Project EPIC (Empowering People to Independence in COPD): Study protocol for a hybrid effectiveness-implementation pilot randomized controlled trial of telephonic, geriatrics-palliative care nurse-coaching in older adults with COPD and their family caregivers.

BACKGROUND: EPIC (Empowering People to Independence in COPD) is a geriatric-palliative care telephonic, nurse coach intervention informed by Baltes' Theory of Successful Aging and adapted from the ENABLE (Educate, Nurture, Advise, Before Life Ends) intervention. EPIC, focused on improving independence, mobility, well-being, and COPD symptoms, has undergone formative and summative evaluation for adults with COPD. METHODS: The primary study aim is to assess the refined EPIC intervention's feasibility and acceptability via a pilot hybrid effectiveness-implementation randomized control trial in community-dwelling older adults with moderate to severe COPD and their family caregivers. The secondary aim is to explore the impact of EPIC on patient and caregiver outcomes. Older adults with COPD and their family caregivers (target N = 60 dyads) will be randomized to EPIC (intervention) or usual COPD care (control). EPIC includes six patient and four family caregiver weekly, telephone-based nurse coach sessions using a manualized curriculum (Charting Your Course), plus three monthly follow-up calls. Feasibility will be measured as completion of EPIC intervention and trial components (e.g., recruitment, retention, data collection). Acceptability will be evaluated using satisfaction surveys and post-study feedback interviews. A blinded data collector will assess exploratory outcomes (e.g., Life-Space mobility, quality of life, caregiver burden, emotional symptoms, loneliness, cognitive impairment, functional status, healthcare utilization) at baseline, 12, and 24 weeks. DISCUSSION: This intervention fills a gap in addressing the geriatrics and palliative care needs and equity for adults with COPD and their family caregivers. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05040386.

Preliminary Validation of the Acute Care Mobility Assessment as a Measure of Hospital Mobility.

BACKGROUND: Despite heighted interest, measurement of hospital mobility remains challenging. Available assessment tools lack patient input regarding level and frequency of hospital mobility. The purpose of this study was to validate a brief self-reported mobility assessment to measure out-of-bed activity during hospitalization. METHODS: We recruited cognitively intact hospitalized adults (age ≥65 years) who walked prior to admission, to wear an accelerometer for 24 hours and to complete the Acute Care Mobility Assessment (ACMA), a self-report of mobility that ranges from bed rest to walking off the hospital unit in the prior 24 hours. For each mobility level from sitting in a chair to walking off the unit, patients reported frequency of the activity and need for help from another person or equipment. Spearman correlation coefficients were calculated using several scoring algorithms to compare ACMA to accelerometer data. RESULTS: Fifty-one patients (mean age 74.3 (SD 6.2) years, 63% female, 39% Black) had complete data. Steps taken in 24 hours ranged from 10 - 2831. Correlation analyses identified strong associations between ACMA scores and total steps, and moderate correlations with total time walking using all algorithms. However, the unweighted frequency count using the three ambulation levels only (walking in room, in hall and off ward) had the highest correlation with total steps (r=0.84; p<0.001) and total time walking (r=0.66; p<0.001). CONCLUSION: ACMA is a valid measure of mobility among cognitively intact hospitalized older adults. The ACMA may add value to our current armamentarium of tools by adding patient report of hospital mobility.

Delirium Due to Potentially Avoidable Hospitalizations Among Older Adults.

