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. Objective: To evaluate whether SDOH are associated with the delivery of skilled rehabilitation during critical illness hospitalization among older adults. Design, Setting, and Participants: This cohort study used data from the National Health and Aging Trends Study linked with Medicare claims (2011-2018). Participants included older adults hospitalized with a stay in the intensive care unit (ICU). Data were analyzed from August 2022 to September 2023. Exposures: Dual eligibility for Medicare and Medicaid, education, income, limited English proficiency (LEP), and rural residence. Main Outcome and Measures: The primary outcome was delivery of physical therapy (PT) and/or occupational therapy (OT) during ICU hospitalization, characterized as any in-hospital PT or OT and rate of in-hospital PT or OT, calculated as total number of units divided by length of stay. Results: In the sample of 1618 ICU hospitalizations (median [IQR] patient age, 81.0 [75.0-86.0] years; 842 [52.0%] female), 371 hospitalizations (22.9%) were among patients with dual Medicare and Medicaid eligibility, 523 hospitalizations (32.6%) were among patients with less than high school education, 320 hospitalizations (19.8%) were for patients with rural residence, and 56 hospitalizations (3.5%) were among patients with LEP. A total of 1076 hospitalized patients (68.5%) received any PT or OT, with a mean rate of 0.94 (95% CI, 0.86-1.02) units/d. After adjustment for age, sex, prehospitalization disability, mechanical ventilation, and organ dysfunction, factors associated with lower odds of receipt of PT or OT included dual Medicare and Medicaid eligibility (adjusted odds ratio, 0.70 [95% CI, 0.50-0.97]) and rural residence (adjusted odds ratio, 0.65 [95% CI, 0.48-0.87]). LEP was associated with a lower rate of PT or OT (adjusted rate ratio, 0.55 [95% CI, 0.32-0.94]). Conclusions and Relevance: These findings highlight the need to consider SDOH in efforts to promote rehabilitation delivery during ICU hospitalization and to investigate factors underlying inequities in this practice.

Home Health Care Use and Outcomes After Coronary Artery Bypass Grafting Among Medicare Beneficiaries.

BACKGROUND: Home health care (HHC) has been increasingly used to improve care transitions and avoid poor outcomes, but there is limited data on its use and efficacy following coronary artery bypass grafting. The purpose of this study was to describe HHC use and its association with outcomes among Medicare beneficiaries undergoing coronary artery bypass grafting. METHODS: Retrospective analysis of 100% of Medicare fee-for-service files identified 77 331 beneficiaries undergoing coronary artery bypass grafting and discharged to home between July 2016 and December 2018. The primary exposure of HHC use was defined as the presence of paid HHC claims within 30 days of discharge. Hierarchical logistic regression identified predictors of HHC use and the percentage of variation in HHC use attributed to the hospital. Propensity-matched logistic regression compared mortality, readmissions, emergency department visits, and cardiac rehabilitation enrollment at 30 and 90 days after discharge between HHC users and nonusers. RESULTS: A total of 26 751 (34.6%) of beneficiaries used HHC within 30 days of discharge, which was more common among beneficiaries who were older (72.9 versus 72.5 years), male (79.4% versus 77.4%), White (90.2% versus 89.2%), and not Medicare-Medicaid dual eligible (6.7% versus 8.8%). The median hospital-level rate of HHC use was 31.0% (interquartile range, 13.7%-54.5%) and ranged from 0% to 94.2%. Nearly 30% of the interhospital variation in HHC use was attributed to the discharging hospital (intraclass correlation coefficient, 0.296 [95% CI, 0.275-0.318]). Compared with non-HHC users, those using HHC were less likely to have a readmission or emergency department visit, were more likely to enroll in cardiac rehabilitation, and had modestly higher mortality within 30 or 90 days of discharge. CONCLUSIONS: A third of Medicare beneficiaries undergoing coronary artery bypass grafting used HHC within 30 days of discharge, with wide interhospital variation in use and mixed associations with clinical outcomes and health care utilization.

Staffing and Antipsychotic Medication Use in Nursing Homes and Neighborhood Deprivation.

