTPF), motivational interviewing (MI), and motivational enhancement therapy (MET) on completion of a set of ACP activities, each as compared with usual care.

Design, Setting, And Participants: This randomized clinical trial was conducted from October 2017 to December 2020 via telephone contact with primary care patients at a single VA facility; 483 veterans aged 55 years or older were randomly selected from a list of patients with a primary care visit in the prior 12 months, with oversampling of women and people from minoritized racial and ethnic groups.

Benefits and harms of oral anticoagulants for atrial fibrillation in nursing home residents with advanced dementia.

Background: Approximately 20% of older persons with dementia have atrial fibrillation (AF). Nearly all have stroke risks that exceed the guideline-recommended threshold for anticoagulation. Although individuals with dementia develop profound impairments and die from the disease, little evidence exists to guide anticoagulant discontinuation, and almost one-third of nursing home residents with advanced dementia and AF remain anticoagulated in the last 6 months of life.

Development and validation of a prediction model for persistent functional impairment among older ICU survivors.

Background: Critical illness often leads to persistent functional impairment among older Intensive Care Unit (ICU) survivors. Identification of high-risk survivors prior to discharge from their ICU hospitalization can facilitate targeting for restorative interventions after discharge, potentially improving the likelihood of functional recovery. Our objective was to develop and validate a prediction model for persistent functional impairment among older adults in the year after an ICU hospitalization.

National Cohort Study of Homebound Persons Living With Dementia: Antibiotic Prescribing Trends and Opportunities for Antibiotic Stewardship.

Background: Over 7 million older Americans are homebound. Managing infections in homebound persons presents unique challenges that are magnified among persons living with dementia (PLWD). This work sought to characterize antibiotic use in a national cohort of PLWD who received home-based primary care (HBPC) through the Veterans Health Administration.

Aggressive End-of-Life Care in the Veterans Health Administration versus Fee-for-Service Medicare among Patients with Advanced Lung Cancer.

Unlike fee-for-service Medicare, the Veterans Health Administration (VHA) allows for the provision of concurrent care, incorporating cancer treatment while in hospice. We compared trends of aggressive care at end of life between Medicare and VHA decedents with advanced nonsmall cell lung cancer from 2006 to 2012, and the relation between regional level end-of-life care between Medicare and VHA beneficiaries. Among 18,371 Veterans and 25,283 Medicare beneficiaries, aggressive care at end of life decreased 15% in VHA and 4% in SEER (Surveillance, Epidemiology, and End Results)-Medicare ( < 0.

Perceived dementia risk and advance care planning among older adults.

Background: Although advance care planning (ACP) is beneficial if dementia develops, and virtually all older adults are at risk for this disease, older adults do not consistently engage in ACP. Health behavior models have highlighted the importance of perceived susceptibility to medical conditions in motivating behavior. Following these models, we sought to determine how often older adults believe they are not at risk of developing dementia and to examine the association between perceived dementia risk and ACP participation.

Association Between Socioeconomic Disadvantage and Decline in Function, Cognition, and Mental Health After Critical Illness Among Older Adults : A Cohort Study.

Background: Older adults admitted to an intensive care unit (ICU) are at risk for developing impairments in function, cognition, and mental health. It is not known whether socioeconomically disadvantaged older persons are at greater risk for these impairments than their less vulnerable counterparts.

Objective: To evaluate the association between socioeconomic disadvantage and decline in function, cognition, and mental health among older survivors of an ICU hospitalization.

Association of Social Isolation With Disability Burden and 1-Year Mortality Among Older Adults With Critical Illness.

Importance: Disability and mortality are common among older adults with critical illness. Older adults who are socially isolated may be more vulnerable to adverse outcomes for various reasons, including fewer supports to access services needed for optimal recovery; however, whether social isolation is associated with post-intensive care unit (ICU) disability and mortality is not known.

Objectives: To evaluate whether social isolation is associated with disability and with 1-year mortality after critical illness.

Effect of the STAMP (Sharing and Talking About My Preferences) Intervention on Completing Multiple Advance Care Planning Activities in Ambulatory Care : A Cluster Randomized Controlled Trial.

Background: Interventions with the potential for broad reach in ambulatory settings are necessary to achieve a life course approach to advance care planning.

Objective: To examine the effect of a computer-tailored, behavioral health model-based intervention on the engagement of adults in advance care planning recruited from ambulatory care settings.

Design: Cluster randomized controlled trial with participant-level analysis.

Anticoagulant Use for Atrial Fibrillation Among Persons With Advanced Dementia at the End of Life.

This cross-sectional study evaluates the degree of anticoagulant use among nursing home residents with advanced dementia and atrial fibrillation at the end of life.

