Emergency department visits and hospital readmissions after a deprescribing intervention among hospitalized older adults.

BACKGROUND: Deprescribing is the planned/supervised method of dose reduction or cessation of medications that might be harmful, or no longer be beneficial. Though benefits of deprescribing are debatable in improving clinical outcomes, it has been associated with decreased number of potentially inappropriate medications, which may potentially reduce the risk of adverse events among hospitalized older adults. With unclear evidence for deprescribing in this population, this study aimed to examine time-to-first unplanned healthcare utilization, which included 90-day emergency department (ED) visits or hospital readmission and associated predictors, during a deprescribing intervention. METHODS: A secondary data analysis of a clinical trial (Shed-MEDS NCT02979353) was performed. Cox regression was used to compare the time-to-first 90-day ED visit/readmission/death from hospital discharge for the intervention and control groups. Additionally, we performed exploratory analysis of predictors (comorbidities, functional health status, drug burden index (DBI), hospital length of stay, health literacy, food insecurity, and financial burden) associated with the time-to-first 90-day ED visit/readmission/death. RESULTS: The hazard of first 90-day ED visits/readmissions/death was 15% lower in the intervention versus the control group (95% CI: 0.61-1.19, p = 0.352, respectively); however, this difference was not statistically significant. For every additional number of comorbidities (Hazard ratio (HR): 1.12, 95% CI: 1.04-1.21) and each additional day of hospital length of stay (HR: 1.04, 95% CI: 1.01-1.07) were significantly associated with a higher hazard of 90-day ED visit/readmission/death in the intervention group; whereas for each unit of increase in pre-hospital DBI score (HR: 1.08 and HR 1.16, respectively) was significantly associated with a higher hazard of 90-day ED visit/readmission/death in the control group. CONCLUSIONS: The intervention and control groups had comparable time-to-first 90-day ED visit/readmission/death during a deprescribing intervention. This finding suggests that deprescribing did not result in a higher risk of ED visit/readmission/death during the 90-day period following hospital discharge.

Acceptability and Feasibility of a Pain and Depressive Symptoms Management Intervention in Middle-Aged and Older African American Women.

Background and Objectives: The intersection of race, gender, and age puts older African American women at high risk of experiencing comorbid pain and depressive symptoms. The purpose of this study was to assess the feasibility and acceptability of a 12-week behavioral activation intervention to target self-selected goals related to pain and depressive symptoms in middle-aged and older African American women. Research Design and Methods: This randomized waitlist control study included 34 self-identified African American women, 50 years of age or older, with moderate-to-severe chronic pain and depressive symptoms. The intervention consisted of 8 in-person or virtual 1-hour visits with a nurse. Follow-up acceptability assessments were conducted with 10 participants. Results: The average age of the participants was 64.8 (standard deviation [SD] 10.5). They reported an average pain intensity score of 7.0 (SD 1.9) out of 10 and an average Patient Health Questionnaire-9 depressive symptoms score of 11.9 (SD 4.0) at baseline. Of the 34 participants who consented, 28 (82.4%) women started the intervention and 23 (82.1%) completed the intervention. Participants described the study as useful and beneficial. Participants recommended including a group component in future iterations. Effect sizes at 12 weeks were -0.95 for depressive symptoms indicating a substantial decrease in experienced depressive symptoms, but pain intensity was virtually unchanged (+0.09). Discussion and Implications: The findings of this study demonstrate that the intervention is acceptable among middle-aged and older African American women and their personal goals were met. Including a group component and identifying effective ways to decrease attrition rates will be key in the next steps of development for this intervention. It is crucial to provide tailored, nonpharmacological approaches to pain, and depression symptom management in older adult populations who experience inequities in pain and mental health outcomes. This study emphasizes the importance of participant-driven goal-setting interventions.

Older Black Americans' Perspectives on Structural Racism-Resilience as a Form of Resistance.

