Annual Wellness Visits and Early Dementia Diagnosis Among Medicare Beneficiaries.

Importance: Early recognition of cognitive impairment is key to optimal dementia care. No previous research has examined the probability of developing mild cognitive impairment (MCI) or Alzheimer disease and related dementias (ADRD) at 5-year follow-up among older adult Medicare beneficiaries by receipt of an annual wellness visit (AWV). Objective: To assess the association of incident AWV with the first ADRD or MCI diagnosis among older adults with Medicare fee-for-service benefits. Design, Setting, and Participants: This retrospective population-based cohort study used 100% Texas fee-for-service Medicare data from 2015 to 2022. Participants comprised 549 516 community-dwelling Medicare beneficiaries aged 68 years or older in 2018, with complete Medicare fee-for-service Parts A and B and no Medicare Advantage plan enrollment for 2015 to 2018. Exposure: Medicare AWVs. Main Outcomes and Measures: The first MCI or ADRD diagnosis (reported as MCI or ADRD diagnosis, MCI diagnosis, and ADRD diagnosis) from the AWV index date in 2018 through December 31, 2022. Results: In this cohort study of 549 516 Medicare beneficiaries with no diagnosis of MCI or ADRD in 2015 to 2017 (mean [SD] age, 76.7 [6.6] years; 289 932 women [52.8%]), 66 433 (12.1%) had an incident AWV in 2018. Annual wellness visit recipients were more likely than those who did not receive an AWV to be female, to be non-Hispanic White (followed by Hispanic, non-Hispanic Black, and other), to have more education, to reside in a metropolitan area, to have more comorbidities, and to have a primary care professional in the 12 months before the AWV index date. After propensity score matching, AWV receipt was associated with a 21% increase in MCI diagnosis (hazard ratio, 1.21 [95% CI, 1.16-1.27]) and a 4% increase in ADRD diagnosis (hazard ratio, 1.04 [95% CI, 1.02-1.06]). The increase in MCI diagnosis associated with AWV was larger when the AWV was censored or treated as a time-dependent covariate in the follow-up period. Conclusions and Relevance: These findings indicate that AWV recipients had a timelier first MCI diagnosis than those who did not receive an AWV, but first ADRD diagnosis differed little. This study suggests that the Medicare AWV health policy may increase MCI identification, prompting more specialized care.

Improving Hurricane Preparedness Among Galveston County Older Adults: Description of a Successful Community-Based Quality Improvement Model.

Older adults are at high risk of experiencing injury, exacerbations of their chronic conditions, and death when evacuations are ordered because of hurricanes or natural disasters. The Homebound seniors residing in Galveston County are at a particularly high risk of morbidity and mortality during evacuations for hurricanes. This paper described the impact of a quality improvement intervention designed and implemented by nurse practitioners during the 2022 and 2023 hurricane season. The education program aimed at increasing the hurricane preparedness of the home-bound patients. Of these patients, 190 returned pre and post surveys. Interventions showed a 43% increase in patients having an evacuation plan in the event of a hurricane, 633% increase in STEAR registration, 16% increase in patients having access to emergency supplies, and 34% increase in patients having an emergency contact list with up-to-date medication list. All improvements on hurricane preparedness items were significant (p < .0001) except for the need for assistance in case of an evacuation. Our findings suggest a need for continuous hurricane preparedness education in the community to ensure safe evacuation, improve hurricane preparation, and increase the number of seniors who registered with the State of Texas Emergency Assistance Registry.

The impact of medication-assisted treatment for opioid use disorder on congestive heart failure outcomes.

Congestive heart failure (CHF) and opioid use disorder (OUD) commonly coexist and are major contributors to high healthcare utilization in the United States. Medication assisted treatment (MAT; e.g., buprenorphine and methadone) reduces opioid-related mortality by about 50 %; yet little is known about how OUD treatment impacts CHF outcomes in patients with both CHF and OUD. We examined the impact of MAT (buprenorphine, methadone, and naltrexone) on CHF outcomes in patients diagnosed with OUD and CHF, and which MAT (buprenorphine or methadone) medication is associated with the fewest CHF outcomes. A retrospective cohort study of patients 18 years or older diagnosed with both CHF and OUD was conducted using Optum's de-identified Clinformatics® Data Mart Database. Multivariate logistic regression modeling was used to compared patients who were prescribed MAT to those who were not. The primary outcomes were CHF hospitalizations and CHF emergency department visits. No significant differences in the primary outcomes between the MAT and non-MAT cohorts were observed. In conclusion, the lack of association of MAT with negative CHF outcomes suggest that life-saving MAT can be safely used for OUD treatment in the CHF setting.