BACKGROUND: Delirium is a common complication during acute care hospitalizations in older adults. A substantial percentage of admissions are for ambulatory care-sensitive conditions (ACSCs) or potentially avoidable hospitalizations-conditions that might be treated early in the outpatient setting to prevent hospitalization and hospital complications. METHODS: This retrospective cross-sectional study examined rates of delirium among older adults hospitalized for ACSCs. Participants were 39 933 older adults ≥65 years of age admitted from January 1, 2015 to December 31, 2019 to general inpatient units and ICUs of a large Southeastern academic medical center. Delirium was defined as a score ≥ 2 on the Nursing Delirium Screening Scale or positive on the Confusion Assessment Method for the Intensive Care Unit during admission, and ACSCs were identified from the primary admission diagnosis using standardized definitions. Generalized linear mixed models were used to examine the association between ACSCs and delirium, compared with admissions for non-ACSC diagnoses, adjusting for covariates and repeated observations for individuals with multiple admissions. RESULTS: Delirium occurred in 15.6% of admissions for older adults. Rates were lower for ACSC admissions versus admissions for other conditions (13.9% vs 15.8%, p < .001). Older age and higher comorbidity were significant predictors of the development of delirium. CONCLUSIONS: Rates of delirium among older adults hospitalized for ACSCs were lower than rates for non-ACSC hospitalization but still substantial. Optimizing the treatment of ACSCs in the outpatient setting is an important goal not only for reducing hospitalizations but also for reducing risks for hospital-associated complications such as delirium.

Life-Space Mobility: Normative Values From a National Cohort of U.S. Older Adults.

BACKGROUND: Life-space mobility, which measures the distance, frequency, and independence achieved as individuals move through their community, is one of the most important contributors to healthy aging. The University of Alabama at Birmingham Life-Space Assessment (LSA) is the most commonly used measure of life-space mobility in older adults, yet U.S. national norms for LSA have not previously been reported. This study reports such norms based on age and sex among community-dwelling older adults. METHODS: A cross-sectional analysis using data from the national REasons for Geographic and Racial Disparities in Stroke cohort study. LSA data were available for 10 118 Black and White participants over age 50, which were grouped by age (in 5-year increments) and sex, weighted for the U.S. national population. Correlations were calculated between LSA and measures of functional and cognitive impairment and physical performance. RESULTS: The weighted mean LSA ranged from 102.9 for 50-54-year-old males to 69.5 for males aged 85 and older, and from 102.1 for 50-54-year-old females to 60.1 for females aged 85 and older. LSA was strongly correlated with measures of timed walking, activities of daily living, cognition, depressive symptoms, and quality of life (all p < .001). CONCLUSIONS: We report U.S. national norms for LSA among community-dwelling Black and White older adults. These norms can serve as a reference tool for determining if clinical and research samples have greater or lesser life-space mobility than typical older adults in the United States for their age and sex.

Changes in Life-Space Mobility with Loss of Relatives and Friends among Older Adults: Results from the UAB Study of Aging.

BACKGROUND AND OBJECTIVES: Increasing age brings greater risk of death of friends and family (hereafter referred to as loss) potentially impacting individuals' life-space mobility (LSM) trajectory. RESEARCH DESIGN AND METHODS: Using the UAB Study of Aging, we examined differences in LSM trajectories of 1000 community-dwelling older Alabamians (65+years) with and without loss over 8.5 years. We measured LSM using UAB's Life-Space Assessment (LSA), a validated instrument assessing movement through zones ranging from their bedroom to out of town. We assessed loss every 6 months using a standard bereavement questionnaire capturing spousal, other relative, or friend loss. We used piecewise linear mixed effects models to compare LSA trajectories. RESULTS: At baseline, those who later experienced loss, compared to those did not were younger, more likely to be female, and overall in better health. Those without loss had a baseline mean LSA score of 49.5 and a decline of 0.08 points per year (p < 0.001). Those with loss had a baseline LSA score of 60 and decline by 1.0 point per year before loss (p < 0.001), accelerating to 1.8 points per year after loss (p < 0.001). DISCUSSION AND IMPLICATIONS: Those with loss do not experience acute decline post loss but do have an acceleration of the pre-existing decline. While additional research may explain the impact of loss on LSM; this finding suggests that more interventions such as social, mental, or healthcare services, may be needed for those who experience loss. Specifically, bereaved individuals may benefit from.

Delirium Mediates Incidence of Hospital-Associated Disability Among Older Adults.