Engagement in Non-Medical End-of-Life Planning by Older Adults.

Context: While medical end-of-life planning has been well characterized, less is known about non-medical planning to prepare for the end of life.

Objectives: To determine the prevalence of engagement in non-medical end-of-life (EOL) planning and its relationship to medical EOL planning.

Methods: Three hundred and four persons age 65 and older recruited from physician offices and a senior center were administered an in-person interview asking about participation in the following non-medical EOL planning behaviors: moving to a location with more help, teaching someone to do things around the house, purchasing long-term care insurance, telling someone the location of important documents, preparing a financial will, conveying wishes for funeral arrangements, purchasing a cemetery plot, and prepaying for a funeral.

Concurrent Hospice Care and Cancer-Directed Treatment for Advanced Lung Cancer and Receipt of Aggressive Care at the End of Life in the Veteran's Health Administration.

Aggressive care at the end of life (EOL) is a persistent issue for patients with stage IV nonsmall cell lung cancer (NSCLC). We evaluated the use of concurrent care (CC) with hospice care and cancer-directed treatment simultaneously within the Veteran's Health Administration (VHA) and aggressive care at the EOL. To determine whether VHA facility-level CC is associated with changes in aggressive care at the EOL.

Feasibility of Delivering a Tailored Intervention for Advance Care Planning in Primary Care Practice.

Background/objectives: To determine the feasibility of conducting a cluster randomized controlled trial providing individualized feedback reports to increase advance care planning (ACP) engagement in the primary care setting.

Design: Pilot cluster randomized controlled trial.

Setting: Two primary care practices selected for geographic colocation.

Assessment of Surrogates' Knowledge of Patients' Treatment Goals and Confidence in Their Ability to Make Surrogate Treatment Decisions.

This study uses telephone interviews of patients and their surrogates to evaluate surrogates’ knowledge of patients’ treatment goals and confidence in their ability to make patients’ treatment decisions.

Effect of the Tool to Reduce Inappropriate Medications on Medication Communication and Deprescribing.

Objectives: To examine the effect of the Tool to Reduce Inappropriate Medications (TRIM), a web tool linking an electronic health record (EHR) to a clinical decision support system, on medication communication and prescribing.

Design: Randomized clinical trial.

Setting: Primary care clinics at a Veterans Affairs Medical Center.

Pioglitazone after Ischemic Stroke or Transient Ischemic Attack.

Background: Patients with ischemic stroke or transient ischemic attack (TIA) are at increased risk for future cardiovascular events despite current preventive therapies. The identification of insulin resistance as a risk factor for stroke and myocardial infarction raised the possibility that pioglitazone, which improves insulin sensitivity, might benefit patients with cerebrovascular disease.

Methods: In this multicenter, double-blind trial, we randomly assigned 3876 patients who had had a recent ischemic stroke or TIA to receive either pioglitazone (target dose, 45 mg daily) or placebo.

Development of Personalized Health Messages to Promote Engagement in Advance Care Planning.

Objectives: To develop and test the acceptability of personalized intervention materials to promote advance care planning (ACP) based on the Transtheoretical Model (TTM), in which readiness to change is a critical organizing construct.

Design: Development study creating an expert system delivering TTM-personalized feedback reports and stage-matched brochures with more-general information on ACP and modifications based on participant reviews.

Setting: Senior centers.

A comparison of the willingness of resident and attending physicians to comply with the requests of patients at the end of life.

Background: Little is known about the differences between physicians in training and post training in their willingness to comply with patient requests at the end of life.

Objective: To compare the attitudes of attendings and residents regarding a range of patient requests at the end of life

Design: Written, cross-sectional survey

Participants: The cohort included 191 attendings randomly selected across the state of Connecticut and 240 residents from 2 university-affiliated Internal Medicine programs.

Main Measures: We surveyed attendings and residents about their willingness to honor the requests of the same decisionally capable elderly patient in five scenarios involving different requests regarding end-of-life treatment.

Modifiable risk factors for pneumonia requiring hospitalization of community-dwelling older adults: the Health, Aging, and Body Composition Study.

Objectives: To identify novel modifiable risk factors, focusing on oral hygiene, for pneumonia requiring hospitalization of community-dwelling older adults.

Design: Prospective observational cohort study.

Setting: Memphis, Tennessee, and Pittsburgh, Pennsylvania.

A pilot randomized controlled trial of a decision support tool to improve the quality of communication and decision-making in individuals with atrial fibrillation.

Objectives: To design a tool for nonvalvular atrial fibrillation (NVAF) to inform individuals of their individual stroke and bleeding risks, assist in clarifying priorities, and promote communication.

Design: Clustered randomized controlled trial.

Setting: Primary care clinics.