Importance: Inappropriate use of antipsychotic medications in nursing homes is a growing public health concern. Residents exposed to higher levels of socioeconomic deprivation in the area around a nursing home may be currently exposed, or have a long history of exposure, to more noise pollution, higher crime rates, and have less opportunities to safely go outside the facility, which may contribute to psychological stress and increased risk of receiving antipsychotic medications inappropriately. However, it is unclear whether neighborhood deprivation is associated with use of inappropriate antipsychotic medications and whether this outcome is different by facility staffing levels. Objective: To evaluate whether reported inappropriate antipsychotic medication use differs in severely and less severely deprived neighborhoods, and whether these differences are modified by higher levels of total nurse staffing. Design, Setting, and Participants: This was a cross-sectional analysis of a national sample of nursing homes that linked across 3 national large-scale data sets for the year 2019. Analyses were conducted between April and June 2023. Exposure: Neighborhood deprivation status (severe vs less severe) and total staffing hours (registered nurse, licensed practical nurse, certified nursing assistant). Main Outcome and Measures: This study estimated the association between neighborhood deprivation and the percentage of long-stay residents who received an antipsychotic medication inappropriately in the nursing home at least once in the past week and how this varied by nursing home staffing through generalized estimating equations. Analyses were conducted on the facility level and adjusted for state fixed effects. Results: This study included 10 966 nursing homes (1867 [17.0%] in severely deprived neighborhoods and 9099 [83.0%] in less deprived neighborhoods). Unadjusted inappropriate antipsychotic medication use was greater in nursing homes located in severely deprived neighborhoods (mean [SD], 15.9% [10.7%] of residents) than in those in less deprived neighborhoods (mean [SD], 14.2% [8.8%] of residents). In adjusted models, inappropriate antipsychotic medication use was higher in severely deprived neighborhoods vs less deprived neighborhoods (19.2% vs 17.1%; adjusted mean difference, 2.0 [95% CI, 0.35 to 3.71] percentage points) in nursing homes that fell below critical levels of staffing (less than 3 hours of nurse staffing per resident-day). Conclusions and Relevance: These findings suggest that levels of staffing modify disparities seen in inappropriate antipsychotic medication use among nursing homes located in severely deprived neighborhoods compared with nursing homes in less deprived neighborhoods. These findings may have important implications for improving staffing in more severely deprived neighborhoods.

Demystifying the Digital Divide: Disparities in Telerehabilitation Readiness Among Older Adults in the United States.

OBJECTIVE: To estimate readiness of older rehabilitation users in the United States to participate in video-based telerehabilitation and assess disparities in readiness among racial and ethnic minoritized populations, socioeconomically disadvantaged populations, and rural-dwelling older adults. DESIGN: Retrospective cohort study using nationally representative survey data from the National Health and Aging Trends Study from 2015 and 2020. Survey-weighted regression models, accounting for complex survey design, were used to generate estimates of readiness and evaluate disparities across racial and ethnic, socioeconomic, and geographic subgroups. Odds ratios (OR) and 95% confidence intervals (CIs) were estimated for each comparison. SETTING: Home or community rehabilitation environments. PARTICIPANTS: A cohort of 5274 home or community-based rehabilitation users aged 70 years or older (N=5274), representing a weighted 33,576,313 older adults in the United States. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): Video-based telerehabilitation readiness was defined consistent with prior work; unreadiness was defined as lacking ownership of internet-enabled devices, limited proficiency of use, or living with severe cognitive, visual, or hearing impairment. Telerehabilitation readiness was categorized as "Ready" or "Unready". RESULTS: Approximately 2 in 3 older rehabilitation users were categorized as ready to participate in video-based rehabilitation. Significantly lower rates of readiness were observed among those living in rural areas (OR=0.75, 95% CI: 0.60-0.94), financially strained individuals (OR=0.37, 95% CI: 0.26-0.53), and among individuals identifying as Black or Hispanic (as compared with non-Hispanic White older adults: Non-Hispanic Black [OR=0.23, 95% CI: 0.18-0.30]; Hispanic [OR=0.17, 95% CI: 0.11, 0.27]). CONCLUSIONS: Our findings highlight significant disparities in the readiness to uptake video-based telerehabilitation. Policy and practice interventions to address telerehabilitation readiness should focus not only on improving broadband access but also on technology ownership and training to ensure equitable adoption in populations with lower baseline readiness.