OBJECTIVE: To examine whether delirium predicts occurrence of hospital-associated disability (HAD), or functional decline after admission, among hospitalized older adults. DESIGN: Retrospective cross-sectional study. SETTING AND PARTICIPANTS: General inpatient (non-ICU) units of a large regional Southeastern US academic medical center, involving 33,111 older adults ≥65 years of age admitted from January 1, 2015, to December 31, 2019. METHODS: Delirium was defined as a score ≥2 on the Nursing Delirium Screening Scale (NuDESC) during hospital admission. HAD was defined as a decline on the Katz Activities of Daily Living (ADL) scale from hospital admission to discharge. Generalized linear mixed models were used to examine the association between delirium and HAD, adjusting for covariates and repeated observations with multiple admissions. We performed multivariate and mediation analyses to examine strength and direction of association between delirium and HAD. RESULTS: One-fifth (21.6%) of older adults developed HAD during hospitalization and experienced higher delirium rates compared to those not developing HAD (24.3% vs 14.3%, P < .001). Age, presence of delirium, Elixhauser Comorbidity Score, admission cognitive status, admission ADL function, and length of stay were associated (all P < .001) with incident HAD. Mediational analyses found 46.7% of the effect of dementia and 16.7% of the effect of comorbidity was due to delirium (P < .001). CONCLUSIONS AND IMPLICATIONS: Delirium significantly increased the likelihood of HAD within a multivariate predictor model that included comorbidity, demographics, and length of stay. For dementia and comorbidity, mediation analysis showed a significant portion of their effect attributable to delirium. Overall, these findings suggest that reducing delirium rates may diminish HAD rates.

Hospital-associated disability due to avoidable hospitalizations among older adults.

BACKGROUND: Hospital-associated disability (HAD) is a common complication during the course of acute care hospitalizations in older adults. Many admissions are for ambulatory care sensitive conditions (ACSCs), considered potentially avoidable hospitalizations-conditions that might be treated in outpatient settings to prevent hospitalization and HAD. We compared the incidence of HAD between older adults hospitalized for ACSCs versus those hospitalized for other diagnoses. METHODS: We conducted a retrospective cohort study in inpatient (non-ICU) medical and surgical units of a large southeastern regional academic medical center. Participants were 38,960 older adults ≥ 65 years of age admitted from January 1, 2015, to December 31, 2019. The primary outcome was HAD, defined as decline on the Katz Activities of Daily Living (ADL) scale from hospital admission to discharge. We used generalized linear mixed models to examine differences in HAD between hospitalizations with a primary diagnosis for an ACSC using standard definitions versus primary diagnosis for other conditions, adjusting for covariates and repeated observations for individuals with multiple hospitalizations. RESULTS: We found that 10% of older adults were admitted for an ACSC, with rates of HAD in those admitted for ACSCs lower than those admitted for other conditions (16% vs. 20.7%, p < 0.001). Age, comorbidity, admission functional status, and admission cognitive impairment were significant predictors for development of HAD. ACSC admissions to medical and medical/surgical services had lower odds of HAD compared with admissions for other conditions, with no significant differences between ACSC and non-ACSC admissions to surgical services. CONCLUSIONS: Rates of HAD among older adults hospitalized for ACSCs are substantial, though lower than rates of HAD with hospitalization for other conditions, reflecting that acute care hospitalization is not a benign event in this population. Treatment of ACSCs in the outpatient setting could be an important component of efforts to reduce HAD.

National Norms for the Elixhauser and Charlson Comorbidity Indexes Among Hospitalized Adults.

BACKGROUND: Comorbidity burden is commonly measured among hospitalized adults, yet the U.S. national norms for 2 commonly used comorbidity indexes have not yet been reported. Thus, this study reports U.S. national norms for both Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Index (ECI) among hospitalized adults based on age, biological sex, and race. METHODS: A retrospective observational cohort study using data from the Agency of Healthcare Research and Quality U.S. National Inpatient Sample database for 2017. Patient data were extracted from 7 159 694 inpatient adults, and analyses were focused on individuals older than 45 years, yielding 4 370 225 patients. International Classification of Diseases, 10th Edition, diagnostic codes were used to calculate CCI and ECI scores. These scores were then weighted for the U.S. national population. RESULTS: The weighted mean CCI was 1.22 (95% confidence interval [CI]: 1.22, 1.22), and the weighted mean ECI was 2.76 (95% CI: 2.76, 2.76). Both indexes had increasing average scores with increasing age, independent of sex and race (all p values < .001). CONCLUSION: For the first time, U.S. national norms for the CCI and ECI are reported for adult inpatients. The norms can serve as a reference tool for determining if clinical and research populations have greater or lesser comorbidity burden than typical hospitalized adults in the United States for their age, sex, and race.