PURPOSE: The purpose of this study was to develop a deep understanding of the lived experiences of structural racism and discrimination among older Black Americans' and their perceptions of structural racism across their lives. We also considered individual and community resilience capacity and response in the face of systemic racism. METHODS: In-depth interviews were conducted with Black community-dwelling adults aged 55 and older in and around Baltimore City. The interview guide used nine contexts to explore perceptions and experiences with structural racism over the life course. Two researchers used reflexive thematic analysis to code and analyze the data. RESULTS: Participants endorsed structural racism to varying degrees across contexts of education, employment, neighborhood, healthcare, and income/wealth. Participants who denied structural racism placed blame for Black underachievement on factors such as personal and community deficiencies, unsafe neighborhoods, and institutional indifference. There was broad agreement about the existence of structural racism within the domains of policing and violence but participants were largely ambivalent about other domains such as environment, media, and civics. Resilience factors that helped individuals to resist and rebound from racism emerged as an unexpected and important theme. CONCLUSIONS: We used Public Health Critical Race Praxis and the Cells to Society frameworks to contextualize these findings. Due to the ubiquitous nature of racism, individuals may not fully appreciate the impact of structural racism and its impact on Black well-being. This ordinariness of racism is harmful but may simultaneously contribute to resilience within Baltimore's Black community.

Barriers and facilitators to deprescribing before surgery: A qualitative study of providers and older adults.

INTRODUCTION: Deprescribing, the collaborative process between providers and patients to streamline medication regimen, may reduce the risk of adverse events following surgery among older adults with multimorbidity. However, barriers and facilitators to deprescribing for surgery has not been explored. METHODS: We conducted a qualitative study of Primary Care Providers (PCP) and patients aged 65 and older who were scheduled for surgery. We used the Theoretical Domains Framework, which informed the interview guide and analysis. RESULTS: A total of 16 participants (n=8 providers, n=8 patients) were included. Themes were regarding: 1) attitudes towards deprescribing before surgery, 2) perceived benefits of deprescribing before surgery, 3) patient-provider relationship and shared decision-making, 4) hope for surgery, 5) barriers to deprescribing before surgery, and 6) preferences for deprescribing follow-up. CONCLUSION: Our study findings regarding provider- and patient-related barriers and facilitators for deprescribing and desired processes before surgery may inform future deprescribing intervention targets before surgery.

The Person Beneath the Hair: Hair Discrimination, Health, and Well-Being.

Discrimination toward black hair is pervasive in today's society. Hair discrimination is negative bias manifested toward black natural or textured hair styles typically worn by persons of African descent. This commentary discusses the potential effects of hair discrimination on the health and well-being of persons of African descent. Specifically, it explores the mental and physical health implications of hair discrimination and situates it within the broader context of social determinants of health. The Creating a Respectful and Open World for Natural Hair Act has been recently passed in the United States House of Representatives, but more work is needed to eliminate hair discrimination and its negative effects.

The Life-Course Perspectives of Mexican American Men With Mobility Limitation.

The life-history narratives of 10 Mexican American men with mobility limitations, age 55-77 years (mean = 63.8, SD = 5.8), were explored using a qualitatively driven, life-history mixed-methods study to understand perceptions of mobility limitations over the life course. Within that methodological and paradigmatic framework, conceptualizations of alterity and masculinity guided interpretation of data. Through an iterative, thematic analysis, we detail the way the men's lives were influenced by growing familial responsibility with age. Quantitative data were integrated into themes of narrative inheritance, family, and masculinity. It was posited that masculinity with mobility limitations shaped and was shaped by ethnic identity and responsibility. This has implications for understanding the experience of Mexican American men over the life course.

A protocol for a wait list control trial of an intervention to improve pain and depressive symptoms among middle-aged and older African American women.