Tackling Brain and Muscle Dysfunction in Acute Respiratory Distress Syndrome Survivors: National Heart, Lung, and Blood Institute Workshop Report.

Acute respiratory distress syndrome (ARDS) is associated with long-term impairments in brain and muscle function that significantly impact the quality of life of those who survive the acute illness. The mechanisms underlying these impairments are not yet well understood, and evidence-based interventions to minimize the burden on patients remain unproven. The National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health assembled a workshop in April 2023 to review the state of the science regarding ARDS-associated brain and muscle dysfunction, to identify gaps in current knowledge, and to determine priorities for future investigation. The workshop included presentations by scientific leaders across the translational science spectrum and was open to the public as well as the scientific community. This report describes the themes discussed at the workshop as well as recommendations to advance the field toward the goal of improving the health and wellbeing of ARDS survivors.

Impact of dementia and socioeconomic disadvantage on days at home after traumatic brain injury among older Medicare beneficiaries: A cohort study.

INTRODUCTION: Time spent at home may aid in understanding recovery following traumatic brain injury (TBI) among older adults, including those with Alzheimer's disease and related dementias (ADRD). We examined the impact of ADRD on recovery following TBI and determined whether socioeconomic disadvantages moderated the impact of ADRD. METHODS: We analyzed Medicare beneficiaries aged ≥65 years diagnosed with TBI in 2010-2018. Home time was calculated by subtracting days spent in a care environment or deceased from total follow-up, and dual eligibility for Medicaid was a proxy for socioeconomic disadvantage. RESULTS: A total of 2463 of 20,350 participants (12.1%) had both a diagnosis of ADRD and were Medicaid dual-eligible. Beneficiaries with ADRD and Medicaid spent markedly fewer days at home following TBI compared to beneficiaries without either condition (rate ratio 0.66; 95% confidence interval [CI] 0.64, 0.69). DISCUSSION: TBI resulted in a significant loss of home time over the year following injury among older adults with ADRD, particularly for those who were economically vulnerable. HIGHLIGHTS: Remaining at home after serious injuries such as fall-related traumatic brain injury (TBI) is an important goal for older adults. No prior research has evaluated how ADRD impacts time spent at home after TBI. Older TBI survivors with ADRD may be especially vulnerable to loss of home time if socioeconomically disadvantaged. We assessed the impact of ADRD and poverty on a novel DAH measure after TBI. ADRD-related disparities in DAH were significantly magnified among those living with socioeconomic disadvantage, suggesting a need for more tailored care approaches.

Trajectories of Recovery Following Traumatic Brain Injury Among Older Medicare Beneficiaries.

It is well-known that older adults have poorer recovery following traumatic brain injury (TBI) relative to younger adults with similar injury severity. However, most older adults do recover well from TBI. Identifying those at increased risk of poor recovery could inform appropriate management pathways, facilitate discussions about palliative care or unmet needs, and permit targeted intervention to optimize quality of life or recovery. We sought to explore heterogeneity in recovery from TBI among older adults as measured by home time per month, a patient-centered metric defined as time spent at home and not in a hospital, urgent care, or other facility. Using data obtained from Medicare administrative claims data for years 2010-2018, group-based trajectory modeling was employed to identify unique trajectories of recovery among a sample of United States adults age 65 and older who were hospitalized with TBI. We next determined which patient-level characteristics discriminated poor from favorable recovery using logistic regression. Among 20,350 beneficiaries, four unique trajectories were identified: poor recovery (n = 1929; 9.5%), improving recovery (n = 2,793; 13.7%), good recovery (n = 13,512; 66.4%), and declining recovery (n = 2116; 10.4%). The strongest predictors of membership in the poor relative to the good recovery trajectory group were diagnosis of Alzheimer's disease and related dementias (ADRD; odd ratio [OR] 2.42; 95% confidence interval [CI] 2.16, 2.72) and dual eligibility for Medicaid, a proxy for economic vulnerability (OR 5.13; 95% CI 4.59, 5.74). TBI severity was not associated with recovery trajectories. In conclusion, this study identified four unique trajectories of recovery over one year following TBI among older adults. Two-thirds of older adults hospitalized with TBI returned to the community and stayed there. Recovery of monthly home time was complete for most by 3 months post injury. An important sub-group comprising 10% of patients who did not return home was characterized primarily by eligibility for Medicaid and diagnosis of ADRD. Future studies should seek to further characterize and investigate identified recovery groups to inform management and development of interventions to improve recovery.