A systematic review and meta-analysis: Assessment of hospital walking programs among older patients.

AIM: The aim of this study is to assess effect of hospital walking programs on outcomes for older inpatients and to characterize hospital walking dose reported across studies. DESIGN: A systematic review and meta-analysis examining impact of hospital walking and/or reported walking dose among medical-surgical inpatients. For inclusion, studies were observational or experimental, published in English, enrolled inpatients aged ≥ 65 yrs hospitalized for medical or surgical reasons. METHODS: Searches of PubMed, CINAHL, Embase, Scopus, NICHSR, OneSearch, ClinicalTrials.gov, and PsycINFO were completed in December 2020. Two reviewers screened sources, extracted data, and performed quality bias appraisal. RESULTS: Hospital walking dose was reported in 6 studies and commonly as steps/24 hr. Length of stay (LOS) was a common outcome reported. Difference in combined mean LOS between walking and control groups was -5.89 days. Heterogeneity across studies was considerable (I2  = 96%) suggesting poor precision of estimates. Additional, high-quality trials examining hospital walking and patient outcomes of older patients is needed.

Comparison of Postoperative Outcomes of Laparoscopic vs Open Inguinal Hernia Repair.

Importance: Advocates of laparoscopic surgery argue that all inguinal hernias, including initial and unilateral ones, should be repaired laparoscopically. Prior work suggests outcomes of open repair are improved by using local rather than general anesthesia, but no prior studies have compared laparoscopic surgery with open repair under local anesthesia. Objective: To evaluate postoperative outcomes of open inguinal hernia repair under general or local anesthesia compared with laparoscopic repair. Design, Setting, and Participants: This retrospective cohort study identified 107 073 patients in the Veterans Affairs Surgical Quality Improvement Program database who underwent unilateral initial inguinal hernia repair from 1998 to 2019. Data were analyzed from October 2021 to March 2022. Exposures: Patients were divided into 3 groups for comparison: (1) open repair with local anesthesia (n = 22 333), (2) open repair with general anesthesia (n = 75 104), and (3) laparoscopic repair with general anesthesia (n = 9636). Main Outcomes and Measures: Operative time and postoperative morbidity were compared using quantile regression and inverse probability propensity weighting. A 2-stage least-squares regression and probabilistic sensitivity analysis was used to quantify and address bias from unmeasured confounding in this observational study. Results: Of 107 073 included patients, 106 529 (99.5%) were men, and the median (IQR) age was 63 (55-71) years. Compared with open repair with general anesthesia, laparoscopic repair was associated with a nonsignificant 0.15% (95% CI, -0.39 to 0.09; P = .22) reduction in postoperative complications. There was no significant difference in complications between laparoscopic surgery and open repair with local anesthesia (-0.05%; 95% CI, -0.34 to 0.28; P = .70). Operative time was similar for the laparoscopic and open general anesthesia groups (4.31 minutes; 95% CI, 0.45-8.57; P = .048), but operative times were significantly longer for laparoscopic compared with open repair under local anesthesia (10.42 minutes; 95% CI, 5.80-15.05; P < .001). Sensitivity analysis and 2-stage least-squares regression demonstrated that these findings were robust to bias from unmeasured confounding. Conclusions and Relevance: In this study, laparoscopic and open repair with local anesthesia were reasonable options for patients with initial unilateral inguinal hernias, and the decision should be made considering both patient and surgeon factors.

Project EPIC (Early Palliative Care In COPD): A Formative and Summative Evaluation of the EPIC Telehealth Intervention.