BACKGROUND: Pain and depression frequently co-occur among older adults with comorbidities and can exacerbate one another. The intersection of race, gender and age puts older African American women at high risk of experiencing comorbid pain and depression. The purpose of this study is to test the feasibility and acceptability of a 12-week behavioral activation intervention called DAPPER (Depression and Pain Perseverance through Empowerment and Recovery) that uses non-pharmacological, tailored strategies to target pain and mood symptoms. We will measure pain intensity and depressive symptoms as outcomes, although we are not powered to test differences. METHODS: We describe the protocol for this study that uses a randomized waitlist control design to examine acceptability and feasibility of an intervention. The study population is comprised of self-identified African American women, 50 years of age or older with chronic pain and who self-report of depressive symptoms. Participants must also be pre-frail or frail and have an ADL or IADL limitation. The intervention consists of eight 1-2-h visits with a nurse interventionist via in-person or virtual telecommunication methods and two visits for non-invasive specimen collection. The primary outcomes include goal attainment, pain and depressive symptoms. Secondary outcomes include stress, frailty, and communication with providers. Follow-up qualitative interviews are conducted with participants to assess intervention acceptability. DISCUSSION: Findings from this pilot study will provide further evidence supporting the use of non-pharmacological techniques to intervene in the cycle of pain and depression among an at-risk sub-population.

Perioperative insomnia trajectories and functional outcomes after total knee arthroplasty.

ABSTRACT: Longitudinal total knee arthroplasty (TKA) studies indicate that a substantial percentage of patients continue to experience clinically significant pain and functional impairment after surgery. Insomnia has been associated with poorer surgical outcomes; however, previous work has largely focused on long-term postsurgical insomnia. This study builds on previous work by examining sleep and pain outcomes about perioperative insomnia trajectories. Insomnia symptoms (using the Insomnia Severity Index) during the acute perioperative period (2 weeks pre-TKA to 6 weeks post-TKA) were used to classify participants into perioperative insomnia trajectories: (1) No Insomnia (ISI < 8), (2) New Insomnia (baseline < 8; postoperative ≥ 8 or ≥6-point increase), (3) Improved Insomnia (baseline ≥ 8, postoperative < 8 or ≥6-point decrease), and (4) Persistent Insomnia (ISI ≥ 8). Insomnia, pain, and physical functioning were assessed in participants with knee osteoarthritis (n = 173; M age = 65 ± 8.3, 57.8% female) at 5 time points: 2 weeks pre-TKA, post-TKA: 6 weeks, 3 months, 6 months, and 12 months. Significant main effects were seen for insomnia trajectory and time, and trajectory-by-time interactions for postoperative insomnia, pain severity, and physical functioning ( P' s < 0.05). The Persistent Insomnia trajectory had the worst postoperative pain at all follow-ups and marked insomnia and physical functioning impairment post-TKA ( P' s < 0.05). The New Insomnia trajectory had notable long-term insomnia (6 weeks to 6 months) and acute (6 weeks) postoperative pain and physical functioning ( P' s < 0.05). Findings indicated a significant relationship between perioperative insomnia trajectory and postoperative outcomes. Results of this study suggest that targeting presurgical insomnia and preventing the development of acute postoperative insomnia may improve long-term postoperative outcomes, with an emphasis on persistent perioperative insomnia due to poorer associated outcomes.

Pandemic-Related Changes in Technology Use Among a Sample of Previously Hospitalized Older Adult New Yorkers: Observational Study.