The interaction between geriatric and neighborhood vulnerability: Delineating prehospital risk among older adult emergency general surgery patients.

BACKGROUND: When presenting for emergency general surgery (EGS) care, older adults frequently experience increased risk of adverse outcomes owing to factors related to age ("geriatric vulnerability") and the social determinants of health unique to the places in which they live ("neighborhood vulnerability"). Little is known about how such factors collectively influence adverse outcomes. We sought to explore how the interaction between geriatric and neighborhood vulnerability influences EGS outcomes among older adults. METHODS: Older adults, 65 years or older, hospitalized with an AAST-defined EGS condition were identified in the 2016 to 2019, 2021 Florida State Inpatient Database. Latent variable models combined the influence of patient age, multimorbidity, and Hospital Frailty Risk Score into a single metric of "geriatric vulnerability." Variations in geriatric vulnerability were then compared across differences in "neighborhood vulnerability" as measured by variations in Area Deprivation Index, Social Vulnerability Index, and their corresponding subthemes (e.g., access to transportation). RESULTS: A total of 448,968 older adults were included. For patients living in the least vulnerable neighborhoods, increasing geriatric vulnerability resulted in up to six times greater risk of death (30-day risk-adjusted hazards ratio [HR], 6.32; 95% confidence interval [CI], 4.49-8.89). The effect was more than doubled among patients living in the most vulnerable neighborhoods, where increasing geriatric vulnerability resulted in up to 15 times greater risk of death (30-day risk-adjusted HR, 15.12; 95% CI, 12.57-18.19). When restricted to racial/ethnic minority patients, the multiplicative effect was four-times as high, resulting in corresponding 30-day HRs for mortality of 11.53 (95% CI, 4.51-29.44) versus 40.67 (95% CI, 22.73-72.78). Similar patterns were seen for death within 365 days. CONCLUSION: Both geriatric and neighborhood vulnerability have been shown to affect prehospital risk among older patients. The results of this study build on that work, presenting the first in-depth look at the powerful multiplicative interaction between these two factors. The results show that where a patient resides can fundamentally alter expected outcomes for EGS care such that otherwise less vulnerable patients become functionally equivalent to those who are, at baseline, more aged, more frail, and more sick. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Cost of U.S emergency department and inpatient visits for fall injuries in older adults.

BACKGROUND: Falls are a leading cause of injury and hospital readmissions in older adults. Understanding the distribution of acute treatment costs across inpatient and emergency department settings is critical for informed investment and evaluation of fall prevention efforts. METHODS: This study used the 2016-2018 National Inpatient Sample and National Emergency Department Sample. Annual treatment cost of fall injury among adults 65 years and older was estimated from charges, applying cost-to-charge and professional fee ratios. Weighted multivariable generalized linear models were used to separately estimate cost for inpatient and emergency department (ED) setting by injury type and individual demographic and health characteristics after adjusting for payer and hospital level characteristics. RESULTS: Older adults incurred an estimated 922,428 inpatient and 2.3 million ED visits annually due to falls with combined annual costs of $19.8 billion. Over half of inpatient visits for fall injury were for fracture. Notably, 23% of inpatient visits were for fractures other than hip fracture and 14% of inpatient visits were for multiple fractures with costs totaling $3.4 billion and $2.5 billion, respectively. Annual ED costs were driven by superficial injury totaling $1.5 billion. Cost of ED visits were higher for adults 85 years and older (adjusted cost ratio (aCR): 1.11, 95% Confidence Interval (CI)I: 1.11-1.12) and those with dementia (aCR: 1.14, 95% CI: 1.13-1.15). Higher inpatient and ED visit cost was also associated with high-energy falls and discharge to post-acute care. CONCLUSION: The study found that more than 3 million older adults in the United States seek hospital care for fall injuries annually, a major concern given increasing capacity strain on hospitals and EDs. The $20 billion in annual acute treatment costs attributed to fall injury indicate an urgent need to implement evidence-based fall prevention interventions and underscores the importance of newly launched ED-based fall prevention efforts and investments in geriatric emergency departments.