CONTEXT: Early, concurrent palliative care interventions in chronic obstructive pulmonary disease (COPD) are limited. Project EPIC (Early Palliative Care In COPD) is a multiphase mixed methods study working to fill this gap. OBJECTIVES: To conduct a formative and summative evaluation of EPIC, a telephonic nurse coach-led early palliative care intervention for COPD adapted from the ENABLE© intervention in cancer. METHODS: Phase I Formative Evaluation: Patients with moderate-to-very-severe COPD, family caregivers, and pulmonary and palliative care clinicians rated the acceptability and feasibility of EPIC (≥4 out of five on a Likert-scale survey). Phase II Summative Evaluation: Patients and family caregivers in Phase I participated in a pilot of the three month EPIC prototype to evaluate intervention and data collection feasibility (≥70% completion) and to seek qualitative feedback. RESULTS: Phase I Formative Evaluation: Patients (n=10), family caregivers (n=10), pulmonary clinicians (n=6), and palliative care clinicians (n=6) found EPIC acceptable and feasible to support adaptation, while priority early palliative care needs in COPD from our prior research mapped well to the EPIC prototype. Phase II Summative Evaluation: Patients (n=5; ages 49-72, 40% moderate COPD, 40% Black) and their family caregivers (n=5; ages 51-73, 40% Black) completed 100% of EPIC prototype components, including weekly telephone sessions, a one month follow-up call, Advance Directive, palliative care clinic attendance, and 95% of monthly phone data collection sessions. Feedback from participants about EPIC was all positive. CONCLUSION: EPIC was acceptable and feasible in patients with COPD and their family caregivers. Larger feasibility and effectiveness trials are warranted.

Novel genetic loci associated with osteoarthritis in multi-ancestry analyses in the Million Veteran Program and UK Biobank.

Osteoarthritis is a common progressive joint disease. As no effective medical interventions are available, osteoarthritis often progresses to the end stage, in which only surgical options such as total joint replacement are available. A more thorough understanding of genetic influences of osteoarthritis is essential to develop targeted personalized approaches to treatment, ideally long before the end stage is reached. To date, there have been no large multiancestry genetic studies of osteoarthritis. Here, we leveraged the unique resources of 484,374 participants in the Million Veteran Program and UK Biobank to address this gap. Analyses included participants of European, African, Asian and Hispanic descent. We discovered osteoarthritis-associated genetic variation at 10 loci and replicated findings from previous osteoarthritis studies. We also present evidence that some osteoarthritis-associated regions are robust to population ancestry. Drug repurposing analyses revealed enrichment of targets of several medication classes and provide potential insight into the etiology of beneficial effects of antiepileptics on osteoarthritis pain.

Survive and thrive: Personal stories of persistence and resilience in aging research.

An academic career in aging research is filled with the incredible highs of important discoveries that improve the lives of older adults and repeated lows when papers and grants are rejected or studies are negative. To normalize the experience of setbacks and failures in aging research, we invited three senior investigators to share their journeys of persistence and resilience as they have navigated their research careers. This career development symposium was presented at the 2021 Annual Scientific Meeting of the American Geriatrics Society, which was held virtually. We aimed to connect researchers in aging, especially trainees and junior investigators, through personal stories of persistence and shared strategies to build resilience and respond to setbacks with a growth mindset.

Development of Dynamic Measures to Assess Balance Confidence and State Anxiety While Walking at Increasing Speeds in Young and Older Adults.

The purpose of this study was to determine the test-retest reliability and construct validity of tools to assess how balance confidence (BC) and state anxiety (SA) change with progressively increasing walking speeds. Sixteen young adults and 15 older adults attended two sessions. Individuals began walking on a treadmill at 0.4 m/s Participants chose to continue increasing the treadmill speed (up to 2.0 m/s) or to discontinue the protocol while rating their BC and SA after completing each speed. BC at participants' fastest speed attempted demonstrated high and moderate test-retest reliability among young (intraclass correlation coefficient [ICC] = .908) and older adults (ICC = .704). SA for young adults and older adults was good (ICC = .833) and fair (ICC = .490), respectively. Our measures also correlated with measures of dynamic stability while walking for young (r = -.67, p = .008) and older adults (r = .54, p = .046). Our dynamic measures of BC and SA are valid and reliable in young and older adults.