BACKGROUND: The COVID-19 pandemic increased the importance of technology for all Americans, including older adults. Although a few studies have indicated that older adults might have increased their technology use during the COVID-19 pandemic, further research is needed to confirm these findings, especially among different populations, and using validated surveys. In particular, research on changes in technology use among previously hospitalized community-dwelling older adults, especially those with physical disability, is needed because older adults with multimorbidity and hospital associated deconditioning were a population greatly impacted by COVID-19 and related distancing measures. Obtaining knowledge regarding previously hospitalized older adults' technology use, before and during the pandemic, could inform the appropriateness of technology-based interventions for vulnerable older adults. OBJECTIVE: In this paper, we 1) described changes in older adult technology-based communication, technology-based phone use, and technology-based gaming during the COVID-19 pandemic, compared to before the COVID-19 pandemic and 2) tested whether technology use moderated the association between changes in in-person visits and well-being, controlling for covariates. METHODS: Between December 2020 and January 2021 we conducted a telephone-based objective survey with 60 previously hospitalized older New Yorkers with physical disability. We measured technology-based communication through three questions pulled from the National Health and Aging Trends Study COVID-19 Questionnaire. We measured technology-based smart phone use and technology-based video gaming through the Media Technology Usage and Attitudes Scale. We used paired t tests and interaction models to analyze survey data. RESULTS: This sample of previously hospitalized older adults with physical disability consisted of 60 participants, 63.3% of whom identified as female, 50.0% of whom identified as White, and 63.8% of whom reported an annual income of $25,000 or less. This sample had not had physical contact (such as friendly hug or kiss) for a median of 60 days and had not left their home for a median of 2 days. The majority of older adults from this study reported using the internet, owning smart phones, and nearly half learned a new technology during the pandemic. During the pandemic, this sample of older adults significantly increased their technology-based communication (mean difference=.74, P=.003), smart phone use (mean difference=2.9, P=.016), and technology-based gaming (mean difference=.52, P=.030). However, this technology use during the pandemic did not moderate the association between changes in in-person visits and well-being, controlling for covariates. CONCLUSIONS: These study findings suggest that previously hospitalized older adults with physical disability are open to using or learning technology, but that technology use might not be able to replace in-person social interactions. Future research might explore the specific components of in-person visits that are missing in virtual interactions, and if they could be replicated in the virtual environment, or through other means.

OLDER ADULTS' SUBJECTIVE WELL-BEING EXPERIENCING THE EXERGAME "I AM DOLPHIN".

The objective of this study was to understand older adults' perceptions of the connections between an exergame intervention, "I Am Dolphin," and their subjective well-being. Researchers conducted three focus groups with 14 older adults who participated in the exergame feasibility study. The semi-structured focus groups were transcribed, coded, and analysed using deductive and inductive techniques. Three themes were constructed related to playing the exergame and participants' subjective well-being: 1) elevated mood (through scheduled activity, immersion, and socialization), 2) feelings of achievement (especially following frustration and competition), and 3) perceived cognitive or physical changes. These findings will help researchers better understand how exergames may relate to the well-being of older adults. Future investigators could use these findings to create and implement new exergame interventions.

Older Adults and Three-Dimensional Exergaming: Motivators and Barriers to Participation and Retention.

Background: Cognitive and physical activity are important for daily functioning. However, limited research exists on the motivators and barriers associated with older adults participating and adhering to exergame studies that promote physical and cognitive activity. Our objective was to examine older adults' motivators and barriers to joining and completing a three-dimensional exergame study. Methods: Fourteen older adults who participated in the exergame study contributed to one of three focus group discussions. Inductive and deductive methods were used to analyze the qualitative data. Results: Motivators for joining were generativity, peer referrals, self-improvement, and curiosity. Accomplishment, immersion, and exercise were motivators for retention. Participants also cited the structured schedule and adaptive difficulty features as motivators for retention. Barriers to participation included frustration due to lack of level advancement and fatigue/pain during gameplay. Some (n = 3) reported camera tracking issues as a barrier. Unanticipated gender-based trends arose when examining perceptions of the study team's role and motivators for retention. Conclusion: These findings will inform future research strategies for participant recruitment, enrollment, and retention, in addition to providing insights into the design of motivating, enjoyable, and sustainable exergames for older adults.

The relationship between older adults' technology use, in-person engagement, and pandemic-related mental health.