Changes in Older Adult Trauma Quality When Evaluated Using Longer-Term Outcomes vs In-Hospital Mortality.

Importance: Lack of knowledge about longer-term outcomes remains a critical blind spot for trauma systems. Recent efforts have expanded trauma quality evaluation to include a broader array of postdischarge quality metrics. It remains unknown how such quality metrics should be used. Objective: To examine the utility of implementing recommended postdischarge quality metrics as a composite score and ascertain how composite score performance compares with that of in-hospital mortality for evaluating associations with hospital-level factors. Design, Setting, and Participants: This national hospital-level quality assessment evaluated hospital-level care quality using 100% Medicare fee-for-service claims of older adults (aged ≥65 years) hospitalized with primary diagnoses of trauma, hip fracture, and severe traumatic brain injury (TBI) between January 1, 2014, and December 31, 2015. Hospitals with annual volumes encompassing 10 or more of each diagnosis were included. The data analysis was performed between January 1, 2021, and December 31, 2022. Exposures: Reliability-adjusted quality metrics used to calculate composite scores included hospital-specific performance on mortality, readmission, and patients' average number of healthy days at home (HDAH) within 30, 90, and 365 days among older adults hospitalized with all forms of trauma, hip fracture, and severe TBI. Main Outcomes and Measures: Associations with hospital-level factors were compared using volume-weighted multivariable logistic regression. Results: A total of 573 554 older adults (mean [SD] age, 83.1 [8.3] years; 64.8% female; 35.2% male) from 1234 hospitals were included. All 27 reliability-adjusted postdischarge quality metrics significantly contributed to the composite score. The most important drivers were 30- and 90-day readmission, patients' average number of HDAH within 365 days, and 365-day mortality among all trauma patients. Associations with hospital-level factors revealed predominantly anticipated trends when older adult trauma quality was evaluated using composite scores (eg, worst performance was associated with decreased older adult trauma volume [odds ratio, 0.89; 95% CI, 0.88-0.90]). Results for in-hospital mortality showed inverted associations for each considered hospital-level factor and suggested that compared with nontrauma centers, level 1 trauma centers had a 17 times higher risk-adjusted odds of worst (highest quantile) vs best (lowest quintile) performance (odds ratio, 17.08; 95% CI, 16.17-18.05). Conclusions and Relevance: The study results challenge historical notions about the adequacy of in-hospital mortality as the single measure of older adult trauma quality and suggest that, when it comes to older adults, decisions about how quality is evaluated can profoundly alter understandings of what constitutes best practices for care. Composite scores appear to offer a promising means by which postdischarge quality metrics could be used.

Public transit stop density is associated with walking for exercise among a national sample of older adults.

BACKGROUND: Walking is the primary and preferred mode of exercise for older adults. Walking to and from public transit stops may support older adults in achieving exercise goals. This study examined whether density of neighborhood public transit stops was associated with walking for exercise among older adults. METHODS: 2018 National Health and Aging Trends Study (NHATS) data were linked with the 2018 National Neighborhood Data Archive, which reported density of public transit stops (stops/mile2) within participants' neighborhood, defined using census tract boundaries. Walking for exercise in the last month was self-reported. The extent to which self-reported public transit use mediated the relationship between density of neighborhood public transit stops and walking for exercise was examined. Covariates included sociodemographic characteristics, economic status, disability status, and neighborhood attributes. National estimates were calculated using NHATS analytic survey weights. RESULTS: Among 4,836 respondents with complete data, 39.7% lived in a census tract with at least one neighborhood public transit stop and 8.5% were public transit users. The odds of walking for exercise were 32% higher (OR = 1.32; 95% confidence interval: 1.08, 1.61) among respondents living in a neighborhood with > 10 transit stops per mile compared to living in a neighborhood without any public transit stops documented. Self-reported public transit use mediated 24% of the association between density of neighborhood public transit stops and walking for exercise. CONCLUSIONS: Density of neighborhood public transit stops was associated with walking for exercise, with a substantial portion of the association mediated by self-reported public transit use. Increasing public transit stop availability within neighborhoods may contribute to active aging among older adults.

Associations between social isolation and diet quality among US adults with disability participating in the National Health and Nutrition Examination Survey, 2013-2018.