Trends in the use of granulocyte colony stimulating factors for older patients with cancer, 2010 to 2019.

INTRODUCTION: Older patients with cancer receiving myelosuppressive treatment are at an increased risk for developing febrile neutropenia (FN) or having chemotherapy dose-reductions or delays, resulting in suboptimal health outcomes. Granulocyte colony stimulating factors (G-CSF) are effective medications to reduce these adverse events and are recommended for patients ≥65 years receiving chemotherapy with >10 % FN risk. We sought to characterize the trends and predictors of G-CSF use between the youngest-old (66-74 years), middle-old (75-84 years), and oldest-old (≥85 years) patients with cancer. MATERIALS AND METHODS: We used registry data from SEER-Medicare for breast, lung, ovarian, colorectal, esophageal, gastric, uterine, prostate, pancreatic cancer, and non-Hodgkin lymphoma (NHL) diagnoses from 2010 to 2019. Cox proportional hazard analysis was used. RESULTS: Overall, 41.4 % of patients received G-CSF from chemotherapy initiation to three days after completion of the first chemotherapy course. The use rate remained relatively stable for all cancers, except for an increase in use for those with pancreatic cancer. G-CSF use decreased as patients got older. The oldest-old were 43.0 % (95 % confidence interval: 40.7-45.2 %) less likely to receive G-CSF compared to the youngest-old. Patients with breast cancer or NHL were more likely to receive G-CSF than those with other cancers. Patients who were female, married, White or Hispanic, and had fewer comorbidities were more likely to receive G-CSF. DISCUSSION: G-CSF is used less often in populations at higher risk of developing FN and related complications. Improving adherence to recommendations can improve health outcomes, especially in the oldest adults, older males, and Black patients.

Central nervous system active medication use in Medicare enrollees receiving home health care: association with chronic pain and anxiety level.

ABSTRACT: No comparative effectiveness data exist on nonopioid analgesics and nonbenzodiazepine anxiolytics to treat pain with anxiety. We examined the relationship between drug class and central nervous system (CNS) active drug polypharmacy on pain and anxiety levels in Medicare enrollees receiving home health (HH) care. This retrospective cohort study included enrollees with diagnoses and 2+ assessments of pain and anxiety between HH admission and discharge. Three sets of linear regression difference-in-reduction analyses assessed the association of pain or anxiety reduction with number of drugs; drug type; and drug combinations in those with daily pain and daily anxiety. Logistic regression analysis assessed the effect of medication number and class on less-than-daily pain or anxiety at HH discharge. A sensitivity analysis using multinomial regression was conducted with a three-level improvement to further determine clinical significance. Of 85,403 HH patients, 43% received opioids, 27% benzodiazepines, 26% gabapentinoids, 32% selective serotonin reuptake inhibitors, and 8% serotonin and norepinephrine reuptake inhibitors (SNRI). Furthermore, 75% had depression, 40% had substance use disorder diagnoses, and 6.9% had PTSD diagnoses. At HH admission, 83%, 35%, and 30% of patients reported daily pain, daily anxiety, and both, respectively. Central nervous system polypharmacy was associated with worse pain control and had no significant effect on anxiety. For patients with daily pain plus anxiety, pain was best reduced with one medication or any drug combination without opioid/benzodiazepine; anxiety was best reduced with combinations other than opiate/benzodiazepine. Gabapentinoids or SNRI achieved clinically meaningful pain control. Selective serotonin reuptake inhibitors provided clinically meaningful anxiety relief.

Addressing the Need for Universal Cognitive Assessment Among Older Adults With Congestive Heart Failure.