Increased Attentional Focus on Walking by Older Adults Limits Maximum Speed and Is Related to Dynamic Stability.

BACKGROUND AND PURPOSE: Older adults with lower balance confidence demonstrate a reduced willingness to experience instability as the task of walking becomes more challenging (i.e., walking with a faster speed). However, the specific reason why is not known. The purpose of this study was to investigate the extent to which capacity of increasing walking speeds relates to the attentional requirements (i.e., automaticity) of walking. METHODS: Sixteen young (31 ± 5.85 years) and 15 older participants (69 ± 3.04 years) began walking on a treadmill at 0.4 m/s, and speed was increased by 0.2 m/s until the participant either chose to stop or reached a speed of 2.0 m/s. Sixty steps were collected at steady-state speed for each walking trial. Kinematic data were collected, and the margin of stability in the anterior direction (MOSAP) at heelstrike was quantified for each step. The timed up and go (TUG) and TUG dual (TUGdual) task were performed, from which an automaticity index (TUG/TUGdual × 100) was calculated. Older individuals were grouped based on whether they did or did not complete all walking speeds (i.e., completers [n = 9] or noncompleters [n = 6]). The fastest walking speed attempted (FSA), automaticity index, and MOSAP were compared, and correlations were assessed between the FSA/MOSAP and the automaticity index. RESULTS: A significant difference was identified in an average MOSAP at heelstrike between older completer and noncompleter groups (p < 0.001). Further, older adults with lower automaticity index choose to stop walking at lower speeds (p = 0.001). The FSA was positively correlated with the automaticity index (ρ = 0.81, p < 0.001). Finally, the average MOSAP at FSA and the automaticity index were also negatively correlated (r = -0.85, p < 0.001). CONCLUSION: Older adults with lower automaticity of walking choose to stop walking at speeds before they completed all walking speeds, which may relate with increased attentional demands required to maintain dynamic stability at higher walking speeds. Given that these were otherwise healthy adults, the combination of FSA and an automaticity of walking may help to identify individuals who should be considered for an assessment to identify walking problems.

An Implementation Assessment of the Virtual Acute Care for Elders Program From the Perspective of Key Stakeholders.

OBJECTIVE: The aim of this study was to obtain feedback from key stakeholders and end users to identify program strengths and weaknesses to plan for wider dissemination and implementation of the Virtual Acute Care for Elders (Virtual ACE) program, a novel intervention that improves outcomes for older surgical patients. BACKGROUND: Virtual ACE was developed to deliver evidence-based geriatric care without requiring daily presence of a geriatrician. Previous work demonstrated that Virtual ACE increased mobility and decreased delirium rates for surgical patients. METHODS: We conducted semi-structured interviews with 30 key stakeholders (physicians, nurses, hospital leadership, nurse managers, information technology staff, and physical/occupational therapists) involved in the implementation and use of the program. RESULTS: Our stakeholders indicated that Virtual ACE was extremely empowering for bedside nurses. The program helped nurses identify older patients who were at risk for a difficult postoperative recovery. Virtual ACE also gave them skills to manage complex older patients and more effectively communicate their needs to surgeons and other providers. Nurse managers felt that Virtual ACE helped them allocate limited resources and plan their unit staffing assignments to better manage the needs of older patients. The main criticism was that the Virtual ACE Tracker that displayed patient status was difficult to interpret and could be improved by a better design interface. Stakeholders also felt that program training needed to be improved to accommodate staff turnover. CONCLUSIONS: Although respondents identified areas for improvement, our stakeholders felt that Virtual ACE empowered them and provided effective tools to improve outcomes for older surgical patients.

The Relation Between Pet Ownership, Anxiety, and Depressive Symptoms in Late Life: Propensity Score Matched Analyses.