Social isolation and disability are established risk factors for poor nutrition. We aimed to assess whether social isolation is associated with diet quality specifically among adults with disabilities. This cross-sectional analysis used data from the National Health and Nutrition Examination Survey, 2013-2018. Adults with a disability, who were not pregnant, breastfeeding, or missing dietary intake data were included (n = 5,167). Disability was defined as a physical functioning limitation based on difficulty with any activities of daily living, instrumental activities of daily living, lower extremity mobility activities, or general physical activities. The Healthy Eating Index (HEI)-2015 measured diet quality; higher scores correspond to higher diet quality. We computed a social isolation index by summing single status, living alone, and two social engagement difficulty measures (one point for each component met; maximum 4 points). Multivariable linear regression, controlling for demographic and health covariates, estimated differences in HEI scores for dietary intake data, by social isolation score. Over half of HEI scores were < 51, corresponding to "poor" diet quality. Higher social isolation score was associated with lower vegetable and seafood/plant proteins intake. Single status and one of two social engagement measures were associated with lower scores on certain adequacy components. Differences were modest. There was little evidence of effect modification by age or gender. Adults with disabilities are not meeting national dietary standards; improving diet quality is a priority. Whether social isolation is associated with specific dietary components in this population requires further investigation. Further research is also needed among younger adults.

Associations of sex, Alzheimer's disease and related dementias, and days alive and at home among older Medicare beneficiaries recovering from hip fracture.

BACKGROUND: Males constitute 25% of older adults who experience hip fractures in the United States; a concerning upward trend given poorer health and outcomes among male survivors. Male sex is associated with worse cognitive performance after hip fracture, impacting participation in rehabilitation and long-term outcomes especially for those with Alzheimer's disease or related dementias (ADRD). However, little research has evaluated whether sex differences in post-fracture recovery are greater among those living with ADRD. METHODS: Data were drawn from 2010 to 2017 Medicare fee-for-service beneficiaries aged 65 years and older who survived hospitalization for hip fracture (n = 69,581). The primary outcome was days alive and at home (DAAH), a validated patient-centered claims-based outcome calculated as 365 days from fracture minus days in hospital, nursing home, rehabilitation facility, emergency department, or time after death. Multivariable Poisson regressions with an interaction term between sex and ADRD status were to model the association between DAAH and ADRD in the 12 months post hip fracture, adjusting for demographics, injury severity, chronic disease burden, and hospital-level fixed effects. RESULTS: Compared to females, males were younger and had more comorbidities at the time of fracture. Among survivors, males with ADRD spent a mean of 160.7 DAAH compared to 228.4 for males without ADRD, 177.8 for females with ADRD, and 248.0 for females without ADRD. In adjusted analyses, males without ADRD spent 8.2% fewer DAAH compared to females (rate ratio [RR] = 0.92, 95% CI 0.92-0.92). This relative sex difference increased significantly when comparing those living with ADRD, with males spending an additional 3.3% fewer DAAH (interaction RR = 0.96, 95% CI 0.96-0.97). CONCLUSIONS: Males spend fewer DAAH after hip fracture than females, and this difference increases modestly for males living with ADRD compared to females. This suggests that cognitive impairment may be a small but significant contributor to sex-based differences observed during hip fracture recovery.

Associations of Days Spent at Home Before Hip Fracture With Postfracture Days at Home and 1-Year Mortality Among Medicare Beneficiaries Living With Alzheimer's Disease or Related Dementias.

BACKGROUND: Hip fracture is a disabling event experienced disproportionately by older adults with Alzheimer's disease or related dementias (ADRD). Claims information recorded prior to a hip fracture could provide valuable insights into recovery potential for these patients. Thus, our objective was to identify distinct trajectories of claims-based days at home (DAH) before a hip fracture among older adults with ADRD and evaluate associations with postfracture DAH and 1-year mortality. METHODS: We conducted a cohort study of 16 576 Medicare beneficiaries living with ADRD who experienced hip fracture between 2010 and 2017. Growth mixture modeling was used to estimate trajectories of DAH assessed from 180 days prior to fracture until index fracture admission, and their joint associations with postfracture DAH trajectories and 1-year mortality. RESULTS: Before a hip fracture, a model with 3 distinct latent DAH trajectories was the best fit. Trajectories were characterized based on their temporal patterns as Consistently High (n = 14 980, 90.3%), Low but Increasing (n = 809, 5.3%), or Low and Decreasing (n = 787, 4.7%). Membership in the Low and Decreasing prefracture DAH trajectory was associated with less favorable postfracture DAH trajectories, and a 65% higher 1-year mortality rate (hazard ratio 1.65, 95% confidence interval 1.45-1.87) as compared to those in the Consistently High trajectory. Similar albeit weaker associations with these outcomes were observed for hip fracture survivors in the Low but Improving prefracture DAH trajectory. CONCLUSIONS: Distinct prefracture DAH trajectories among hip fracture survivors with ADRD are strongly linked to postfracture DAH and 1-year mortality, which could guide development of tailored interventions.