Congestive heart failure (CHF) and cognitive impairment (CI) are common in older age and often occur together. However, CI is often unrecognized leading to more hospitalizations and increased morbidity and mortality in patients with co-occurring CHF and CI. Universal screening can help identify these patients earlier and the use of the Institute of Healthcare Improvement's (IHI) 4Ms Framework (i.e. "What Matters, Medication, Mentation, and Mobility") can serve as a tool for providers to meet patients' needs surrounding goals of care, medication regimens, mental and emotional well-being, and mobility capabilities through a social determinants of health lens. Providers should engage in serious illness conversations early to honor patient preferences, reduce polypharmacy, use a validated instrument to assess cognition such as the Mini-Cog or Functional Activities Questionnaire, and assess the need for assistance completing activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Consultation with social work is highly recommended given the complexity of the medical and social needs of newly discharged cognitively impaired CHF patients and the need to optimize the use of all available community resources.

Patterns of gabapentinoid use among long-term opioid users.

OBJECTIVE: Understanding the clinical and demographic profile of patients on gabapentinoids can highlight areas of prescribing disparities, inform clinical practice, and guide future research to optimize effectiveness and safety of gabapentinoids for pain management. We used a national sample of Medicare beneficiaries to examine trends, patterns, and patient-level predictors of gabapentinoid use among long-term opioid users. METHODS: Using a national Medicare sample between 2014 and 2020, we examined factors associated with gabapentinoid use among long-term opioid users. We included Medicare eligible long-term opioid users with no prior gabapentinoid use. The primary outcome was gabapentinoid use after the long-term opioid use episode. Logistic regression was used to test the association with gabapentinoid use for year, age, sex, race/ethnicity, region, Medicare entitlement, low-income status, frailty, pain locations, anxiety, depression, opioid use disorder, and opioid morphine milligrams equivalent. RESULTS: Gabapentinoid use among long-term opioid users increased from 12.6% in 2014 to 16.8% in 2019 (p < .0001). Factors associated with increased gabapentinoid use were Hispanic ethnicity, back pain, nerve pain, and moderate or high opioid usage. Factors associated with decreased gabapentinoid use were older age and Medicare entitlement due to old age. CONCLUSIONS: Variation of gabapentinoid use by socio-demographics and insurance status indicates opportunities to improve pain management and a need for shared therapeutic decision making informed by discussion between pain patients and providers regarding safety and effectiveness of pain therapies. Our findings underscore the need for future research into the comparative effectiveness and safety of gabapentinoids for non-cancer chronic pain in various subpopulations.

Vision Impairment and Frailty Among Mexican American Older Adults: A Longitudinal Study.

We examined the relationship between vision impairment (VI) and new-onset frailty among non-frail Mexican American older adults (≥70 years) at baseline and determined the differential impact of VI on each frailty criteria. Data were from an 18-year prospective cohort from the Hispanic Established Population for the Epidemiologic Study of the Elderly (1998/1999, N = 1072 to 2016, N = 175). Frailty was defined as ≥3 criteria: unintentional weight loss of >10 pounds, weakness, exhaustion, low physical activity, and slowness. VI was defined as difficulty in recognizing a friend at arm's length's away, across the room, or across the street. We found that participants with VI (near or distant) and distant VI had greater odds of frailty (near or distant VI, OR = 1.89, 95% CI = 1.30-2.73 and distant VI, OR = 1.95, 95% CI = 1.34-2.86, respectively) after controlling for covariates over time. Early screening (optimal management) of VI may prevent or delay onset of frailty among older Mexican Americans.

Trends in co-prescribed opioids and benzodiazepines, non-prescribed opioids and benzodiazepines, and schedule-I drugs in the United States, 2013 to 2019.

Concurrent opioid and benzodiazepine users are at increased risk of overdose death, compared to opioid-only users. The objective of this study was to understand recent time trends in opioid and benzodiazepine concurrent use, misuse, and schedule-I drug use, and how these differ by age, sex and geographic region. Commercial, United States medical insurance claims data and urine drug test results from 2013 to 2019 were used to study the outcomes of concurrent use (n = 756,258), schedule-I drug use (n = 746,672) and prescription misuse (n = 452,523). Drug use outcomes were studied at quarterly time points for each year. Data analysis included joinpoint regression models to estimate quarterly drug use rates, determined by positive urine tests for corresponding drug categories, and was conducted from November 2021 through January 2022. Concurrent use decreased from 19.3% to 9.8%, misuse generally decreased from 75.6% to 55.1%, and schedule-I use increased from 8.9% to 13.8%, from 2013 to 2019. Concurrent use decreased at greater rates after 2016, after the Centers for Disease Control and Food and Drug Administration guidelines against concurrent use were released, while schedule-I use increased, notably after the 2014 hydrocodone reschedule. This indicates a potential shift from prescription use to non-prescribed drug use, where most affected groups included males, younger individuals, and those residing in Northeastern regions. Study results support public health initiatives focused on policy that increases access to multimodal pain management and substance use disorder management programs-critical steps in preventing patients from seeking non-prescribed drugs for self- medicating due to pain or addiction.