The purpose of this study was to explore the differences in anxiety and depressive symptoms between older adult pet owners and non-pet owners after accounting for various correlates. Research findings on the anxiety-relieving and antidepressant effects of late-life pet ownership are mixed and limited. This may be due in part to various characteristics that impact the likelihood of owning a pet. Propensity score matching was used to pair 169 pet owners with 169 non-pet owners aged 70 to 91 years who participated in the University of Alabama at Birmingham Study of Aging. One set of propensity scores was created using age, sex, race, rurality, marital status, and income, as well as self-reported health, difficulty with activities of daily living, and difficulty with instrumental activities of daily living. A second set of scores was created using age, sex, race, rurality, marital status, and income. Multiple linear regression analyses were then used to explore the relation between pet ownership status and anxiety or depressive symptoms, controlling for the other symptoms. Pet ownership was significantly associated with lower self-reported anxiety symptoms (ß = -0.14) but not depressive symptoms (ß = -0.03) in the data matched without health variables. When propensity score matching included health variables, pet ownership was related to neither symptoms of anxiety (ß = -0.08) nor depression (ß = 0.05). These results suggest that owning a pet in later life is related to fewer anxiety symptoms, over and above the impact of depressive symptoms, even after accounting for various demographic and economic covariates. However, general and functional health appear to be critical to this relation, but the direction of this relation could not be determined from our analyses (i.e., it is not clear whether the relation between pet ownership and anxiety symptoms is confounded by, mediates, or is mediated by health). This study is the first large-scale analysis to find a significant relation between pet ownership and fewer anxiety symptoms in older adults.

Health Professionals Palliative Care Education for Older Adults: Overcoming Ageism, Racism, and Gender Bias.

Purpose of review: Most aging Americans lack access to specialist palliative care aimed at those experiencing serious illness and/or high symptom burden at end of life. The curricula used by training programs for all healthcare professions should focus on helping learners develop the primary palliative care skills and competencies necessary to provide compassionate bias-free care for adults with serious illness. We believe there is much opportunity to improve this landscape via the incorporation of palliative care competencies throughout generalist healthcare professional programs. Recent findings: Several recent publications highlight multiple issues with recruitment and retention of diverse students and faculty into healthcare professional training programs. There are also concerns that the curricula are reinforcing age, race, and gender biases. Due to these biases, healthcare professionals graduate from their training programs with socialized stereotypes unquestioned when caring for older adult minority patients and caregivers. Summary: Important lessons must be incorporated to assure that bias against age, race, and gender are discovered and openly addressed in healthcare professional's education programs. This review highlights these three types of bias and their interrelationships with the aim of revealing hidden truths in the education of healthcare professionals. Ultimately, we offer targeted recommendations of focus for programs to address implicit bias within their curricula.

Racial and Ethnic Disparities in Access to Local Anesthesia for Inguinal Hernia Repair.

BACKGROUND: Many studies have identified racial disparities in healthcare, but few have described disparities in the use of anesthesia modalities. We examined racial disparities in the use of local versus general anesthesia for inguinal hernia repair. We hypothesized that African American and Hispanic patients would be less likely than Caucasians to receive local anesthesia for inguinal hernia repair. MATERIALS AND METHODS: We included 78,766 patients aged ≥ 18 years in the Veterans Affairs Surgical Quality Improvement Program database who underwent elective, unilateral, open inguinal hernia repair under general or local anesthesia from 1998-2018. We used multiple logistic regression to compare use of local versus general anesthesia and 30-day postoperative complications by race/ethnicity. RESULTS: In total, 17,892 (23%) patients received local anesthesia. Caucasian patients more frequently received local anesthesia (15,009; 24%), compared to African Americans (2353; 17%) and Hispanics (530; 19%), P < 0.05. After adjusting for covariates, we found that African Americans (OR 0.82, 95% CI 0.77-0.86) and Hispanics (OR 0.77, 95% CI 0.69-0.87) were significantly less likely to have hernia surgery under local anesthesia compared to Caucasians. Additionally, local anesthesia was associated with fewer postoperative complications for African American patients (OR 0.46, 95% CI 0.27-0.77). CONCLUSIONS: Although local anesthesia was associated with enhanced recovery for African American patients, they were less likely to have inguinal hernias repaired under local than Caucasians. Addressing this disparity requires a better understanding of how surgeons, anesthesiologists, and patient-related factors may affect the choice of anesthesia modality for hernia repair.