Associations between living alone, social interactions, and physical performance differ by sex: Results from the Baltimore Hip Studies.

BACKGROUND: There is mixed evidence on whether living arrangements and social interactions are associated with poorer health outcomes after hip fracture repair. Distinct social profiles among male and female older adults may explain some of the differences. However, prior studies did not evaluate these differences by sex. This article aims to assess if the associations between living alone, social interaction, and physical performance differ by sex among hip fracture survivors. METHODS: This prospective cohort study is part of the Baltimore Hip Studies seventh cohort, with 168 male and 171 female hip fracture patients assessed at baseline (≤22 days after hospitalization) and at 2, 6, and 12 months post admission. Living arrangements and interaction with children or siblings and others in the past 2 weeks were collected at all visits. Physical performance was measured in the follow-up visits with the Short Physical Performance Battery (SPPB). Linear mixed models tested associations of living alone and social interaction with SPPB over time adjusted for age, education, comorbidities, physical functioning pre-fracture, cognitive function, self-rated health, and time. RESULTS: For men only, living alone was associated with worse performance (0.7 points lower SPPB scores, p = 0.05). Higher social interaction was associated with 0.8 and 1.2 point higher SPPB scores for men and women, respectively (p < 0.05). Visiting with friends was significantly associated with better function among males, while visiting with children or siblings was associated with worse SPPB among females. CONCLUSIONS: Living arrangements and types of social interaction are differentially associated with physical function for older men and women. Screening for social isolation/integration and including interventions that promote social interaction and participation should be considered in healthcare programs for hip fracture survivors.

High-intensity home health physical therapy among older adult Veterans: A randomized controlled trial.

BACKGROUND: Older adult Veterans are at high risk for adverse health outcomes following hospitalization. Since physical function is one of the largest potentially modifiable risk factors for adverse health outcomes, our purpose was to determine if progressive, high-intensity resistance training in home health physical therapy (PT) improves physical function in Veterans more than standardized home health PT and to determine if the high-intensity program was comparably safe, defined as having a similar number of adverse events. METHODS: We enrolled Veterans and their spouses during an acute hospitalization who were recommended to receive home health care on discharge because of physical deconditioning. We excluded individuals who had contraindications to high-intensity resistance training. A total of 150 participants were randomized 1:1 to either (1) a progressive, high-intensity (PHIT) PT intervention or (2) a standardized PT intervention (comparison group). All participants in both groups were assigned to receive 12 visits (3 visits/week over 30 days) in their home. The primary outcome was gait speed at 60 days. Secondary outcomes included adverse events (rehospitalizations, emergency department visits, falls and deaths after 30 and 60-days), gait speed, Modified Physical Performance Test, Timed Up-and-Go, Short Physical Performance Battery, muscle strength, Life-Space Mobility assessment, Veterans RAND 12-item Health Survey, Saint Louis University Mental Status exam, and step counts at 30, 60, 90, 180 days post-randomization. RESULTS: There were no differences between groups in gait speed at 60 days, and no significant differences in adverse events between groups at either time point. Similarly, physical performance measures and patient reported outcomes were not different at any time point. Notably, participants in both groups experienced increases in gait speed that met or exceeded established clinically important thresholds. CONCLUSIONS: Among older adult Veterans with hospital-associated deconditioning and multimorbidity, high-intensity home health PT was safe and effective in improving physical function, but not found to be more effective than a standardized PT program.

Severe neighborhood deprivation and nursing home staffing in the United States.