Pain Control Associated With Gabapentinoid Prescription After Elective Total Knee Arthroplasty.

BACKGROUND: Gabapentinoid (GABA) prescribing has substantially increased as a nonopioid analgesics for surgical conditions. We examined the effectiveness of GABA use for postoperative pain control among patients receiving total knee arthroplasty (TKA). METHODS: This retrospective cohort study using 2016 to 2019 data from a 20% national sample of Medicare enrollees included patients aged 66 and over years who received an elective TKA, were discharged to home, received home health care, and had both admission and discharge assessments of pain (n = 35,186). Study outcomes were pain score difference between admission and discharge and less-than-daily pain interfering with activity at discharge. Opioid and GABA prescriptions after surgery and receipt of nerve block within 3 days of surgery were also assessed. RESULTS: There were 30% of patients who had a pain score decrease of 3 to 4 levels and 55.8% had pain score decreases of 1 to 2 levels. In multivariable analyses, receiving a nerve block was significantly associated with pain score reduction. A GABA prescription increased the magnitude of pain score reduction among those receiving a nerve block. Results from inverse probability weighted analysis with propensity score showed that coprescribing of GABA and low-dose opioid was associated with significantly lower pain scores. CONCLUSIONS: Post-TKA opioid use was not associated with pain score reduction. Receiving a nerve block was associated with a modest pain score reduction. Co-prescribing GABA with low-dose opioid or receiving a nerve block was associated with increasing magnitudes of pain reduction. Further research should identify alternatives to opioid use for managing postoperative TKA pain.

Trends in Diabetes Medication Taking and Incidence of Depression in Patients with Type 2 Diabetes: A Retrospective Cohort Study from 2010 to 2018.

BACKGROUND: This study examined the trends in diabetes medication taking and its association with the incidence of depression in patients with type 2 diabetes (T2D). METHOD: A retrospective cohort of Medicare enrollees with regular care in 2010 was defined from 100% Texas Medicare claims. The impact of medication taking on incident depression was evaluated from 2010 to 2018. Cox proportional hazards regressions were used to estimate the association between medication taking and depression. RESULTS: A total of 72,461 patients with T2D and with regular care were analyzed. Among 60,216 treated patients, the regular medication taking rate slightly increased from 60.8 to 63.2% during the study period. Patients with regular medication taking at baseline had a 9% lower risk of developing depression (hazard ratio [HR]: 0.91, 95% confidence interval [CI]: 0.89-0.94), and the magnitude of the association increased after adjustment of the model for time-varied medication taking (HR: 0.82, 95% CI: 0.79-0.85). The presence of nephropathy had the greatest mediating effect (23.2%) on the association of medication taking and depression. CONCLUSION: We demonstrated a steady but modest increase in regular diabetes medication taking over a 9-year period and a significant relationship between medication taking and incident depression in patients with T2D.

Comparative effectiveness of pain control between opioids and gabapentinoids in older patients with chronic pain.

ABSTRACT: Gabapentinoid (GABA) prescribing has substantially increased while opioid prescribing has decreased since the 2016 Centers for Disease Control and Prevention Guidelines restricted opioid prescribing for chronic pain. The shift to GABA assumes equal analgesic effectiveness to opioids, but no comparative analgesic effectiveness data exist to support this assumption. We compared GABA to opioids by assessing changes in pain interfering with activities (activity-limiting pain) over time in patients with chronic pain. We used 2017 to 2019 data from a 20% national sample of Medicare beneficiaries diagnosed with chronic pain who initiated a GABA or opioid prescription for ≥30 continuous days and received home health care in the study year. The main outcome was the difference in reduction in pain score from pre- to post-prescription assessments between the 2 groups. Within a 60-day window before-and-after drug initiation, our sample comprised 3208 GABA users and 2846 opioid users. Reduction in post-prescription scores of pain-related interference with activities to less-than-daily pain was 48.1% in the GABA group and 41.7% in the opioid group; this remained significant (odds ratio = 1.29, 95% confidence interval: 1.17-1.43, P < 0.0001) after adjustment for patient demographics and comorbidities. The adjusted difference in reduced pain-related interference score between the 2 groups was -0.10 points on a 0 to 4 scale ( P = 0.01). Gabapentinoid use had greater odds of less-than-daily pain post-prescription, in a dose-dependent manner. Thus, GABA use was associated with a larger reduction in chronic pain than opioids, with a larger effect at higher GABA dosage. Future research is needed on functional outcomes in patients with chronic pain prescribed GABA or opioids.