OBJECTIVE: The objectives of this study are to 1) describe changes in in-person communication/activity and changes in older adult technology use during the COVID-19 pandemic and 2) examine whether less in-person communication/activity mediates the relationship between pandemic-related mental health and technology use. METHOD: Linear regressions (stratified by age and financial strain) and structural equation modeling were employed using a nationally representative, cross-sectional survey of 3,188 older adults from the 2020 National Health and Aging Trends Study's COVID-19 Questionairre. RESULTS: Older adults engaged in more technology-based activity (b = 0.24; p<.001), more technology-based health care communication (b = 0.22; p<.001), and more technology-based food acquisition (b = 0.21; p<.001) during the COVID-19 pandemic, as compared to before the pandemic. Results indicate that adults <80 years old demonstrated greater increases in technology-based activity, technology-based health communication, and technology-based food acquisition, compared to adults ≥80 years old. Change in in-person communication significantly mediated the relationship between pandemic-related mental health and technology-based communication (standardized coefficient= -0.012; p=.005), and change in in-person activity significantly mediated the relationship between pandemic-related mental health and technology-based activity (standardized coefficient= -0.017; p=.020). CONCLUSIONS: This study suggests that older adults are utilizing technology more, and therefore should be considered in technology design and dissemination. Technology use could be an important positive response to help those with pandemic related worries stay safely engaged with friends and family. Technologies should be produced that are modifiable for older adults with disabilities and affordable for older adults with fixed incomes.

Depressive Symptoms in Older African Immigrants with Mobility Limitations: A Descriptive Study.

OBJECTIVES: Before, during, and after their immigration to the United States, immigrants face stressful life circumstances that may render them at risk for depressive symptoms. However, there is a dearth of research on the mental health of African immigrants. We performed secondary data analyses of two studies in the Baltimore-Washington area to describe and identify correlates of depressive symptoms in older African immigrants. METHODS: Chi square tests, one-way ANOVAs, and linear regressions were used to describe and examine associations between depressive symptoms and immigrant-related risk factors. RESULTS: This sample included 148 participants who had a mean age of 62 (SD ± 8.2). Clinical depressive symptoms were present in 8.1% of participants, and trouble falling asleep for more than half of the days was the most prevalent symptom (20%). Levels of education, income, and migration reasons differed significantly from clinical depressive symptoms, but these were not significantly associated with more depressive symptoms after controlling for covariates. CONCLUSIONS: Longitudinal designs may further elucidate incidence, correlates, and long-term effects of depressive symptoms within this population. CLINICAL IMPLICATIONS: Knowledge of depressive symptom burden and risk factors can inform timely assessment, referral, and treatment of depressive symptoms and other mental health outcomes in older African immigrants.

Considerations of Intersectionality for Older Adults with Palliative Care Needs in the Emergency Department: An Integrative Review.

Purpose of Review: We sought to identify current interventions, research, or non-research evidence that has direct or indirect consideration of intersectionality in the care of older adults in the emergency department (ED). An integrative review informed by Crenshaw's Theory of Intersectionality was conducted in accordance with Whittemore and Knafl's five-stage methodology. A rigorous review process determined appropriateness for inclusion, and articles were analyzed for areas related to direct or indirect relationship to intersectionality. Recent Findings: Older adults aged 60 and above in the United States (US) account for more than 20% of ED visits annually, and half of older adults will visit the ED in their last year of life. There has been a growing focus on adapting the ED to meet the palliative care needs of older adults, but relatively little consideration has been given to older adults' intersectional identities. Summary: Six articles were identified that provided indirect insights into the status of intersectionality in ED-based palliative care for older adults. Two areas of interest were identified: (1) intersectional elements or reference to such elements embedded within the studies; and (2) the challenges of adapting quantitative methodologies to incorporate variables and approaches that would allow for intersectional analysis. This review highlights areas for future research along with recommendations for adopting an intersectional framing into commonly used methodologies.

The impact of low back pain and vigorous activity on mental and physical health outcomes in older adults with arthritis.