BACKGROUND: Low nursing home staffing in the United States is a growing safety concern. Socioeconomic deprivation in the local areas surrounding a nursing home may be a barrier to improving staffing rates but has been poorly studied. Thus, the objective of this paper was to assess the relationship between neighborhood deprivation and nursing home staffing in the United States. METHODS: This cross-sectional study used 2018 daily payroll-based staffing records and address data for 12,609 nursing homes in the United States linked with resident assessment data. Our primary exposure of interest was severe economic deprivation at the census block group (neighborhood) level, defined as an area deprivation index score ≥85/100. The primary outcome was hours worked per resident-day among nursing home employees providing direct resident care. Marginal linear regression models and generalized estimating equations with robust sandwich-type standard errors were used to estimate associations between severe neighborhood deprivation and staffing rates. RESULTS: Compared to less deprived neighborhoods, unadjusted staffing rates in facilities located within severely deprived neighborhoods were 38% lower for physical and occupational therapists, 30% lower for registered nurses (RNs), and 5% lower for certified nursing assistants. No disparities in licensed practical nurse (LPN) staffing were observed. In models with state-level and rurality fixed effects and clustered on the county, a similar pattern of disparities was observed. Specifically, RN staffing per 100 resident-days was significantly lower in facilities located within severely deprived neighborhoods as compared to those in less deprived areas (mean difference: 5.6 fewer hours, 95% confidence interval [CI] 4.2-6.9). Disparities of lower magnitude were observed for other clinical disciplines except for LPNs. CONCLUSIONS: Significant staffing disparities were observed within facilities located in severely deprived neighborhoods. Targeted interventions, including workforce recruitment and retention efforts, may be needed to improve staffing levels for nursing homes in deprived neighborhoods.

Association Between Race and Receipt of Home- and Community-Based Rehabilitation After Traumatic Brain Injury Among Older Medicare Beneficiaries.

Importance: Non-Hispanic Black (hereafter Black) patients with traumatic brain injury (TBI) experience worse long-term outcomes and residual disability compared with non-Hispanic White (hereafter White) patients. Receipt of appropriate rehabilitation can improve function among older adults after TBI. Objective: To assess the association between race and receipt of home- and community-based rehabilitation among a nationally representative sample of older Medicare beneficiaries with TBI. Design, Setting, and Participants: This cohort study analyzed a random sample of Medicare administrative claims data for community-dwelling Medicare beneficiaries aged 65 years or older who were hospitalized with a primary diagnosis of TBI and discharged alive to a nonhospice setting from 2010 through 2018. Claims data for Medicare beneficiaries of other races and ethnicities were excluded due to the small sample sizes within each category. Data were analyzed January 21 to August 30, 2022. Exposures: Black or White race. Main Outcomes and Measures: Monthly use rates of home-based or outpatient rehabilitation were calculated over the 6 months after discharge from the hospital. The denominator for rate calculations accounted for variation in length of hospital and rehabilitation facility stays and loss to follow-up due to death. Rates over time were modeled using generalized estimating equations, controlling for TBI acuity, demographic characteristics, comorbidities, and socioeconomic factors. Results: Among 19 026 Medicare beneficiaries (mean [SD] age, 81.6 [8.1] years; 10 781 women [56.7%]; and 994 Black beneficiaries [5.2%] and 18 032 White beneficiaries [94.8%]), receipt of 1 or more home health rehabilitation visits did not differ by race (Black vs White, 47.4% vs 46.2%; P = .46), but Black beneficiaries were less likely to receive 1 or more outpatient rehabilitation visits compared with White beneficiaries (3.4% vs 7.1%; P < .001). In fully adjusted regression models, Black beneficiaries received less outpatient therapy over the 6 months after TBI (rate ratio, 0.60; 95% CI, 0.38-0.93). However, Black beneficiaries received more home health rehabilitation therapy over the 6 months after TBI than White beneficiaries (rate ratio, 1.15; 95% CI, 1.00-1.32). Conclusions and Relevance: This cohort study found relative shifts in rehabilitation use, with markedly lower outpatient therapy use and modestly higher home health care use among Black patients compared with White patients with TBI. These disparities may contribute to reduced functional recovery and residual disability among racial and ethnic minority groups. Additional studies are needed to assess the association between the amount of outpatient rehabilitation care and functional recovery after TBI in socioeconomically disadvantaged populations.