Signal detection of adverse events associated with gabapentinoid use for chronic pain.

INTRODUCTION: Gabapentinoids (GABA) prescribing as a potential and conceivably safer substitute for opioids has substantially increased. Understanding all potential adverse drug events (ADEs) associated with GABA will guide clinical decision-making for pain management. METHODS: A 20% sample of Medicare enrollees with new chronic pain diagnoses in 2017-2018 was selected. GABA users were those with >=30 consecutive days prescription in a year without opioid prescription. Opioid users were similarly defined. The control group used neither of these drugs. Propensity score match across three groups based on demographics and comorbidity was performed. We used proportional reporting ratio (PRR), Gamma Poisson Shrinker, and tree-based scan statistic (TBSS) to detect ADEs within 3, 6, and 12 months of follow-up. RESULTS: Immunity disorder was detected within 3 months of follow-up by PRR compared to opioid use (PRR:2.33), and by all three methods compared to controls. Complications of transplanted organs/tissues and schizophrenia spectrum/other psychotic disorders were consistently detected by PRR and TBSS within 3 months. Skin disorders were detected by TBSS; and stroke was detected by PRR within 3 months compared to opioid use (PRR:4.74). Some malignancies were detected by PRR within 12 months. Other signals detected in GABA users were neuropathy and nerve disorders. CONCLUSIONS: Our study identified expected and unexpected ADE signals in GABA users. Neurological signals likely related to indications for GABA use. Signals for immunity, mental/behavior, and skin disorders were found in the FDA adverse event reporting system database. Unexpected signals of stroke and cancer require further confirmatory analyses to verify.

Pain and incident cognitive impairment in very old Mexican American adults.

BACKGROUND: Studies have investigated the association between pain and cognitive impairment among older adults, but the findings are mixed. We assessed the relationship of activity-limiting pain (pain interference) with incident cognitive impairment and the mediating effect of depressive symptoms among Mexican American adults aged ≥80. METHODS: Data were taken from the Hispanic Established Population for the Epidemiological Study of the Elderly (2010-2016). Pain interference, or pain that limited daily activities in the last 12 months, was categorized into none, untreated pain interference, and treated pain interference. Cognitive impairment was defined as scoring <21 on the Mini-Mental State Examination and difficulty with at least one instrumental activity of daily living. We used general estimation equations to assess this relationship between pain and incident cognitive impairment over the 6-year period (n = 313). RESULTS: Participants reporting both untreated and treated pain interference had higher odds of incident cognitive impairment than those reporting no pain or pain interference (untreated adjusted odds ratio [aOR]: 2.18; 95% confidence interval [CI]: 1.09-4.36; treated aOR: 1.99; 95% CI: 1.15-3.44). Depressive symptoms explained 15.0% of the total effect of untreated pain and 25.3% of treated pain. CONCLUSIONS: Among very old Mexican American adults, both treated and untreated pain interference was associated with incident cognitive impairment. This association was partially mediated by depressive symptoms, underscoring a need for depression screening in patients with chronic pain. Future work is needed to examine mechanistic/causal pathways between pain and subsequent cognitive impairment and the role of pharmacological and non-pharmacological treatments in these pathways.

Inequitable access to nonpharmacologic pain treatment providers among cancer-free U.S. adults.