Background: Nearly 50% of Americans aged 65 and above have been diagnosed with arthritis and an estimated 80% of adults experience low back pain (LBP). Little is known about the experience of LBP in older adults with arthritis and its relationships with mental and physical health. Objective: In this study, we examined the relationships between LBP and four physical and mental health conditions (psychological distress, insomnia, mobility limitations, and self-rated health) in older adults with arthritis in the National Health and Aging Trends Study (NHATS). We also examined whether vigorous exercise mediated the relationships between LBP and these four conditions. Materials and Methods: The data from this study comes from waves five through nine of the NHATS. The sample size ranged from 3,490 to 2,026 across these waves. All variables in this study are based on self-report. We used descriptive analyses including means and standard deviations for continuous variables or frequencies and proportions for demographic data. We used structural equation modeling (SEM) to examine if vigorous activity mediated the relationship between LBP with the four conditions. Results: The age range of the sample was 65 years of age and older. Among those with back pain 78.53% had no mobility limitations. There was a significant relationship between LBP with insomnia (B = 0.48, p < 0.001), perceived health status (B = -0.38, p < 0.0010), and psychological distress (0.67, p < 0.001). Activity mediated the relationship between LBP and insomnia, psychological distress and physical health in adjusted models. Discussion: The presence of low back pain in older adults with arthritis increases the risk of insomnia, psychological distress, mobility limitations, and poorer self-rated health. Consequently, targeting comorbid LBP may be an important component of the treatment plans of older adults with arthritis. In addition, providers of patients with arthritis and LBP should conduct routine assessments of mental and physical health to ensure the LBP is being adequately addressed.

Exploring the Experiences of Co-morbid Pain and Depression in Older African American Women and Their Preferred Management Strategies.

The intersection of race, gender, and age places older African American women at an increased risk for untreated physical pain and depression that can significantly diminish their quality of life. The objectives of this study were to (1) explore older African American women's perceptions of pain and depressive symptoms and how these symptoms influence each other, and (2) explore effective pain and depression alleviation strategies used by the women. We conducted five focus groups with older African American women (N = 18). We used deductive coding to analyze focus group transcripts and qualitative description to summarize themes. We identified five major themes: (1) Spiritual Suffering from Linked Pain and Depression, (2) Lack of Understanding from Healthcare Providers, (3) Push Through and Live Through, (4) Medications Not Worth the Risk and, (5) Strategies for Pain and Depression. This study offers insight into the experiences of pain and depression in older African American women, and alleviation strategies they perceive as effective. These qualitative findings may be used to inform interventions for older African American women who experience pain and depressive symptoms.

Pain catastrophizing: A patient-centered approach to assessment.

ABSTRACT: Pain is a subjective experience and its perception and expression vary widely. Pain catastrophizing, which refers to patients' thoughts or feelings about their pain, may impact their communication of pain and nurses' subsequent response. This article discusses how nurses can more readily recognize, assess, and manage pain catastrophizing.

Prevalence of functional limitations among foreign and US-born Black older adults: 2010-2016 National Health Interview Surveys.

OBJECTIVE: To determine whether the prevalence of functional limitations in United States (US) born differs from that of foreign-born Black older adults. DESIGN: We performed a cross-sectional analysis of data from 14,438 US-born and 1583 foreign-born Black older adults (≥50 years) in the 2010-2016 National Health Interview Surveys (NHIS). Functional limitations were defined by upper and lower extremity limitations, and global functional limitations. Generalized linear modeling using a Poisson distribution and logarithmic link function was used to compare the predicted probabilities of functional limitations in both groups. RESULTS: The mean age (SE) of US-born Blacks was 63.56 (0.12) years and foreign-born Blacks was 62.06 (0.32). The majority (92%) of foreign-born Blacks had resided in the US for ≥10 years. US-born older adults were more likely to have upper (46% vs. 29%, p < .001) and lower (61% vs. 40%, p < .001) extremity limitations than foreign-born Blacks. The prevalence of lower extremity limitations was 22% less in foreign-born Blacks compared to US-born Blacks after adjusting for sociodemographic and health profiles (Prevalence Ratio [PR]: 0.78, 95% CI:0.73-0.84). The adjusted prevalence of upper extremity limitations in foreign-born Blacks was 27% (PR: 0.73, 95% CI: [0.68-0.79]), compared to US-born Black older adults. And that of global functional limitations was 22% less (PR: 0.78, 95% CI [0.73-0.83]) in foreign-born compared to US-born Blacks. CONCLUSION: Compared to their US-born counterparts, foreign-born Black older adults had a markedly lower prevalence of upper and lower extremity functional limitations. Future comparative studies should examine reasons for this apparent health advantage among foreign-born adults to inform social and medical interventions to prevent functional decline in Black older adults in the US.