OBJECTIVE: Using evidence-based nonpharmacologic pain treatments may prevent opioid overuse and associated adverse outcomes. There is limited data on the impact of access-promoting social determinants of health (SDoH: education, income, transportation) on use of nonpharmacologic pain treatments. Our objective was to examine the relationship between SDoH and use of nonpharmacologic pain treatment providers. Our goal was to understand policy-actionable factors contributing to inequity in pain treatment. METHODS: Based on Andersen's Health Utilization Model, this cross-sectional analysis of 2016-2019 Medical Expenditure Panel Survey data evaluated whether use of outpatient nonpharmacologic pain treatment providers is driven by enabling (i.e., advantageous socioeconomic resources) or need (i.e., perceived disability and diagnosed disease) factors. The study sample (unweighted n = 28,188) represented a weighted N = 81,912,730 noninstitutionalized, cancer-free, U.S. adults with pain interference. The primary outcome measured use of nonpharmacologic providers relative to exclusive prescription opioid use or no treatment (i.e., neither opioids nor nonpharmacologic). To quantify equitable access, we compared the variance-between access-promoting enabling factors versus medical need factors-that explained utilization. RESULTS: Compared to enabling factors, need factors explained twice the variance predicting pain treatment utilization. Still, the adjusted odds of using nonpharmacologic providers instead of opioids alone were 39% lower among respondents identifying as Black (95% Confidence Interval [CI], 0.49-0.76) and respondents residing in the U.S. South (95% CI, 0.51-0.74). Higher education (95% CI, 1.72-2.79) and income (95% CI, 1.68-2.42) both facilitated using nonpharmacologic providers instead of opioids. CONCLUSIONS: These findings highlight the substantial influence access-promoting SDoH have on pain treatment utilization.

Access to Medications for Opioid Use Disorder During COVID-19: Retrospective Study of Commercially Insured Patients from 2019-2022.

INTRODUCTION: This study assesses disparities in medications for opioid use disorder in adults with opioid use disorder and examines the associations between state-level COVID-19 lockdown and telehealth policies and medications for opioid use disorder utilization rates during the COVID-19 pandemic. METHODS: This retrospective cohort study of 396,872 adults with opioid use disorder analyzed monthly medications for opioid use disorder utilization rates between January 2019 and June 2022 using data from Clinformatics Data Mart Database. Primary outcome measure was monthly medications for opioid use disorder utilization rates. Variables of interest were patients' demographics and state-level characteristics (telehealth policies for controlled substance prescribing, COVID-19 lockdown policy, and registered buprenorphine providers/100,000). In multivariable analyses, time trend was grouped into four time periods: before COVID-19, early COVID-19, early vaccine, and Omicron-related COVID-19 surge and thereafter. RESULTS: Medications for opioid use disorder rates increased from a 1.2% change in slope monthly on a log scale to 2% monthly from February 2021 to October 2021, after which the utilization rate increased to a lesser degree. Women had 28% lower odds of receiving medications for opioid use disorder than men; Hispanic, Black, and Asian patients had 40%, 34%, and 32% lower odds of receiving medications for opioid use disorder than White patients, respectively. These sex and racial disparities persisted throughout the pandemic. Regional medications for opioid use disorder rate differences, mediated by buprenorphine providers/100,000 state population, decreased during the pandemic. States with telehealth policies for controlled substance prescribing had greater percentages of patients on medications for opioid use disorder (11.7%) than states without such policies (10.4%). CONCLUSIONS: Monthly medications for opioid use disorder rates increased during the pandemic, with higher rates in men, White individuals, and residents of the Northeast region. States with policies permitting telehealth prescribing of controlled substances also had higher medications for opioid use disorder rates, supporting a future expansion of medications for opioid use disorder-related telehealth to improve access to care.

Acculturation and Disparities in Telemedicine Readiness: A National Study.

Telemedicine provided older adults the ability to safely seek care during the coronavirus disease (COVID-19) pandemic. This study aimed to evaluate the potential impact of acculturation factors in telemedicine uptake between ethnic groups. As part of the National Health and Aging Trends Study 2018 survey, 303 participants (≥65 years) were interviewed. We assessed the impact of acculturation on telemedicine readiness by race and ethnicity. Compared to the white non-Hispanic immigrant population, Hispanic and Asian/Pacific Islander (API) populations had significantly lower telemedicine readiness and uptake. Limited English proficiency or older age at the time of migration was associated with telemedicine unreadiness and uptake in the Hispanic and API populations. Our findings suggested that acculturation factors play a substantial role in telemedicine uptake among older adult immigrants in the United States. Therefore, acculturation factors should be considered when promoting and adopting telemedicine technologies in older adults.